The veteran reality stuntman, co-creator of the Jackass media franchise, and self-proclaimed ‘blunt force trauma guy’ may finally be rea y to stay behind the camera after suffering serious brain damage during the filming of Jackass Forever

One can’t help but make the Icarus comparison as the vision of Johnny Knoxville (aka Philip John Clapp) being shot out of a giant cannon wearing wings flashes ac oss the big screen in Jackass Forever, the ninth movie installment in this physical comedy franchise which kicked off in 2002 with Jackass: The Movie, preceded by the MTV series simply titled Jackass. As I watch Knoxville fly th ough the air in superb form, I wonder if even he thinks this may be taking things just a little too far. “When I shot out and I spread my wings like planned, I was so happy, then gravity kicked in. I started going down and turned into a big chicken in flight,” says Knoxville. “But as illie Nelson once said, ‘There’s nothing I can do about it now.’” When asked what he does for a living, Knoxville replies “I work with gravity and Newton’s third law of motion”. Well, technically, but that isn’t quite the whole picture. An American stunt performer, actor, and filmmake , Knoxville started his career in commercials and as an extra in a variety of films.

Outside of the infamous Jackass franchise, Knoxville’ filmography includes Men in Black II, A Dirty Shame, Walking Tall, The Dukes of Hazzard, and The Ringer among others. He also voiced Leonardo in Teenage Mutant Ninja Turtles. Additionally, Knoxville owns his own production company— Dickhouse Productions—and if that weren’t enough, he’s had a notable involvement with World Wrestling Entertainment, Inc. (WWE) including appearances in their Royal Rumble and SmackDown productions, facing off against Canadian professional wrestler Sami Zayn. Of all of Knoxville’s career highlights, it may seem like his involvement with the WWE could have Inspired his claimto-fame, Jackass, with their common thread of controlled, over-the-top stunt performances. However, Jackass came to be long before Knoxville stepped into the WWE ring. Some speculate that his pre-entertainment industry vocation of being a test dummy for various self-defense weapons could have been the creative spark that ignited the Jackass concept, but that wouldn’t be correct either. In fact, it was Knoxville’s failure to secure his ‘big break’ in Hollywood that prompted him to follow his natural talent for “making a spectacle of himself” [his words].

After years of chasing mainstream success in the entertainment industry, Knoxville, with help from directors Jeff remaine and Spike Jonze, pitched a television series to MTV with the simple concept of a cast of nine carrying out stunts and pranks on each other or the public, and voila, Jackass was born. The show debuted on October 1st of 2000 and the rest is history. Beginning with the television series and culminating with the most recent Jackass addition, Jackass Forever—released in February of 2022, over the years, the stunts and pranks have escalated from the benign—at least by Jackass standards—to the downright dangerous, and even PTSD inducing. “By the end of filming, they’ e [the crew] suffering f om PTSD. You can just tap them on the shoulder, and they’ll go down. They’re in terror.” says Knoxville. Take, for example, the classic escapade from the first Jackas movie, ‘Golf Course Airhorn’. This harmless—and hilarious— prank involved the Jackass crew sounding airhorns just as golfers wound up their backswings, throwing them off balance an sabotaging their endgame, the innocent antics harkening back to the simple pranks of the MTV series.

Knoxville and his crew stepped things up in later Jackass film with ‘Super Mighty Glue’, in which the crew got their hands on some extremely potent glue, and then used it to affix their bodi together and then pull them apart [ouch!], and ‘Mousetraps’ in which a member of the crew dressed as a mouse crawled through a field of mouse traps in pursuit of a piece of cheese As for Jackass stunts that Knoxville himself has performed, they have run the gamut. To name a few, there was the renta-car crash up derby, in which Knoxville came close to being crushed, the big red rocket which Knoxville rode hundreds of feet into the sky before it malfunctioned and almost blew him to pieces, and the giant evergreen tree Knoxville climbed to the top of before his crew chopped it down at its base, sending him plummeting to the ground.

The injuries that most certainly ensued after the latter mentioned stunts are undeniable, however, as the Jackass cast’s forthcoming feats proved, viewers had not seen anything yet. Enter the bulls. Bovines have held a special place in Jackass history. There was the bull that was encouraged to charge four men—one of which was Knoxville—riding a teeter-totter. And the bull whose vision was put to the test when challenged to see the camouflage Knoxville as he stood against a painted backdrop, himself painted to blend in—the bull passed the test and not only spotted Knoxville but charged at him aggressively. And finall , the less contrived stunt where a blindfolded Knoxville simply entered an enclosure with an agitated bull and just waited to be pummeled, which he was, severely. Fast forward to Jackass Forever.

Suffice it to say , Knoxville has taken things to another level, no bull, and the bodily damage it has caused is proof of that—namely a severe concussion and brain hemorrhage that caused him to lose most of his cognitive abilities for three months. In other terms, he suffe ed a traumatic brain injury (TBI). And what exactly initiated Knoxville’s TBI? You guessed it, a bull. In the most recent rendition of the Jackass staple, Knoxville enters a bullring in full magician garb and performs a magic trick for said bull, who obviously was not in the mood to be entertained. The magic show culminated in Knoxville being charged and rammed by the animal, catapulting him ten feet into the air with one and a half rotations, finally landing him squa ely on his head. “I guess that bull just didn’t like magic.” Knoxville later said. After the calamity, Knoxville lay motionless on the dirt snoring, yes snoring. “My doctor said that was me trying to swallow my tongue,” he says. It’s ironic how even his unconscious bodily response to the trauma played into Jackass’s trademark slapstick humor. All joking aside, this was serious. After about a minute, Knoxville came to, and shortly after, an ambulance shuttled him off to the hospital whe e the damage was accessed.

In the broken bones department, he got off pretty easy—just a broken rib and wrist. But in the days and weeks following the accident, the brain damage caused Knoxville to struggle cognitively and mentally. “My doctor asked me, ‘Are you having trouble concentrating?’ Apparently, I scored 17 out of 100 on a test measuring my cognitive ability. I couldn’t focus, I couldn’t edit.” Knoxville says. He also slipped into a depression—a first for him—and had debilitating headaches “My brain was just playing tricks on me. I got really depressed and over-focused on things.” Depression or no, Knoxville faced his TBI treatment headon, in true Jackass form. His team of neurologists and neuropsychologists tackled his symptoms using a combination of psychiatric medication, behavioral therapy, and transcranial magnetic stimulation (TMS), all of which are common treatments for the symptoms of TBI.

Though TBI Times is not aware of the precise medication Knoxville was prescribed, it is well-published in medical journals that selective serotonin reuptake inhibitors, commonly referred to as SSRIs, are the most effective antidep essants for people with TBI. Specificall , sertraline and citalopram—commonly known as Zoloft® and Celexa®—may have the fewest side effects an may even improve cognition. That being said, according to an article published in the Mental Health Clinician by Sophie Robert, BPharm, PharmD, BCPP, tricyclic antidepressants such as bupropion and lithium, are best avoided or used cautiously in the treatment of depressive symptoms caused by TBI.

Often prescribed as a companion treatment to psychiatric medications, cognitive behavioral therapy (CBT) is another goto for helping TBI patients experiencing emotional regulation and mental health issues—both of which CBT is extremely effective at add essing. According to a study conducted by Jennie Ponsford, Ph.D., and published in the Journal of Head Trauma and Rehabilitation, depression, anxiety, obsessive-compulsive tendencies, mood swings, impulsivity, lack of emotion, and difficulty with social interactions e all potential TBI symptoms that can be effectively t eated using CBT. Based on Michael Faraday FRS’s principle of electromagnetic induction, TMS uses low-intensity magnetic pulses to stimulate the nerve cells of the brain which some studies have shown to alleviate the mental health side effects of TBI as well as imp ove cognitive ability.

The treatment is performed in a doctor’s office while the patient is fully awake, and each session approximately 20 minutes in length. Though TMS is becoming a popular treatment for TBI, the jury is still out on its actual benefit for TBI patients. As is true with any medical treatment, results may vary, but in Knoxville’s case, his treatment combo did the proverbial trick. In his own words: “It was a really hard recovery from this last injury, but I’m great now. I feel like I’m the healthiest I’ve ever been.” Like many stuntmen and women, Knoxville has effectivel sacrificed his body for his career. He says that his doctors equate his collective trauma to “being involved in a major car crash”— aside from his TBI, the list of injuries he has incurred filmin the Jackass franchise is jaw-dropping and includes a broken collarbone, broken wrists and ribs, sprained ankles, herniated discs, torn tendons, and orbital blowout fractures. So, it isn’t surprising that after decades of extreme physical comedy and an injury list as long as his career—which spans 27 years—Knoxville is finally eady to admit defeat, or at least take a step back just shy of it. “I knew heading into this [the filming of Jackass Fo ever], that it was my last hurrah with big stunts,” says Knoxville. “You can only take so many chances before one forever catches up with you. I realized that and, amazingly, I’m still walking around. I think I’ve pushed my luck far enough.” With the next Jackass movie already in the works—Jackass 4.5— only time will tell if Knoxville stays true to his pledge to stay behind the camera

Neuroscientists in Germany and the US have recently shown that brain tsunamis, waves of cell depolarization — massive short-circuits of the neurons — sweep the cortex within ten minutes of cardiac arrest. These waves of spreading depolarization mark the beginning of the end, and trigger a gradual poisoning of neurons. They recorded brain tsunamis not just as people died but also after other critical events, such as a brain hemorrhage. Their findings coul have immediate application in emergency centers and critical-care wards.

Dr. Jens Dreier at the Center for Stroke Research Berlin and Dr. Jed Hartings at the University of Cincinnati saw an opportunity to apply these principles to their work in neurocritical care. Their centers monitor the brain activity of patients with brain conditions, such as traumatic brain injury or bleeding after an aneurysm. This neuromonitoring involves putting electrodes either directly onto the surface of the brain or deep into the cerebral cortex. Clinicians can then record electrical activity directly from the cortex.

Patients who were taken off of life-sustaining therapy whil neuromonitoring continued as the patient died revealed something striking. “Previously, it was thought that the end occurs when the brain stops its electrical activity and goes silent,” said Hartings. “But it doesn’t. We can show that the brain remains in a viable state for several minutes after this flatline, at which point a wave of depolarization sweep through the cortex. This is referred to as a brain tsunami.”
“The spreading depolarization shows that brain cells are dying, and gives a tremendously useful clinical marker for brain damage,” said Dreier. This is not just a curiosity, but something actionable in intensive care.”

By studying the brain at the end of life, these researchers have made the connection between death and spreading depolarization in a very controlled clinical setting with strong data. This may be the first step in discovering othe ways in which spreading depolarizations impact the brain and could inform breakthroughs in brain injury research and treatment.

Polytrauma is a specific medical term that describes the condition of someone who has sustained injuries to multiple body parts and organ systems. For instance, in a car crash, an individual may suffer serious burns over large portions of his or her body in addition to broken bones or a traumatic brain injury (TBI). The critical nature of an injury is evaluated in the U.S. medical community through a scale referred to as the Injury Severity Score (ISS). Polytraumas have scores of 16 or greater on this scale.

CAUSES OF POLYTRAUMA
Motor vehicle accidents are a major cause of polytrauma among civilians. The high speeds and sudden impacts that occur in many types of car crashes often lead to disastrous outcomes. The U.S. military has used the medical designation of polytrauma to categorize injuries sustained by military personnel during conflicts. Military personnel are subject to some of the most serious threats of polytrauma injuries, including blasts from explosive devices.

Beyond serious motor vehicle accidents and military-related incidents, causes of polytrauma can also include knife wounds, physical altercations, gunshot wounds, fire-related injuries, and falls from elevated heights. Polytrauma often involves a combination of TBI with other debilitating injuries such as serious eye damage, hearing damage, amputations, spinal cord injury, and severe burns. In addition, some individuals experience post-traumatic stress disorder (PTSD). Historically, polytrauma survival rates have been low, however, with advances in medical technology these statistics have greatly improved.

TREATMENT OF POLYTRAUMA PATIENTS WITH TBI
In medical terms, the presence of TBI in a polytrauma patient is referred to as Polytrauma and Concomitant Traumatic Brain Injury. According to the Journal of Neurosurgery, clinicians face unique challenges from decision-making and rehabilitative perspective when it comes to the treatment of these patients. Treatment management is complex and should be systematic, beginning at the scene with timely transport. Early operative interventions are also key.
According to the World Journal of Emergency Surgery, critical trauma care is ever-improving, yet TBI-related mortality rates are rising compared to other causes of death. Managing the acute phase after a severe TBI with polytrauma represents a challenging situation for every trauma team member and often involves the ‘damage control’ approach to sustain life. The challenge with polytrauma and concomitant traumatic brain injury patients is making sure equal emphasis is placed on stabilizing life-sustaining systems and doing everything possible to minimize brain damage.

POLYTRAUMA COULD WORSEN BRAIN INJURY
Primary brain injury results from mechanical injury at the time of the trauma whereas secondary brain injury is caused by the physiologic responses to the initial injury. Post-trauma care, as it relates to traumatic brain injury, is focused on halting or minimizing bleeding or clotting in the brain, among other biochemical processes, all of which result in secondary brain injury. Because polytrauma patients may require multiple damage control procedures, there is a risk of not providing ample emphasis on brain care. In addition, the presence of hypotension (low blood pressure), hypoxia (low oxygen levels), and fever — all commonly found in polytrauma patients — have been shown to initiate secondary brain damage.

TRAUMA NEUROSURGERY
The trauma neurosurgeon plays a key role in being able to ensure optimal treatment of polytrauma and concomitant TBI patients while minimizing secondary brain damage. Although brain surgery is highly complex and specialized, how it helps TBI patients comes down to decompression. Known as a craniotomy, this surgery relieves pressure on the brain, in turn slowing secondary brain damage. Dating back to Hippocrates, who is documented to have suggested their use in treating TBI, craniotomy revolutionized neurosurgery.

CHOOSING THE BEST TRAUMA CENTER
The best facilities for polytrauma patients to receive care are level one trauma centers. According to the American Trauma Society, A level one trauma center is capable of providing total care for every aspect of injury from prevention through rehabilitation, including surgical intervention. Although a level one trauma center can provide comprehensive treatment to trauma victims, they are not always capable of providing what is known as Simultaneous Multisystem Surgery (SMS) — which allows for different surgical teams to work on a patient simultaneously — the key to optimally treating polytrauma patients with TBI.
For a level one trauma center to provide SMS they must be equipped with a hybrid-emergency room system (HERS) where diagnostic procedures, such as CT scans, and damage control interventions, such as neurosurgery, can be performed simultaneously without patient transfer. Studies have shown that the HERS approach has been associated with a shorter time to initiate CT scanning, emergency surgery, and fewer unfavorable outcomes in polytrauma patients with and without TBI — ultimately resulting in higher – and more functional — survival rates.

While the ability to perform SMS seems to be straightforward and beneficial, very few centers in the United States are equipped with HERS and have trained staff to perform SMS in the context of TBI complicated by polytrauma. Other countries appear to be ahead of the curve in this area of trauma response. For example, not only are many of Japan’s trauma centers equipped with HERS, but they have also developed the Japanese Association for Hybrid Emergency Room Systems to specifically address the needs of specialized HERS trauma teams. 

FACTORS TO CONSIDER FOR THE BEST OUTCOME
According to an article published in the National Library
of Medicine, the occurrence of TBI in polytrauma patients increases mortality and reduces their quality of life. Studies have shown that the crucial factors for ensuring the best outcomes in these cases involve getting the most appropriate care as quickly as possible. Factors such as the speed in which ambulatory care is on scene and the patient being transported to a level one trauma center — when possible one equipped to administer SMS — can make substantial differences in a patient’s recovery.

COVID-19 has been a presence in all of our lives for more than two years — and for many, so has the vaccination debate. Since the U.S. Food and Drug Administration (FDA) authorized the first COVID-19 vaccine, more than one hundred million people in the U.S. have been vaccinated. While the mainstream medical community has promoted COVID-19 vaccination — with high profile organizations like Johns Hopkins Medicine among others expressing their views that all authorized COVID-19 vaccines are highly effective at preventing serious disease, hospitalization and death from COVID-19 — there are still many who question not only the safety of COVID vaccines, but the safety of vaccines in general. A SHORT HISTORY OF VACCINES The first vaccines were based on using weaker strains of viruses to generate immunity, while not giving the recipient of the vaccine the full-blown illness or, preferably, any symptoms of the disease at all. In May 1796, a British physician named Edward Jenner tested his hypothesis that direct inoculation of a person cowpox, which is not deadly, would render that person immune to smallpox, which was. Jenner based this theory on his observations of milkmaids. Those milkmaids who had acquired cowpox through their contact with cows were immune to smallpox even when exposed multiple times to the deadly disease. Jenner’s detailed descriptions of his experiments convinced his colleagues and the authorities that inoculation with cowpox — which he called vaccination —was a viable way to protect people from smallpox. Another important figure in the history of vaccination was Louis Pasteur. Pasteur stepped onto the world stage with a famous experiment borne out of necessity. In July 1885, a rabid dog attacked a boy named Joseph Meister. At a time when this would have been a death sentence from rabies, Joseph’s mother asked for help from Louis Pasteur, who she heard was working on a cure for rabies. Pasteur inoculated the child with 13 increasingly strong doses of an experimental rabies vaccine. At the end of the treatment, the child did not develop rabies, and a new era of vaccination began.

EARLY ANTI-VACCINATIONISM
The beginnings of anti-vaccinationism were rooted in the idea of personal rights rather than health risks. In the early nineteenth century, smallpox vaccination in Europe became mandatory and societies of anti-vaccinationists formed to protest what they saw as infringement of individual liberty. Anti-vaccinationism spread to the United States later that same century, largely by visitors and immigrants from Europe, and it has been with us ever since. GENERAL VACCINE CONCERNS Vaccines, though designed to protect from disease, have been shown to cause side effects that range from mild-to-serious. According to the Centers for Disease Control and Prevention (CDC), the most common side effects of vaccination are soreness, swelling or redness at the injection site. Some vaccines

are associated with fever, rash and achiness. Serious side effects from vaccination appear to be rare, but may include lifethreatening allergic reaction, seizure and even death. However, according to the CDC, when considered on a population basis, the incidence of serious complications of vaccination is minute when compared with the outcome of natural infection. In order to understand the range of possible vaccination side effects, it is useful to compare a vaccine with relatively few associated side effects, such as the Haemophilus influenza type B vaccine, with a vaccine known to have many potential side effects, such as the smallpox vaccine, which is still used in a military context today. In the case of Haemophilus influenza type B, side effects may include redness, warmth or swelling at the injection site and elevated fever with no serious side effects having been reported. In contrast, with the smallpox vaccine, risks include encephalitis (inflammation of the brain which can lead to permanent brain damage), severe infection beginning at the vaccination site and even death — for every million people vaccinated for smallpox, up to 52 people could experience life threatening side effects.

THE CASE FOR VACCINATION
Even with anti-vaccine sentiment and vaccine concerns, the origins of vaccines do seem to make a great case for themselves, and modern science backs this up. According to the National Foundation for Infectious Diseases, The US has a robust approval process to ensure that all licensed vaccines are safe. They say that potential side effects associated with vaccines are uncommon and much less severe than the diseases they prevent. According to the CDC, getting all recommended vaccinations is a powerful step in taking charge of your health. They say that when given as directed, FDA-authorized vaccines can prevent severe disease and save lives. WHEN HARM IS CAUSED BY VACCINES When vaccines first began to be widely used, people who experienced serious side effects from vaccination had little recourse to compensation from manufacturers, physicians or the government. This was particularly a problem when vaccine production techniques were in their infancy, and contamination of vaccines occasionally occurred during or after manufacture. Since the passage in 1902 of the U.S. Biologics Control Act, which initiated the regulation of vaccines, such problems with negligence in manufacturing have greatly declined. As product liability law evolved during the 20th century, it eventually provided an avenue for compensation for individuals harmed by vaccines — they could sue vaccine manufacturers or they could sue physicians who administered vaccines. To help keep track of adverse reactions to vaccinations, the CDC and the FDA established The Vaccine Adverse Event Reporting System (VAERS) in 1990. According to the CDC, VAERS is used “to detect possible signals of adverse events associated with vaccines.” About 30,000 events are reported each year to VAERS. Between 10% and 15% of these reports describe serious medical events that lead to hospitalization, lifethreatening illness, disability or death. COVID VACCINES According to the National Foundation for Infectious Diseases, as of April 15, 2022, 19 vaccines have been authorized for emergency use and 12 given full approval for use. In 2020, the FDA authorized two mRNA COVID vaccines for emergency use. In 2021, the FDA approved the Pfizer-BioNTech COVID-19 vaccine for people ages 16 and older, and following that, the Pfizer-BioNTech vaccine for children ages 5 through 15. In 2022, the FDA approved the Moderna COVID-19 vaccine, now called Spikevax, for people age 18 and older. Researchers continue to study and develop several other COVID-19 vaccines. It’s estimated that COVID-19 vaccination results in a low risk of another infection with a similar variant for at least six months. HOW COVID VACCINES WORK According to the CDC, COVID-19 vaccines work with your immune system so your body will be ready to fight the coronavirus if you are exposed to it — including coronavirus variants. In addition, COVID-19 vaccination might offer more protection than becoming infected with COVID-19. A recent study has shown that unvaccinated people who already had COVID-19 are more than twice as likely as fully vaccinated people to be reinfected with COVID-19. Recent research also suggests that people who got COVID-19 in 2020 and then received mRNA vaccines produce very high levels of antibodies that are likely effective against current and possibly future variants. Some scientists call this hybrid immunity however further research is needed to confirm this phenomenon. DO COVID VACCINES EFFECT THE BRAIN? Though cases of neurologic symptoms related to COVID vaccination are uncommon, they are not unheard of. Two cases, published in the Cureus Journal of Medical Science, show that neurological inflammatory responses and the presence of neurooncologic lesions are possible after COVID vaccination. The journal describes two patients that presented with neurologic deficits that were not present prior to being vaccinated. One of the cases presented in the article was of a 58-year-old woman who experienced high-grade fevers, slurred speech and facial droop approximately two weeks following her second dose of a COVID-19 vaccine. According to the journal, the patient’s symptoms were attributed to post-vaccination Bell’s Palsy. Her fevers resolved over the next 24-48 hours as is typical with post-vaccination symptoms, however facial weakness persisted until approximately two weeks later when she developed acute

worsening of her facial droop with associated slurred speech, drooling as well as left arm and leg weakness. A contrastenhanced MRI of the brain demonstrated a large hematoma in the right frontal lobe. The patient underwent surgery to remove the hematoma. The second case presented in the journal was of a 52-yearold woman who developed severe headache and neck stiffness associated with intermittent high-grade fevers four days after her first dose of a COVID-19 vaccine. Contrast-enhanced MRI scans showed an abnormal mass on her brain. RISK VS. REWARD Despite this evidence of COVID vaccines effecting the brain, studies have shown that adverse events after COVID vaccination are rare and many COVID vaccines have proven over 90% effective with no safety threat. Additionally, other studies have shown that brain health may be more at risk after COVID infection than after vaccination. Whether or not to receive a COVID-19 vaccination is a personal decision, however, it is important to be aware of the potential adverse effects.

Each year, an estimated 1.7 million people in the United States (US) sustain a brain injury. Many treatments are being studied to help these patients to recover and regain their normal lives — art therapy is one. Art therapy is a distinct discipline that incorporates creative methods of expression through visual art media. Art therapy, as a creative arts therapy profession, originated in the fields of art and psychotherapy and may vary i definition. This modality aids in the ecovery process by allowing the patient to do something they enjoy while working on various functional skills such as fine moto skills, gross motor skills, standing tolerance, endurance, communication, expression of feelings, relaxation, socialization, memory, and problem-solving skills. In the inpatient setting, art therapy can be used daily with both pediatric and adult patients. This form of treatment allows patients to be creative while simultaneously motivating them. The format for this type of therapy can be straightforward, for example, drawing and painting, or the approach can be much more creative. Take for example a pediatric patient with traumatic brain injury who was very interested in coloring and painting. To help with her walking and coordination, her therapist painted her feet and had her walk throughout the facility. This allowed the patient and her family to see the progress she made through the footprints she created. She was allowed to express herself daily by choosing the colors for her footprints and was motivated to continue walking more each day.

Art therapy is also being explored as a form of complementary and integrative care for military veterans affected by trauma and injuries in the line of duty includin traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The self-soothing qualities of making art can most certainly aid in TBI recovery. Art therapy offers many psychologica and cognitive benefits for patients after a TBI and als helps improve mood, problem-solving skills, attention, and coordination. Most importantly, making art helps patients find a healthy outlet for their emotions, and ebuild their sense of self, something few other therapies can offer after traumatic brain injury.

According to John Hopkins Medicine, Body Dysmorphic Disorder (BDD) is a mental illness that causes a person to be obsessively focused on a perceived flaw in their appearance. A person with BDD may be so preoccupied with the appearance of their body that they cannot lead a normal life and may be overcome with feelings of self-hate and dissatisfaction. They may spend an excessive amount of time each day worrying about how they look, so much so that they neglect their daily responsibilities. Suicidal thoughts may also be a symptom. Some behaviors that may accompany this disorder include a person constantly checking themselves in the mirror, avoiding social activities have shown that individuals with BDD have deficiencies in this area. In one study of verbal and nonverbal memory — including visual organization strategies — subjects were asked to copy and recall a complicated figu e drawing.

The BDD group recalled more specific parts of the drawin instead of the overall structure, which may reflect poo organizational strategies marked by an imbalance in local (detail) and global information processing. Another study using the same test found impaired copying and recall in individuals with BDD. There was also evidence of impaired visual working memory as well as auditory, verbal and logical memory.

“THERE IS NO QUESTION THAT PHYSICAL DAMAGE TO THE BRAIN CAN CAUSE
COGNITIVE, EMOTIONAL, AND BEHAVIORAL ISSUES. RESEARCH HAS SHOWN THAT
THE SPECIFIC AREA OF THE BRAIN AFFECTED BY TBI TRANSLATES DIRECTLY TO THE
POTENTIAL SIDE EFFECTS A PATIENT MAY EXPERIENCE.”
- Dr. Rod Amiri, MD, Neuropsychiatrist

New research has started to identify abnormal areas and connections in the brain in hopes of developing biomarkers or brain correlates that can help identify those at risk for developing BDD. Medical research is beginning to make connections between the disorder and frontal lobe brain damage. Trauma or injury to the frontal lobe of the brain can cause a wide range of problems and changes to your personality due to the frontal lobe’s role in shaping social behavior and personal characteristics. It controls things such as personality, decision making, motivation and voluntary movements. The frontal lobe is also responsible for memory, and studies. Individuals with BDD also tend to do poorly in tasks related to decision-making, specifically those involving planning, inhibition or organization, pointing again to the frontal lobe. One study found that compared to healthy controls, those with BDD made more errors on a search task, demonstrating deficits in working memor . They also were slower on a task measuring planning ability and exhibited higher risk-taking behavior in a decision-making experiment. Based on these studies, the connection between frontal lobe abnormality and BDD is clear. However, because of the complexity of the disorder, future research is necessary to understand the exact combiniation of factors that lead to BDD.

War ravages lives across borders and cultures and within military ranks. The physical casualties [of war] are front and center, but the less talked about and equally debilitating occurrences of traumatic brain injury (TBI) are the silent wounds effecting millions globally — wounds which often goes untreated. In a conflict setting, TBI is commonly caused by blasts and leaves service members and civilians alike to grapple with life-altering cognitive difficulties, sometimes without adequate medical care to support recovery. Though the problem is more prevalent than the help, there are many agencies and organizations dedicated to assisting these victims of war.

The Office of the UN High Commissioner for Human Rights (OHCHR), the UN Assistance Mission (UNAMA), the United Nations Children’s Fund (UNICEF), and others, are dedicated to shedding light on the problem and providing solutions. SERVICE MEMBERS AND TBI According to the Joint Theater Trauma Registry, compiled by the U.S. Army Institute of Surgical Research, 22 percent of soldiers wounded in the U.S. war in Afghanistan had injuries to the head, face or neck. This percentage can serve as a rough estimate of the fraction who have TBI, according to Deborah L. Warden, a neurologist and psychiatrist at Walter Reed Army Medical Center who is the national director of the Defense and Veterans Brain Injury Center (DVBIC). Warden said the true proportion is probably higher, since some cases of closed brain injury are not diagnosed promptly.

In the Vietnam War, by contrast, 12 to 14 percent of all combat casualties had a brain injury, and an additional 2 to 4 percent had a brain injury plus a lethal wound to the chest or abdomen, according to Ronald Bellamy, former editor of the Textbooks of Military Medicine, published by the Office of the Surgeon General of the U.S. Army. Bellamy said that because mortality from brain injuries among U.S. combatants in Vietnam was 75 percent or greater, soldiers with brain injuries made up only a small fraction of the casualties treated in hospitals. Kevlar body armor and helmets are one reason for the high proportion of TBIs among soldiers wounded in more current conflicts. They work by shielding the wearer from bullets and shrapnel and have improved overall survival rates.

Kevlarhelmets have reduced the frequency of penetrating head injuries. However, the helmets cannot completely protect the face, head and neck — nor do they prevent the kind of closed brain injuries often produced by blasts. Most brain injuries in war zones are caused by improvised explosive devices (IEDs), and closed brain injuries outnumber penetrating ones among patients seen at Walter Reed, where thousands of patients with TBI are treated. All admitted patients who have been exposed to a blast are routinely evaluated for brain injury — 59 percent of them have been given a diagnosis of TBI, according to Warden.

Of these injuries, 56 percent are considered moderate or severe, and 44 percent are mild. A blast creates a sudden increase in air pressure by heating and accelerating air molecules and, immediately thereafter, a sudden decrease in pressure that produces intense wind. These rapid pressure shifts can injure the brain directly, producing concussion or contusion. Air emboli — a blockage of blood supply caused by air bubbles — can also travel to the brain, causing the death of brain tissue. When service members have serious brain injuries, they receive immediate care on the battlefield and are then transported to military combat support hospitals, where they undergo brain imaging and are treated by neurosurgeons.

Treatment may include the removal of foreign bodies, control of bleeding or craniectomy — which relieves pressure from swelling. Soldiers with TBI often have symptoms affecting several areas of brain function. Headaches, sleep disturbances and sensitivity to light and noise are common. Cognitive changes, diagnosed on mental-status examination or through neuropsychological testing, may include disturbances in attention, memory or language, as well as delayed reaction time during problem solving. Often, the most troubling symptoms are behavioral ones — mood changes, depression, anxiety, impulsiveness, emotional outbursts or inappropriate laughter.

Some symptoms of TBI overlap with those of post-traumatic stress disorder, and many effected in the military sector have both conditions. The good news is service men and women are young and healthy, and as such are in a good position to recover. CIVILIANS INJURED IN CONFLICTS The U.S. wars in Iraq, Afghanistan, Yemen, Syria and Pakistan, military operations in Somalia as well as the more recent conflict in Ukraine have taken a tremendous human toll on those countries. Hundreds of thousands of civilians have been injured as a result of these conflicts and many of these injuries have resulted in TBI. For example, according to the Watson Institute for International and Public Affairs, blast-induced TBI has been referred to as the signature injury of the conflicts in Iraq and Afghanistan. People living in these war zones have been attacked in their homes, in markets and on roadways. They have been subjected to bombs, bullets, fire and IEDs.

Civilians are victimized at checkpoints, as they are run off the road by military vehicles, when they step on mines or cluster bombs, as they collect wood or tend to their fields and when they are kidnapped and executed for purposes of revenge or intimidation. A new book, published by world-renowned UCSF neuroradiologist Dr. Alisa Gean, tackles the complexity of TBI, how it is sustained and how it affects both civilians and combatants alike. The text includes information and research gathered from nearly three decades of studying civilian TBI, as well as five intensive years of studying TBI sustained from combat, terrorism and natural disasters. “Aproximately 85% of injured World War II soldiers suffered from gunshot wounds.

Today’s enemy is using a new weapon to kill, defeat and demoralize — the improvised explosive device.” says Dr. Gean. The U.S. war in Afghanistan lasted for 22 years and resulted in an enormous footprint of civilian casualties. In their Afghanistan Protection of Civilians in Armed Conflict Annual Report, the Office of the UN High Commissioner for Human Rights (OHCHR) and the UN Assistance Mission (UNAMA) documented some 8,820 civilian casualties (3,035 deaths and 5,785 injuries) in 2020. These civilians paid a terrible price for the failure of peace negotiations and the country remains amongst the “deadliest places in the world to be a civilian”, according to Michelle Bachelet, UN High Commissioner for Human Rights. “I am particularly appalled by the high numbers of human rights defenders, journalists and media workers killed since peace negotiations began”, she says.

According to the report, the overall drop in civilian casualties in 2020 was due to fewer casualties from suicide attacks by anti-government elements in populated areas, as well as a drop in casualties attributed to international military forces. There was, however, a “worrying rise” in targeted killings by such elements — up about 45 per cent since 2019. The use of IEDs by the Taliban, air strikes by the Afghan Air

Force and ground engagements also resulted in increased casualties, according to the report. Anti-government elements bore responsibility for about 62 percent of civilian casualties, while pro-government forces were responsible for about 25 pe cent of the casualties. About 13 percent of casualties were attributed to crossfire and other incidents. The report went on to note that the years-long conflict in Afghanistan “continues to wreak a shocking and detrimental toll” on women and children, who accounted for 43 percent of all civilian casualties — 30 percent children and 13 percent women. “This report shows the acute and lasting needs of victims of the armed conflict and demonstrates how much remains to be done to meet those needs in a meaningful way”, High Commissioner Bachelet said. “The violence that has brought so much pain and suffering to the Afghan population for decades must stop and steps towards reaching a lasting peace must continue.”

June 3rd marked the 100th day of the war in Ukraine — a war that has shattered the lives of millions of children. Only days before, on June 1st, the International Day for Protection of Children [in Ukraine and across the region] was marked. “June 1 is the International Day for Protection of Children,” said UNICEF Executive Director Catherine Russell. “Instead of celebrating the occasion, we are solemnly approaching the 100th day of the war. Without an urgent ceasefire and negotiated peace, children will continue to suffer — and fallout from the war will continue to impact vulnerable children around the world.” The scale and speed of the emergency in Ukraine have not been seen since World War II, the United Nations said in a statement, which estimated that 5.2 million children in the region need humanitarian assistance; three million inside the country and more than 2.2 million in refugee-hosting countries. As intense artillery exchanges continue between Russian and Ukrainian forces in eastern Donetsk region and amid reports that Russian troops are continuing their campaign, UNICEF said that almost two in three children in Ukraine have been displaced by fighting. “Civilian infrastructure on which children depend continues to be damaged or destroyed,” the agency explained. “This so far includes at least 256 health facilities and one in six UNICEF-supported ‘Safe Schools’ in the country’s east. Hundreds of other schools across the country have also been damaged.

Conditions for children in eastern and southern Ukraine where fighting had been quite intense are increasingly desperate.” In addition to the trauma of fleeing their homes, UNICEF states that children fleeing violence faced a significant risk of family separation, abuse, sexual exploitation and trafficking. The UN agency also reiterated its call for “full humanitarian access” so that teams can “safely and quickly reach children in need wherever they may be”. Inside Ukraine, UNICEF and partners have already distributed life-saving health and medical supplies for nearly 2.1 million people in war-affected areas. Equally important, critical safe water access has also been secured for more than 2.1 million people living in areas where networks have been damaged or destroyed.

The long-lasting mental health toll of the war on children has also contributed to an acute child protection crisis, made worse by the fact that many displaced families are out of work and unable to meet their children’s basic needs. “These children urgently need safety, stability, child protection services and psychosocial support — especially those who are unaccompanied or have been separated from their families. More than anything, they need peace,” UNICEF insisted. Over 610,000 children and caregivers have also received mental health and psychosocial support, while nearly 290,000 children have been given learning supplies. In addition, almost 300,000 vulnerable families have registered for a humanitarian cash assistance program run by UNICEF and the Ukrainian Ministry of Social Policy. In countries hosting Ukrainian refugees, the UN agency continues to look out for the most vulnerable of children by providing anti-trafficking training for border guards and encouraging local authorities to integrate refugee children into schools.

Providing vaccines and medical supplies for displaced Ukrainians is a key component of UNICEF’s response, and so too is establishing play and learning hubs to provide young children with a much-needed sense of normalcy and respite. In total, 25 UNICEF-UNHCR “Blue Dots” — one-stop safe havens that provide support and services for families on the move, have been established along major transit routes in Moldova, Romania, Poland, Italy, Bulgaria and Slovakia, the agency said.

In Moldova, more than 52,000 refugees, mostly in female-headed households, have been reached through a UNICEF-UNHCR multi-purpose cash assistance program. Highlighting the devastating and lasting consequences of the war on millions of the country’s youngest citizens, UN Children’s Fund UNICEF maintains that most of the victims were from “attacks using explosive weapons in populated areas”, a claim 1.6 BILLION CHILDREN ARE LIVING IN A CONFLICT AFFECTED COUNTRY supported by the UN human rights office, OHCHR. With the use of explosive weapons, it is inevitable that many of these children will be effected by TBI. According to the Save the Children Blast Injury Report, the use of explosive weapons, traditionally meant for the open battlefield, in densely populated towns and cities continues to cause devastation to children.

Time after time, these weapons result in death, life-changing injuries and the destruction of vital facilities, such as schools and hospitals. From Syria, to Yemen, to Afghanistan, the families of the injured are left to manage TBI among other devastating injuries with health systems often at the point of collapse. And children are particularly vulnerable to blasts with their bodies being lighter, and thus easily thrown farther than an adult’s body. There are good reasons why the killing and maiming of children in conflict is defined as a grave violation by the United Nations.

If children survive explosive weapons, they often find themselves dealing not only with physical trauma and disability, but with the loss of family members, the destruction of their homes and the disruption of their education — and with it their future prospects. To say nothing of the acute stress already caused by growing up in a war zone. Though children can be quite resilient, they cannot be expected to recover without sustained and specialist support. Left untreated, the long-term effects of blast injuries will leave children facing a lifetime of suffering, and will ultimately create an entire generation at risk of exclusion. The Pediatric Blast Injury Partnership (PBIP), led by Imperial College London with Save the Children, is a practical response to the unique medical challenges faced by children with blast injuries. One of the PBIP’s most valuable resources to date is the Pediatric Blast Injury Field Manual, which gives medical staff in conflict settings, who often have to operate with little or no previous experience or training, the knowledge and technical guidance needed to treat children from the point of injury onwards. It also offers advice on how to provide long-term rehabilitation care and mental health support.

Smart initiatives like these will make a real difference to injured children, and medical institutions and humanitarian agencies like Save the Children will undoubtedly continue to build on this work to ensure children have the best chance of recovery. But in order to truly protect children in conflict, governments need to take an active role to advocate for children. This is why PBIP is calling on all warring parties to Stop the War on Children by taking steps to uphold international laws and norms, ensuring accountability for crimes against children and investing in the support necessary to help children recover from the physical and psychological trauma caused by conflict. PBIP found that 80% of pediatric blast patients experienced penetrating injuries to the head. By comparison, just 31% of adult blast patients experienced the same injury. Within this, younger children are more affected. Children under seven are almost twice as likely to present with head injuries as older children. In one study, 90% of children who died from blast injuries had skull fractures.

When children survive a blast, they are almost always left with life-limiting brain injury. Take 12-year-old Mahmoud who lives in Gaza. In 2014 when he was playing in the street, he was hit by an explosive weapon. “I heard an explosion and I felt something go into my eye. I touched my eye and felt blood pouring out. I ran for help and was taken to the hospital. I woke up missing one of my eyes.” Mahmoud’s family says byond his physical injuries, he was not himself after the accident. Mahmoud ikely suffered an undiagnosed TBI. Helle Thorning-Schmidt, CEO of Save the Children International and former Prime Minister of Denmark is uncompromising in her assessment: “International law makes clear that everyone has a responsibility to make sure children are protected in war. Yet explosive weapons continue to kill, maim and terrorize thousands of children every year. Every warring party — from armed groups to governments — must do more to protect children and abide by this important moral principle.”

The World Health Organization estimates that traumatic brain injury (TBI) is and will remain the most important cause of neurodisability in the coming years. The search for neuroprotective therapies for severe TBI has been extensive but unfruitful over the last few decades, testified by mo e than 30 failed clinical trials, and we still have no specific neu oprotective therapy, that is, effective in clinica TBI. The burden of mortality and residual disability calls for new approaches to promote recovery of function of TBI patients in the acute and chronic phase.

Classically described as a sudden event with short-term consequences, TBI induces dynamic pathological cascades that may persist for months or years after injury with a major impact on outcome. Among dynamic mechanisms, the neuroinflammatory esponse and the accumulation of aberrant proteins may have a critical role in establishing a neuropathological link between acute mechanical injury and late neurodegeneration. The close association between post-TBI neurological changes, persistent neuroinflammation, and lat neuropathology highlights the fact that the window of opportunity for therapeutic intervention may be much wider than previously thought and that long-term treatment encompassing the acute and chronic phase should be tested to effectively interfe e with this complex condition.

An emerging technology, virtual reality (VR), represents a new tool for this purpose and might provide TBI care teams with new neuro-restorative strategies readily available at the bedside. Since the late 1980s, this term has been used to describe a 3D synthetic environment created by computer graphics, where the user has the feeling of being inside. VR can be described as “an advanced form of human-computer interface that allows the user to interact with and become immersed in a computer-generated environment in a naturalistic fashion”. For its flexibilit , sense of presence (i.e., the feeling of “being there”) and emotional engagement, VR has been tested in motor and cognitive rehabilitation, with good results. In stroke patients, the number of VR programs is rapidly increasing with compelling data showing an improvement in recovery of motor function and daily living activities. VR has been successfully used both as assessment instrument and as therapeutic intervention. As assessment tool, VR has been used to detect visual-vestibular deficits in adults after concussion and mild BI. VR assessment protocols appear to be primarily implemented for mild TBI. Conversely, VR treatment protocols for cognitive rehabilitation are used transversely from mild to severe conditions, although effectiveness of thes kinds of interventions needs to be further explored.

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable survival of an accident in which a large iron rod was driven completely through his head, destroying much of his brain’s left frontal lobe, and for that injury’s reported effects on his personality and behavior over the remaining 12 years of his life‍. Long known as the “American Crowbar Case”‍—once termed “the case which more than all others is calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines” ‍—Phineas Gage influenced 19t -century discussion about the mind and brain, particularly debate on cerebral localization, and was perhaps the first case to suggest the brain’s ole in determining personality, and that damage to specific parts of the brain might induce specific mental changes I n 1848, Gage, 25, was the foreman of a crew cutting a railroad bed in Cavendish, Vermont. On September 13, as he was using a tamping iron to pack explosive powder into a hole, the powder detonated. The tamping iron—43 inches long, 1.25 inches in diameter and weighing 13.25 pounds— shot skyward, penetrated Gage’s left cheek, ripped into his brain and exited through his skull, landing several dozen feet away. Though blinded in his left eye, he might not even have lost consciousness, and he remained savvy enough to tell a doctor that day, “Here is business enough for you.”

Gage’s initial survival would have ensured him a measure of celebrity, but his name was etched into history by observations made by John Martyn Harlow, the doctor who treated him for a few months afterward. Gage’s friends found him“no longer Gage,” Harlow wrote. The balance between his “intellectual faculties and animal propensities” seemed gone. He could not stick to plans, uttered “the grossest profanity” and showed “little deference for his fellows.” The railroad-construction company that employed him, which had thought him a model foreman, refused to take him back. So Gage went to work at a stable in New Hampshire, drove coaches in Chile and eventually joined relatives in San Francisco, where he died in May 1860, at age 36, after a series of seizures. In time, Gage became the most famous patient in the annals of neuroscience, because his case was the first to suggest a link between brain trauma and personality change. In his book An Odd Kind of Fame: Stories of Phineas Gage, the University of Melbourne’s Malcolm Macmillan writes that two-thirds of introductory psychology textbooks mention Gage. Even today, his skull, the tamping iron and a mask of his face made while he was alive are the most sought-out items at the Warren Anatomical Museum on the Harvard Medical School campus. Michael Spurlock, a database administrator in Missoula, Montana, happened upon the Wilgus daguerreotype on Flickr in December 2008. As soon as he saw the object the one-eyed man held, Spurlock knew it was not a harpoon. Too short. No wooden shaft. It looked more like a tamping iron, he thought. Instantly, a name popped into his head: Phineas Gage. Spurlock knew the Gage story well enough to know that any photograph of him would be the first to come to light. He knew enough, too, to be intrigued by Gage’s appearance, if it was Gage. Over the years, accounts of his changed character had gone far beyond Harlow’s observations, Macmillan says, turning him into an ill-tempered, shiftless drunk. But the man in the Flickr photogragh seemed well-dressed and confident It was Spurlock who told the Wilguses that the man in their daguerreotype might be Gage. After Beverly finished her online research, she and Jack concluded that the man probably was. She e-mailed a scan of the photograph to the Warren museum. Eventually it reached Jack Eckert, the public-services librarian at Harvard’s Center for the History of Medicine. “Such a ‘wow’ moment,” Eckert recalls. It had to be Gage, he determined. How many mid-19th-century men with a mangled eye and scarred forehead had their portrait taken holding a metal tool? A tool with an inscription on it? The Wilguses had never noticed the inscription; after all, the daguerreotype measures only 2.75 inches by 3.25 inches. But a few days after receiving Spurlock’s tip, Jack, a retired photography professor, was focusing a camera to take a picture of his photograph. “There’s writing on that rod!” Jack said. He couldn’t read it all, but part of it seemed to say, “through the head of Mr. Phi...”

In March 2009, Jack and Beverly went to Harvard to compare their picture with Gage’s mask and the tamping iron, which had been inscribed in Gage’s lifetime: “This is the bar that was shot through the head of Mr. Phinehas P. Gage,” it reads, misspelling the name. Harvard has not officially decl ed that the daguerreotype is of Gage, but Macmillan, whom the Wilguses contacted next, is quite certain. He has also learned of another photograph, he says, kept by a descendant of Gage’s. As for Spurlock, when he got word that his hunch was apparently correct, “I threw open the hallway door and told my wife, ‘I played a part in a historical discovery!’ ” Popular reports of Gage often depict him as a hardworking, pleasant man prior to the accident. Post-accident, these reports describe him as a changed man, suggesting that the injury had transformed him into a surly, aggressive heavy drinker who was unable to hold down a job. Harlow presented the first account of the changes in Gage’s behavior following the accident. Where Gage had been described as energetic, motivated, and shrewd prior to the accident, many of his acquaintances explained that after the injury he was “no longer Gage.” Since there is little direct evidence of the exact extent of Gage’s injuries aside from Harlow’s report, it is difficult to know exact how severely his brain was damaged. Harlow’s accounts suggest that the injury did lead to a loss of social inhibition, leading Gage to behave in ways that were seen as inappropriate. Gage’s case had a tremendous influence on early neu ology. The specific changes observed in his behavior pointed t emerging theories about the localization of brain function, or the idea that certain functions are associated with specific a eas of the brain. In those years, neurology was in its infancy. Gage’s extraordinary story served as one of the first sou ces of evidence

that the frontal lobe was involved in personality. Today, scientists better understand the role that the frontal cortex has to play in important higher-order functions such as reasoning, language, and social cognition. After the accident, Gage was unable to continue his previous job. According to Harlow, Gage spent some time traveling through New England and Europe with his tamping iron to earn money, supposedly even appearing in the Barnum American Museum in New York. He also worked briefly at a livery stabl in New Hampshire and then spent seven years as a stagecoach driver in Chile. He eventually moved to San Francisco to live with his mother as his health deteriorated. After a series of epileptic seizures, Gage died on May 21, 1860, almost 12 years after his accident. Seven years later, Gage’s body was exhumed. His brother gave his skull and the tamping rod to Dr. Harlow, who subsequently donated them to the Harvard University School of Medicine. They are still exhibited in its museum today.

Foreign accent syndrome (FAS) is a speech disorder that causes a sudden change to speech so that a native speaker is perceived to speak with a “foreign” accent. FAS is most often caused by damage to the brain caused by a stroke or traumatic brain injury. Other causes have also been reported including multiple sclerosis and conversion disorder and in some cases, no clear cause has been identified Norwegian neurologist Georg Herman Monrad-Krohn reported the best-known case of FAS, in which speech was altered in terms of timing, intonation, and tongue placement causing the subject to sound foreign. In FAS, speech remains highly intelligible and does not necessarily sound disordered. FAS has been documented in cases around the world, including accent changes from Japanese to Korean, British English to French, American English to British English, and Spanish to Hungarian.

There have been only about 100 known cases of the syndrome since it was first eported in the 1940s. The most famous case was a Norwegian woman who was hit by shrapnel in World War II; she developed a German accent and was ostracized as a result. Other cases include a British woman from Devon who developed a Chinese accent following a migraine, and another British woman who had a stroke after which she acquired a French accent. FAS affects only a small a ea of speech — the pattern and intonation — and in some recorded cases appears to have been brought on by a stroke or traumatic brain injury (TBI). The primary symptom of foreign accent syndrome is speaking in an accent associated with a country where the person has never lived or in a language, they have never spoken. For example, a native English speaker who has never left the United States may begin speaking English with a

Spanish accent. Most people with foreign accent syndrome also show symptoms of a psychological or neurological condition. They might have schizophrenia or depression, a recent brain injury, or a medical condition, such as MS or dementia, that damages the brain. A person whose foreign accent changes slightly or who develops a new accent after living abroad would not be considered to have foreign accent syndrome. A person with foreign accent syndrome may seek treatment because they or someone they know noticed the change in their speech. In some cases, however, foreign accent syndrome presents secondary to another symptom. In this scenario, a person seeking emergency psychiatric care might also have an unusual accent, or a head injury survivor may develop a new speech pattern. No specific test can assess for fo eign accent syndrome. Instead, doctors work to diagnose the cause using a variety of tests, including blood tests to test for infections and some illnesses, brain scans, such as MRI scans, to look for lesions or damage in the brain, a lumbar puncture, to test for infections in the spinal flui and to check for signs of certain central nervous system conditions, a complete medical history, to determine when the symptoms

appeared and what may have caused them, and psychiatric screenings, such as assessments for depression and schizophrenia. If a doctor cannot find a physiological cause, they will usuall diagnose a person with psychogenic foreign accent syndrome and work to identify a possible psychological cause. Foreign accent syndrome itself is not dangerous. However, it may warn of a serious medical condition, such as a tumor or lesion in the brain, dementia, or MS. In these cases, treatment will focus on addressing the cause of the foreign accent syndrome. A doctor might prescribe medication for conditions such as MS or surgery for certain brain growths. When there is a psychiatric cause, a doctor may recommend therapy, medication, or both. Many causes of foreign accent syndrome are not curable, though medication can help manage symptoms. In most cases, a doctor will recommend speech therapy to help a person regain their normal habits. When the cause of foreign accent syndrome is unclear — such as in the case of the woman who developed it following dental surgery — speech therapy may be the only treatment option