Aspects Psychologiques de la rééducation

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Psychological Aspects of Coma Recovery (from the Patients Perspective)

When a patient first comes out of coma, especially a prolonged comatose patient, the type of responses that you may see will still be minimal but as progress continues you will notice that certain emotional responses will become more prevalent.

Four of the most common emotional responses by a recovering comatose patient are:

Depression	One of the most common responses is depression and usually manifestation of depression does not occur right away. A patient who is depressed shows depression by withdrawing or doing less than previously. That is not always a negative sign. WHY? Because it shows that intellectually and cognitively the patient is making progress enough to recognize that there is a reason to be depressed and that is a very good sign. Another reason for depression is because they are frequently if not constantly comparing their present condition to the way it used to be. This also shows a cognitive progress allowing for that kind of understanding. Families may like to show them pictures of themselves and mean well in doing so but it certainly is a clear cut reminder of the fact that the patient is not functioning now as the way he used to. Depression, although it is positive in that it shows intellectual progress, certainly can interfere with on-going progress in a rehabilitative program. A patient who is depressed tends to be less interested in doing much of anything and certainly not interested in rehabilitative efforts. If you think about most things that are done in the early stages of rehabilitation--they are boring. They are not the kind of things that most people want to do and a person who is depressed will have even less of an incentive to do so.
Anger	Anger can be in existence for a number of reasons. Patients can be angry about what caused the coma although for the most part they don't really recall that much about it. However they have heard about it in many cases through family and friends. Even if they don't know exactly what caused coma, they are angry about the fact that they were in a coma with all the changes that it has caused in their lives. They are angry about the lack of progress they are making and in many cases family members will see progress but the patient will not, especially if progress is slow. Patients will express this anger frequently, intensely, a lot of temper tantrums, lots of yelling and screaming. Again anger as an emotional reaction is not always negative as it is showing progress is taking place. Ask anyone whose loved one is still in coma and they would be thrilled if their loved one would show anger as anger is a sign of progress.
Low Self Esteem	Very frequently patients who are recovered to the point where they can start communicating verbally will indicate that they believe they are inferior human beings. A number of patients refer to themselves as retarded cripples. We know for a fact that doesn't exist because for the most part those that call themselves retarded cripples are intelligent enough not to be. They see themselves as being inferior to their peers, in fact inferior to just about anybody and this can be a contributing factor to depression or withdrawal as well.
Denial	The recovery patient who denies there is a problem says, "I'm fine. I don't have a problem, I don't need any more therapy," when it is obvious to everyone else around him that that's not the case. It's important to you to be aware of what the patient is going through so you can provide the best possible support for that patient. Obviously, there are other common emotional reactions such as the reaction of anxiety, or regression to childlike behaviour. Emotion is a very important part to any recovery process as emotions play an important part in our behaviour.

 

What are the different aspects of patient functioning that need retraining after coma arousal?

They are physical retraining, medical stabilization, and speech and communication improvement. These are all very important parts of the rehabilitation process. There are also behavioural aspects dealing with the way the patient is functioning and the cognitive aspects of the way the patient's mind is working. From the behavioural aspects point of view, one of the first things that takes place in retraining is basic functioning. Retraining one to feed himself, eat, dress – taking care of the basic needs. This of course is very elementary but for some patients, who are making slow progress, the need is exorbitant and it takes a long time to teach even some of the most basic skills and this is when a patient is willing to cooperate.

The other important aspect of behavioural function is social functioning, getting along with other people. This brings up one of the most important changes that takes place in a lot of patients following arousal from coma. It is called loss of impulse control. Think about children, as they grow they become less and less spontaneous in things they do. The reason is as we raise our children we try to teach then the difference between right and wrong and as they grow they learn the difference between appropriate and inappropriate behaviour. It's almost like there is a little switch in their brain which previously was in the "on" position controlling their impulses and has now malfunctioned and they are no longer able to control their impulses. You may see major changes in personality and behaviour in patients following head injury. Patients who before were nice, sweet gentle people prior to the onset of coma now become monstrous. You don't recognize this person-he has changed so much. It doesn't occur in all cases but when it does occur it is frightening.

There are three basic ways that the patient will show loss of impulse control:

Physical violence	Physical violence can be used against anyone or anything. Maybe the patient is lashing out because of the frustration in himself or maybe this is the only way he can express himself or because he cannot control himself. Patients do not seem to recognize that what they are doing is wrong.
Sexual aggressiveness	Sexual aggressiveness does not just have to be physical. There can be a lot more suggestive and verbal content and overt sexuality on their part such as exhibitionism or public masturbation.
Verbal aggressiveness	Verbal abusiveness can really be profane. Words that you didn't think the patient knew pour out and can be embarrassing to all.

 

The most prominent question dealing with the loss of impulse control is: "Can it be retrained?". Yes. A combination of time and implementation of certain behavioural modification techniques can effectively retrain this loss. In over months and years the progress toward regaining this loss is steady and in some cases some recover more quickly than others.

The other aspect of functioning that is important for retraining is the cognitive aspect. How is the patient's mind working? This aspect can contribute to a lot of the emotional or behaviour problems mentioned above. Memory is the major cognitive problem faced by the recovering patient and the most common problem experienced by patients. The memory problem that exists tends to be the short term memory.

• Immediate recall-if asked to repeat a word just spoken to you and you repeat it.
• Short term memory-if asked tomorrow to repeat the word.
• Long term memory-if next year you are asked to repeat the word.

 

Not all cases but in most, patients have little difficulty in immediate recall. If asked to repeat a sequence of two or three numbers, they can usually do it quite well. Long term memory is also not much of a problem. Patients will remember childhood friends, teachers, hobbies, etc. Most of the retraining is for the short term memory. Patients have a lot of emotional and social problems because of their memory problems. They may have difficulty carrying on a conversation because by the time they get to the end of the sentence they have forgotten what they have said in the beginning or they may not remember who they are talking to. If they pick up the phone to dial a number, they may be able to remember the number but not whose number it is. They can have emotional problems because they can't remember what they did this morning or yesterday or even five minutes ago. They feel like they are living in a twilight zone. They are living for the minute literally and they don't have recall for what happened!

All the patient can go by is what others tell them they have experienced and this can be very frightening. Short-term memory problems are one of the biggest problems the patient has to face. The key to helping them is repetition. You must tell them everything over and over and over again.

In addition to memory, concentration is a problem to recovery patients. Attention span is very, very short which makes any therapy incredibly difficult. A patient with small attention span is easily distracted and they tire very easily. Patients recovering from a coma show a high rate of learning disability. The learning disabilities are not necessarily the same as children who are diagnosed as being learning disabled. This simply refers to the fact that they may have more difficulty remembering material that they are being taught because of the memory problem. Also a recovering patient may show difficulty with abstract thinking and reasoning skills. They tend to be more concrete in their thinking.

In many cases they tend to be less likely to understand jokes that are abstract, whereas the more physical slap-stick kind of comedy they can readily perceive and understand and laugh at.

So don't forget to make some fun.