Neurologist
On behalf of Hersenletsel-uitleg we asked neurologist Paulien Frima a number of questions.
We did this to give an idea of what a neurologist can do for people with brain injury and their loved ones.
Doctor Frima has her own brain injury practice in which she works together with a psychiatrist, a neuropsychologist and a social worker in Rotterdam and The Hague.
Please note! Doctor Frima is a neurologist working in a Dutch practice. What she reports about reimbursement by insurers and bureaucracy of insurers applies to the Dutch situation. This may be different in other countries.
Trained as a doctor and subsequently trained as a neurologist
Since 2003 I have been involved in behavioral changes and cognitive problems that can occur in people with Acquired Brain Injury.
At that time, there was hardly any knowledge and interest in this field among neurologists in the Netherlands.
A neurologist is a doctor who, after medical training, is trained for five years to become a medical specialist, the neurologist.
No insight into non-physical consequences
A patient had 'come out well' if there were no or few physical limitations after a brain injury. Cognitive problems and certainly behavioral changes were not considered.
Until 2003, like most of my fellow neurologists, I worked in a hospital, where we treated people with a disease or condition in the brain, either clinically or outpatients.
For example, people with a stroke, CVA, a brain tumor, but also Parkinson's disease, MS and hernias.
In this work, I missed the more direct contact with the patients, and that is also when my interest in cognition and behavior in people with Brain Injury arose.
Eye opener
My eyes were opened when I saw the influence of a disease like
Parkinsonism, PSP and MSA-P on behavior, after my father was diagnosed with it.
Fortunately, I was able to support my mother by giving a lot of explanation about the how and why of certain behavior.
Passion for brain injury
My interest had turned into a 'passion' to treat this forgotten group as well as possible.
I realized that this could only be done in a team with a psychiatrist and a neuropsychologist. After all, people with non-congenital brain damage also have depression or post-traumatic stress disorder more often. Not to forget, personality is also important in how you deal with the problems you experience.
I have always been bothered by the time pressure that exists in a hospital. I still think that insufficient attention can be given to the patient and not to forget the relatives.
In my colleague who is a psychiatrist, I have found an ally in this respect. In addition to the interest in and knowledge of this beautiful field, he also has the same passion as I do.
Together with our neuropsychologists and a social worker, we form the BreinPoli. This is a small Specialist Mental Health institution, where we map out cognitive, psychological and behavioral problems and treat them as well as possible. Of course, we always take into account any physical limitations.
Diagnosis
In order to make a good diagnosis, we always request all information from the hospitals and other institutions.
If I find it necessary, I also request an MRI or CT-scan of the brain.
The neuropsychologist can perform a NeuroPsychological Examination.
Ultimately, we are able to make a correct diagnosis, because we can assess the complaints from a neurological, psychiatric and neuropsychological point of view.
I do not always request an MRI scan of the brain, because people with brain injury can have a ‘normal’ MRI scan of the brain.
Sometimes, for example, the abnormalities are so small that they are not visible on an MRI scan.
On the other hand, it also happens that people with an abnormal MRI scan of the brain have NO complaints at all.
Medicines and learning to deal with
The psychiatrist and I are the ones who can treat people with medicines. The neuropsychologist treats people with cognitive behavioral therapy or teaches them, for example, how to deal with their problems as well as possible.
We think it is very important that there is sufficient attention for
loved ones and so we also try to support them.
We still see very often that people are treated with the wrong medication, that someone with a so-called 'short fuse' is prescribed antipsychotics, or that too little account is taken of other medications that people are taking.
This is especially important for people with epilepsy or Parkinson's disease.
Very important in the choice of medication is that we never prescribe medications that reduce attention, so no drugs like Lorazepam, and no antipsychotics.
We try to improve attention if possible.
Irritability or even aggression and a certain form of overstimulation can be treated with the same medication, whereby we always start with a low dosage.
My experience is that it is very important to discuss any side effects thoroughly, and to keep in regular contact after the start.
It is true that certain side effects disappear once people get used to the medication. People are then very happy that they have persevered.
A complaint such as taking little or no initiative can also improve with medication.
Referral
We started BreinPoli in 2019.
People can register with us with a referral from their GP or medical specialist. The referral must state that it is a referral for Specialist Mental Health Care. Of course, there must also be a brain injury.
All examinations and treatment are then reimbursed by the insurers.
Treatment
The intake phase starts with an intake by the neuropsychologist. After that, the client is seen by the psychiatrist and by me.
These are three separate contact moments.
After this, when the information from the other institutions is in, and a neuropsychological examination has been done if necessary and a brain scan has been made if necessary, the client is discussed in our Multidisciplinary Consultation.
In our Multidisciplinary Consultation, each patient is discussed, the diagnosis is made and the treatment is determined.
In general, treatment sometimes consists of medication, sometimes an EMDR treatment if there are still PTSD complaints, and conversations with the neuropsychologist.
The treatment lasts an average of six months to a year, sometimes longer. It can also happen that someone is first treated for PTSD and that the remaining complaints of, for example, overstimulation, being easily irritated and/or aggression are treated afterwards.
We are a small institution and unfortunately run up against the bureaucracy of the insurers.
This creates too much administrative hassle, which is especially a problem for the psychiatrist. As a result, we are unfortunately not always able to treat all the patients we would like to help.
Paulien Frima,
Neurologist