after a brilliant morning in the surf catching the most magnificent waves with my dolphin friend i emerged feeling amazing, for the first time in a long time i felt myself, ordered some flowers for meredith then went to work where it all went slightly nuts. firstly the dude i was working with had left the place a mess, and then from the very start things went wrong as he abandoned me with 5 very difficult clients all deciding to act out at the same time, i was dealing with high level noise plus aggression various screaming and threatening behaviours. under normal circumstances this would never get to this point, i have never seen the clients acting like this en masse before and it was quite disturbing, at one point i ran to where the screaming was coming from and found one of them had been left in a huge bath, with the taps on and she was drowning, the look of horror on her face was shocking, i lunged in and pulled the plug. then i froze, the stress hit my head fast, just like a bullet, i was immobilized when the phone rang, it was meredith, we had a conversation i can't recall then i found myself beginning to swoon, a pounding in my head, a throbbing like helicopter stalling. i knew i had to get out.
i left work and arrived home, sat in darkness alone while i felt a numbness envelope me, my head still pounding, unable to move i was frozen with fear.
the next morning i spoke to my shrink who said i was experienceing 'competing attention syndrome' which is very common in head injuries. anyway i spoke at length about my feelings, fears and needs. she suggested i consult my dr. re the head ache as it could be serious, i did and underwent a ct scan that afternoon, results in two days.

there was a lot of sadness hanging around for a couple of days as i made my way through the mess of frontal lobe damage and considered the fact that somewhere deep inside me was a bad personality that had now awoken, but it appears that the dr.s and specialists have all said that this is not me and is only cuased by my brain swelling up. anyway i started to do the mindfullness and meditative excersises and can't begin to explain how great i felt, almost immediatly. this is becuase these exercises are close to the true nature of myself, therefore i'm feeling much more in control and certain about the direction i am heading towards.
things with meredith are excellent, each day i love her more, we talk on the phone and i feel close by, it's very rare that the distance bothers me.

Bad Personality

I gotta bad personality
Slipped in on your kitchen floor
I fell through good fortunes way
Missed the peace and harmony door
You say what’s wrong and
Ask me what is up
I say I had a blow to my brains
And I don’t give a… (fuck)

I got a bad personality
Making my spliffs, king size
We smoke them in the night
And then we close our eyes
You ask me which ways up
And I say I don’t care
Ask me where we are going
And I say going somewhere

My concentrations fucked up
And my shrink thinks I am a lost cause
But we know that my mind is torn
And we are in for the long haul
Smile and laugh
but don’t cry with me
Goodbye Mr. Nice guy
Hello bad personality

I got a bad personality
Went falling up the steps again
Yes I look a little dazed
But I have such crazy friends
Some come in from interstate,
But all are out of their trees
And there is only one thing
On which they all agree

I’m not a bad person

This morning it appears i shouted at a co worker and client, for a really insignificant reason, i can't even recall. My co worker took me aside and asked me how i felt after my concussion, she was great, listening to me tell her about my fear and the way i had spoken to meredith. she told me about a number of people she knew had undergone severe personality changes, profound changes, mild people suddenly becoming agggressive, and we looked up some stuff on the net about post concussion syndrome. the descriptions matched my behaviour.
i went to the drs. and was told i had brain damage, that my personality had transformed and that i will need pychiatric help. fucking great hey, i guess all those previous blows to the head must have caused some damage and this recent one been the one that sent me over the edge.
I printed some info out to send to meredith, and then went to see a dr. apparently the dr. says i have brain damage and will need to see a psychiatrist and that it may take up to 6 months for my old personality to make an appearence, so understandably i am somewhat bewildered.
part of me wnats to have a bit of fun with captain mission V2 but to be honest i was quite happy with V1


Traumatic Brain Injury:
A brief overview of traumatic injuries and the neurobehavioral deficits that can occur

What is a neurobehavioral deficit?

Neurobehavioral deficits or disorders include impairments of cognition, mood and/or behavior. Cognition includes intellectual functions of the brain such as memory, attention, and problem solving.

What is the scope of the problem in TBI?

Traumatic brain injury (TBI) is a widespread and very significant source of disability, often due to neurobehavioral deficits. But there are no clear guidelines on how to manage these deficits. There is a critical need for research in this area.

TBI is an insult to the brain caused by an external physical force that may produce a diminished or altered state of consciousness. According to the CDC, an estimated 5.3 million Americans (just over 2% of the population) currently live with disabilities resulting from TBI. Yearly, 80,000 Americans experience the onset of long-term disability following TBI. Vehicle crashes are the leading cause of TBI. Falls are second, and the leading cause of brain injury in the elderly. Risk of TBI is highest among adolescents, young adults and those older than 75 years of age. The cost of traumatic brain injury in the US is estimated to be $48.3 billion annually. The number of TBI patients seeking services has increased, as survival rates have improved due to improved care.

The purpose of this information is to provide the reader with a basic knowledge of the mechanics of TBI, and the resulting neurobehavioral deficits. General information regarding evaluation and treatment will be covered. It is important to identify problems as early as possible so that appropriate evaluations and treatment can be established.

How does TBI cause changes in mental functions?

The way in which TBI affects the brain, which is referred to as the neuropathology of TBI, may be especially pertinent to the risk for neurobehavioral problems. There are several important components that can contribute to neurobehavioral (intellect, mood, behavior) outcome:

What was the person’s level of function and medical condition before the injury?
What is the location and severity of the brain injury?
How diffusely is the brain injured?
Has the person had previous injuries or diseases of the brain?
Has the person used, or still use, certain street drugs or alcohol?

The direct effects of trauma may be skull fractures, contusions (sort of a brain "bruise"), and/or bleeding into or around the brain. Injury to the brain can occur at several different levels, and depends upon the nature of the trauma. Penetrating injuries can be fairly well circumscribed, such as from a knife or bullet. In injuries such as from motor vehicle accidents or blunt trauma, common sites of contusions are the front part of the brain (frontal lobes) and the temporal lobes. This is because these parts of the brain sit next to bony prominences within the skull (see figure 1).



Figure 1: Picture of the brain with major areas identified. The frontal and temporal lobes are commonly damaged in trauma such as from motor vehicle accidents.

The majority of trauma, however, seems to result in diffuse or more widespread damage, and hence diffuse deficits and symptoms. The more diffuse injury to the brain is called diffuse axonal injury (DAI). It is characterized by stretching and shearing of individual axons, which are parts of the nerve cells. The brain normally floats in fluid within the skull. In accidents where there is an abrupt change in acceleration or deceleration, such as in a motor vehicle accident, the brain can be thrust forward and backward against the inside of the skull. This can cause a contusion to the part of the brain that directly strikes the skull, but it also results in the more diffuse injury to other nerve cells in the brain. This diffuse injury may underlie a broad range of symptomatology, such as deficits in arousal, attention, mood disturbance, and behavioral changes, even in "mild" head injury.

Severity of TBI: In assessing severity of the original injury, several factors are involved. Duration of loss of consciousness (LOC), initial score on the GCS (Glascow Coma Scale - a 15-point scale that determines depth of coma), and length of PTA (posttraumatic amnesia) are generally the measures used. Definitions can vary, especially in the area of so called "mild" injury, and can include brain-imaging criteria. In cases of mild injury, the initial GCS is usually 13-15; moderate 9-15; and for severe, 8 or less. In terms of LOC, there are also general guidelines. A mild injury usually results in LOC of less than 30 minutes; moderate injuries up to 24 hours; and severe injuries may have LOC greater than 24 hours. A mild injury generally results in PTA less than 1 hour. Within the spectrum of mild injury, attempts have been made to more accurately classify but there is no real consensus as of yet. Moderate injuries are associated with PTA of 1 - 24 hours. Moderate-severe injuries have PTA's of 1-7 days, and severe injuries usually result in PTA of over 7 days.

Post traumatic amnesia (PTA): PTA is the period of time after a patient emerges from coma that he has no continuous memory for day to day events. In other words, there is impaired memory for new information. Staff has to continually orient them to time and events. The end of PTA is defined as the return of continuous memory.

Seizure disorders: If seizures develop, they may have a role in certain symptoms. The incidence of seizure disorder or epilepsy developing within five years of closed head injury (CHI) is about 2 - 5%. The incidence following penetrating injuries is much higher. Since the type of seizure can often be complex partial (a type of seizure that may have motor and behavior changes associated with it), this contributes to the risk of developing mood and/or behavior symptoms.

Secondary mechanisms of injury: There are also secondary mechanisms of injury, besides the direct effects. Secondary mechanisms include delayed damage to the brain due to the release in the brain of substances that may aggravate the injury (excitatory neurotransmitters), or derangements in neurotransmitter function. Neurotransmitters are substances that naturally occur in the brain and allow cells to communicate and function. Examples include dopamine, norepinephrine, and serotonin. Although the status of neurotransmitters in more chronic TBI is not fully understood, disturbances in the function of these substances may underlie certain problems that follow TBI, such as mood, behavior or intellect problems. Medications may be used to try and normalize function, and consequently improve symptoms.

Chronic pain: Not infrequently, patients will develop acute or chronic pain after the TBI, such as headaches, which can be quite debilitating and aggravate mood, thinking, and behavior. Or the pain may be from other injuries that were sustained. This needs to be fully assessed and adequately treated.

What are the Neurobehavioral Deficits that can result?

TBI can result in variable constellations of cognitive or intellectual deficits, mood disturbances, personality changes, or behavioral problems (Table 1). The nature and severity of these changes depend upon a number of factors as mentioned, such as location and size of lesion, duration of coma and posttraumatic amnesia (PTA). Premorbid level of function, history of any substance abuse, as well as psychosocial factors also interact with the actual injury to affect outcome. Other factors also play a role, such as age and medical health, and history of previous brain injury. Different problems may arise at different stages of recovery.

Certain types of symptoms or deficits can be explained by the areas that are commonly damaged in TBI, such as the frontal lobes or temporal lobes. Injury to these parts of the brain can result in a range of behavioral, mood, and cognitive problems. But the more diffuse injury that can occur also contributes to the outcome. In general, there are certain loosely defined syndromes that can be referred to, such as post-concussion syndrome, or frontal lobe syndrome. But the qualification and quantification of symptoms that comprise these syndromes has not been standardized. Certain of these will be reviewed below.

Table 1: COMMON NEUROBEHAVIORAL DISORDERS OF TBI

Post concussion syndrome
Frontal lobe syndromes
Behavioral/personality changes
Cognitive (intellectual) deficits
Mood disorders
Sleep disorders
Post traumatic epilepsy or seizures
Chronic Pain, such as headaches

Postconcussion syndrome (PCS): The postconcussion syndrome (PCS) has been poorly defined and controversial for many years. It has come to refer to a rather broad range of symptoms and signs that can follow a brain injury (table 2). The term PCS is generally used to describe the cluster of symptoms that often follow mild brain injury and persist for a variable period of time, although the symptoms themselves can be seen after any severity of injury. Estimates of how often this syndrome can develop may not be entirely accurate, as many people do not seek medical attention for milder cases, but reports of 50% or so is not unusual. Although the majority of patients who develop these symptoms seem to show recovery over time, there appears to be a significant minority with persistent difficulties. Hence, even milder injuries can result in disabling symptoms in some cases.

In general, the symptoms can occur directly following an injury, or after a period of time. The role of other variables, such as psychological factors in delayed PCS is debated. Symptoms fall into several categories including somatic (physical symptoms), mood, behavior, and cognitive difficulties. They include headaches, dizziness, sensitivity to noise and light, irritability, anxiety, depression, fatigue, sleep and appetite disturbances, as well as problems with information processing, attention, concentration and memory. The symptoms can be variable and diverse, and very distressing to the patient and family members. The patient may worry that they sound like a hypochondriac, or that people will think they are "crazy." But these symptoms can be explained by the nature of the injury to the brain. Hence, they are truly neurological symptoms, and not primary psychiatric symptoms.

Loss of consciousness is not necessary for brain injury or for the development of PCS. In general, a mild injury is usually diagnosed when loss of consciousness is 30 minutes or less, and the patient does not show evidence of specific abnormalities on neurologic exam. Brain injury or dysfunction can be present even if the neurologic exam and tests such as a CT or MRI are normal. These tests may not be sensitive to the more subtle or diffuse effects of trauma on the brain (e.g., DAI). Cognitive impairments include deficits in information processing, attention, and concentration, which can persist in some cases.

Table 2: POSTCONCUSSION SYNDROME

Drowsiness
Blurred vision
Nausea/vomiting
Headache
Fatigue
Dizziness/light headedness
Memory problems
Concentration/attention problems
Depression
Anxiety/irritability
Insomnia
Sensitivity to noise and light
Somatic complaints
ETOH intolerance

Headaches: Headaches are fairly common following even mild brain injury. They can resolve over time, even up to a year out from the injury. In some cases, they persist, and can be disabling. They can be migrainous, tension type or mixed in nature. There is very little research on posttraumatic headaches, and their treatment is often that of other chronic headaches. This approach can be effective, but not always.

Frontal Lobe Syndromes: Trauma commonly effects the frontal regions, either directly or indirectly. Dysfunction of the prefrontal regions can result in a variety of neurobehavioral symptoms. Generally referred to as "frontal lobe" syndrome, the profile includes symptoms of behavioral dyscontrol such as impulsivity and aggression, amotivation, apathy, disorganization, attentional and memory deficits, and mood dysregulation (e.g., moodiness, irritability, "mood swings"). Neuropsychological testing (see below) and reports from family and caretakers who know the patient are essential to the assessment.

Essentially, treatment consists of several components. These include pharmacologic treatment, behavioral strategies, and education and support of the family. The frontal lobe patient often losses his ability to control or monitor his own behavior, but will respond well when consistent external structure is set up. Treatment can focus on particular aspects, such as dyscontrol, aggression, or mood disturbances using certain medications.

Mood Disorders: Mood disturbances following brain injury can present in a variety of ways. It is not unusual for the mood symptoms to be subtle, but for behavioral manifestations to predominate, such as irritability, uncooperativeness, apathy, poor progression or effort in rehabilitation. The mood disturbances may not necessarily meet traditional psychiatric criteria, but may present more as a mood lability or dyscontrol. Often, it is more accurate to refer to a dysregulation of mood, as brain injured patients can show features of several mood disorders, rather than fit neatly into any one diagnostic category currently used. The traumatic brain injured population is at increased risk for developing depressive disorders, with estimates of major depression occurring at about 25% or higher.

In general, a depressive disorder should be suspected when the patient's degree of disability is greater than would be expected given the severity of injury, or when the patient fails to meet rehabilitation goals, or cooperate with treatment. It is not unusual for some mood disturbed patients to deny a depressed mood upon questioning. Since mood disturbances can often be missed in this population, and can have deleterious effects on outcome, it is wise to have a high level of suspicion.

For depression, the treatment is often similar to that of non-neurologically impaired depressed patients. Choice of treatment often depends on the patient’s individual response and side effect profiles of these drugs. Another disturbance of mood, mania or hypomania, can result, but is not as common. Mania refers to the presence of pressured speech, inability to stay on topic or on track, hyperactivity, a feeling of racing thoughts, and sometimes unusual ideas. The person may seem "wired" and edgy. It is important not to equate symptoms with diagnosis in this population. A patient who shows features of mania does not necessarily have a true bipolar disorder, and this may be over-diagnosed. Damage to the frontal lobes can produce a similar picture, and may respond to certain treatments.

Behavioral / Personality Changes: Depending on the location and severity of the injury, different types of behavioral disturbances can occur. These include irritability, lability, impulsivity, disinhibition, aggression, poor motivation, poor self-regulation of behavior, poor judgement and insight, risk taking, or sexual disturbances. Certain of these symptoms are separated out for purposes of discussing assessment and treatment, but clinically, they often occur together, as in a more generalized frontal lobe syndrome. Aggression can occur following brain injury, particularly in the more acute stages, and cause significant disruption of rehabilitation efforts. It can range from mild verbal abusiveness to physical assaultiveness. It is important to characterize the aggressive behavior. Is the patient labile? Is the patient impulsive and unable to self regulate? Is there a mood change associated with the behavior? What are the triggers? Is the aggression against self, others, or objects? A thorough evaluation of the behavior is needed. Only then can an appropriate behavioral strategy and possibly pharmacologic intervention be instituted. Behavioral strategies are beyond the scope of this review, but can be very helpful.

Aggression is a symptom that can have a variety of underlying causes. For example, if it is part of a frontal lobe syndrome, then the treatment may be different than for aggression resulting from psychosis, mood disturbance, or seizure disorder. This is often not obvious, and treatment may be trial and error. Polypharmacy (the use of more than one medication) may be unavoidable in the complex patient, and it is best to obtain a consultation.

Personality Changes can be viewed as existing on a spectrum with other behavioral problems. The patient may not seem like his or her "old self." On the milder end, you can see an exaggeration of the patient's premorbid negative personality traits. For example, an impulsive, irritable person may become more so. In more serious cases, it is common for families to complain that the patient has become a "different person." Children can appear hyperactive or develop symptoms consistent with attention deficit disorder, or conduct disorder.

Personality and behavioral changes can be seen as a result of two factors. First, damage to structures directly responsible for behavior and emotion. Second, cognitive (intellectual) deficits can alter and impair the patient’s interpretation of the environment or a situation, which in turn effects the patient's response.

It is important to educate the families concerning these possible changes, as they will tend to interpret the patient as purposefully aggravating them or being mean or difficult. Pharmacologic treatment is usually aimed at a syndrome, such as PCS or frontal dysfunction, or could target predominant symptoms such as depression or irritability.

Cognitive Deficits: These can be a significant cause of disability and distress for the patient and family. In general, the common nonspecific symptoms are disturbances in arousal, attention and concentration. Memory impairments can occur, either due to direct effects on memory function, or secondary to poor attention and concentration. Disturbances of higher level or executive functions (frontal lobe functions) are fairly common, due to the high percentage with frontal lobe involvement. These include poor planning, sequencing, and judgment. The patient may make errors due to impulsivity, and have trouble shifting between tasks. Specific deficits in cognition will depend upon location and severity of injury, as well as some of the factors already mentioned, such as level of education. These deficits may not be apparent while the patient is recovering at home, if no real intellectual challenges are present. Not uncommonly, the patient will realize these problems when they try and return to work, and they find they can’t do the quality or amount of work they used to do.

Pharmacotherapy has expanded and has great potential in the area of cognition. Cognitive Rehabilitation is gaining increased acceptance as an important component in the rehabilitation of brain injured patients. It may be particularly critical in the acute stage of recovery (up to 6 months post-injury), and could complement pharmacotherapy. It often involves techniques to retrain the patient in specific domains such as memory and attention. Different theoretical frameworks have been proposed to guide remediation strategies, and recent assessments support their effectiveness.

Sleep disturbance: This can be a significant problem following brain injury. It can be overlooked, but can significantly impede the patient's rehabilitation. Lack of sleep can worsen cognition, behavior and mood, and undermine treatment attempts. Disturbed sleep is very common in the first few months following traumatic brain injury, and may or may not resolve. Daytime sleepiness can also be a problem. There is often a reversal of the sleep-wake cycle, which seems to be part of a general dysregulation that can also be seen in other functions such as appetite. Treatment consists of medication and behavioral management. Behaviorally, standard sleep hygiene should be used. The patient should keep regular hours, avoid caffeine, alcohol and tobacco, and activities that are too stimulating before bedtime. If a sleep disorder is persistent and treatment refractory, a sleep study is warranted. In our clinic there have been at cases of sleep apnea identified after an injury, although there is no clear data on the incidence of this disorder following trauma.

How should someone with these difficulties be evaluated?

It is important to see someone with expertise in the assessment of TBI, as it is a specialized area. This is a multidisciplinary area, so there are neurologists, rehabilitation doctors, neuropsychiatrists, neuropsychologists, and other specialists who can provide components of the assessment.

Physician Exam: Part of the evaluation often consists of an examination by a physician with expertise in TBI. This may include obtaining a thorough history, as well as a neurological examination.

Neuropsychological testing: Another important part of the assessment is a battery of tests referred to as the neuropsychological assessment. This will give a clear picture of the quantity and type of intellectual deficits, as well as assess emotional and behavior problems. This evaluation may take several hours or longer, depending on the length of the battery. The results provide an excellent "map" of the actual brain functions that can serve as a guide to direct treatment.

Brain Imaging: With the advances in neuroimaging, or brain scanning techniques, it is rapidly becoming an excellent tool to help assess brain injury. Usually it is most helpful in conjunction with the other parts of the evaluation. In resting imaging, such as with CT or MRI, we can take a snapshot of the brain to look for structural changes. Brain injury, particularly the more diffuse kind, is not always visible on routine brain imaging, such as CT or routine MRI. There are now more specialized ways to image this type of injury, such as advanced techniques with MRI.

Functional imaging such as with MRI (magnetic resonance imaging), PET (positron emission tomography) or SPECT (single photon emission computed tomography) may be more likely to show areas of injury or dysfunction in the brain, but are not usually routine in a clinical setting. In functional imaging, the patient is asked to perform certain tasks such as finger tapping, remembering a list of words, or choosing a response while in the scanner. This allows us a window to look at how the brain actually works during a task. Details of types of brain imaging will be covered in another review. Brain imaging also has allowed us to advance the type of research we can do. It provides a way to assess how certain drugs or other interventions may work in TBI.

What are Options for Treatment?

Neuropharmacology: This is a complicated and evolving area that shows considerable promise for improving outcome and quality of life for brain injured patients. Treatment is driven by several considerations: alleviation of specific syndromes/symptoms (such as depression or apathy), the underlying neuropathology (nature of the injury) , improving cognition, and potential effects on recovery. Choice of a medication that can cover more than one area is always preferable. Specific medications will be covered in separate reviews.

General guidelines to pharmacologic treatment can be followed:

Use neuropharmacology based on underlying disturbances related to TBI- such as knowledge about which neurotransmitters or brain chemicals are affected.
In addition, certain target symptoms, such as insomnia, fatigue, depression or attentional problems can be addressed
Associated problems such as chronic pain or seizures must be addressed and adequately treated.
All efforts to be made to avid drugs for any condition that could worsen mental status or possibly interfere with recovery
Conclusion:

As technology improves, more people who suffer brain injury can survive. And even the less life threatening forms of TBI can result in significant problems that may persist, or even arise down the road from the injury. These individuals are often young, and otherwise healthy. Persistent cognitive, behavioral, or mood disturbances significantly affect short and long term outcomes. They are commonly referred to as the "walking wounded." They may appear physically recovered, but problems reintegrating into family, work, or school can quickly become apparent. They become labeled as difficult, lazy, somatic, or histrionic. They may be diagnosed and treated incorrectly, resulting in a worsening of the situation.

Education and appropriate referrals /interventions must be initiated as early as possible. Too often, these patients receive excellent acute care and initial rehabilitation, then are lost to follow-up. The loop of care must be closed. A significant number of these patients can achieve good function, but will require continuous and possibly life long access to various components of an interdisciplinary team. This ensures maximized quality of life, and is the most efficient, cost-effective route in the long term. This process should start at the initial contact with the patient and family. It should involve close collaboration between the family, patient, neurosurgeons, neuropsychiatrists, rehabilitation medicine, neurologists, other therapists, rehabilitation facilities, the workplace if applicable, and community groups.

Our emphasis on the neurologic basis for the outcome of TBI in no way negates the important role of other factors and non-medication treatments. TBI patients suffer significant losses, and these should be addressed. In general, supportive therapy and education of the patient as well as family are important components of treatment. Also, behavioral strategies are an essential component in the management of these patients. Cognitive rehabilitation is a promising and expanding area, that may either by itself or in conjunction with medication result in improved outcomes and function. Medication alone is rarely adequate.

i'm wrestling with a demon.
meredith rings me at about 10pm to say she is really looking forwards to chatting with me and will call me as soon as boston legal finishes. i say, great i am really excited, i am at work and its one of those opurtunities where we can chat all night.
the call don't come.
i call her home line, it rings out, later her mobile rings out. try again, i call her home leave messages, send texts, call mobile it's engaged, then it rings out, same with home, later the message bank comes on.
anyway there's my mind playing tricks, going down all sorts of senerios that i don't like to think about, seizure in the bath tub perhaps, i mean, it's pointless. but this is the demon that exists in my head, i need to face all my fears and exorsice them before they overwhelm me. relationships and love brings out fear, it's understandable, its the first time i felt it in this relationship and i need to process it. perhaps meredith just fell asleep and that's the end of story, i don't really know at time of report, perhaps i just need to chill out.
instincts are all over the place, i guess i just need to face up to my fear and deal with it, after all that's what captain mission does.
anyway i feel like listening to lloyd cole right now.

later when we do talk we uncover she's had a seizure and i am kinda freaking out at her, it's totally irrational, i'm not sure i understand it myself but its bad. shes upset at me, poor thing, i turn into a brute interrigating her, suggesting that she move up here, my head pounds with sleeplessness, i feel everything slipping away, the more i reach out the further it slips. i don't know what to say or do, so i start saying crazy things, i can't even recall what i am saying, the word salad happens.

i'm up with the sun, early pan and i head down to watch the sun, we stop off for coffee and chat to the old sicillian lady, we walk through the green, we pass evan and pops place, we head back to mission control where the piles of paper on the floor annoy me, the strange half written notes and ideas, the telephone numbers of people i will never call, the half finished songs, there's top much paper here, to many unfinished things, i start throwing things away. I do some work on the computer, photoshop, i'm learning some new tricks, it's requiring a lot of concentration, the phone rings it's meredith.
for the first time i feel like she's really positive, really on track, filled with enthusiasm and it leaves me feeling very good about things. she confirms my own feelings about one another, i really need to hear this as i tend to think meredith is living with one foot in the past and another not quite commited to the idea of us. it's a very life affirming conversation, i hang up with a sparkle in my eye.
work is easy, its nice being surrounded by good people all really supportive and obviously glad to see me healthy, i can see how much i have distressed everyone, i can see their joy at my recovery and its good to know i loved, respected and considered.
Its late now and i am going to do some breathing excersises and then maybe watch some tv, i have not watched tv for a while, i'll test my concentration, maybe i'll watch a whole show.

i imagine when you have a siezure of blackout, it takes a while for the new information to settle, i guess its like having an operating system upgrade, me i have a new life ahead of me, the last 5 months have been pretty much an information overload, a new partner, some life changing decisions, my poor brain needed a change to rearrange the new information and process it.
i have a history of passing out, it's nothing new.
Last night on lateline my fave journalist was interveiwed regarding the world bank scandal, it was a very intresting interveiw as Chris Hitchens is an old leftie who has recently taken a swing towards what can be described as a more balanced approach. The interview revealled some truths that most people would find uncomfortable, given their addiction to their memes and belief patterns.
Christopher Hitchens has just released a book called God is not great, i have a copy but have not read it, i am looking forwards to it, he is a great writer and needs to be heard at least.

Transcript
VIRGINIA TRIOLI: Well now to Miami and Christopher Hitchens, who's on a tour of the United States to promote his latest book, God is Not Great How Religion Poisons Everything . But the author and Vanity Fair columnist has paused from his book tour to talk to us tonight about what he sees as a poison of another kind, in American public life - the treatment by the media of the now fallen World Bank president Paul Wolfowitz and in particular, Mr Wolfowitz's partner, Shaha Ali Riza.

Christopher Hitchens, welcome back to Lateline .

CHRISTOPHER HITCHENS: Very nice to be back, thank you.

VIRGINIA TRIOLI: Christopher Hitchens, it was a long time coming, I guess. Was this inevitable did Paul Wolfowitz have no choice in the end but to stand down in this way, in your view?

CHRISTOPHER HITCHENS: No, I think he had the choice to stay on but it would have been impossible to convince himself, I think, that by doing so he wouldn't have damaged the bank.

But I don't think that the horns of the dilemma were, so to speak, his fault. In either sense… either horn, if I can put it like that.

VIRGINA TRIOLI: You see Paul Wolfowitz's forced resignation as a great injustice. Can you tell us why you see it that way?

CHRISTOPHER HITCHENS: Well, yes. It's an injustice in itself, and as I was saying, it's self imposed because he realised that he couldn't go on without damaging the bank. But it's an injustice that's been necessitated by an initial injustice and that's the simplest thing to understand.

His partner, Ms Riza, who had been at the bank for 10 years, she's been there since 1997, was told when he was appointed, ‘you're fired’. Now, in order or in other words, to find all of this intelligible or fair, you have to be able to say it's completely right that a senior woman at the World Bank is told she loses her job when her partner is made the president.

I can't see how - in any sense, legal or moral - that is fair, and if I had been her, I would have sued, as she had the right to do and would have had the right to do under all possible laws governing discrimination.

She chose not to do that, not to make a fuss, but expected to receive, and was promised, a promotion and raise as compensation for losing her job. That's all there is to this.

VIRGINA TRIOLI: Well there's also the role…

CHRISTOPHER HITCHENS: It's an absolute, it's absolutely that's all there is initially to it. Then all you need to add is the rape of her privacy by interested parties at the bank who leaked her confidentiality agreement, broke it I mean to say - which is an agreement she only had to sign in the first place because of the injustice done to her - made her private life a public thing.

She's a very shy and private person as I happen to know. I have known her for a very long time. Had her referred to in the press as "girlfriend" and "mistress”, terms that are almost never used these days about unmarried people who have some kind of relationship. Usually the neutral word "partner" is used. In this case, even in newspapers like the New York Times "mistress" and "girlfriend" were bandied about freely.

I have a feeling that it might not have been the case if she wasn't an Arab woman for example. Then because this has become so unpleasant, her partner has to resign as well. Well I hope they're all happy with having done this.

VIRGINIA TRIOLI: So there's an element…

CHRISTOPHER HITCHENS: They have - it is these people who have paralysed the work of the Bank, wasted an enormous amount of time and money and are now gloating presumably over their victory.

VIRGINIA TRIOLI: But the other key mess in the whole thing is on both sides, surely. I mean, he was put in jeopardy. Paul Wolfowitz was put in jeopardy, surely you could argue, because he was put in charge of reassigning her somewhere else, giving her another job, and also in charge of that pay increase, but equally he was foolish by agreeing to take part in that in such a fatally compromising process.
Doesn't the blame cut both ways?

CHRISTOPHER HITCHENS: No, I don't really think so because when he arrived, he said to the relevant officials at the Bank, what I presume some of them must have already known, he said, "If you don't know this already, you'd better hear it from me. There's someone who works at this institution with whom I have a personal relationship. What I propose is that I disclose this to you and I sign a statement recusing myself in advance on any decision that might affect her work or her position."

She wasn't actually in a part of the Bank that reported directly to the President in any way. It wasn't in any sense an immediate relationship within the terms of the bank itself.

VIRGINIA TRIOLI: Yes, but the Bank found that unacceptable.

CHRISTOPHER HITCHENS: Unfortunately. They said, "No, I'm sorry, you have to be in charge of reassigning her". They won't take his first offer, which was a perfectly decent one. They say, "No, she's got to go, you have to be involved in it". And then they told him, "I've seen the documents". The ethics committee say in print, in terms, "We now think this has been settled in a way that is satisfactory to all parties".

And they agreed in advance that naturally, given she was on the fast track for promotion anyway, had a very high standing and reputation, had had her career damaged and her integrity questioned, that she should receive promotion and more pay.

Now they blame him for doing as they advised. It is absolutely monstrous.

VIRGINIA TRIOLI: Do you argue, Christopher Hitchens, that Paul Wolfowitz has acted with complete integrity throughout this process?

CHRISTOPHER HITCHENS: Absolutely I do. I have not read anything that he has done anything in any underhanded way.

VIRGINIA TRIOLI: Can I make one suggestion...

CHRISTOPHER HITCHENS: Unless you're able...

VIRGINIA TRIOLI: Can I make one suggestion? In the New Yorker profile in May, his spokesman and senior adviser said Wolfowitz had nothing to do with Ms Riza's transfer and compensation, it was all handled by a board of directors. That was utterly untrue and came from the Wolfowitz camp, so he was trying to cover it up even then.

CHRISTOPHER HITCHENS: In the first place, I don't see where that's untrue. It was at the direct stipulation of the ethics committee of the bank's board that the transfer and related arrangements were made.

VIRGINIA TRIOLI: It's a true quote.

CHRISTOPHER HITCHENS: It wasn't his idea. If it had been up to him, she would have kept, as she should have done, her original job. That's the original problem, the original sin, is that a woman is told, ‘you're being fired without cause because of an appointment given to someone with whom we know you have a relationship’.

In what world, let me appeal to you, is that fair?

VIRGINIA TRIOLI: The larger problem, I guess he was grappling with at the World Bank, was this atmosphere of almost complete hostility towards him when he first took the job. The employees' association and people within it did not want Wolfowitz at the job for various reasons his close association with the White House, with the President and as one of the chief architects of the war. Is that Jermaine in this case?

CHRISTOPHER HITCHENS: That is the only thing that is Jermaine. That's all there is to this. The rest is a campaign of defamation against a woman who did not start any wars in Iraq and has fought get a friendship with the White House. We're talking politics. A lot of people at the bank don't like the preponderance of the American shareholding that more or less guarantees that the President of the United States can appoint the president. They haven't liked this for some time. Obviously, people who think like that, tend to be European and Asian, are, I would say, pretty likely to take the anti war view on Iraq so Mr Wolfowitz's position on that might be called an additional exacerbation.

I wrote a book about the United Nations a few years ago and pointed out the World Bank and IMF is supposed to be the credit arm of the United Nations. That's how they started. Got moved to Washington during the Cold War, became more like than American dominated World Bank credit institution. All kinds of arguments one might want to have about how that could and should be reconfigured. As a matter of fact, since we're talk about it, I can't think of anyone who would have been more open minded on these points than Paul Wolfowitz, or more interested in discussing them or more of an internationalist. I'm afraid that chance has been missed in this appalling sexist vendetta.

VIRGINIA TRIOLI: Given he walked into a climate of hostility. Anyone as politically savvy as Wolfowitz, you would expect them to handle the better. When you come into a climate of hostility, don't you have to be like Caesar's wife, you have to be above reproach.

CHRISTOPHER HITCHENS: That's right. On day one he says, "There's something you need to know. I propose to recuse myself of anything".

VIRGINIA TRIOLI: You insist on not taking part in the review. No matter if they want you to, you say, "I won't oversee her assignment or pay increase".

CHRISTOPHER HITCHENS: I don't think that that would have been prudent, given their insistence he did take part. Here's the thing. You must have noticed it you have noticed it he's being indicted for following the advice of the people who now blame him for doing so and she has been treated in the most miserable, discriminatory way. Now, where is the justice in this?

I'll give you another example about you also mentioned the politics of the bank. It has been whispered against him that he threatened to cut off aid to Uzbekistan.

VIRGINIA TRIOLI: Yes.

CHRISTOPHER HITCHENS: Mr Kareem's horrible dictatorship, which also around that time have been having a quarrel with the US about its human rights policy and had, in effect, lost its position of the host of the United States base for the Afghan war. People said, "There you are, it's Wolfowitz punishing Kareem for not toeing the line”. It had nothing to do with that. It had it do with the human rights policy.

Imagine what would have been said if Wolfowitz had gone on giving aid to Uzbekistan while it was mowing down civilian demonstrators. You know what would have been said. But no, he's attacked for not doing it. Under no circumstances was he not going to be subject to an extraordinary campaign of defamation that did not exempt an innocent woman, a very serious professional, well known in Washington for more than a decade as one of the most important people in trying to rebuild and reconstruct the Middle East and now her life, private and public, has been ruined in an attempt to get to her companion.

VIRGINIA TRIOLI: You know Paul Wolfowitz quite well. I understand you have had him to your home a number of times. What are his qualities that appeal to you?

CHRISTOPHER HITCHENS: I know both of them well. I have known her longer than him. I suppose the thing that would surprise most people one Wolfowitz is what a bleeding heart he is.

He's had to read all the time, for many years now, that he's a member of a Jewish, heartless, neocon, cabal of hardline interventionists. As a matter of fact, I came to know him because he was in favour of an intervention to save the Muslim population of Bosnia from extermination by Christian fascists in the 1990s, a subject in which the State interests of Israel were not involved, can I just say. I knew that previously he'd been instrumental in persuading the Regan administration to dump the Marcos dictatorship in the Philippines, even if it meant losing the American basis there, very important change in the early '80s.

I was impressed by his view the risks of democracy and democratisation are very great. They're nothing compared to the risks of dictatorship. He's been retatively consistent on that, more than most in Washington.

VIRGINIA TRIOLI: Christopher Hitchens, how does this affect his standing and employment prospects?

CHRISTOPHER HITCHENS: I simply don't know about his employment prospects. As to his standing, I think he's conducted himself with great dignity but I wish he had not conceded to this rabble and to this defamation and slander.

VIRGINIA TRIOLI: You think he could have toughed it out?

CHRISTOPHER HITCHENS: I think anyone of his conscience would have had to come to the conclusion at some point that the self fulfilling prophecy that as long as you stay you're damaging the bank or the whole institution's been disrupt was to some extent true. Remember who made that prophecy come right.

VIRGINIA TRIOLI: On Iraq, given Mr Wolfowitz's key role as an architect of the war, how do you assess the current stand off of Congress and the President over the situation there and the continuing surge?

CHRISTOPHER HITCHENS: Well...the President and the Congress in fact are now both talking about timetables for withdrawal. It's only a matter of now when rather than if. There's much less difference in some ways than there appears to be, which means that those who hope to, shall I say inherit Iraq the other side in this war, in other words more or less only have to set their watches.

I hope again that the people who want this will be happy with what they get.

VIRGINIA TRIOLI: So the President is making a mistake by engaging in this discussion about a timetable?

CHRISTOPHER HITCHENS: Well, I think he is, yes.

VIRGINIA TRIOLI: Because it just brings about the inevitable result of the civil war escalating and the country descending further into disaster?

CHRISTOPHER HITCHENS: It simply means that those who wish to reduce Iraq to the level of Somalia or Afghanistan in the name of God, the Al Qaeda forces and the other parties of God who are in the process of destroying Iraqi civil society have only to wait it out now. The anti war side appears to have won the argument in the media and in the Congress and elsewhere. And from what I understand, this would be true for a lot of public opinion in Australia as well. I hope that they will be delighted by the Iraq they'll get.

VIRGINIA TRIOLI: On other matters, in your home country Gordon Brown prepares to take over the leadership of the country. How can he distinguish himself, in your view, of the man who goes before him and leaves a very mixed legacy?

CHRISTOPHER HITCHENS: Well, the way people keep saying he's going to do this is by being more sceptical about what is sometimes called the special relationship between the UK and the United States and maybe he will find a way of making that plain. That might indeed mean an earlier timetable or a faster one for the withdrawal of British forces from Iraq.

Interestingly, though, and I think unexpectedly from most people's point of view, while the British are undergoing that, if you like, rethink, both France and Germany for the first time in a very long time have elected heads of Government who are fairly solidly Atlantisists. In the rest of Europe, you might say paradoxically or ironically, the tendancy is another way.

There are people who say, "If the British don't want to be America's best friend, we do". If there's a vacancy they'll fill it. What's funny about that is it was David Cameron's idea first. This is really something I didn't expect to live to see, a race between Labour and the Tory Party with the Tories in the lead to take distance from Washington. That's really extraordinary. We saw David Cameron last September 11, he chose that day to make a press conference saying America shouldn't count on us anymore. Brown is still catching up with the right wing on this.

VIRGINIA TRIOLI: Could Gordon Brown surprise us all by not stepping back so quickly from that special relationship?

CHRISTOPHER HITCHENS: Yes, he could. Yes, he certainly could. I don't know how surprised we'll be. I can tell you, the atmosphere of anti Americanism in Britain is so toxic now, so widespread, so deep going, that there probably are political rewards to be had from exploiting it. Brown has to know that and has to know on most projections currently Cameron would beat him. I know it is early days to say that. He might not want to hand this demagogic advantage to this new little smooth talking Tory.

VIRGINIA TRIOLI: Christopher Hitchens, thanks for taking time from your book tour.

CHRISTOPHER HITCHENS: It’s a pleasure, thanks for asking me.

well about 9.30 i put myself to bed and i am in the throes of a deep sleep when a passing low flying space ship wakes me up, the flashing blue and red lights bounce around my bedroom, the hum and throb of its anti gravity force fields pulsates through my nocturnal journey and my dreams begin to melt, i ran outside to sit with pan and gaze up at the huge vessel overhead, we poise ourselves gracefully, i am ready for abduction, bring it on. however what it actually turns out to be is a very very low flying helicopter about to land in the field accross the street. its huge. i take myself back to sleep. nightmares wake me, i toss and turn, then drift back for a few hours, in the morning i take pan for a walk, i chat with meredith on the phone, i drink a coffee and walk through the rain. sometimes i feel like i am dreaming when i am actually awake, its the old butterfly man thing, maybe i am a butterman.

well another sleepless night, i do feel rather good at the moment though, as i know tonight i will sleep well. remarkable day, met adonis at the mall, he gave me a huge hug and wouldn't let go, then i caught up with rowan who told me about how he was crying when he heard the news about me, it appears i managed to cause a few ripples for people. never mind, i am alive and meredith is alive and we move onwards, hurling out lives closer and closer to the inevitable. i am surrounded by people who really care for me, thats worth something. evan told me he would have flown down if he had known, agent stone said she would have if she had the cash, mitch and rowan both deeply upset. the world is spiralling out of control, i catch glimpses on tv, news reports, it all seems so hopeless, yet i seem to be filled with hope. love i guess makes ya slightly derranged.
so what to do with myself?
i'm going to bed.

sleepless night yet again, i lay on my matress staring at the space on the ceiling thinking about the sleep i had at merediths. it appears to have been the deepest most sublime sleep i ever recall, i was at peace, for the first time in my life i felt a sense of belonging. anyways the mundane reality is i need to focus on more practical problems and less abstract ones, bills need to be paid, refunds claimed, drs appointments kept, letters posted, dogs and cars cleaned, mission control needs a good seeing to, my brother needs me, agent stone and i plan a short gym session this evening, and then there's unfinished buisness with petrina my wonderful artistic director and stylist. my photographs need to be completed, i can't say i can really afford them now but onwards i go. moving forwards is the only way i can do things, sideways don't work for me.

all clear, i'm going to have a drink and smoke something green, then i'm going to sleep, the world seems very still right now. i did have a little chat with her, looks like the dr was excellent and she is making great progress, looks like she will be having more conclusive tests in 4 months, looks like she will be staying in adalaide until the new year and i'm feeling just ecstatic that she is alive and kicking.
we spoke a lot about my hospitalization and how she stuck by me, through think and thin, i was so ashamed at my behaviour, i cannot recall anything, but i feel scared that a hidden dimension to my personality just invaded my mind, it took five people to restrain me. That i could have hurt some one i love and that a blow on the head could efffect me so much.
Speaking to some other folk who spoke to me in hospital i discovered that i was totally coherent sometimes and at others i was not.

Disturbing dreams have kept me awake all night, I cannot sleep any more, it’s late, I write a letter to Meredith, then hours later I read it, it’s strange, I’m slightly embarrassed by its contents, I am unsure what I have written, but I send it anyway. We speak on the phone briefly, today she will find out if she has a brain tumour, in fact she’s in the hospital right now, and I’m just waiting for the call.
My intuition says its just stress, but there are always other possibilities and although I am positive focused and fixed on the task ahead I am also very aware that I may have to prepare for the worst.
So the worst-case scenario plays itself through my head like a weird tragic love story and I find myself in the horrifically selfish arena of self-pity. I shake that loose, it’s the one place I don’t want to be. Consider Meredith’s perspective, she’s the most bravest strongest woman I have ever met, she is a true angel, she’s been fucked over many times yet she makes everyone laugh, she’s so unselfish it makes me ashamed. She gives 100% of herself to everyone. She faced my demonic experience in hospital while under her own strain, handled a situation really well and put me first. How many girls do that these days?
So yeah Meredith, whatever happens looks like your stuck with me.

I was 30 thousand feet over the Victoria and New South Wales border when the tears came, I was overwhelmed with them and before I knew it people were beginning to stare at me. I admit being slightly embarrassed but not ashamed; ‘Fuck it!’
I’ve lived half my life if I wanted to show some emotion then I would. Besides none of the other passengers had ever met Meredith so I guess they had no real insight into how I was feeling.
You spend half your life travelling the world, being open to adventure and sucking the marrow from the bones of life, sometimes you get knocked down and ya learn to get up again, sometimes it leaves a bruise or two but you learn to roll with the punches, ride the waves, eventually you figure out its better to express your emotions rather than keep em suppressed, keep em cooking slowly turning into a cancer or something.
You change your address so many times, you never know where you are heading to but you know you gotta keep going, because she’s out there somewhere. Then the girl of your dreams the one you been looking for out there, in the wilderness turns up, the wild child, the most beautiful girl you ever gazed at, the most intelligent girl you ever held hands with, the one that you been looking for, the reason you feel so lonely in a crowd of friends, the reason you just can’t ever stop dreaming, the reason you were born, your destiny, her destiny, all about to converge.
She’s everything that gives your life meaning, And you have to leave her at 5am to get your plane that takes you away from her beating heart, and therefore breaks yours. Yeah that’s worth a few tears.
I’d spent the week with her, most of it in a haze of time lapse tenderness with occasional kookiness and danger. I had found a peace, a perfect moment, i can die happy now.

so meredith asks me outright if the parcel coming down is me. I can't lie to such a direct question so i say yeah, she flips out, and thus the element of surprise is gone.
i arrive at her doorstep, happy and madly in love with this crazy girl, we prepare for her house warming party as a handful of guests arrive, i meet the people most important in merediths life, her friends. cool group all warm, gracious and obviously very fond of our heroine meredith who is subduded after her siezure and sits quietly holding my hand. anyway its a nice evening, we get a good nights sleep in and spend the day lazing around, then it all goes pear shaped, when that night meredith finds me passed out in her kitchen, yeah she somehow managed to get me in a taxi to hospital where i was apparently a 'code blue.' While informing all relevant people agent stone, my brother, work, and introducing herself as mrs. mission, dealing with drs and nurses and a belligerent capt. who is being very difficult, meredith is swimming upstream, dealing with her own anxieties and now a new drama, she battles on, reassuring everyone and being a real trooper but stubborn old capt. mission he is just getting more madder and crazier every second.
i have had a history of blackouts, not for many years now but certainly in my early 20's, it became a bit of a joke amonst my friends, that i am renouned for strange neurological idiosyncrasies, narcolepsy, siezures, a stutter, various delusions and obsessions have all plaugued me at one time or the other, very rarely to they stick around any longer than a year. Mosy of theese are a response to stress, but i certainly didn't see this one coming. anyways i have stolen merediths thunder with my own, on release it takes a few days for me to understand what has happened. I am filled with sadness that i have hurt the person that i love, but i am confused by it as well. anyways time heals all wounds and in a few days of snuggling intimacy, i certainly felt healed. meredith revealled so much to me about herself, i fully believe that she is the yin to my yang, like a jig saw peice we connect. for the first time just sleeping with some one was so beautiful, we both are chronic insommniacs and we both felt perfect after we slept finally together (i'm not talking about sex)
all in all the trip to adalaide despite the drama, was life affirming for me. i finally feel i met my soul spirit partner. its just beautiful.

this is the plan, friday night call meredith to inform her a parcel will be arriving by courier mail, she will need to sign for it on sat, afternoon, sat morning i grab a taxi to the airport, fly to adalaide with my guitar and some nice threads. arrive outside merediths, call her on the phone and initiate chat, while she is speaking i'll knock on the door and start my song....lets see how it pans out in reality.....