Sometimes, people speak about the effects of traumatic brain injury (TBI) or the consequences of post-traumatic stress disorders (PTSD) as if they are separate conditions; they are. Yet for the person who is living with the dual diagnoses of TBI and PTSD, it may be difficult to separate them. The combination of TBI and PTSD can be overpowering and destructive for all in its path.
Traumatic brain injury (TBI) - Also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull. Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object penetrating the skull, such as a bullet or shattered piece of skull, also can cause traumatic brain injury.
Post-traumatic stress disorder (PTSD) - Defined as a mental health condition that is triggered by a terrifying event, either experiencing it or witnessing it. After a trauma or life-threatening event, it is common to have reactions such as upsetting memories of the event, increased jumpiness, or trouble sleeping. PTSD can occur in people of any age, including children and adolescents. More than twice as many women as men experience PTSD following exposure to trauma. Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur with PTSD. Post-traumatic stress disorder is classified as an anxiety disorder in the DSM IV; the characteristic symptoms are not present before exposure to the violently traumatic event.
A person with TBI and PTSD is living in a state unlike previously experienced. For family members and friends, home is no longer the safe haven it was, but an unfamiliar front with unpredictable and at times frightening currents and events. While awareness of PTSD has increased greatly with recently returning service members and veterans, it is not new or limited to combat.
Anyone at all - children, adolescents, adults and seniors, who is exposed to a life-threatening trauma may develop PTSD. Things such as:
May happen to any person anywhere. But the rate of PTSD following a brain injury is far higher in veterans than civilians due to their multiple and prolonged exposure to combat. One estimate suggests up to 35% of returning veterans with a mild brain injury also experience PTSD. The symptoms of PTSD can include the following:
People with PTSD are at increased risk for a number of things such as depression, substance abuse, physical injuries and sleep issues, which may then affect the person's thoughts and actions. These risk factors also occur with brain injury.
Post-traumatic stress disorder (PTSD) is a mental health disorder, yet the associated stress may cause physical damage. Traumatic brain injury (TBI) is a neurological disorder caused by trauma to the person's brain. It might cause a wide range of impairments and changes in a person's:
The brain is so complex the potential effects of a TBI are extensive and different for each person. When PTSD and TBI coexist, it is often hard to sort out what is going on. Changes in cognition such as concentration and memory, anxiety, depression, insomnia, anxiety and fatigue are common with both of these diagnoses. One feeds and reinforces the other so it is a complicated mix. It might help to consider and compare changes commonly found with TBI and PTSD.
TBI, PTSD and Memory
People with TBI experience a period of amnesia concerning what occurred just before or after the injury happened. The length of time, whether minutes, hours, days, or even weeks of amnesia is an indicator of the severity of the person's brain injury. The person may not have memories of what happened just before or after a car crash or IED explosion, for example.
People with PTSD, by contrast, are plagued and often times haunted by unwanted and continuing intrusive thoughts and memories of what occurred. The memories keep coming at any time of day or night and in such excruciating detail that the person relies the trauma repeatedly.
TBI, PTSD and Sleep
Where TBI's are concerned, sleep disorders are very common following brain injury. Whether it is difficulties with falling asleep, remaining asleep, or waking early - average sleep patterns are disrupted, making it difficult to get the restorative rest of sleep the person so badly needs.
Where PTSD and sleep are concerned, the mental state of hyper-vigilance interferes with slowing the mind and body down for sleep. Nightmares are so common with PTSD that many people actually dread going to bed and spend long nights watching television, or lying on the couch to avoid the nightmares. Waking up with night sweats so drenching that sheets and the person's clothes are soaked. Flashbacks so strong that bed partners have been struck or strangled while sleep battles are waged.
TBI, PTSD and Isolation
Many survivors of TBI recall the early support and visits from friends, relatives and co-workers who gradually visit or call less and less often over time. A loss of friends and co-workers leads to social isolation, one of the most common long-term consequences of a TBI.
Isolation with PTSD is different as it is self-imposed. For many who are affected, it is just too difficult to interact with people. The feeling of exposure outside the safe confines of the home is simply too much. The person might avoid leaving their home as a means of containing stimuli and limiting exposure to potential triggers of memories. As a result, the person's world becomes increasingly smaller.
TBI, PTSD and Emotions
When areas of a person's brain that control emotions are damaged, the survivor of a TBI might have what is called, 'emotional lability,' what this means is that emotions are unpredictable and swing from one extreme to the other. The person may unexpectedly burst into tears or laughter for no apparent reason. Due to this, it may give the mistaken impression that person is mentally ill or unstable.
With PTSD, emotional numbness and deadened feelings are major symptoms. It is difficult for the person to feel emotions or to find joy in life. The emotional shutdown creates distance as well as conflicts with spouses, partners and children. It is a major cause of loss of intimacy with spouses.
TBI, PTSD and Fatigue
Cognitive fatigue is a hallmark of brain injury. Thinking and learning are simply more difficult. Cognitive fatigue feels, 'like hitting the wall,' and everything becomes more challenging. Building rest periods or naps into a daily routine helps to prevent cognitive fatigue and restores alertness.
The cascading effects of PTSD symptoms make it so hard to get a decent night's sleep that fatigue often becomes a constant companion, spilling over into a number of areas. The fatigue is cognitive, physical and emotional. Feeling, 'wrung out,' tempers shorten, frustrations mount, concentration decreases and behaviors escalate.
TBI, PTSD and Depression
Depression is the most common form of psychiatric diagnosis after brain injury - the rate is nearly 50%. Depression can affect every aspect of a person's life. While people with more severe brain injuries experience higher rates of depression, those with milder brain injuries have higher rates of depression than people without a form of brain injury.
Depression is the second most common diagnosis after PTSD in OIF and OEF veterans. It is very treatable with mental health therapy and/or medication, yet veterans in particular often avoid or delay treatment due to mental health stigma related to mental health care.
TBI, PTSD and Anxiety
Instead of appearing anxious, a person with TBI behaves as if nothing matters. Passive behavior may look like laziness or, 'doing nothing all day,' when in fact it is an initiation issue, not an attitude. Brain injury can affect a person's ability to initiate or begin an activity; the person needs prompts, cues and structure to get started.
Where PTSD is concerned, anxiety may rise to such levels the person is unable to contain it and becomes overwhelmed by feelings of panic and stress. It might be prompted by a particular event such as being left alone, or it may happen for no apparent reason. The waves of anxiety make it difficult to think, reason, or act clearly.
TBI, PTSD and Anger
Damage to the frontal lobes of a person's brain may cause more volatile behavior. The person might be more irritable and anger more easily - especially when the person feels overloaded or frustrated. Arguments can quickly escalate and attempts to reason with or calm down the person are often not effective.
Domestic violence is a pattern of controlling abusive behaviors. PTSD does not cause domestic violence, although it may increase physical aggression against partners. Guns or weapons in the home increase the risks for family members. Any spouse or partner who feels afraid or threatened should have an emergency safety plan for protection in place.
Speaking About the Trauma
A person with a TBI might retell an experience repeatedly in excruciating detail to anyone who is willing to listen. The repeated telling of their experiences might be symptomatic of a cognitive communication disorder, although it may also be due to a memory impairment. Events and stories are repeated endlessly to the exasperation and frustration of family members, friends and caregivers who have heard it in detail many times before. For those with PTSD, avoidance and reluctance to speak of the trauma of what was seen and done is a classic symptom, particularly among combat veterans.
TBI, PTSD and Substance Abuse
The effects of alcohol are magnified following a brain injury. Consuming alcohol:
The only safe amount of alcohol following a brain injury is - None. Where PTSD is concerned, using alcohol and drugs to self-medicate is dangerous. Veterans who drink more heavily and binge drink more often than civilian peers are at increased risk. Alcohol and drugs are being used often by veterans to cope with and dull the symptoms of PTSD and depression. The fact is, alcohol and drug use creates additional issues with thinking, memory and behavior.
TBI, PTSD and Suicide
Suicide is unusual in civilians with TBI. TBI and PTSD are another matter where veterans are concerned. Rates of suicide have risen among veterans of OIF and OEF. Contributing factors include difficult and dangerous nature of operations, long deployments and multiple redeployments, combat exposure and diagnoses of traumatic brain injury, chronic pain, depression and PTSD, poor continuity of mental health care and strain on marital and family relationships. Veterans use guns to commit suicide more often than civilians do.
There is no easy, 'either/or,' when it comes to describing the impact of TBI and PTSD. While each diagnoses has distinct characteristics, there is an incredible overlap and interplay among the symptoms. Navigating this storm is challenging for survivors, family members, friends and caregivers, as well as the person's treatment team. By pursuing the quest for effective treatment by experienced clinicians, gathering accurate information and enlisting the support of peers and family members, it is possible to chart a course through the mayhem.