Post Traumatic Stress Disorder and Traumatic Brain Injury

Post Traumatic Stress Disorder and Traumatic Brain Injury Kathleen Goren Ph.D Mary Lu Bushnell, Psy.D. Carl T. Hayden VA Medical Center

TRAUMATIC BRAIN INJURY (TBI)

TRAUMATIC BRAIN INJURY (TBI) • Damage to the brain due to externally inflicted trauma • Mild traumatic brain injury is the lower-grade forms of TBI • Caused by a penetrating or blunt trauma or from the force of rapid acceleration and deceleration

TBI the signature injury of this war • Many soldiers are experiencing blast exposures at greater frequencies than in past wars • The significance of the blast wave itself is not yet well understood • Vets are returning with c/o memory, concentration and problem solving difficulties

Difficulties with identifying mTBI • Difficult to determine if a mTBI has occurred when we see the soldier 1 to 2 years after the injury • Neuropsychological evaluations are conducted to help identify current strengths and limitations

TYPES OF HEAD INJURY • Closed Head Injury • Contusion/concussion • Coup/Contre-Coup • Bloodflow and metabolic changes • Cerebral edema • Diffuse Axonal Injury • Blast Injury • Open Head Injury

CONTUSION/CONCUSSION • A mild injury or bruise to the brain which may cause a short loss of consciousness • It may cause headaches, nausea, vomiting, dizziness, and problems with memory and concentration

DIFFUSE AXONAL INJURY (DAI) • Brain injury does not require a direct head impact • During rapid acceleration of the head, some parts of the brain can move separately from other parts • This type of motion creates shear forces that can destroy axons necessary for brain functioning • These shear forces can stretch the nerve bundles of the brain

BLAST INJURY • Blast injuries are the number one cause of injury or death in Iraq • 69.4% of Wounded In Action caused by Blast or Explosion • 62% of Blast Injuries result in Traumatic Brain Injury (TBI) • 85% of TBIs are closed head Injuries

SYMPTOMS OF MTBI • Emotional • Behavioral • Physical • Cognitive • Social

EMOTIONAL • Depression • Anxiety • Hopelessness • Helplessness • Reduced confidence • Apathy • Emotional numbness • Intense fear

BEHAVIORAL • Impatience • Anger • Frustration • Confrontational behaviors • Impulsivity • Increased avoidance of situations or activities that feel uncomfortable (like being around others, riding in cars) • Withdrawal

PHYSICAL • Headaches • Chronic pain • Fatigue • Weakness or numbness • Changes in vision • Changes in hearing • Other sensory changes (touch, taste, smell)

PHYSICAL • Changes in sleep • Changes in appetite • Vertigo (dizziness) • Nausea • Impairments in fine motor speed and coordination • Changes in sexual functioning

COGNITIVE • Changes in attention • Diminished memory • Slowed speed of mental processing • Confusion • Disorientation • Changes in decision making • Alterations in judgment • Changes in ability to plan and organize

SOCIAL • Changes in relationships • Changed ability to engage in hobbies and leisure activities • Decreased ability to perform at work or school • Isolation • Increased alienation from others

POST TRAUMATIC STRESS DISORDER

Topics: Fight or Flight Response Effects on our brain & body PTSD Symptoms Treatment Options

Fight or Flight Response • Hard-wired instinct • Essential tool for survival • Begins when we perceive something as a threat • When triggered, the brain alerts the body to danger and initiates a series of important changes

When Fight or Flight is Triggered… • Glucose and fats are released into the bloodstream – they provide fuel for the muscles • Oxygen is needed to burn the fuel – so our breathing rate increases • In order to get this fuel to our muscles as soon as possible – our heart begins to beat faster

Fight or Flight • Blood is shunted away from our digestive tract and directed into our muscles and limbs, which require extra energy and fuel for running and fighting • Our pupils dilate • Our awareness intensifies • Our sight sharpens • Our impulses quicken

Fight or Flight • Our perception of pain diminishes • Our immune system mobilizes • We become prepared physically and psychologically for fight or flight • We scan and search our environment, “look for the enemy”

Our rational mind is disengaged – the blood supply to the parts of our brain that allows us to think rationally is reduced, while the blood supply to the more primitive parts is increased We rely on our instincts and reflexes Military drills are used to build a conditioned reflex - so, even when fight or flight is triggered – you are able to follow orders/training

PTSD can develop when… • The threat is severe • The threat persists over a long period of time • The individual was in close proximity to the threat (direct or witnessed) • There is lack of support from family and/or community after the event • There is a history of other traumatic events prior to the event

PTSD • In PTSD, the fight or flight state remains activated • The body continues to respond as though it were under threat • The body’s physical, mental, and emotional batteries are drained

Our immune system is prevented from running at full capacity. There is an increased likelihood of developing stress-related illnesses We are likely to use the fight or flight reaction in situations that are NOT life or death

Brain Boosters Group • Evolved out of a need to assist soldiers to develop coping strategies to address the changes resulting from mTBI and/or PTSD • The focus is to maximize strengths and minimize limitations

Brain Boosters Group • 10 week group consisting of psychoeducation and experiential exercises in order to illustrate different facets of brain injury and what can be done to improve cognitive functions

Brain Boosters Group Group Topics include: • Overview of PTSD and TBI • General Health • Neroanatomy • Attention • Executive Functioning • Communication Skills • Memory • Communications Skills • Insomnia and nightmares

Brain Boosters Group • Several unique aspects of the group • Covers a wide range of skills and problem areas • Coputer assisted rehab using easily available systems and use of on-line websites • Other VA clinicians provide expert input in their speciality areas (speech, PTSD and insomnia)

Brain Boosters Group • Feedback is sought from group members at the end of each group and modifications are made as needed. • Preliminary findings from the first three groups are demonstrating that the group is effective in reducing the subjective perception of problems in depression, PTSD, cognitive functioning and insomnia.

Directions for the future • Empirically validate the efficacy of this group • Validate the use of computerized hand held computer interventions • Produce a manual that can be used by other VHA clinicians • Develop an imaging protocol to determine if there is a change in brain structure after group intervention

KEEPING IT IN PERSPECTIVE

War may be hell… but home ain’t exactly heaven, either. When a Soldier comes home from war, he finds it hard…

…to listen to his son whine about being bored.

…to keep a straight face when people complain about potholes.

…to be tolerant of people who complain about the hassle of getting ready for work

…to be understanding when a co-worker complains about a bad night’s sleep

…to control his panic when his wife tells him he needs to drive slower

…to be grateful that he fights for the freedom of speech.

…to be silent when people pray to God for a new car.

…to be compassionate when a businessman expresses a fear of flying.

…to not laugh when anxious parents say they’re afraid to send their kids off to summer camp.

…to not ridicule someone who complains about hot weather.

…to control his rage when a colleague gripes about his coffee being cold.

…to remain calm when his daughter complains about having to walk the dog.

…to be civil to people who complain about their jobs.

…to just walk away when someone says they only get two weeks of vacation a year.

…to be happy for a friend’s new hot tub

…to be forgiving when someone says how hard it is to have a new baby in the house.

Post Traumatic Stress Disorder and Traumatic Brain Injury