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Addressing the trauma in traumatic brain injury

Posted Sep 19 2010 12:00am

Source: Scott Butner

As I’ve been exploring the landscape of my head injuries over the past few years, one aspect of my life experience has consistently come to the fore trauma… and its long-term effects on lives of both survivors and the ones they love and live/work with on a daily basis.

It’s almost a total fluke that trauma should even have this on my radar. But over the years, I’ve befriended and been befriended by a number of psychotherapists and counselors, most of whom specialize in trauma. In retrospect, I suspect that many of them have assumed that my difficulties were due to past traumatic episodes rough childhood, misspent youth, etc. In fact, one of them has flatly denied that my issues could be due to TBI, and they became more and more insistent about me getting a therapist, which was probably the worst thing I’ve ever done, in retrospect. (This friend’s denial is a topic for another post it’s quite interesting, “clinically” speaking.)

Now, I have to say that after more than 10 years of being around these friends of mine, I get a little tired of every ill known to humanity being ascribed to after-effects of trauma. When I talk about experiences I’ve had and people I’ve encountered who have annoyed me or done some seriously sick stuff, I’ve often heard the refrain, “Oh, they’re a trauma survivor, so they’re dissociating/being triggered/experiencing kindling/re-enacting their past traumas.”

There’s not much room for just being an asshole. For some of my friends, it’s all about the trauma. And in an attempt to better understand what it is they’re talking about, I’ve attended some trauma workshops, as well as read some books. I’ve got Peter Levine on my bookshelf, along with Belleruth Naparstek. And now I’m reading Robert Scaer, M.D.’s  book The Body Bears the Burden, which explains (from a neurologist’s point of view) the effects of trauma on both the body and mind of someone who’s gone through awful experiences and those whose experiences don’t seem that terrible, compared to, say, Pakistan’s flooding or suicide bombings in Kabul.

The DSM-IV defines a “traumatic stressor” as:

[an stressor] involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate

The part that interests me is the “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity”. The other parts are just as significant, but I’m not going to speak to them at this time.

When it comes to mild traumatic brain injury, I think sometimes the severity of the experience tends to get downplayed. After all, the injury is mild, right? Well, interestingly, mTBI survivors apparently can show more disruptive symptoms of traumatization after the fact, than survivors of more severe injuries. And these long-term effects  can wreak havoc in the lives of survivors, as well as their immediate circle.

Problems such as fatigue, emotional volatility (emotional lability), rage, agitation, irritability, insomnia, sleep deprivation, anger, temper flares, temper tantrum, anxiety, fear, panic, risk-taking, danger-seeking, not to mention all the crisis and drama that can accompany hormonal spikes during times of stress, certainly don’t make things any easier. If anything, they complicate recovery by flooding the system with stress hormones which interfere with your ability to learn from your experiences. So, at the time when you’re having to get a new grip on your newly changed life with its “new normal,” the biochemical processes going on behind the scenes may be getting in the way.

How maddening is that? At just the time when you need your brain to be able to recover, it’s busy cranking out all sorts of interesting concoctions that specifically get in the way of your recovery.

Because (I believe) there is unresolved and un-dealt-with trauma wreaking havoc behind the scenes.

Trauma in mild traumatic brain injuries is particularly tricky. After all, the injury itself may not have been that dramatic something gets dropped on your head, or you get in a fender-bender, or you slip and fall down and clunk your head on something. You get up again, walk away from the scene… maybe pay a visit to the emergency dept of your local hospital, get scanned, and you get a “clean” bill of health (and maybe a few pointers on what to watch out for to make sure you don’t have more serious issues later on). Then you’re expected to get on with your life.

But inside your skull, something else is happening. Some of the fragile connections in your brain have been sheared or severed or frayed, and your brain isn’t able to communicate with itself like it used to. On a fundamental, profound level, your very existence has been threatened only nobody can see it. Even you can’t see it very well, because your brain is either still bathed in the stress hormones designed to keep you from feeling a bunch of pain (and thus preventing you from fleeing an immediate threat), or it’s just not making the connections it “should” in order to give you the resident owner a clear picture of what’s going on. Or it could be both things going on.

In some cases, from what I’ve read in Dr. Scaer’s book, the onset of problems can be delayed by hours, even days. So, right after the accident/event, you’re walking around looking fine, seeming to be fine… maybe you’re a little shaken up, but that’s to be expected.  But then you start to slip away… decline… feel the effects of what was supposed to be a mild event that had no serious immediate effects you. In your system, hidden from view, the process of gradual (and possibly debilitating) problems has begun.

This process is utterly maddening. Everyone around you, who was worried for your safety, just wants to be relieved that you’re okay. But all of a sudden, you’re acting strangely, you don’t seem like yourself, and you’re complaining all the time. The complaints don’t get better over time, either. They get worse. And for no apparent reason. People think you’re looking for attention, that you’re trying to “milk” your accident for all it’s worth. They just want you to get back to being your old self. But you’re doing the exact opposite.

And the pressure to return to normal builds, even as your system is being eroded by the biochemical havoc of trauma that was introduced to your system which has not been cleared it hasn’t even been recognized. How can you clear away what you can’t see/hear/detect?

Indeed, the most insidious and problematic manifestations of trauma take root when the person having the experience is taken by surprise. Studies have shown that bracing for impact limits the impact, but being blindsided makes it worse. And it makes the experience as a whole worse. The body detects this threat to its safety and existence all of a sudden out of nowhere and it unleashes myriad biochemical substances for us to deal with it including endogenous opioids designed to numb the pain of injury. Animals in the wild which are being chased by predators, when there is no way to escape, will often fall down as though dead, their bodies full of chemical substances that will both numb the pain of being devoured and turn them into “dead” prey which might discourage a predator from actually killing them.

The same biochemical process is in place with human beings. After all, once upon a time, we were hunted as prey by animals larger than us. Indeed, we still are, in some cases the predators happen to be other people, more often than not. In times of combat and assault, when all escape routes have been blocked off and we believe (on some level) that we’re done for, our brains and bodies do their natural thing they bathe us in substances to protect us from feeling that knife going through our lung or feeling that bullet smash through muscle and bone.

Our brains and bodies are doing their utmost to protect us as best we can. But our minds tend to interpret the experience differently.

In the case of animals who freeze and then survive the assault, they shake themselves, go through a series of shuddering/jerking motions, do heavy, deep breathing, and then pick themselves up and get on with their lives. In the case of humans who freeze and then survive the assault, we tell ourselves we were wusses for freezing the way we did, and we plunge into cycles of self-doubt and conflict, feeling like we failed when we were simply being the biological creatures we are designed to be.

And the self-perpetuating downward spiral of the PTSD loop starts. Where it stops, is anybody’s guess.

Therapies which have been successful in freeing people from that negative feedback loop are those which engage the body to discharge the sudden burst of biochemical self-protection, and get the autonomic nervous system back into balance. In the completion of the fight-flight-freeze cycle, the body is allowed to return to its most effective ways of working. And we can get on with our lives.

Here’s where the problem starts with mTBI. (Note, I’m not a doctor or certified health professional this is just my belief system about how our systems interact with the world around us.) If the injury is “mild” then what’s the big deal? Why should we even need to complete the fight-flight-freeze cycle? Wasn’t the injury itself mild? We just got clunked on the head. Big deal, right?

Hardly. I think with mild traumatic brain injury, there may be another aspect of it that comes into play. With “mild” injuries (not that any brain injury is ever mild, mind you), the brain itself perceives the threat on a basic, biological level. It knows something’s wrong, and it kicks into overdrive, trying to right what’s wrong.

I suspect this is why people who have sustained concussions or mTBIs are so prone to denying that there’s anything wrong. Our brains are so busy trying to right their internal systems, that they fail to communicate with the rest of the world that includes our conscious mind.

Based on what’s happened to me, what I’ve observed, and what I’ve read, here’s the cycle that I believe gets set up:

As you can see assuming this progression is at least somewhat accurate (and I believe it is) the impact of a head injury need not be severe, in order to lead to severe consequences.

To fully understand the pervasive effects of mild traumatic brain injury, you need to look at multiple systems from the brain’s inner workings, to the autonomic nervous system, to the demands of adult living or childhood development, to the expectations of one’s surrounding social milieu. With mild TBI, it’s never just one issue that sends you down the dark road it’s a million little, subtle, interrelated issues that combine to create a recipe for disaster that, like bread dough sitting near a hot wood stove, will inevitably begin to rise and expand.

Trauma and the body’s internal responses to perceived threat and our interpretation of those threats, is like yeast added to a sugar-water-flour mix of our injury. With enough heat and time, it’s going to double, triple, even quadruple (and more) the issues that initially come with mild traumatic brain injury. Unfortunately, it appears that our systems are designed to work that way, and unless we can figure out alternative ways to address the issues, we’re in for a rough ride… till we can find help, sort things out, or end up incarcerated or dead.

What strategies and approaches we can hope to employ in this trickiest of situations which might actually work is a topic for another post.

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