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 lowergrade forms of TBI
 Caused by a penetrating or blunt
trauma or from the force of rapid
acceleration and deceleration
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TBI the signature injury of this war
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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
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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
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Closed Head Injury
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Contusion/concussion
Coup/Contre-Coup
Bloodflow and metabolic changes
Cerebral edema
Diffuse Axonal Injury
Blast Injury
Open Head Injury
CONTUSION/CONCUSSION
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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)
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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
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EMOTIONAL
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Depression
Anxiety
Hopelessness
Helplessness
Reduced confidence
Apathy
Emotional numbness
Intense fear
BEHAVIORAL
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Impatience
Anger
Frustration
Confrontational behaviors
Impulsivity
Increased avoidance of situations or activities
that feel uncomfortable (like being around
others, riding in cars)
Withdrawal
PHYSICAL
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Headaches
Chronic pain
Fatigue
Weakness or numbness
Changes in vision
Changes in hearing
Other sensory changes (touch, taste, smell)
PHYSICAL
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Changes in sleep
Changes in appetite
Vertigo (dizziness)
Nausea
Impairments in fine motor speed and
coordination
Changes in sexual functioning
COGNITIVE
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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
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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
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Effects on our brain & body
PTSD
 Symptoms
 Treatment Options
Fight or Flight Response
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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…
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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
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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
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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”
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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
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We rely on our instincts and reflexes
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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…
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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
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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
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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
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Evolved out of a need to assist soldiers to
develop coping strategies to address the
changes resulting from mTBI and/or PTSD
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The focus is to maximize strengths and
minimize limitations
Brain Boosters Group
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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:
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Overview of PTSD and TBI
General Health
Neroanatomy
Attention
Executive Functioning
Communication Skills
Memory
Communications Skills
Insomnia and nightmares
Brain Boosters Group
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Several unique aspects of the group
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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
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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
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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.
…to not punch a wall when someone says we
should pull out immediately.
The only thing harder than being a Soldier…
is loving one.
A gentle reminder to
keep your life in perspective.
And when you meet one of our
returning Soldiers,
please remember what they’ve been through
and show them
compassion and tolerance.
Thank you.
CPT Alison L. Crane, RN, MS
Mental Health Nurse Observer-Trainer
7302nd Medical Training Support
Battalion
"Sometimes combat comes at you so hard, the
memories don't get processed properly. They
become free floating, like raw footage that hasn't
been edited down to make sense." - Article
"Bringing the War Home"
"Combat trauma is different from other kinds of trauma
because the horror of war – the trauma-inducing
murderousness of it – is inextricably linked with
sacrifice, courage, honor, pride, and patriotism. And
the trauma occurs in the context of profound
personal loyalty. Some soldiers will never
experience bonds as intense as those formed with
buddies fighting or dying beside them in desperation
of battle or the confines of an exploding Humvee.
No other trauma is so intermingled with our deepest
values and strongest fears of overwhelming loss. Is
it any wonder that soldiers have a hard time letting
go?" – Article "Bringing the War Home"
"The journey home marks the beginning of an
internal war for Marines. Give them the time
they require to slowly turn the switch. The
switch from violence to gentle. The switch
from tension to relaxation. The switched from
suspicion to trust. The switch from anger to
peace. The switch from hate to love." – Lt.
Col. Mark Smith
"Happy to be home? On one level, yes, but on
another it's kind of a letdown. I get so bored most of
the time that I'm always thinking of something to do
that can get me up and going. The worst thing is
driving. I'm looking toward the bridges and the
overpasses all the time; looking at the sides of the
roads and the guardrails. Driving is different now,
and it's really strange to get stuck in traffic. No more
hitting the gas pedal and jumping over curbs,
speeding across highway medians or cutting off
vehicles piled up at an intersection. In Iraq I could
do whatever I wanted…" – A Marine home from Iraq
"Before I deployed down range I was different
about my wife and kids. Now that I'm back I
can only let them get so close before I have
to get away from them. I used to have fun
letting my boys jump and crawl all over me.
We would spend hours playing like that. Now
I can only take a couple of minutes of it
before I have to get out. I usually get in my
truck and drive back to the base to be with
my platoon." – A paratrooper home from Iraq