This is a continuation of the discussion about PTSD from TBI – Exploring some possibilities. (Updated June 10, 2012)
When it comes to who develops post-traumatic stress disorder and who manages to recover from the trauma without post-event effects, how close you are to a traumatic event can determine the degree to which you are affected.
People who are closer to traumatic events have been shown to develop more symptoms — folks who were closer to Ground Zero after the attack on the World Trade Center in 2001 had almost three times as much PTSD symptoms (up to 20%, versus 7.5%) as folks who were in Lower Manhattan, but farther away.
Physical proximity doesn’t always play a role in the development of symptoms. Research has shown that people who watched the WTC attack on television from a great distance, many miles away, developed PTSD after the event, and in some cases, their symptoms were more extreme and persisted longer than folks who were physically closer to Ground Zero.
One of the key factors in all this is not only actual physical proximity to a threatening event — it’s the individual’s interpretation of the even as threatening… their perceived level of danger.
Now, when it comes to this aspect of PTSD, TBI can play a significant role.
But the role that TBI plays can be quite different from the role that other injury situations (like war or motor vehicle accidents) can play. In the case of those other two examples, the danger is immediate, extreme, and it can lead to deer-in-headlights freezing, which “locks” the experience in place, to be played out time and time again. In the cases of “classical” trauma, the single injuring event itself is the culprit. In TBI, while the injury itself can be a source of trauma, very often the injured party has either dim or missing recollections of the event, so like someone who’s drunk behind the wheel of a car who gets into an accident but comes out the other side without any PTSD whatsoever, in traumatic brain injury, the brunt of the trauma is felt after the injury, when cognitive functioning and decision making and perceptions are all out of whack. Not only can you end up making decisions and taking action which puts you in harm’s way over and over again, but your reactions to those situations can be heightened to make matters far more traumatic than they “should” be.
Let’s get into this a little more…
First, brain injury can impact a person’s ability to assess risk. They can end up underestimating the danger of a given situation and rush in “where angels fear to tread.” They’re not necessarily fools. They’re brain-injured.
I myself have been a walking, talking example of this. I can’t even count the number of times I’ve done really dense things that I didn’t realize were dense, till much later. One time stands out, in particular:
One day, a couple of years after my most recent head injury (but before I realized that I had been injured as much as I was) I went hiking bright and early one morning on the first day of deer hunting season. I was wearing natural earth-tone colored clothing and wandering off the beaten path, deliberately following deer tracks because I wanted to “get in touch with nature”. Seriously poor judgment. In the course of my ill-conceived hike, I happened to cross paths with a deer hunter who was watching the very area where I was hiking, gun in hand, ready to shoot. I was in very real danger of being shot.
Now, I know better. I’m from a family filled with avid deer hunter – my dad and all my uncles and my brother go hunting regularly with almost religious fervor. I know that the first day of buck season is NOT the day to go hiking in the woods, and if you have to, you wear bright colors and you stick to the trail(s). But that morning my brain totally failed me. I literally could have been killed in one of those hunting accidents I grew up hearing about.
Believe me, I’m not proud of this genuinely impaired choice, but it’s a great example of how TBI-limited thought processing can put a person in mortal danger, without them even knowing it.
The second way TBI can contribute to the proximity of danger is by heightening the intensity of one’s response to situations.
For example, a head-injured person can quickly lose their temper in a confrontation with someone bigger and badder and meaner than them. That has happened to me many times, and I’ve been injured in the process. I know from personal experience that an impaired brain can make you think you can take on that opponent — and win — only to have your body find out that’s not the case. And if you piss someone off who carries a grudge, you can find yourself looking over your shoulder at every turn… becoming increasingly paranoid and jumpy… which eventually can add up to a hefty dose of PTSD.
Now, one of the things that Belleruth Naparstek mentions in her book Invisible Heroes (this discussion is based on info from Chapter 4 therein), is that another factor is internal perception of danger/trauma. If someone doesn’t know they’re in danger, they may not be impacted by even a serious event. People who are involved in accidents when they’re drunk have been shown to develop less PTSD than might be expected. That’s not to say everyone should run around intoxicated, only that having your perceptions impaired or dulled or distracted somehow can keep PTSD at bay.
But if you believe you’re in danger — even in the case of a near miss — you can really find yourself on the PTSD ride of your life. It’s your perception of danger that sets off the reaction… which can build and recur, build and recur, build and recur, till you don’t know whether you’re coming or going and you feel like you’re losing your mind. Even if you escape a traumatic situation relatively unscathed, you can end up with some nasty symptoms.
The third way TBI can contribute to PTSD is by slowing information processing and reaction times, so it can be hard to get out of a worsening situation before it turns really ugly.
Remember, slowed processing time is one of the most common hallmarks of mild traumatic brain injury. And fatigue is not only a common after-effect of TBI, but it’s also a factor in diminshed attentional abilities and cognitive functioning. When you’re in a potentially dangerous situation, the last thing you need is to be thinking and reacting more slowly than you could/should/otherwise would. But with TBI and its after-effects, that’s precisely what can happen.
As an example, say you’re driving down a deserted country road after dark one winter evening. It’s late and you’re worn out from a long day, and you just want to get home and fall into bed. Out of the corner of your eye you see a shape standing on the grassy shoulder beside the road. A huge six-point buck comes into view in your headlights. Something tells you to slow down, but tou’re not thinking clearly, you’re tired and foggy and slower than usual, and it takes you a few seconds longer to hit the brake than you normally would.
Suddenly, the buck turns and starts across the road right in front of you. Before you can react, you hit the deer head-on, crumpling the front of your car and inflating the airbags in your vehicle. Your head bounces off the airbags, breaking your glasses, and slams against the headrest. Dazed and confused, you sit stunned for a few moments. Then you climb out of the car and go see what just happened. As you approach the deer, you feel something sticky and warm on your face. Your broken glasses cut into your scalp, and the cut — like many scalp wounds — is bleeding profusely. Clamping one hand to your head, you you try to drag the deer off the side of the road so you can drive on, but it’s too heavy — the carcass won’t budge.
You head back to the car to find your cell phone, but you’re so confused you can’t find it anywhere. It’s dark, and it’s cold, and your car looks like it’s totaled. Your scalp is bleeding, you’re disoriented and confused, and it’s been over an hour since you passed an inhabited area. It’s too cold to get out and walk anywhere. You’re cut off. Alone. You spend the night keeping your car running, so you can stay warm, afraid you’re going to bleed to death, uncertain if and when you’re going to get help, having countless scenarios of impending doom running through your mind.
In the morning, a local deliveryman finds you and your car and the dead deer and radios for help. A tow truck comes and delivers you to the nearest town, which is just a quarter of a mile away, up the road, ’round the bend you couldn’t see in the dark the night before. You find your cell phone in your car’s glove compartment and you call a family member to come pick you up. Then you get on with the business of dealing with your totaled car, getting back to work, getting on with your life. You seem okay physically, with just the cut (that stopped bleeding) and a nasty headache. But you can’t get that vision of the deer out of your head, and you keep waking up in a cold sweat, your heart pounding, feeling like there’s something sticky on the side of your face.
Now, this is not to say that someone without a TBI wouldn’t have the same experience. But having thought processing slowed can contribute to slower reaction times, poor judgment calls, and impaired coping techniques… which can contribute to and complicate bad conditions, making them worse than need be — and making them seem worse, too. And that can happen not only with someone who has a TBI going into a tight spot, but someone who experiences a TBI and then has to deal with challenging situations with an injured brain. A double whammy.
The forth way TBI can contribute to PTSD is by making everything seem a whole lot worse than it is.
With TBI, impaired risk assessment can go both ways, I believe. It can not only be impaired, but it can be hyperactivated. TBI can make you think things are lot more hazardous than they are, that you’re in more dire peril than you are, and that you need to respond more intensely than you necessarily need to. PTSD alone can do this, but when your brain isn’t firing with all pistons, your impaired judgment just feeds the PTSD fire.
So, even if you don’t end up in that car accident, or you really aren’t in danger of getting your ass kicked by that Very Large And Angry Person, or you walk away unharmed from a fall that was broken by soft snow, your (impaired) perception of “immediate danger” can trigger a bunch of biochemical reactivity that puts you very much on edge and eventually adds up to full-blown PTSD.
Warning, Will Robinson!
You may not be in danger at all. But your injured brain tells you that you are/were. And your impaired judgment, thinking it’s protecting you from a perceived threat, gets the gears going and sets off a potent chain reaction that — while bothersome at first — can lead to serious trouble, on down the line.
So, there are several distinct aspects to how TBI affects the proximity factor of PTSD (including, but not limited to):
- It can create conditions of actual physical proximity to danger by impairing someone’s ability to detect (and avoid) risk/danger.
- It can make a person’s responses more intense and/or more precipitous, so they overreact to situations and put themself (unintentionally) in danger.
- It can keep someone from getting themself out of trouble in a timely manner and keep them from adequately dealing with an existing tricky situation.
- It can heighten the perception of physical proximity to danger.
All of these (and I could think of a bunch of other examples, but I won’t take up the time here), not only do a number on your head, but also on your body. PTSD is very much about physical reactions… and they tie in with mental processes. So, if your brain is impaired by an injury, and you’re backed into a corner (or think you are), you can end up with a more potent mix of trauma experience that heightens the post-traumatic stress impact.
And that’s no friggin’ fun.
8 thoughts on “PTSD/TBI Factor #1 – Proximity to a traumatic event”
This is so true! Good insights, very validating…
After my roll over accident and acquiring this “mild” TBI, (only “mild” if you don’t have one:) I was diagnosed with PTSD. I was outraged I remember, the psychiatrist, seemed to focus on this issue alone. I live in a very rural area and the next “big city” is almost 4 hours away. Seven years ago, they did not have much experience with TBI’s here. That has changed. The doctor I mentioned relocated and I no longer see him. I have had time to take in the PTSD diagnosis and realize I do have it. I have a wonderful doctor now. Education on brain injuries has increased and along with ADD, I know now that they “go along” if you will, with my TBI, in my case. I must say that I have never had it explained as well as here on this blog. My new doctor explained it in this way; I just didn’t get it I suppose. After my accident, I lost my business, had to give up homeschooling my kids, my husband tried to save my store, but everything spiraled in a daze and we lost our home. The kids still, have this huge “hole” from not owning a home, or rather, not having a “home” of their own. We have been in one rental for over 3 years, and still in a state where buying a home is not very expensive, we struggle do to my lack of income. I have begun to sell handmade things, do mixed media art, photography, and trying to find an extra source of income. I was a “stay-at-home” mom for so long that I do not qualify for Disability. Struggling with what was lost, not only our home, but my lifestyle, the “mom” that engaged fully, daily, with four kids, even the ability to handle a boy scout meeting, and a trip to the grocery store in one day, yeah, it is pretty traumatic. I have been reading and appreciate your blog very much. Seven years later, I am trying to embrace and flourish in the “new” normal. Some of the choices I have made, poor judgment calls, such as in my mind, a wonderful gesture of laying a wreath on a friend’s mom grave I made for her. Simple. Not so much, they don’t plow cemeteries. The snow seemed to be maybe a foot high, “I got this.” Well my cell phone in my pocket to call for help was my savior as I sank, wreath still above my head, in snow up to my chest. I spent so much time trudging through the snow trying to locate the resting place, was confused and cold. It was in the negative temps and I really do not know what I was thinking. The poor judgment, not even thinking clearly, could have been a disaster. Thanks for all the great info and to know you’re not alone, is very helpful. On to find the new normal and try and flourish, or at least not freeze.
Thank you so much for writing. And thanks for your kind words. I really believe that the link between MTBI and PTSD is under-researched and misunderstood, with the result that countless people fall between the cracks and don’t get the help they need. Mild traumatic brain injury does such a number on our lives. Who *wouldn’t* think we’d develop PTSD?
The things you talk about sound very familiar – having something explained to you, but not getting it… the life changes because of the injury, and the difficulty coming back. Going to the cemetery in chest-deep snow sounds exactly like something I would have done, myself. It’s good you had your cell phone handy.
I once went for an off-trail hike to see if I could see some deer, early in the morning — during deer season. If the hunter that had his rifle trained on me hadn’t had good judgement and hadn’t waited to shoot (I wasn’t wearing any bright colors – I was in brown and green clothing), I could have been seriously injured – or worse. You’d think, having grown up with deer hunters in a rural area, I would know better – right? Yeah, not so much on that morning.
Fortunately, things have improved a great deal for me. What has helped me, has been learning to stop and think before I do something rash. So many times I am convinced that something is a *great* idea, only to wade in and discover it is nothing of the kind. So, I’ve learned how to “talk myself down” from things like making a promise to do a favor for anyone within earshot, as well as committing to a certain activity — things are usually a lot more complicated than I expect them to be at the start, and then I run out of steam, and I go through the same old “you screwed up again” conversation in my head.
Then again, sometimes I think that doing something is a terrible idea and it will only lead to ruin, but that’s just the voice of fear and anxiety. I have stopped myself from doing a lot of great things, because of anxiety about the unknown. I can’t even think about it, half the time, because it is seriously depressing.
It’s hard to tell, unless I try things out. And it’s not easy to find a balance between thinking things through and over-thinking them… between being courageous, and just being plain stupid. It’s a balancing act, I guess — but with plenty of rest and a positive attitude, things have a way of (eventually) working themselves out.
Thanks again for writing and have a great day.
I like that; “talking yourself down.” It may sound weird but there are times that my “great ideas”, get side lined due to an overwhelming problem with multi-tasking, and I find that sometimes now that the idea has sat and I have thought about it, it wasn’t that great. I also love the part about not doing a favor to everyone within earshot. I do take on projects people ask me to do because I am honestly, good at the task. I then feel an overwhelming disappointment with myself when I can’t get them done in the “normal” time frame that people might expect. I so can relate to the “you screwed up again” feeling! I beat up on myself, feeling bad, go into panic mode, and become sleep deprived, when I rarely get more than 5 hours anyhow. And all it would have taken is a simple “no.” I guess from reading your blog, I have to begin with myself and reach within to find my “balance.”
It is making my kids freak a bit I must say, they are getting older and much more demanding with places to go and people to see, and it throws me for a loop just getting them to this or that.
I sometimes feel (no offense meant at all, my father was in the Navy for over 10 years and fought in Vietnam), that most of the PTSD and TBI information is surrounded by one obtained in the military. I just wish the “civilian” community and doctors would realize that it is found here in our civilian world as well. I imagine if the two shared, maybe there would be more insight? How the accident happened, events that took place after, and possibly this culture we live in plays a part. I haven’t figured that all out yet. On with my “to do’s” for today. Goal for this week: Do what I can, let others help, and say “no” when I just really can’t. I long for time to draw in my art journal; I have a problem with line and form and want to just “play” on my sketch book! I will find the time. Have a great Sunday.
Thanks for writing, helps me think about “thinking first” 🙂
Thanks for writing. I think you’re absolutely spot-on about TBI and PTSD coming from the military. At least, that’s the mainstream understanding of it. The other problem I have with PTSD information, is that so much of it comes from the psychotherapy “camp” that serves victims of incest and rape and other sorts of assault. So, many (most) of the conversations are centered around extremely difficult situations that are hard for people to hear about. Tying PTSD to sexual assault has — in my opinion — been one of the biggest “strategic” mistakes of the therapeutic community.
Not everyone needs to be shocked to get the point.
Meanwhile, so many of us are suffering in silence, because somehow our trauma doesn’t quite rate highly enough, or it’s not supposed to even matter, compared to the other horrors people — civilians and military — have been through.
My argument is (and may always will be) that the initial trauma is just the start of the traumatic cycle for mild TBI folks — we continue to be traumatized by our changing lives and our sudden shifting circumstances, being constantly taken by surprise by the alterations within us, and building up a real backlog of biochemical sludge from all the upset and drama… not to mention the abandonment by just about everyone and everything that used to sustain and support us.
This is based on my own personal experience and observing others, and there’s also a ton of science to support this. But because daily doses of stress and strain don’t quite register on the extremes-oriented richter scale of the rehabilitative community, we’re pretty much s.o.l. when it comes to finding help and getting the assistance we need. I’m included in that — the person I’ve been working with to deal with my issues has been helpful to a tremendous extent, but they still have real gaps in their abilities, partly because they seem to think they have things all figured out, and partly because they don’t apparently “get” the cumulative impact of seemingly minor upsets over the course of days, weeks, months, and years.
Mild TBI is terribly isolating — first within our minds and spirits, second within the larger community — and even the experts don’t seem particularly interested in helping us out, because even they cannot tell just how difficult it is for us.
It makes me truly sick at heart. The good news is, we have the internet. There are also a number of core activities we can do, to get our proverbial boats righted in the proverbial water, and we can take it from there. But in many ways, we really are on our own. Sometimes that sucks, but in other ways, it’s actually beneficial.
Personally, I can’t imagine interacting with tons of people who want to help me everyday. That would get old pretty quickly.
Anyway, enough from me. Have a great week.