I’ve been reading Robert Scaer, M.D.’s book The Body Bears the Burden, thinking a good deal about the role of trauma in traumatic brain injury.
Trauma in TBI, I believe (from personal experience and observation of others’ lives) happens both during the injury and afterwards.
It’s not just the injury itself that brings on the terrible sense of threat to your very existence — it’s the life afterwards that emerges, when you are forced to face up to changes in your life and your personality and your capabilities that require a whole new way of working.
The repeated shocks and hurts and surprises and disappointments and the overwhelming sense that you’re not who you are anymore — and your whole existence is in question — threatens us on such a deep level, that the trauma of the initial injury can sometimes be dwarfed by the after-effects of the changes.
Suddenly, you’re angry all the time — for no apparent reason.
Suddenly, you can’t read things and understand — and you don’t find out till after your job (which depends on your reading comprehension) is in danger.
Suddenly, your balance is off, you can’t tolerate light and sound, and you’re breaking down in tears over nothing.
Who IS this person? Where did you go? And who has taken your place?
This change and the questions that arise can be abrupt and alarming — and the worst part is, it’s an internal storm that rages, almost (but not quite) in plain view, vague enough to elude explanation, but pervasive enough to disrupt much about your life — and throw you into a tailspin about the rest of your life which hasn’t been impacted, but might be.
If this doesn’t constitute a threat to your existence — one of the chief requirements for the classification of trauma — I don’t know what is.
So, as we approach traumatic brain injury, let’s not just focus on the brain. Let’s focus on the trauma, as well. Let’s help the countless folks out there — including our returning wounded warriors bearing the signature wounds of the Iraq and Afghanistan wars — who are struggling with both TBI and PTSD, and watching their symptoms get worse for no apparent reason.
Let’s stop dividing up the treatments into “disciplinary territories” and discounting the importance of body and mind and heart and spirit and how they interconnect to create the whole of us.
Traumatic brain injury has been getting a lot of press, lately, with regard to the brain. But unless we seek to understand trauma as diligently, I fear we are a far cry from a comprehensive solution for this widespread issue.
6 thoughts on “Understanding the trauma in traumatic brain injury”
I wanted to respond to your previous post and then interestingly you wrote this and now I feel even more compelled.
Let me start by saying that I FULLY agree and support the idea that traumatic brain injury and mental illness are two distinct ‘disease states’ with different etiologies. I also support (and indeed have advocated for) the separation of mental health systems and brain injury systems. Now having said that…..
In addition to my TBI work I have in past done work with NAMI on mental health – and I have strongly supported their goal to de-stigmatize and educate people on mental health issues.
I believe the psychiatrists are very much co-opted professsioanlly by insurance companies and the drug companies. Yes, I have friends who are psychiatrists and I don’t mention this to them at parties but lets face it – insurance doesn’t cover comprehensive psychiatric care unless you are given a serious dms-iv label, the drug companies pander to these labels and push off-label use of BILLIONs of dollars of drugs (with VERY serious side effects), most psychiatrists DO not provide any kind of therapy outside of pharmaceutical, the American public wants the quick fix and most significantly – we have absolutely NO STANDARD for normal.
That last one is very important – our culture and society has changed – and yet we still persist in holding onto many ideas of what makes normal – these is based on male, white guys of a certain class and not a lot of other folks. Just as they discovered that women have different symptoms for heart attacks and strokes I would suggest this be true for emotional behaviors. Culture, community, economic status etc also are likely to express themselves in what constitutes as mentally healthy. This concept is not directed at a small subset of people – rather it is a goodly percentage of folks who are taking mind altering drugs.
What is mental illness? If you take it down to its bio-chemical basis it is a disruption or alteration of neurochemical response that produces behaviors that are detrimental to the full functioning of an individual in society.
What is a TBI? If you take it down to its bio-chemical basis it is a disruption or alteraration….you get the drift.
Furthermore I will make a very controversial statement – I honestly believe that EVERYONE who lives with a TBI has had to deal with ‘mental illness’. This can be in the form of changed behavior which is a direct result of the injury but equally it is also because of the emotional response to living with the cognitive and perceptual changes wrought by the injury. Including the trauma of the experience of the injury.
Its taken a long time but oncology specialists and cardiology specialists have come to finally acknowledge that there are psychological response to cancer and heart attacks – psychological responses that are a reaction to the illness but also may be psychological issues that existed minimally before but are not brought to the forefront due to the vulnerability and trauma of experiencing a near mortal event.
These ‘secondary’ psychological responses can produce a number of classified mental illnesses. Certainly having a physiological problem that goes undiagnosed but which impacts your ability to function creates a psychological set of behaviors that may take years (if ever) to unravel – a person gets conditioned to react and feel and think a certain way.
Furthermore the trauma, the awareness of loss and possible death, the changes to personal and work relationships, changes in lifestyle etc AND the physiological damage all make TBI survivors MUCH more likely to experience depression. I have long believed that depression serves a biological purpose for people – it is a mechanism to ‘depress us’ – to bring us down, slow us down , get us to a reduced state of functioning so that we can address something that is out of whack. Maybe this is why it is correlated with brain injury.
At the same time I recently attended a lecture on Alzheimers (TBI survivors are at a higher risk for Alzheimers) – and one of the key prophylactic measures against Alzehimers is cognitive stimulation – cognitive stimulation is linked to neurogenesis – and this includes physical stimulation – such as exercise. In fact you have mentioned this in recent posts. I actually think many mTBI survivors actually crave stimulation and seek it out in some form or another. It can be risky behavior, or a renewed desire to study or learn (I am endlessly surprised by how many TBI survivors go on to get advanced degrees AFTER their accident – and sure there are many factors involved, including the need to prove they are capable, but it seems that the ones who are included to knowledge NEED it), some pursue physical activities (I certainly did both academic and physical things), some mute the urges through alchohol and or drugs which provide a false stimulation etc. Certainly it seems reasonable that if a key factor in maintaining cognitive health is to keep stimuliating your brain in healthy ways that this also plays a significant role in recovery.
At the same time however – as you also mentioned – even TBI survivors with complex cognitive abilities can struggle with ‘quirky’ behaviors such as perseverance , initiation and a tendency t o see things as black and white – I can either be dull or hyperactive, I can either be happy or sad. And most folks – TBI or not – tend to think that the immediate situation is static – thus if I am feeling good I should not expect to feel bad – or if I am feeling bad I should not expect to ever feel good again. TBI folks may even take this to a greater extreme – because they fear the loss of initiation, because of perseveration, because they fear they will forget what they must do, or because they want to feel accomplished, or simply because they lack impulse control, they have a great need drive to have something ‘done’ – complete, accomplished – and thus the art of doing a little bit every day towards a goal is harder for them to manage. hey have a need to say ‘it’s done’ and so they can push themselves beyond what is reasonable They exhaust themselves, go into overdrive and demonstrate almost manic behaviors.
And of course society doesn’t help – our culture asks this of us; and if we have trouble with boundaries, if we are not easily able to manage conflicts (because we fear our loss of control) we don’t learn how to say no or temper a situation – we take on too much expect too much. As long as we can get it done we feel okay. But when we go beyond, when we fail, when we drain our cup – then we get angry at ourselves, we feel frustrated and get caught in a negative cycle. Then we explode, or collapse or cry – and we start again.
Behind those cycles are feelings, emotions, and emotional moods – all of which do a pretty damn good job of imitating mental illness – which indeed ARE mental illnesses. And there is no shame in that, no loss, no crime, no weakness or failure or anything at all. If you go through life struggling with communication or vision issues, memory problems, vertigo, distraction etc it will take a toll. It will create circuitry and neuronal pathways that might – if they could be visualized – look just like someone who had a ‘mental illness’.
One of the problems with telling someone they have a mental illness is that the only tools people see to fight that with are drugs and talking about their past. But many (not all but many) of the current set of mental illnesses are similar to brain injury in that the way out is to rebuild or recreate the circuitry. To develop new or compensatory cognitive responses, to see things not as weaknesses but as challenges or problems t o address – one thing at a time, one step at a time till you are at a level that works for you. Many folks with depression for example report cognitive deficits just like tbi survivors. And many tbi survivors who have made excellent recoveries will experience activation of their deficits under emotional stress.
Yes they are different and the practitioner who is helping needs to understand these subtle differences. But the prejudices against brain injury are similar to the prejudices against emotional illness. We say ‘Oh, thank god , it’s a brain injury – I am not crazy’ – but in truth I am not sure which is worse or which is better. And if you have a brain injury they become interwoven.
The neurological community is rapidly changing – in many ways for better but in other ways not – we are still looking for the magic pill for TBI but what I have found and what I have seen is that rebuilding is simply a process, repeating functions and making the same effort over and over and over. Which is exactly how people’s brains worked when they were developing – you learned skills through repetition of use, through making mistakes and adjusting yourself accordingly. You didn’t acquire the ability to focus or organize in one easy step. Indeed this is one of the reasons why I think it is so vital the TBI folks get the opportunity to work productively as soon as possible. IF they can do work and make mistakes and learn from them they will have a far greater chance to rapidly recover their skills and abilities than if they let their brain rebuild circuitry that does not include the recovery of certain abilities. The end result is that it is even harder – once that initial recovery phase is over your brain is even more reluctant to struggle through.
I said it before and I will say it again the brain looks to create the most efficient workflow processes it can – it looks for ways to build patterns in behavior, cognition, response and emotion. Aristotle said it – we are what we do – and its still true. Once we have developed habits – be it emotional or cognitive – they are hard to break.
As I said brain injury and mental illness are two different things – but neither one is better than the other and they share similar ancestry. We don’t know much about either one – because we don’t really know much about brains.
by the way BB – that is m who posted under another name….
Oh – and I apologize – the last two paragraphs were supposed to be deleted – but being that I am a tbi survivor I hope you can forgive the typos…..wanted to get this done tonight and not delay any more….:)
Not a problem – I made the changes to the comments, thanks.
I thought as much. Thanks for sharing.
Wish I had more time to respond in depth right now. Long day. Exhausted. More later.