The hazards of mtbi micro-traumas

Another Monday, another week. The weekend was pretty good, all things considered. I got a fair amount done, and I also had some time to just relax. Not much, but some.

I did a little reading about “The Cognitive Control of Emotion” by Ochsner and Gross, who say

“Conflicts, failures, and losses at times seem to conspire to ruin us. Yet, as Marcus Aurelius observed nearly two millennia ago, we humans have an extraordinary capacity to regulate the emotions occasioned by such travails. Importantly, these regulatory efforts largely determine the impact such difficulties will have on our mental and physical well-being.”

They also include a good quote from Marcus Aurelius:

If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.
Marcus Aurelius (Meditations)

The rest of the paper is about fMRI results and neural mechanisms, most of which went over my head because I’ve been having trouble focusing and comprehending what I’m reading. I’ll have to go back and re-read it, because I believe there’s something in there I can use. But the thing that I took away from it, is that we actually can choose how we will experience and react to and emote over our circumstances, and the better we are at that, the better off we may be.

Or course, this doesn’t speak to people being in just plain crappy living situations, but there is at least a little bit there that I can use.

Anyway, I’ve been thinking about how bent out of shape I’ve been for the past month or so. It feels like a whole lot is piling up with me, and I haven’t been able to get out from under. Certainly, not getting enough sleep is not helping. I’m working at turning that around. It’s slow going, but at least I’m making the attempt.

And I’ve been thinking about all the things that have gotten me worked up, bothered, troubled, anxious, etc. A lot of those things aren’t even that big a deal, on some people’s scale. But for me they are. And they seem to add up a whole lot faster than one would expect. It’s a little dispiriting, but that’s how it is. Everything adds up. Quickly. Even the little stuff.

Especially the little stuff. I have a name for all those little things that “shouldn’t” bother me — micro-traumas. Specifically, mtbi micro-traumas. They’re the little things that get under my skin and set me off — because I’m tired and/or stressed and/or not paying attention. They’re the little things that “shouldn’t” happen because regularly functioning people don’t have these problems — like waking up one morning and not being able to read or write as well as you could the day before… like forgetting so much stuff that if you don’t write it down, it might as well not even exist… like getting incredibly bent out of shape over developments at work that most people take in stride… like flipping out over dropping a spoon while you’re making your breakfast.

Those little experiences, those tiny explosions, may not seem like a whole lot in and of themselves. But when they happen again and again and again, tens (even hundreds) of times a day, they add up. And they wear at you. It’s like a death by a thousand cuts. It’s not even the exact events themselves that constitute the explosions — it’s the experience of those events, the biochemical bursts and blasts and ka-booms that take place out of sight of anyone else, that set you on edge and tear the living crap out of your interior.

Isolated and not considered in light of the continuous whole, these explosions, these micro-traumas probably don’t look like much to the outside observer, but internally and over time, they add up. And they add up to cumulative trauma — just like all those sub-concussive hits (from practices and full-on collision play) take down professional football players years later, the micro-traumas that bombard mtbi survivors day in and day out also take a toll. And it all adds up.

This is coming back to the ANS balancing issue I talked about yesterday. And it also ties in with PTSD and resilience. I really believe that unaddressed TBI issues — especially “mild” TBI issues — lend themselves extremely well to creating an everyday “substrate” of stress and fight-flight orientation, which erodes our personal resilience and gradually over time in countless invisible ways pulls us down into a way of life that is hallmark PTSD. For all the talk about traumatic brain injury, there is remarkably little overlap between the TBI and PTSD conceptualizations, that I can see. Everybody is trying to establish that THEY are the ones who have it all figured out, and precious few people are giving quarter. But that’s a bit dense and self-serving. It’s also not practical, nor is it accurate. The two overlap and feed into each other — obviously (to me at least) — and any approach to TBI recovery (yes, I’ll say recovery) must necessarily include an approach to trauma that is patently unlike the talk-therapy approaches that just serve to drive us half-mad with all the emotional stirring-up and provocation.

Let me put it simply. This is what I believe:

  • That Traumatic Brain Injury is by nature a traumatic event. It is a physiologically traumatic event. Even if the individual is not aware of their environment at the time of injury (or they forget it due to their brain trauma), their physiological experience nevertheless primes them for trauma.
  • The nature of brain trauma, as a fundamental insult to the very command center of so much of our functioning (as well as the biochemical reactions which take place as a result) puts the body into overdrive to both survive the injury and escape the imminent danger that TBI poses to the individual. The brain has to work overtime to recover and come up with compensatory techniques. And the individual can be in a perpetual state of insecurity and confusion and fight-flight, because their usual ways of approaching life are no longer available the way they once were.
  • The extreme fluctuations of emotion and ability, can fire off biochemical reactions that are disproportionate to many of the events. This is a function of an over-tweaked autonomic nervous system which is “stuck in high gear” like a Prius with its floor mat wedged to the accelerator. The injured individual can be so confused and disoriented that their ability to monitor and understand their own situation can be completely compromised, which leads to more stress — Post-Traumatic Stress.
  • To make matters worse, the general cluelessness (even hostility) of the surrounding social environment exacerbates things even further, by insisting that everything should be fine, that there should be no problems, and that the TBI survivor should be able to function as they did before. This puts the survivor into an all but permanent fight-flight mode, eventually either pushing the parasympathetic nervous system out of the picture or creating wild swings between the two ANS branches, which totally screws things up (that’s my scientific assessment 😉
  • This is especially true of mild traumatic brain injury survivors, whose brains are still rewired and who have to make more subtle changes and advances, in the face of — among other things — cognitive fluctuations, and surprisingly extreme and shocking biochemical reactions to “non-events”.
  • Unless and until a TBI survivor deals with the trauma aspects of their situation (no, not “They did this to me, and it hurt” kind of dealing, but the physiological effects of the biochemical roller coaster), they can continue to suffer and continue to struggle. Long-term prospects may actually worsen, as their post-traumatic stress is exacerbated and accentuated by ongoing issues which have not been properly balanced by exercise, rest, nutrition, and plenty of water.

It might sound over-simplistic, but may be to some extent it is that simple. And in the end, I believe that TBI survivors are not going to get proper care and assistance until the physiological aspects of trauma recovery are fully explored and matured. The vast majority of trauma research that I have encountered has to do with psychological trauma, and certainly there is plenty of that. But approaching trauma only in terms of psychology, and addressing it only in terms of talking and emoting (both of which can be extremely taxing for TBI survivors to do with great success), is just pulling us backwards.

It’s not helping.  There has to be a better way, and I think I have actually found it.

Whether anyone in a position to study this and pursue new courses of treatment is going to catch on, is anybody’s guess. I do believe that the military is the closest to making progress on this front, due to their increased focus on Total Force Fitness. They have a vested interest in coming up with what works, because their (and our) survival literally depends on it. And it is in their research that I find the most hope and the most useful material to work with, at this time.

Researchers at institutions may or may not get it. I think in fact that they usually don’t, in no small part because they are so far removed from the issues, personally speaking. Doctors and therapists may or may not get it, because of their indoctrination and their intellectual biases (plus their own trauma issues get in the way). Those of us out here walking around in the word trying like crazy to figure out WTF is going on in our lives… we’re like mobile laboratories, chock full of anectdotal tidbits.

We’ll see if things change. But for now, it’s time to go to work. Onward.

Advertisements

From the DCoE – Mind Body Skills for Regulating the Autonomic Nervous System

Warrior Resilience Conference – Thank you for your service – at home and abroad

Last June, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury released a report (pdf) called Mind Body Skills for Regulating the Autonomic Nervous System, which surveys a number of techniques for regulating the fight-flight and rest-digest functions of the ANS.

I may have seen this before, but I honestly don’t remember. In any case, I’m recording it now here on this blog, so I can remember and find it later. I also saved a copy to my hard drive, and I am reading through it.

The ANS has been hugely important to me over the past years of my recovery. When I am able to step back and objectively view my progress and my capacity to live well, I can generally judge from the degree of ANS balance, how happy, productive, and involved I am in my life. More ANS balance = more sense of well-being. Less ANS balance = struggle and difficulty and feeling useless. And that holds true, whether I am more unbalanced towards rest-digest or towards more fight-flight. Either way, it’s a recipe for struggle and difficulty.

ANS balance is hugely important to me. And the mind-body approach is the often-missing piece of TBI recovery that I’ve been filling in myself, along with weekly visits to my neuropsych, to help balance things out. When I have kept my fight-flight/rest-digest nervous system activities in balance, things have usually been going well. When I have not had them in balance, things have gone rapidly south, and it’s taken me weeks to get back to where I am functioning to my satisfaction again.

I’m smack-dab in the middle of one of those recovery periods right now.  It’s taking me longer than I expected, to “right my ship” so to speak, and it’s frustrating and feels defeating, but I do feel like I’m getting there… gradually. I do need to be easy on myself – pushing harder has a way of setting me back, ironically. It doesn’t feel “right” but backing off and paying attention to the small things, while letting events take their course and work themselves out, seems to be what works best for me.

The main thing is to not get all caught up in myself and get down on who I seem to be at the moment. I keep seeing this slogan, “Life isn’t about finding yourself – it’s about creating yourself.” I agree. And I really believe it’s also about creating things that benefit other people — about literally making the world a better place through our words and thoughts and deeds.

When I don’t take care of my ANS, and I allow myself to wallow in that awful feeling of sympathetic overdrive, things tend to not go so well. I also tend to get down on myself AND not be able to see the future prospects ahead of me. The more I strive, sometimes, the more depressed I get — someone once said to me that depression is the result of driving too hard for too long, and having your system get fried, without allowing it to catch up and rest. I can see that in my own life – in the way I get so down, after I have been so up.

My neuropsych once told me about an individual with TBI who had been diagnosed as “bi-polar” by their doctor, and they’d been put on meds for it. The doctor believed that they had a “short cycling bi-polar disorder” where it took them less than a day to run the gamut between manic episodes and a depressive crash. My neuropsych worked with them to work out their daily routines and activities, and when they had gotten some balance, back — poof, the “fast-cycling bi-polar disorder” was gone.

Now, I’m not a doctor, and I’m not board-certified to make diagnoses and prescribe treatments, but in my own life, I can see a direct correlation between episodes of intense activity (even if it is activity for the greater good and/or activity that is beneficial to me), and sinking into a pit of despair. I can see patterns of lots and lots of activity being followed by an extended crash.

So, regulating my ANS — when I remember it — is really a big key to me keeping stable and sane. (If you have any doubts, check out the posts when I have not been at my best – 9 times out of 10, they came at times when I was stressed and in full fight-flight mode without respite.)

Seeing the Defense Centers of Excellence releasing a report on Mind Body Skills for Regulating the Autonomic Nervous System is really encouraging to me. I have been very troubled by the lack of support and assistance that’s been offered to our returning vets (thank you to all of you for your service, by the way). It sort of seems to me that a report like this is a way for the DCoE to provide extended assistance in the way of ideas that people can learn and use to help take care of themselves. I think it would be absolutely impossible for the VA to provide personal assistance to each and every vet who returns — especially because there are so, so many who are returning with brain injury issues, and so little is actually known about brain injury AND each injury is a little different, so short of providing a full comprehensively trained team to assist each vet who returns, the level of care is just not going to be enough, coming only from the VA. There aren’t enough people and there isn’t enough money to do it all from one central source. We literally need to pull together as a country and provide support in a variety of ways.

But a report like this from the DCoE is a step in the right direction.

The cover these topics:

  • Introduction and Background
  • Practices for Regulating the Autonomic Nervous System (ANS)
    • Emotions, Arousal and the ANS
    • Breath Techniques for Regulating the ANS
    • Posture and Tension-Modulation Techniques for ANS Regulation
    • Mindfulness, Meditation and Guided Imagery
    • Mind-Body Programs
    • Biofeedback

There are other approaches, and I’m sure time will show changes to how each of these is perceived. But it’s a start. I’m having a little trouble focusing today and keeping my attention on what’s in front of me, so I can’t speak in depth about what’s there. I haven’t been able to read more than a page at a time, honestly. But in the coming days and weeks, I hope to see that change. And I’m taking steps to get that to happen.

I encourage you to follow the link and read up on it yourself. There may be something good in it. In any case, the report was created in the interest of strengthening troops in the face of new kinds of war, and since dealing with TBI can be a series of battles, in and of itself, I can see how this same orientation might benefit me and many, many others.

These techniques are not just for soldiers — although they were explored with soldiers in mind. They can help the rest of us, too.

Now obviously, there can be no true comparison between coping with the daily micro-traumas of TBI, and being deployed three times to several different desert battlefields. The scale and quality is completely different. But in principle, if not in practice, there are ideas and habits that can cross-pollinate and assist on many levels. In TBI, especially, where we are so often in uncharted territory, it makes no sense to write off a potentially beneficial approach because of perceived differences between cases. We have to pull out all the stops and do everything we can to achieve what progress we can.

Now I need to pull out all the stops and run some errands. Life goes on.

Or was it a traumatic brain injury?

Source: http://www.army.mil/

I’m reading Mindsight by Daniel Siegel, these days. I’ve been slowly making my way through it while I ride the exercise bike each morning. 15-20 minutes is about the right amount of time for me to read and ride. I’ve been wanting to learn more about mindfulness, and this mindsight variation of it, which (from what I gather so far) involves intentional focus on something specific, seems like it could be quite useful to me.

Apparently, the practice of “mindsight” helps to physically build connections in the prefrontal cortex, which is where complex processing and social “maps” are created. I’m not 100% clear on all the details of it — I’ll have to re-read the book, most likely — but it looks promising.

One thing that grabbed my attention right off, was the opening story about a family that came to therapy, because one of the kids had stopped talking. She was selectively mute, except at home. One thing that appeared to be the main factor was that her mother had sustained a traumatic brain injury in a car accident, and she was no longer the same person she was before the accident.

Needless to say, that got me to sit up and pay close attention.

The story culminated with the little girl starting to talk again, but the mother was still relatively incapacitated. The discussion of the family situation was a lot more about the little girl, than about the mother, so I didn’t get much more out of that account that could help me, specifically relating to TBI.

Later, in the second part of the book, the author talks about a young man who came to see him who was essentially a normal teenaged boy — 16 at the time — but who was having a lot of trouble with feeling low, crying in bouts that came out of nowhere, and flying into rages over relatively minor incidents. His explosions of rage were getting worse, he admitted sheepishly, and both he and his parents were increasingly concerned. He was depressed, and he sometimes had thoughts of suicide.

He hadn’t always been this way — this had started around the time he started middle school, when he was 13. He’d had some outbursts, but everyone thought he was just being a teenager. Still, things were getting worse.

The diagnosis that might have been assigned to him, according to his symptoms, was either depression or bipolar disorder.  But the description of his situation sounded a whole lot like a concussion or mild traumatic brain injury to me, when I first read it. We pretty much always see what we’re trained to see, so of course I thought, “That kid’s not mentally ill! He’s dealing with the after-effects of a head injury that either nobody realized he’d had, or they didn’t take that seriously.”

Indeed, reading about this guy’s situation — the  unprovoked, uncontrolled rages, the bouts of feeling down, the general blah-ness, the crying jags that came out of nowhere, and the embarrassment about it all on top of it — really hit a nerve with me. It sounded all too familiar. And I wondered if he might have had a concussion when he was about 13. Maybe he got beat up at school. Maybe he fell off his skateboard. Maybe he had a bike accident. Most TBI’s happen to boys, so the odds are not exactly against  him having sustained a traumatic brain injury.

I’m no psychiatrist, of course, but I wonder… if mental health professionals first screened for TBI before they cracked open the DSM, what would that mean for mental health care in this country? How many people would be kept off medications — a TBI can really muck with your body’s sensitivities to medicine — that they either didn’t need or couldn’t tolerate? How many people would have actual answers to why their behavior has evolved as it has? How many people would be spared the stigma of a diagnosis of “biopolar disorder”?

Of course, the stigma of traumatic brain injury could be even worse — and given the low level of awareness around what TBI survivors are like in real life (especially mild TBI survivors), a TBI diagnosis could socially do more harm than good. Perhaps.

But still, what if screening for TBI were the first thing that happened, instead of some afterthought or the result of a chance inquiry? What if instead of medications and talk therapy, a regular regimen of exercise and good sleep hygiene and a battery of taught coping skills for their specific difficulties were prescribed? What if, instead of medicating kids who are having these kinds of troubles, we took away their mobile phones and cut off their texting and IM’ing at least an hour before bed, and enforced good sleep hygiene — or else? What if we had them get on a treadmill or an exercise bike for 20 minutes, before anything else happened in the day?  What if people could see past their conditioning and their formal training, to see the underlying physiological/neurological underpinnings of these kinds of conditions, and clinicians were open to the idea that structural changes in the brain could be the root cause — and the best way of addressing that is NOT to numb/dull the symptoms, but build in new neural pathways to “route around” the compromised areas?

If you come to a washed-out road on your way to an important appointment, you don’t pull the car over, wring your hands, talk to someone for hours about how sad it is that you can’t go that normal route… and take a pill to take the edge off your discomfort while you contemplate your bad fortune. You turn the car around, and you go find another route. The brain’s neural pathways are much the same as the roads we travel in larger life — if one route doesn’t get us where we need to go, there are other ways to get there.  Imagine what would become of us, if we all did the logistical equivalent of diagnosing a disorder, and then coming up with a pill to take the edge off the discomfort of our inactivity… Would anything ever get done?

Of course, what really drives a lot of the diagnosing is the DSM, is that fact that it  offers codes to plug into insurance forms. So you can get your care paid for. And it has designations of disorders which map to certain drugs and therapies — TBI is not nearly as clear-cut or straightforward as a “standard-issue” mental illness. Not enough is known about it. And not enough people (therapists, doctors, and other sorts of clinicians) are willing to take on the seemingly daunting task of dealing with an injured brain at the neurological level.

What’s more, there aren’t any clear, easily obtained, ready-made, neatly packaged treatments for TBI, that people can prescribe and dispense. TBI recovery is an extended process, and a tricky one at that. It could lend itself well to a hybrid sort of therapy, which involves cognitive behavioral elements, nutritional and fitness education and coaching, not to mention plain old-fashioned talking things through with an impartial party who has a good head for what you’re tackling. But that sort of treatment (from what I’ve seen) doesn’t yet exist. What’s more, TBI has a nasty way of telling you you’re fine, so even if you do engage in that therapy for an extended period of time, you’re prone to quit, ’cause you think you’re all better now (and then you’re likely to end up back in therapy again, after things get mucked up all over again).

It’s worth the effort and well worth the investment of healthcare professionals to develop a system like this. But until people get more educated — and they stop being so afraid of the brain — and they develop formally recognized ways of dealing with TBI, a mental illness diagnosis is the most likely thing one can expect from a trip to a clinician for help with inexplicable mood and behavior issues.

Which, frankly, sucks.

We need a better approach. And we need something that works. ‘Cause no therapist I know of is going to start poking around looking for trouble that they don’t know how to solve — or that seems innately unsolvable.

Until we do figure out how to solve this brain injury problem, it’s going to keep getting categorized as good old-fashioned mental illness. And in that case, a lot of us are probably safer going it alone, rather than seeking out clinical assistance in the mental healthcare swamp that’s lined by the slippery slopes of DSM-driven diagnosis.

But let me ponder this a while longer. Maybe practicing mindsight will help me settle down the outrage and frustration I feel and channel it into more productive activities, than cursing the darkness that seems to surround us.

“So, have they tried to label you bipolar?”

Thus asked my neuropsychologist, the other day.

I was telling them about my psychotherapist friends who are well-meaning, but ascribe all kinds of cognitive and behavior issues to psychological ones.

I’ve been labelled all sorts of things by psychologist types — obsessive-compulsive, depressed, manic, repressed childhood sexual abuse survivor (which to my knowledge, information and belief is not the case), etc. — and I told my neuropsych as much.

“Or, maybe you just got hit on the head a lot,” they said, shaking their head in frustration. And disbelief.

They also told me, that visit, about another patient of theirs who had been diagnosed with “rapid cycling bipolar disorder” because they were slow and sluggish getting up in the morning, their mood picked up in mid-day, and then they wound down at night.

Turns out, they just had a wicked case of ADD and their brain worked more slowly at the beginning and end of the day. But they had to get saddled with an “extremely rare version of bipolar disorder” diagnosis… and perhaps have to take god-knows-only-what-kind of meds, on top of it.

Sometimes the mental health profession just makes me crazy nuts. Do they do it for job security? I have to wonder… 😉