PTSD/TBI Factor #1 – Proximity to a traumatic event

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!

Danger! Danger!

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.

Thinking about PTSD and Tetris…

I’ve been giving some thought to the whole “Tetris fixes PTSD flashbacks” concept, over the past few weeks.

Some people agree, others don’t. Here’s an interesting discussion over at Vetvoice.com about it.

I have to admit, I have found some relief while playing Tetris. It’s so interactively neutral — no people to shoot, no mortal danger to avoid, no sudden loud sounds and flashing colors to tax my already frazzled system. I have tried playing it when I was extremely agitated about stuff that was coming up in therapy… flashbacks, in particular. For whatever reason, I found the flashbacks subsiding and images of dropping brightly-colored Tetris pieces showing up instead of the shadowy figure appearing suddenly in front of me. It seemed me me that Tetris images were literally replacing the unwanted flashbacks.

Or maybe it’s just me. But I can tell you, my system really started to chill out. I don’t think it’s a coincidence.

One of the commenters at the discussion about this over at Vetvoice.com suggested. “And why not win every tetris computer game you play, while you’re at it design a new one!”

It made sense to me, so I decided to do just that. I’ve been working on alternative versions of the game, with different colors. My first attempts are a bit rudimentary, the changes being isolated to the colors alone. But it’s working.

Tetris Screenshot 1

Tetris Screenshot 2

Tetris Screenshot 3

You can get to “PTSTetris” by following this link: http://ptstetris.110mb.com/

I don’t know if it really works, but the logic seems sound. I think we can’t make generalizations all across the board about whether it will fix what’s wrong, but if nothing else, spending a few minutes rearranging colored blocks beats flashing back on wretchedness that intrudes on my regular day, getting all anxious and agitated and freaked out over stuff that happened a long time ago in a very different place.

I’ll probably be creating more color schemes, as time goes on, but for now, at least this is up and running.

Cheers

PTST – Post-Traumatic Stress Tetris

This has not been an easy few weeks. I tend to make light of my difficulties, and try to not get all mired in them, but between my job stress, money problems, social issues, and the resurgence of some pretty intense pain that just won’t quit, it hasn’t been a walk in the park.

I don’t want sympathy, but I do need to say it out loud, so I don’t keep denying the impact it’s having on me.

I think that Natasha Richardson’s fatal accident also threw me for a loop. There’s part of me that doesn’t understand why I could have so many bad falls and survive, while she didn’t have as rough a tumble (from what I read), yet she’s gone. On the one hand, I’m so very grateful to still be here. On the other, I am feeling some survivor’s guilt that is buried very deep and is taking a while to get to the surface.

On top of this, I’ve been dredging up some rough old “stuff” that happened to me 25 years ago that was pretty bad. Basically, I got my wires crossed with the wrong person — I wasn’t reading their social cues very well, and it turned ugly, and that person was not only an active addict and alcoholic, but they were overly aggressive, as well. So, I got my ass kicked. More than once.

It left me not only physically injured, but it set me back pretty intensely in other ways. I couldn’t figure out what I’d done wrong, I couldn’t figure out why it had happened, and I ended up isolating and acting out in un-helpful ways, and generally going downhill and ending up with some nasty post-traumatic stress.

Now I’m dealing with it in therapy, and it’s not pretty. I couldn’t have picked a worse time to deal with this, considering everything that’s going on with my job and health and bank accout. But there’s never a good time to deal with this crap, so what-evah. Fine. I’ll deal with this, too.

I’ve not been sleeping well, and I’ve been having flashbacks. Unpleasant stuff. Trying to navigate all this is bad enough, but my TBI situation isn’t helping. I’m pretty much at an impasse with what to do.

One thing that has helped me with my flashbacks, playing Tetris at http://www.gosu.pl/tetris/.

I don’t know what it is about the game, but I’ve been playing it, on and off over the past couple of weeks, and it actually seems to be helping me with flashbacks. Something about the movement and the colors and how emotionally neutral the shapes are, is very soothing.

I had read something about it helping with ptsd flash backs — and why it may work. I’ll have to dig that up and write about it. It’s pretty interesting, I think.

But for now, I’ve got to get going to work and see what the day ahead of me brings.