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 mightbe.
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.
I got a good lesson this morning. I managed to sleep in till 8:15, with my earplugs firmly wedged in my ears and extra curtains pulled across the windows to block out the light. Even the birds that fill the trees around my house, clamoring for attention from each other and battling for position at the bird feeder first thing in the morning didn’t wake me up, as they often do, ’round about 6 a.m.
I’ve been feeling progressively more under the weather over the past few days, with my balance getting worse and worse and the headache starting up again. Work has been really good – very rewarding and satisfying. But it’s taken a toll, and when I got up this morning — without doing my usual breathing exercise (I did that at 4 a.m. when I was trying to get back to sleep) — I was feeling wobbly and out of it. I had to lean against the walls as I walked to the bathroom, and while I brushed my teeth, I had to prop myself up with one hand firmly on the sink counter.
I managed to get downstairs in one piece, and I made my breakfast slowly, deliberately. I took my time with it, taking care to not move too quickly and put myself off balance. In the past, when I was still dealing with the early years after my last injury, being off balance would send me into a panic and it would throw me off for the whole day, even before the day began. But since I’ve been making important changes in my daily life — including regular exercise — the panic has subsided considerably, and I’ve learned how to handle the sense of teetering on the edge of collapse without having my psyche collapse, too.
And that’s important.
So, anyway, after I had my breakfast, I decided to spend my day reading and writing and checking in with myself. The weather has been pretty wet, lately, and I can’t do much outdoor work. Plus, I’m not feeling well, and I would love to just spend the day reading, studying, and writing. Taking it easy, instead of taking care of everybody else’s business. I put some water in the electric kettle and fixed myself some fruit with crackers and goat cheese and went up to my study to settle in.
After a little bit, I realized I’d forgotten my trusty writing cardigan, and I went back downstairs to get it from the kitchen. While standing in the kitchen, looking around to see if there was anything else I’d forgotten, I heard an odd hissing sound. I went over to the kitchen counter and found my tea mug with a dry tea bag in it, and beside it was the electric kettle, hissing away, nearly all the water boiled out of it.
Now, the way the kettle has always worked in the past, is that when it gets low on water or reaches a certain temperature, it shuts off. This time, it did not shut off. So, I did. And when I looked closely at the heating element, it was showing signs of rust — perhaps from the intense oxidation from the coils evaporating off the water?
I kind of went into a tailspin about this. Yes, I know my alarm was disproportionate to the situation, but I got seriously upset by this and I started to beat myself up over having put water on and then walked away. I won’t write all the things that went through my head, because they are not the kinds of things I care to archive for posterity. Suffice it to say, for a few minutes this morning, I was not my best friend.
But then I realized I was pretty off the charts with my distress — how much would a replacement kettle cost? not very much, really — and it was more about me being absentminded and not paying close enough attention … no to mention feeling ill and “off” this morning. So I was wasting a lot of precious time getting bent out of shape over this. It’s turned out to be a beautiful fall day, and I have given myself permission to take time off to take care of myself. Why should I waste my time and energy beating myself up over a simple case of absent-mindedness that really anybody could have done, too?
Okay, so I established that it wasn’t worth wrecking myself over this oversight. And I realized that this electric kettle is not going to automatically turn off whenever it’s low on water, as I assumed. I would just get in the habit of A) putting more water in the kettle and B) not leaving the kitchen till it’s done heating the water, which takes all of maybe 30-60 seconds. Simple solution, right?
Well, what came up next was the burning question (and yes, I realize this sounds a bit neurotic, but I am not feeling well this morning) about what to do with the “extra” water that I wasn’t using for my tea? See, when I pour water in, I pour exactly as much as I need, so when it’s hot, I don’t have to check the level of liquid in my mug. I just know that I have exactly as much water as I need. If I heat more than I need, what will I do with the extra?
This was the hotly burning question in my fuzzy brain this morning (in the moment it seemed extremely important). I was all up in my head about the evils of waste and getting frantic about not having the exact amount of water I needed in the kettle, and having to gauge how much I was pouring in… and so on.
Then it occurred to me that having the extra water would come in handy for clearing the drain. I’ve been having some problems with the kitchen sink drain getting sluggish. My fix for it is to pour boiling hot water down, and that often works. So, this “problem” is actually no problem at all — in fact, it solves some problems, namely:
I need to slow down more in the morning, and this will help me do it.
I need to heat more water in the kettle, so it doesn’t fry the coils, and this will let me do that.
I need to periodically clear the drain with boiling water, and this will let me clear it daily, so the buildup doesn’t accumulate and become a bigger problem down the line.
So, there’s really no problem at all. Not anymore. But this morning, for about 15 minutes, I was going into a tailspin that threatened to wreck my entire day and set me down a spiraling path of upset — at the innocent electric kettle and at myself for getting so bent out of shape.
The electric kettle is forgiven, and so am I. I know full well that I am off balance, not feeling well, and I am spending an awful lot of cognitive energy just trying to keep myself vertical and not get hurt. I can cut myself a break, and just get on with my day and my recovery from the past week+ of hectic activity.
I’d better cut myself a break. Because rust never sleeps.
Neil Young reminds me of that constantly, while I’m driving to and from work. For some reason, radio stations in my area keep playing his music, and “rust never sleeps” is often what I hear him singing about. My, my, hey, hey… It’s better to burn out, than to fade away… And this gets me thinking. Especially in the autumn, when the effusive growth of summer is giving way to frosts and withering and deadening, and the cycle of life turns to a cycle of death, my thoughts become, well, a little maudlin. The change of the season gets me to wondering “what’s it all about?” and “is this all there is?” and all manner of existentially angst-y ruminations. And my brain starts to perseverate and lock onto misperceptions and misconceptions and any number of irregular reasons to doubt my ability to live effectively in the world.
Some days, I suspect it’s due to the way my life turned in the course of my concussion-punctuated years. Each injury left a mark on me — a “ding” or two or three in the fuselage of my vehicle that didn’t exactly ground me, but kept me from achieving the heights I might otherwise have reached. I don’t want to blame the brain injuries for my ills — certainly, they have played a part, but they’re not the only reason I’ve had difficulties.
More than the traumatic brain injuries, in fact, I believe that the aftermath, the reactions, the later reactions of others and myself (which were based largely on ignorance about what brain injury does to the personality) and the meanings I gave to those reactions, had the biggest impact. And the time when I was actually recovering from the physical effects, I was sinking into a psychological morass of confusion, dread, insecurity, and the conviction that this temporary situation was permanent, totally screwed me up. After my injuries, my neuroplastic, adaptable brain was on the mend and finding new ways of doing the things I wanted to do, but because those new ways were different from the old ways — and therefore threatening and alarming to me — I discounted them and told myself they were WRONG and I should not be doing things the way I was doing them.
I had it in my head that the roundabout way I learned was Wrong.
I had it in my head that the way I communicated with people was Wrong.
I had it in my head that the way I structured my daily life — much more downtime than most people I knew — was Wrong.
I had it in my head that the choices I made about my social life — who I would and would not interact with — were Wrong.
I had it in my head that the choices I made about my domestic life — not having children and not officially getting married until 15 years into the settled, intricately entwined relationship — were Wrong.
Now, to be fair, there was an awful lot of social pressure to adhere to certain ways of doing things, so I had plenty of reinforcement for judging myself and my choices. And the rigidity of my upbringing didn’t help. But I suspect that the rigidity of my parents and wider social circles wasn’t the only reason I was so locked in, and so quick to judge myself. Indeed, I believe that the head injuries I sustained as a young kid (when I was about 4, then again when I was 7 and 8 ) predisposed me to an intense rigidity that locked out any alternatives to routines or “standard issue” behaviors.
WHY IS RIGIDITY/INFLEXIBILITY IMPORTANT FOR SOME STUDENTS AFTER TBI?
Students with TBI or other neurological conditions sometimes demonstrate extreme forms of rigidity or inflexibility. Rigidity/inflexibility is often associated with damage to the frontal lobes, the most common site of injury in TBI. Therefore, some degree of inflexibility is common in students with TBI. This may manifest itself as difficulty (1) making transitions during the school day (e.g., from lunch or gym back to classroom work), (2) tolerating changes in schedules or everyday routines, (3) adjusting to changes in staff, (4) ending an intense emotional feeling, and the like. In extreme cases, a transition as apparently simple as from sitting to standing may be difficult and cause stress.
Related but not identical to inflexibility is the phenomenon of perseveration. Perseveration is a possible result of neurologic impairment and is characterized by continuation of the same behavior or thought or words or emotions after the reason for the behavior, thought, word, or emotion has passed or the thought or behavior is no longer appropriate to the situation. . For example, a student may remain focused on a given emotional behavior state long after the reason for that state has been forgotten.
This pretty much describes me when I was a kid, though today I’d have to say that emotional rigidity and perseveration is much more of an issue than cognitive. Cognitively, I can move on. But emotionally, I’m still stuck. I think that getting out in the world and holding down jobs and having gotten positive reinforcement in work environments has helped me cognitively. I’ve been able to really reap great rewards from using my head, and that’s encouraged flexibility and creativity. Emotionally, though, I get jammed up and stuck. That’s where I get rusty — stuck in place and wedged into an old pattern that doesn’t serve me or the people around me.
No, rust never sleeps. So, what do I do? Do I drive myself onward-onward-onward, in hopes of burning out before I fade away? Do I race at top speed through life and damn the torpedoes?
Um… No. Racing around and pushing myself are the very things that encourage rust. Like the super-heated coils in electric kettle caused the metal to rust, so does my super-heated life cause my system to lock up and show signs of wear. Maybe not in Neil Young’s case, but in my case, pushing for burnout is a sure route to rust. And I don’t have all the time in the world — I’m not getting any younger, and my window of non-fatigued time is significantly less than most people’s I know — so I just don’t have a lot of time to spare, cleaning up after myself when I crash and burn.
That’s no way to live.
What to do?
This is the eternal question, and it keeps coming around with me, no matter how much time I put between myself and my injuries. My first TBI probably happened when I was about 4 years old. And there were two more when I was 7 and 8 years old. More came over the years, including sports concussions and car accident mTBIs, for a total of at least nine separate instances of head injuries that involved some level of disruption of consciousness, followed by cognitive, behavioral, and physical problems. I never got help for any of them, until about 3 years ago — just a lot of headaches (literally and figuratively) — and only in the past 3 years have I started to systematically and mindfully approach my issues with a focused desire to overcome them.
I’ve learned a lot about how to deal with the basic things — get my exercise regularly, eat right, get enough sleep, and check in with my neuropsych on a regular basis. But as the basic issues get resolved, the “higher level” questions emerge — as in, how to make the most of what life I have left, so that I can have the best life possible, whenever possible?
Ironically, the answer to this question has gone hand-in-hand with the answers to my most basic human needs. The answer is to just slow down and pay attention. For someone who is as driven as I am, it’s a tall order, and not that easy to do. But you know what? When I not only slow down but also pay very close attention to what I’m doing with myself and my life and my choices, many of my TBI related issues resolve.
When I slow down and pay attention to my physical fitness, my joint pain and headaches subside considerably.
When I slow down and pay attention to what people are saying to me, the problems I have with understanding and following clear up considerably.
When I quit going 150 miles per hour through every single day and pay attention to what I eat and how rested I am, my need to pump myself full of adrenaline and push past all sensible limits becomes far less pronounced.
Now, slowing down and paying attention is the sort of thing I’ve had to learn from scratch. A big driver behind my rushing is a constant low-level panic that simmers in my gut, day in and day out. It’s that constant restlessness, the constant agitation that comes with TBI. It’s my brain working overtime trying to find its way through the tangled networks that have developed over the years. It’s my body’s reaction to the intense energy needs of my very-active brain, and the low fatigue threshold I have.
Slowing down and paying attention has been closely connected with my exercise routine, taking the edge off my stress, finding outlets for the nervous energy, and clearing out the biochemical sludge that builds up after countless experiences of surprise/shock/dismay/confusion that come at me in the course of each day, when the things I expect to happen … just don’t… and I need to immediately adjust and move in a different direction to get where I’m going.
That surprise/shock/dismay/confusion is an ongoing situation for me, and it may never change. I may find myself spending the rest of my life realizing I was all wrong about something and needing to find another way to think/act/be. But at least I have my exercise to help me clear out the chemistry of those micro-traumas. And I have an understanding of that bio-cognitive action that lets me cut myself a break and not get all bent out of shape — for extended periods of time — over things that are either directly attributable to my brain having gotten a bit banged up over the years… or are long since over and done.
But even if I do spend the rest of my born days troubleshooting these kinds of cycles of pseudo-drama, I always have my fall-back, my comfort in the midst of the storms — the knowledge that slowing down and paying close attention to what’s going on around me, with heightened awareness and intense curiosity, can and will pull me out of my funks, can and will restore me to some sense of myself, can and will connect me to my life once more, in ways that running around at top speed never can and never will.
Rust may never sleep, but I don’t need to run from it. Ultimately, it’s not the quantity of life that staves off the debilitating freeze, the rust. It’s the quality. Cooling the hot elements, adding more water than I “need”, and just sticking with my life in all its aspects till I find some peace, some resolution, and I can make my tea… that’s what does it for me.
Not long ago, one of my readers posted a comment about how important it is to be careful, so you don’t sustain a brain injury. Those words (at least, the gist of them, as I’ve since forgotten exactly how they said it) have stayed with me over the past day or so.
I have been working overtime a lot, having taken on a lot more responsibility that is a pretty big deal. And I have not been eating quite as well as I should be. I’ve been hitting the vending machines regularly — not insanely, chowing down on Skittles and Pop Tarts and Swedish Fish and all manner of sugar and chocolate. But I have been eating a chocolate bar a day, along with my beloved peanut M&Ms that keep me going (I need the protein).
At the time when I’ve been needing more sleep, I’ve been getting less. The Headache is back — not headaches but Headache — the long-lasting, perpetual one that doesn’t have any breaks and just keeps going to the point where I barely even notice it anymore. Except when I do. I’ve started to get the tactile sensitivity — my clothes are hurting me — and light sensitivity and noise sensitivity. I’m kind of wired, as I’m sure you can tell. And in fact, it doesn’t take a whole lot to get me wired, so I’m feeling the burn, right about now.
On the bright side, I am functional. I’m able to do my work and get things done and interact with people at work. But that’s a downside, too. Because when I get like this, I tend to push myself and go faster than I should. And when that happens, I can get hurt. I’ve fallen down stairs a number of times in the past six months, because I was in a hurry. Nothing bad enough to injure me, but enough to rattle me.
I must be very, very careful. Especially because the BIGGEST symptom I’m having, which I neglected to mention above, is the vertigo. Dizziness. Crazy spinning head and the inability to turn quickly in any one direction, without my head going haywire. I am so dizzy, I have to keep my back absolutely ramrod straight, or I start to lose my balance. Standing at the tops of stairs is interesting, too. And I have to hold onto walls as I walk along, or I tend to wobble and stagger like I’m drunk.
I can’t even close my eyes without the room spinning, and I have felt like I was going to throw up for three days running. Fortunately, I’m able to keep it together reasonably well with a discretion that masks my issues. Nobody needs to know that I’m as badly off as I am. Nobody needs to know that I’m about to heave all over my office. Nice for them. Not so nice for me.
Yes, this sucks.
But you know what? It’s all in the line of duty, and it’s all for a good cause, and I get to lay low this weekend. I don’t have any pressing activities I must do. I can lay low and be ill and take care of myself at my own pace. My spouse has a bunch of commitments over the weekend, so again I’ll have the place to myself for most of the coming two days. So I can roll myself up in my blankets, pull the blinds, and just hibernate in my cave. Drink hot tea — the nasty cold season tea I can’t drink with anyone around, it smells so awful — and read a book. I never did finish The Bourne Identity. I got it it out of the library again a week ago, so I can spend my time catching up (and seeing how much I remember from before).
All in all, I feel physically awful, but I’m still bright-eyed and bushy-tailed. I’m so tired I’m literally falling over, but it’s a good tired that comes from having spent so many, many hours doing work I love in an environment where I’m actually able to do it.
But I have to be careful. Seriously. I need to watch myself, make sure I don’t fall, make sure I take care of myself better this weekend, and get some recovery under my belt. I can’t continue on at this pace — must take some downtime. And be very, very careful, as I’m moving about.
Times like this, I’m reminded of how head-injured folks — especially athletes — so often re-injure themselves.
We tend to have have crappy risk assessment skills after we get hurt.
We also tend to over-estimate our ability to navigate challenging situations.
And all too often we feel like we have something to prove, so we push ourselves even harder than most — even with diminished co-ordination and balance.
These things I know. These things I know about myself. As euphoric as I am about this new job and all the great potential for it, I still know that I am running a risk every time I push myself, and I am running a risk every time I don’t take it easier than I am. I know that I am in danger of being injured — as anyone is who’s overtired and tremendously off-balance and walking up and down stairs, driving in heavy traffic, and generally going about their business in environments where you can slip and fall and get hurt.
See, here’s the thing – when you’ve been through a truckload of trauma (be it combat, assault, disaster, car accident, traumatic surgery, random violence, or some other life-altering/impacting event that seems like it’s going to kill you), your body responds the way any living organism would. It floods your system with biochemicals to either help you escape or make dying less painful. And if you do neither — you can’t escape, but you don’t die — there’s this huge backlog of chemicals still stuck in your bloodstream.
If you’ve ever been a flood victim, you know what it’s like — the waters rise, sometimes very quickly, and then they recede. When they go, they can take with them some of the most precious belongings you own… they can wash out roads and compromise foundations of buildings, and turn a familiar place into a hellhole. And what’s left, when all the water is gone, is this nasty goo and muck that you have to wash out, sweep out, clean out. Sometimes you can never get it out completely. And the odor stays in that place for years afterwards.
That’s sort of like what happens when you go through intense trauma, and you end up surviving (despite how things looked when you were going through it all). Your body has responded the way it’s supposed to — adrenaline, noradrenaline, epinephrine, cortisol, glucose, and more… it’s all poured into your bloodstream, your muscles, your soft tissues, to help you get through it all.
But once you’re on the other side, even though your body doesn’t need those chemicals anymore, it doesn’t know it. It’s your body. It’s on autopilot. And it’s so fried from the experience(s) it’s been through, it can’t think straight.
And you end up extremely jumpy over every little thing. It’s not “just stress” — it’s something much bigger and much badder. It’s your body expecting and planning for more danger, being on high alert — whether it needs to be or not — because that’s what helped you before. That’s what helped you get through. And as your body continues to hyper-react to the world around you (it thinks it’s protecting you, the same way it did before), you end up marinating in this stress chemical soup that becomes a self-fulfilling prophecy and a self-perpetuating loop.
People keep telling you to “relax” — clearly, they don’t understand what’s going on with you. They just don’t get it.
So, what to do? You can’t go on indefinitely, stewing in your own stress juices. You’ve got to do something. I should know — I’m one of those people who was on high alert for years, thanks to my body being convinced that it needed to be. Couldn’t relax. Didn’t want to relax. Relaxation meant danger. It meant death, to my wired system. Relax? Ha! But still, I just couldn’t go on like that.
Here’s what I’ve done that has actually helped me. In more ways than I can say.
I exercise. Not fanatically, not extremely, like some folks do. But I do it religiously, with a daily discipline that surprises me sometimes. I get up in the morning, do controlled breathing exercises (to counteract out my always-at-the-ready fight-flight response) and then I get on the exercise bike for 10-20 minutes. If I’m away from home, I do some other sort of exercise for 10-20 minutes. I do knee bends. Light calisthenics. Jumping jacks. Anything to get my body moving and get the blood flowing. As I do it, I imagine my veins and arteries and muscles clearing out the gunk from years of always-on alertness, and I breathe into it. I push myself, on and off, to get myself in a frame of mind to focus in and finish what I’ve started. If I’m riding the bike, I do intervals that really make me work at it — I’ll ride hard for about a minute, then pedal slowly for 15-30 seconds, then I’ll ride hard again for about a minute. If I’m not on the bike, I push myself with the jumping jacks or the arm/leg raises.
After the bike or calisthenics, I stretch and then do some light weight lifting. The lifting (I use relatively light dumbbells) is important for building strength to help with my balance and overall physical stamina. It also feels good.
Again, I don’t go overboard with this. I stay focused and keep it limited to about 30 minutes a day, because I have to get on with my day, and I can’t spend all my time working out.
The results, as I said, have been phenomenal. My mood issues — the extreme ups and downs and violent temper flares — have lessened to about 15% of what they once were. Once upon a time, I was very difficult to be around, if I was tired or agitated or anxious. I’m not like that anymore. I’m literally a different person. I look people in the eye. I listen to what they have to say. I am involved in my own life on a level that I never before thought possible. And it just keeps getting better.
So, if you’re struggling with TBI and/or PTSD, I really encourage you to start exercising first thing in the morning. First thing is important, because it gets your metabolism going better, and it also gets you woken up in ways not even a cup of coffee can. It’s good for your head and it’s good for your heart, and it helps you fight off infection and sickness as well as strengthens your whole system.
I’m probably sounding like a religious convert, and in a way, I am. I truly want to testify that the impact on my life has been nothing short of phenomenal. I believe it has a lot to do with me clearing out the biochemical sludge from all those floods of emotion and stress and hyper-reaction over the years of being ON. Seriously — I was so driven, so pumped up all the time, someone close to me once said was the most driven person they knew. At the time, I thought it was a compliment, but now I realize it had a price.
Now, there are experts who say you need to do moderate-to-intense exercise 30-60 minutes a day, 5 days a week. My life was changed (at first) by 15-20 minutes of light exercise every morning… and it slowly evolved into 30-45 minutes of light-to-moderate exercise. Do what you can, and work from there. But do it.
As I’ve been exploring the landscape of my head injuries over the past few years, one aspect of my life experience has consistently come to the fore — trauma… and its long-term effects on lives of both survivors and the ones they love and live/work with on a daily basis.
It’s almost a total fluke that trauma should even have this on my radar. But over the years, I’ve befriended — and been befriended by — a number of psychotherapists and counselors, most of whom specialize in trauma. In retrospect, I suspect that many of them have assumed that my difficulties were due to past traumatic episodes — rough childhood, misspent youth, etc. In fact, one of them has flatly denied that my issues could be due to TBI, and they became more and more insistent about me getting a therapist, which was probably the worst thing I’ve ever done, in retrospect. (This friend’s denial is a topic for another post — it’s quite interesting, “clinically” speaking.)
Now, I have to say that after more than 10 years of being around these friends of mine, I get a little tired of every ill known to humanity being ascribed to after-effects of trauma. When I talk about experiences I’ve had and people I’ve encountered who have annoyed me or done some seriously sick stuff, I’ve often heard the refrain, “Oh, they’re a trauma survivor, so they’re dissociating/being triggered/experiencing kindling/re-enacting their past traumas.”
There’s not much room for just being an asshole. For some of my friends, it’s all about the trauma. And in an attempt to better understand what it is they’re talking about, I’ve attended some trauma workshops, as well as read some books. I’ve got Peter Levine on my bookshelf, along with Belleruth Naparstek. And now I’m reading Robert Scaer, M.D.’s book The Body Bears the Burden, which explains (from a neurologist’s point of view) the effects of trauma on both the body and mind of someone who’s gone through awful experiences — and those whose experiences don’t seem that terrible, compared to, say, Pakistan’s flooding or suicide bombings in Kabul.
The DSM-IV defines a “traumatic stressor” as:
[an stressor] involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate
The part that interests me is the “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity”. The other parts are just as significant, but I’m not going to speak to them at this time.
When it comes to mild traumatic brain injury, I think sometimes the severity of the experience tends to get downplayed. After all, the injury is mild, right? Well, interestingly, mTBI survivors apparently can show more disruptive symptoms of traumatization after the fact, than survivors of more severe injuries. And these long-term effects can wreak havoc in the lives of survivors, as well as their immediate circle.
Problems such as fatigue, emotional volatility (emotional lability), rage, agitation, irritability, insomnia, sleep deprivation, anger, temper flares, temper tantrum, anxiety, fear, panic, risk-taking, danger-seeking, not to mention all the crisis and drama that can accompany hormonal spikes during times of stress, certainly don’t make things any easier. If anything, they complicate recovery by flooding the system with stress hormones which interfere with your ability to learn from your experiences. So, at the time when you’re having to get a new grip on your newly changed life with its “new normal,” the biochemical processes going on behind the scenes may be getting in the way.
How maddening is that? At just the time when you need your brain to be able to recover, it’s busy cranking out all sorts of interesting concoctions that specifically get in the way of your recovery.
Because (I believe) there is unresolved and un-dealt-with trauma wreaking havoc behind the scenes.
Trauma in mild traumatic brain injuries is particularly tricky. After all, the injury itself may not have been that dramatic — something gets dropped on your head, or you get in a fender-bender, or you slip and fall down and clunk your head on something. You get up again, walk away from the scene… maybe pay a visit to the emergency dept of your local hospital, get scanned, and you get a “clean” bill of health (and maybe a few pointers on what to watch out for to make sure you don’t have more serious issues later on). Then you’re expected to get on with your life.
But inside your skull, something else is happening. Some of the fragile connections in your brain have been sheared or severed or frayed, and your brain isn’t able to communicate with itself like it used to. On a fundamental, profound level, your very existence has been threatened — only nobody can see it. Even you can’t see it very well, because your brain is either still bathed in the stress hormones designed to keep you from feeling a bunch of pain (and thus preventing you from fleeing an immediate threat), or it’s just not making the connections it “should” in order to give you — the resident owner — a clear picture of what’s going on. Or it could be both things going on.
In some cases, from what I’ve read in Dr. Scaer’s book, the onset of problems can be delayed by hours, even days. So, right after the accident/event, you’re walking around looking fine, seeming to be fine… maybe you’re a little shaken up, but that’s to be expected. But then you start to slip away… decline… feel the effects of what was supposed to be a mild event that had no serious immediate effects you. In your system, hidden from view, the process of gradual (and possibly debilitating) problems has begun.
This process is utterly maddening. Everyone around you, who was worried for your safety, just wants to be relieved that you’re okay. But all of a sudden, you’re acting strangely, you don’t seem like yourself, and you’re complaining all the time. The complaints don’t get better over time, either. They get worse. And for no apparent reason. People think you’re looking for attention, that you’re trying to “milk” your accident for all it’s worth. They just want you to get back to being your old self. But you’re doing the exact opposite.
And the pressure to return to normal builds, even as your system is being eroded by the biochemical havoc of trauma that was introduced to your system which has not been cleared — it hasn’t even been recognized. How can you clear away what you can’t see/hear/detect?
Indeed, the most insidious and problematic manifestations of trauma take root when the person having the experience is taken by surprise. Studies have shown that bracing for impact limits the impact, but being blindsided makes it worse. And it makes the experience as a whole worse. The body detects this threat to its safety and existence — all of a sudden out of nowhere — and it unleashes myriad biochemical substances for us to deal with it — including endogenous opioids designed to numb the pain of injury. Animals in the wild which are being chased by predators, when there is no way to escape, will often fall down as though dead, their bodies full of chemical substances that will both numb the pain of being devoured and turn them into “dead” prey which might discourage a predator from actually killing them.
The same biochemical process is in place with human beings. After all, once upon a time, we were hunted as prey by animals larger than us. Indeed, we still are, in some cases — the predators happen to be other people, more often than not. In times of combat and assault, when all escape routes have been blocked off and we believe (on some level) that we’re done for, our brains and bodies do their natural thing — they bathe us in substances to protect us from feeling that knife going through our lung or feeling that bullet smash through muscle and bone.
Our brains and bodies are doing their utmost to protect us as best we can. But our minds tend to interpret the experience differently.
In the case of animals who freeze and then survive the assault, they shake themselves, go through a series of shuddering/jerking motions, do heavy, deep breathing, and then pick themselves up and get on with their lives. In the case of humans who freeze and then survive the assault, we tell ourselves we were wusses for freezing the way we did, and we plunge into cycles of self-doubt and conflict, feeling like we failed — when we were simply being the biological creatures we are designed to be.
And the self-perpetuating downward spiral of the PTSD loop starts. Where it stops, is anybody’s guess.
Therapies which have been successful in freeing people from that negative feedback loop are those which engage the body to discharge the sudden burst of biochemical self-protection, and get the autonomic nervous system back into balance. In the completion of the fight-flight-freeze cycle, the body is allowed to return to its most effective ways of working. And we can get on with our lives.
Here’s where the problem starts with mTBI. (Note, I’m not a doctor or certified health professional — this is just my belief system about how our systems interact with the world around us.) If the injury is “mild” then what’s the big deal? Why should we even need to complete the fight-flight-freeze cycle? Wasn’t the injury itself mild? We just got clunked on the head. Big deal, right?
Hardly. I think with mild traumatic brain injury, there may be another aspect of it that comes into play. With “mild” injuries (not that any brain injury is ever mild, mind you), the brain itself perceives the threat on a basic, biological level. It knows something’s wrong, and it kicks into overdrive, trying to right what’s wrong.
I suspect this is why people who have sustained concussions or mTBIs are so prone to denying that there’s anything wrong. Our brains are so busy trying to right their internal systems, that they fail to communicate with the rest of the world — that includes our conscious mind.
Based on what’s happened to me, what I’ve observed, and what I’ve read, here’s the cycle that I believe gets set up:
An individual experiences a sudden, unexpected impact or injury, which injures their brain. This can be a fender-bender, a tackle or collision in a sports game, getting cold-cocked by an attacker, or having something fall on/hit their head.
Fragile connections in their brain are frayed, sheared, or destroyed completely… or all three. On the surface, they seem to be fine. The injury doesn’t look like that big of a deal. It’s just a bump on the head or a hard hit or a bit of soreness or being dazed after the fact.
The body interprets the impact as a threat to the system, and it unleashes a biochemical cascade of hormones and other neurochemicals which narrow the focus, numb the system to pain, and shunt energy away from “extraneous” body functions.
The injured person’s brain senses something is amiss, and it works like crazy trying to sort out what just happened. The whole body-brain connection needs to be tested to make sure everything is still online, so the system can correct itself as need be. Any outside talk or input is dismissed and rejected — “Are you alright?” isn’t a sign of concern, it’s an intrusion into the vital process of the brain checking through the bodily system for problems. And the brain is so focused on its internal process, that it “forgets” to tell the rest of the world what’s going on. There is no full communication loop with the brain — it’s in damage assessment mode, and it blocks out any input as well as refuses to provide output.
The impacted individual wanders around in a bit of a daze, then they appear to recover, and they get on with the rest of their activities. They drive on in the car, they get up off the bench and go back in the game, they pick themself up off the pavement, or they go back to work.
In the course of going about their business — both immediately and over the course of the coming days and weeks — their brain is having trouble figuring out how to do the things it used to do so effortlessly. The old connections have been disrupted, as though a massive storm had torn through a region, torn up trees, unleashed flash floods, and made many of the old roadways either treacherous or impassable.
The brain senses something is amiss — the inability to do things it used to do before is intensely distressing, and it doesn’t understand why things aren’t working. This confusion represents a “threat to one’s physical integrity” and the body reacts as though its very existence were being threatened. The cascade of stress hormones and fight-flight-freeze substances wash through, and the sympathetic nervous system is activated.
Unfortunately, the incidents of confusion and disorientation and disrupted functioning aren’t intermittent. They can be regularly occurring — as well as unexpected. Time after time, the brain is surprised by its sudden (and unexplained) inability to do what it’s always done. Surprise sharpens the experience, making it both more intense and more indelible in the body and brain.
The brain/mind interprets these inabilities as a problem with the self, and a chain reaction of personal recrimination starts up, which assigns more meaning to the events, which triggers further releases of adrenaline and cortisol into the system when the amygdala is tweaked by this interpretation.
When cortisol and adrenaline are released, higher reasoning is impaired, and lessons which might be learned from trial-and-error are not retained. One misstep after another occurs… one screw-up after another… confusion compounding confusion… anxiety heightening anxiety. What was originally “just a bump on the head” elaborates into a full-scale debilitating condition which becomes more and more entrenched over the ensuing months, even years.
Social pressure doesn’t help at all. Impairments to speech understanding (that happened to me) aren’t interpreted as symptoms of brain injury, rather as laziness or stupidity. Sensitivity to light or sound, which foster distractability and make holding a conversation difficult are not perceived, but the results — wandering attention and apparent oblivion to what others are saying — are obvious (and not at all appreciated). Social pressure leads to increased stress, which in turn triggers the release of more chemicals that prevent the injured person from effectively learning new patterns and building new pathways in their brain.
The brain is still trying to sort out what’s going on, and it’s not very communicative, either with others or with the “resident” in this body. It gets wrapped up in the drama of flawed interpretations of what’s going on, the crisis of stories it’s invented about what’s going on around it, and the increasing struggle to make sense of anything.
Time passes, and things just seem to get worse. Self-esteem plunges, and resilience declines. Self-recrimination builds, and difficulties at work and at home erode the ecosystem of the impacted individual. Jobs are lost, relationships fail, and money seems to fly away for no apparent reason.
If they’re lucky, the impacted individual can find help from a competent neuropsychologist, counselor, or neurologist — or even friends who are up to the task of helping them get back from the brink. If they’re like all too many traumatic brain injury survivors, they cannot get the help they need, and they end up becoming permanently unemployed (or sporadically employed), with no savings or source of income, no social support network, and no justification for going on disability or collecting insurance payouts.
Muddling through, maybe they make it, maybe they don’t. Ultimately, many end up on the streets, in jail for behavior problems, or on medication for psychological disorders that mimic brain injury after-effects and carry lasting side-effects. And unfortunately, a number eventually commit suicide, hastening the process that an oblivious, uneducated society and tough-it-out culture sets in motion.
As you can see — assuming this progression is at least somewhat accurate (and I believe it is) — the impact of a head injury need not be severe, in order to lead to severe consequences.
To fully understand the pervasive effects of mild traumatic brain injury, you need to look at multiple systems — from the brain’s inner workings, to the autonomic nervous system, to the demands of adult living or childhood development, to the expectations of one’s surrounding social milieu. With mild TBI, it’s never just one issue that sends you down the dark road — it’s a million little, subtle, interrelated issues that combine to create a recipe for disaster that, like bread dough sitting near a hot wood stove, will inevitably begin to rise and expand.
Trauma and the body’s internal responses to perceived threat and our interpretation of those threats, is like yeast added to a sugar-water-flour mix of our injury. With enough heat and time, it’s going to double, triple, even quadruple (and more) the issues that initially come with mild traumatic brain injury. Unfortunately, it appears that our systems are designed to work that way, and unless we can figure out alternative ways to address the issues, we’re in for a rough ride… till we can find help, sort things out, or end up incarcerated or dead.
What strategies and approaches we can hope to employ in this trickiest of situations — which might actually work — is a topic for another post.