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Post Traumatic Stress Disorder and Traumatic Brain Injury. Kathleen Goren Ph.D Mary Lu Bushnell, Psy.D. Carl T. Hayden VA Medical Center. TRAUMATIC BRAIN INJURY (TBI). TRAUMATIC BRAIN INJURY (TBI). Damage to the brain due to externally inflicted trauma

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Post Traumatic Stress Disorder and Traumatic Brain Injury

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post traumatic stress disorder and traumatic brain injury

Post Traumatic Stress Disorder and Traumatic Brain Injury

Kathleen Goren Ph.D

Mary Lu Bushnell, Psy.D.

Carl T. Hayden VA Medical Center

traumatic brain injury tbi3
  • Damage to the brain due to externally inflicted trauma
  • Mild traumatic brain injury is the lower-grade forms of TBI
  • Caused by a penetrating or blunt trauma or from the force of rapid acceleration and deceleration
tbi the signature injury of this war
TBI the signature injury of this war
  • Many soldiers are experiencing blast exposures at greater frequencies than in past wars
  • The significance of the blast wave itself is not yet well understood
  • Vets are returning with c/o memory, concentration and problem solving difficulties
difficulties with identifying mtbi
Difficulties with identifying mTBI
  • Difficult to determine if a mTBI has occurred when we see the soldier 1 to 2 years after the injury
  • Neuropsychological evaluations are conducted to help identify current strengths and limitations
types of head injury
  • Closed Head Injury
    • Contusion/concussion
    • Coup/Contre-Coup
    • Bloodflow and metabolic changes
    • Cerebral edema
    • Diffuse Axonal Injury
    • Blast Injury
  • Open Head Injury
contusion concussion
  • A mild injury or bruise to the brain which may cause a short loss of consciousness
  • It may cause headaches, nausea, vomiting, dizziness, and problems with memory and concentration
diffuse axonal injury dai
  • Brain injury does not require a direct head impact
  • During rapid acceleration of the head, some parts of the brain can move separately from other parts
  • This type of motion creates shear forces that can destroy axons necessary for brain functioning
  • These shear forces can stretch the nerve bundles of the brain
blast injury
  • Blast injuries are the number one cause of injury or death in Iraq
    • 69.4% of Wounded In Action caused by Blast or Explosion
    • 62% of Blast Injuries result in Traumatic Brain Injury (TBI)
    • 85% of TBIs are closed head Injuries
symptoms of mtbi
  • Emotional
  • Behavioral
  • Physical
  • Cognitive
  • Social
  • Depression
  • Anxiety
  • Hopelessness
  • Helplessness
  • Reduced confidence
  • Apathy
  • Emotional numbness
  • Intense fear
  • Impatience
  • Anger
  • Frustration
  • Confrontational behaviors
  • Impulsivity
  • Increased avoidance of situations or activities that feel uncomfortable (like being around others, riding in cars)
  • Withdrawal
  • Headaches
  • Chronic pain
  • Fatigue
  • Weakness or numbness
  • Changes in vision
  • Changes in hearing
  • Other sensory changes (touch, taste, smell)
  • Changes in sleep
  • Changes in appetite
  • Vertigo (dizziness)
  • Nausea
  • Impairments in fine motor speed and coordination
  • Changes in sexual functioning
  • Changes in attention
  • Diminished memory
  • Slowed speed of mental processing
  • Confusion
  • Disorientation
  • Changes in decision making
  • Alterations in judgment
  • Changes in ability to plan and organize
  • Changes in relationships
  • Changed ability to engage in hobbies and leisure activities
  • Decreased ability to perform at work or school
  • Isolation
  • Increased alienation from others

Fight or Flight Response

Effects on our brain & body



Treatment Options

fight or flight response
Fight or Flight Response
  • Hard-wired instinct
  • Essential tool

for survival

  • Begins when we

perceive something as a threat

  • When triggered, the brain alerts the body to danger and initiates a series of important changes
when fight or flight is triggered
When Fight or Flight is Triggered…
  • Glucose and fats are released into the bloodstream – they provide fuel for the muscles
  • Oxygen is needed to burn the fuel – so our breathing rate increases
  • In order to get this fuel to our muscles as soon as possible –

our heart begins to beat faster

fight or flight
Fight or Flight
  • Blood is shunted away from our digestive tract and directed into our muscles and limbs, which require extra energy and fuel for running and fighting
  • Our pupils dilate
  • Our awareness


  • Our sight sharpens
  • Our impulses quicken
fight or flight22
Fight or Flight
  • Our perception of pain diminishes
  • Our immune system mobilizes
  • We become prepared physically and psychologically for fight or flight
  • We scan and search our environment, “look for the enemy”
Our rational mind is disengaged – the blood supply to the parts of our brain that allows us to think rationally is reduced, while the blood supply to the more primitive parts is increased

We rely on our instincts and reflexes

Military drills are used to build a conditioned reflex - so, even when fight or flight is triggered – you are able to follow orders/training

ptsd can develop when
PTSD can develop when…
  • The threat is severe
  • The threat persists over a long period of time
  • The individual was in close proximity to the threat (direct or witnessed)
  • There is lack of support from family and/or community after the event
  • There is a history of other traumatic events prior to the event
  • In PTSD, the fight or flight state remains activated
  • The body continues to respond as though

it were under threat

  • The body’s physical, mental, and emotional

batteries are drained

Our immune system is prevented from running at full capacity.

There is an increased likelihood of developing stress-related illnesses

We are likely to use the fight or flight reaction in situations that are NOT life or death

brain boosters group
Brain Boosters Group
  • Evolved out of a need to assist soldiers to develop coping strategies to address the changes resulting from mTBI and/or PTSD
  • The focus is to maximize strengths and minimize limitations
brain boosters group28
Brain Boosters Group
  • 10 week group consisting of psychoeducation and experiential exercises in order to illustrate different facets of brain injury and what can be done to improve cognitive functions
brain boosters group29
Brain Boosters Group

Group Topics include:

  • Overview of PTSD and TBI
  • General Health
  • Neroanatomy
  • Attention
  • Executive Functioning
  • Communication Skills
  • Memory
  • Communications Skills
  • Insomnia and nightmares
brain boosters group30
Brain Boosters Group
  • Several unique aspects of the group
    • Covers a wide range of skills and problem areas
    • Coputer assisted rehab using easily available systems and use of on-line websites
    • Other VA clinicians provide expert input in their speciality areas (speech, PTSD and insomnia)
brain boosters group31
Brain Boosters Group
  • Feedback is sought from group members at the end of each group and modifications are made as needed.
  • Preliminary findings from the first three groups are demonstrating that the group is effective in reducing the subjective perception of problems in depression, PTSD, cognitive functioning and insomnia.
directions for the future
Directions for the future
  • Empirically validate the efficacy of this group
  • Validate the use of computerized hand held computer interventions
  • Produce a manual that can be used by other VHA clinicians
  • Develop an imaging protocol to determine if there is a change in brain structure after group intervention

War may be hell…

but home ain’t exactly heaven, either.

When a Soldier comes home from war,

he finds it hard…


…to not ridicule someone

who complains about hot weather.


A gentle reminder to

keep your life in perspective.

And when you meet one of our

returning Soldiers,

please remember what they’ve been through

and show them

compassion and tolerance.

Thank you.

CPT Alison L. Crane, RN, MS

Mental Health Nurse Observer-Trainer

7302nd Medical Training Support Battalion

"Sometimes combat comes at you so hard, the memories don't get processed properly. They become free floating, like raw footage that hasn't been edited down to make sense." - Article "Bringing the War Home"
"Combat trauma is different from other kinds of trauma because the horror of war – the trauma-inducing murderousness of it – is inextricably linked with sacrifice, courage, honor, pride, and patriotism. And the trauma occurs in the context of profound personal loyalty. Some soldiers will never experience bonds as intense as those formed with buddies fighting or dying beside them in desperation of battle or the confines of an exploding Humvee. No other trauma is so intermingled with our deepest values and strongest fears of overwhelming loss. Is it any wonder that soldiers have a hard time letting go?" – Article "Bringing the War Home"
"The journey home marks the beginning of an internal war for Marines. Give them the time they require to slowly turn the switch. The switch from violence to gentle. The switch from tension to relaxation. The switched from suspicion to trust. The switch from anger to peace. The switch from hate to love." – Lt. Col. Mark Smith
"Happy to be home? On one level, yes, but on another it's kind of a letdown. I get so bored most of the time that I'm always thinking of something to do that can get me up and going. The worst thing is driving. I'm looking toward the bridges and the overpasses all the time; looking at the sides of the roads and the guardrails. Driving is different now, and it's really strange to get stuck in traffic. No more hitting the gas pedal and jumping over curbs, speeding across highway medians or cutting off vehicles piled up at an intersection. In Iraq I could do whatever I wanted…" – A Marine home from Iraq
"Before I deployed down range I was different about my wife and kids. Now that I'm back I can only let them get so close before I have to get away from them. I used to have fun letting my boys jump and crawl all over me. We would spend hours playing like that. Now I can only take a couple of minutes of it before I have to get out. I usually get in my truck and drive back to the base to be with my platoon." – A paratrooper home from Iraq