TBI and PTSD Resource Guide
Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) can have devastating consequences on individuals. Both are associated with high rates of disability and suicide. Although they are separate conditions, they commonly co-occur. For example, a soldier who has developed PTSD as a result of a traumatic experience may have also sustained a brain injury during that experience.
Significant research has been conducted to understand the brain mechanisms underlying PTSD and TBI. Today it is critical for experts to understand the signs and symptoms of PTSD. According to the National Institute of Health (NIH), only about half of PTSD patients are receiving adequate treatment. Active and retired military service members make up the majority of PTSD cases and these patients lack access to the medical care they need.
Living with a brain injury can require a range of resources, strategies and supports. The range of possible supports can be tremendous and overwhelming. In an effort to raise awareness of TBI's and the link to PTSD, we have developed a Resource Guide for those in need of additional information. A TBI can happen to anyone and PTSD can affect even more people. This guide, along with the support of treatment providers and family members, is intended to help individuals begin to understand, recognize, and cope with PTSD and TBI's. This guide is only for informational purposes and is not intended to be used for the treatment or diagnosis of any medical condition. Only qualified professionals in the medical field can diagnose and treat medical and mental health conditions, including TBI and PTSD.
What is Post-Traumatic Stress Disorder (PTSD)?
Post-traumatic Stress Disorder (PTSD) is a mental health issue some individuals develop after experiencing or witnessing a life-threatening event such as a car accident, natural disaster, combat or sexual assault. It can be an extremely debilitating psychiatric disorder that impacts a person's ability to perform daily activities. Individuals with PTSD continue to relive and have vivid thoughts and feelings related to the event long after it has occurred. PTSD can be acute, chronic or delayed PTSD. Acute PTSD lasts between one to three months but the diagnosis can be changed when the symptoms last for longer than 3 months.
What is a Traumatic Brain Injury?
Traumatic Brain Injury (TBI) is caused by an external force which then causes injury to the brain. It usually is caused by sudden impact to the head or a sudden whipping of the head on the neck, such as the force caused by a severe rear-end car crash. According to Medline Plus, half of TBIs come from motor vehicle accidents. People who suffer a TBI might not experience symptoms right away. Depending on the injury, sometimes complete recovery is possible, other times permanent disability or death can occur.
A person who has a TBI can experience physical, cognitive, emotional and behavioral symptoms. It is important to be assessed by a medical professional after any brain injury. Individuals who experience a TBI should not be taking certain medications and are at higher risk for falls and other accidents, particularly if they are driving.
What are the Risk Factors for PTSD?
Individuals of all ages can experience post-traumatic stress disorder. Some factors may make you more likely to develop PTSD after a traumatic event. Some of these factors are listed below:
- Experiencing intense or long-lasting trauma
- Having experienced trauma early in life - childhood abuse
- Being employed where there is a higher risk of being exposed to traumatic events - military and first responders
- Mental health problems - anxiety or depression
- Substance abuse issues - alcohol or drug use
- Lacking a good support system of family and friends
- Blood relatives with mental health issues - similar to the above
Who is most at Risk for a TBI?
According to the Center for Disease Control, approximately 5.3 million Americans are living with a disability related to their TBI.
The people most at risk of TBI include:
- Children, especially newborns to 4-year-olds
- Young adults, especially those between ages 15 and 24
- Adults age 75 and older
After a life changing traumatic event, the emotional aftermath can lead to shame, guilt, self-blame, aggression and even suicidal thoughts. Drinking or self medicating is also a common way of coping with mental health or loss of control after a life changing event. If you or someone you know may be feeling suicidal, call the Suicide Prevention Lifeline at 1-800-273-8255.
The three groups most at risk for brain injury are children (0-4), teenagers (15-19) and elderly adults (65+) Children are at risk because of their playing habits, teenagers because of sports and auto accidents, and elderly people tend to sustain brain injury from falling.
Prevention technology consists of seat belts and helmets, which should be used while whenever driving a car or motorcycle. Remember to wear a seatbelt every time and to buckle children in using the appropriate type of booster seat or child safety seat in accordance to their height weight and age. Use the right protective equipment and gear for hobbies and make sure that they are stored and maintained properly. Helmet safety guide.
For children, make sure that playground surfaces have shock-absorbing materials such as mulch or sand. Make homes safer for children and seniors by ensuring that rugs and mats are secure.
How do you identify PTSD?
PTSD can be characterized into four general symptoms:
- Re-experiencing the event- Memories of the traumatic event can come back at any time. A person may feel the same fear and horror you did when the event took place. Nightmares and flashbacks are two examples.
- Avoidance of people, places, or thingsthat serve as reminders of incident - Examples include, avoiding crowds or driving
- Negative changes in mood- This symptom has many aspects, including minimal positive feelings towards others or thinking no one can be trusted.
- Chronic hyperarousal and hypervigilance- A feeling of being jittery, or always alert and on the lookout for danger. Suddenly becoming angry or irritable (hyperarousal). Difficulty sleeping, concentrating or startled by loud noises.
You can also check out this screening quiz for additional symptoms.
How do you identify TBI?
A common misunderstanding is that TBI screens are used to diagnose the TBI itself. However, even if the screen result is positive, it does not serve as a diagnosis for TBI, it actually indicates a need for further assessment. A neurological examination will determine the prognosis and next steps in rehabilitation. A physician will be able to formally diagnose a TBI by further examining patient reports, clinical presentation and brain imaging results (CT scans and MRI). Afterwards an interdisciplinary team will address specific recovery needs from the TBI. Depending on the needs of the individual who sustained the injury, this team can consist of occupational therapists, speech language pathologists, physical therapists, audiologists, nurses, social workers and teachers.
Common Symptoms following a TBI
If an individual has experienced a blow to the head, it's important to watch for several physical indications of a TBI. Below are common physical symptoms:
- A loss or change in consciousness
- Headache or other head pain
- Nausea or vomiting
- Ringing in the ears
- Inconsolable crying (particularly in infants and children)
- Poor balance
- Blurry vision
- Slurred speech
After a brain injury, some individuals may experience issues with their ability to concentrate, think, and remember. These cognitive symptoms may appear immediately after a brain injury, though others can begin to show long after. Below are common cognitive symptoms to be aware of:
- Issues concentrating
- Unable to organize
- Issues with planning
- Memory loss
- Difficulty completing tasks on sequence
- Problems staying attentive
- Trouble solving problems, or multi-tasking
- Reasoning and decision making difficulty
- Issues with reading, writing and speaking
Individuals may also experience behavioral or emotional issues after a brain injury. The following are common behavioral issues:
- Verbal and/or physical
- Impulsive behavior
- Lack of interest or enthusiasm
- Lack of motivation
|Difficulty organizing tasks||Re-experiencing the event over and over again|
|Blurred vision or eyes tiring easily||Avoid people, places and feelings that remind you of the event|
|Easily irritated||Hypervigilance, being on edge|
|Tiring easily||Night Terrors and Flashbacks|
|Ringing in Ears||Survivor guilt|
|Headache, dizziness and nausea||Physical and emotional reactions to “triggers”|
|Sensitivity towards light or sound||Heart Palpation's|
|Trouble with memory and concentration||Feelings of estrangement and detachment|
TBI and Children
Children and infants tend to express their symptoms and communicate their needs differently. To identify a brain injury in a child, one must observe carefully consider any behavioral changes or social problems. A neuropsychological evaluation is often needed to provide critical information to parents, teachers and caretakers in order to help them develop appropriate strategies to deal with cognitive deficits. Common consequences of brain injury in children include problems with impulse control, inattention and hyperactivity. There are acute signs of TBI that parents should look out for such as vomiting, persistent headache and crying, restlessness and change in sleep patterns. Children who have a TBI depend on a positive and supportive family to aid the recovery process.
TBIs have significant impact on children's developing brains. The symptoms and effects might not be noticeable right away. For young children, memory loss might create learning and developmental challenges since they’re still grasping the building blocks of fundamental information. If your child has suffered a TBI, it is important to let their school know about their needs so that teachers can be attentive to changes and challenges they might experience. Modifying the classroom experience for children with TBIs will help create stability and nurture recovery. The effects of TBI For more resources about Child Behavior.
Individuals who have TBIs might experience physical disabilities such as exhaustion, seizure, muscle spasms, difficulty maintaining balance and sometimes even partial paralyzation. Brain injury can also impair thinking and cause memory loss, concentration and judgement. Social behavioral or emotional problems such as restlessness, changes in mood, anxiety and depression. After problems are identified, is best to create a plan and seek physical or occupational therapy and counseling early on. These changes will make a big difference in growth and recovery for a child with a brain injury. It is also critical to understand that as children grow and develop, new injury related problems may pop up as well. Ask your child's medical team for suggestions and work with teachers to develop a plan that will support your child in school.
According to the Brain Injury Association of America, approximately 1,400 cases of abuse related TBI occur in the US every year. Often times these injuries go unreported and children risk being hurt again if they return to a violent home. It is necessary to assess their behavior, developmental stage and the home history of the child. Caretakers often don’t report history of trauma because it is either being inflicted by someone else without their knowledge, or they don’t want others to know. It is important to look out for signs such as seizures, dizziness or confusion, personality changes, increase temper tantrums, lethargy and lack of interest in favorite toys.
Children are also able to develop PTSD after witnessing or experience a traumatic event. The Department of Health and Human Services estimates that abuse is still under reported. There are not many studies about young children and the effects of PTSD and it is unclear how a child’s age at the time of exposure affects the severity. Exposure and intensity are two risk factors that directly contribute to the severity of PTSD.
According to the National Center for PTSD, risk factors for PTSD include:
Female genderWomen experience PTSD at 2 to 3 times the rate that men do. Source.
Previous trauma exposure
Preexisting psychiatric disorder
Low Social Support
What are Treatments for TBI?
Most people recover from mild TBIs without formal medical treatment. Depending on the injury, a medical professional may prescribe medication, suggest an operation or refer to rehabilitation. Professional treatment usually consist of rehabilitation to improve functioning. Often times people who experience head injury exhaust easily even as they return to a normal routine.
A brain injury can affect just about everything — including the way you walk, talk, and think. There are several forms of treatments available which attempt to restore the parts of life that have been affected by a brain injury. Brain injury rehabilitation refers to different types of support services offered.
Types of Brain Injury Rehabilitation
Physical therapy, its most basic form, attempts to address the illnesses, or injuries that limit a person's abilities to move and perform functional activities in their daily lives. Physical therapists use an individual's medical history and physical exam in order to diagnose and establish a treatment plan for the individual. In addition, physical therapists may also use the results of X-rays, CT scans and MRI's if needed. Physical therapy typically involves exercising, manual therapy, hot/cold therapy, sound waves, and education. Physical therapists work with individuals in order to retain functional movement which is central to what it means to be healthy.
Physical therapists are trained in movement and movement dysfunction to help strengthen a patient’s physical abilities. They help relieve pain are specialists in evaluating and treating disorders of the human body by using physical means rather than drugs. By increasing coordination, strength and endurance, a PT can help a patient recover from physical injuries and impairments.
Speech and Language Therapy
After a traumatic brain injury, some individuals can have cognitive and communication problems. Individuals may have difficulty organizing their thoughts, processing new information, or trouble finding the right words. This can be extremely frustrating for the individual and their family members. The person may even have difficulty swallowing, chewing, or forming basic word sounds.
Speech therapy is a service which focuses on improving an individuals speech and abilities to understand and express language. This can also include nonverbal language. Speech therapy most commonly includes two components - coordinating the mouth to produce sounds to form words and sentences, and understanding and expressing language.
Coordinating to form words includes therapy to address articulation, fluency and volume regulation of speech. When speech therapists work to address expressing language, they are working to improve written language, body language, sign forms, and even aspects related to social media and computers.
In its simplest terms, occupational therapists and occupational therapy assistants help people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations). Common occupational therapy interventions include helping children with disabilities to participate fully in school and social situations, helping people recovering from injury to regain skills, and providing supports for older adults experiencing physical and cognitive changes. Occupational therapy typically includes:
- an evaluation - the client, family and occupational therapist will determine goals
- an intervention to improve the client’s ability to perform daily activities and reach goals previously set
- an evaluation - ensure goals are being met, make changes to the goals
Occupational therapists take a holistic approach which focuses on adapting the environment to fit the individual so they are an integral part of the therapy team.
This chart shows other ways individuals can take control of the healing process.
|What Can Help?||What Can Hurt?|
|Rest and sleep||Any activity which can cause another brain injury|
|Establish a routine||Alcohol|
|Write everything down||Caffeine|
|Avoid multi-tasking||Medication containing pseudo ephedrine (often used in allergy cold and diet medicine)|
|Check with someone you trust when decision making||Sleeping aids slow thinking and memory|
The Rehabilitation Process
During and after the physical recovery from a brain injury, a person may receive various tests that help determine what parts of the brain have been affected. Sometimes this testing is conducted by a neuropsychologist or a clinical evaluator who is experienced in brain injury screening. If the need for rehabilitation is evident, then specific rehabilitation services will be recommended. In most cases, a hospital social worker or case manager will help direct a person to programs that offer the type of treatment the person needs.
The actual length of the rehabilitation process varies according to the person and to the severity of their injury. Some people may only require a few weeks or months of rehabilitation, and others may require years or even lifelong rehabilitation.
While most people agree that rehabilitation should begin as early as possible following a brain injury, it is not uncommon to begin rehabilitation months or years following the injury event. With the help of specialized rehabilitation, anyone with a brain injury can continue to make improvements in his or her life, no matter how many years have transpired since the injury.
What are the Treatments for PTSD?
Since traumatic events occur out of a person's control, PTSD can be very disorienting to a person's world view.
There are two main forms of therapy for PTSD: Cognitive Processing Therapy and Prolonged Exposure. You can read more about possible treatments from the National Center for PTSD.
Cognitive Processing Therapy
Cognitive therapy teaches an individual to change the upsetting thoughts and feelings about the trauma and is usually done through talking and writing. This helps with getting “unstuck” from the perception of the world being bad or unsafe. The Department of Veteran Affairs endorses this method and also has a Mobile App for people who prefer CPT. The goal of CPT is to help patients overcome the overgeneralizations of PTSD and recognize a shift in their beliefs after the event.
Prolonged exposure teaches individuals to gradually approach traumatic memories, feelings and situations which most have been avoiding since trauma. The reasoning behind this treatment is that by confronting these challenges, individuals can control or decrease their symptoms. According to the U.S. Department of Veterans Affairs, this method has been known to be effective for those who experience PTSD and substance abuse. The first step is to verbally recount the experience. The second, is to confront situations and objects that were part of the trauma but are not inherently dangerous to help overcome fear and avoidance.
Eye Movement Desensitization and Reprocessing
This treatment is a psychotherapy treatment involving exercises that help individuals make sense of the trauma by paying attention to a back and forth movement or sound. This treatment was developed originally for adults, but can also be used for adolescents and children with PTSD. This approach involves processing the past event, targeting triggers and re-imagining future events. Bilateral stimulants are used to help reprocess the memory.
Other therapies include:
Brief Eclectic Psychotherapy
Practicing relaxation recalling details, re-framing thoughts, writing a letter about the event and holding a farewell ritual to leave it in the past.
Narrative Exposure Therapy
Developed for trauma from war, conflict or ongoing violence. This involves talking through chronologically and putting events in a story.
Cognitive Behavioral Therapy
Evaluating your perception and reaction to the event, and recognizing that as more powerful than the traumatic event itself. Provider will guide individuals to change unhelpful behavior or thoughts.
PTSD Advocacy and Sexual Violence PTSD
To read more about PTSD advocacy, visit http://www.ptsdalliance.org/ for more information and resources.
There are also organizations that are for sexual violence related PTSD a culture of respect.org. A Culture of Respect is a nonprofit organization dedicated to eliminating sexual violence at schools and support for survivors.
Where can you receive treatment?
Treatment can come in many forms. As mentioned above, rehabilitation can consist of physical therapy, speech therapy, recreation therapy, occupational therapy and vision therapy. Outside of medical support, counseling, community support and supportive employment are also helpful.
Finding a therapist who aligns with your style of treatment and communication can be difficult, especially if someone is needed immediately. Different treatment options will often take different amounts of time to see results.
Questions to ask your Therapist
- What experience do you have working with people with trauma and or PTSD?
- Do you have any specialized training in PTSD treatment?
- What kinds of PTSD treatments do you use?
- Have they been proven effective for dealing with my kind of problem or issue?
Questions to ask yourself
- What do I want from my treatment?
- Am I open to medication, psychotherapy or both?
What is the link between PTSD, TBI?
It can be difficult to identify the underlying problem after a traumatic and life changing event occurs. Symptoms from a Traumatic Brain Injury and Post Traumatic Stress Disorder can often overlap because they occur physiologically and psychologically after trauma. A TBI is considered a neurological disorder caused by physical trauma to the brain. PTSD is a mental illness associated with the psychological ramifications after a traumatic incident, but the associated stress from trauma is likely to cause physical damages. PTSD and TBI each have a major impact on a person's memory, sleeping patterns and emotions.
Doctors and scientists have believed a link exists between (PTSD) and (TBI) since veterans began returning from the wars in Iraq and Afghanistan with head injuries. New research is confirming those beliefs with findings that suggest concussive bomb blasts may make brains more vulnerable to the later development of PTSD.
Patients with TBI often meet criteria for PTSD on screening instruments for TBI and vice versa. Some of these positive screens may represent false positives, but many Veterans have experienced a mild traumatic brain injury as well as have PTSD related to their combat experience.
In a recent study, Army STARRS, 4,645 soldiers who were deployed to Afghanistan were studied. Results showed 18% of soldiers experienced mild TBIs while 1.2% of soldiers experienced more-then-mild TBIs during deployment. Even after taking into account other known risk factors for combat PTSD causes, it was found:
- There was a greater risk of PTSD at the three month and nine month mark.
- There was a greater risk of generalized anxiety disorder (GAD) at the three month and nine month mark.
- There was a greater risk of a major depressive episode at the three month mark.
The study shows there is a risk of PTSD and other mental health issues for those who have suffered a TBI.
While experts do not currently totally understand the link between TBIs and PTSD, it is clear there is one. Other studies also suggest PTSD is a physical illness and not simply something "in an individuals head". What this means for individuals who suffer a brain injury, particularly soldiers, is greater care should be taken in screening for PTSD after a TBI is sustained. Studies show, brain injuries, even mild cases, can increase an individuals risk of PTSD.