Post-traumatic Stress Disorder After Brain Injury

Hello everybody.

Um so over the years I have specializ in trauma and brain injury rehabilitation and I'm particularly fascinated about the two things in the link. So hopefully today I'll be able to share some of my expertise with you all.

I guess at one point or another everybody has heard of PTSD and there is so much information out there about trauma that paradoxically it it almost makes it hard to define.

So what is it? What is trauma? Why certain people develop PTSD and others don't? Why people with ben injury can be particularly vulnerable to to this?

So my aim for today is to try and give a grounded practical overview of how our body works and some some of the helpful models to understand what happens.

So here we go.

Understanding how the brain and body handle stress

To understand PTSD, we first need to look at how our brain and body handle stress in everyday life.

The brain can be divided in many ways. you know frontal lobe, occipital lobe. But one simple way to think about it is this. We've got an emotional brain which is the subcortical region and a thinking rational brain which is the cortical region. You can see it clearly highlighted on the in the picture on the left.

Now the emotional brain, it's what we sometimes call the mammal brain because we share with all mammals is very old. It's around 200 millions years old if I'm correct. It's supposed to be fast, instinctive, and designed to keep us alive. It's the part that reacts before we even think. The one that shouts, "Run!" or "Freeze" when it senses danger.

In the picture on the right, we see some key elements that form something called the LIC system. We're going to talk more about some of these structures, but just to mention a few, we got the amydala, the hippocampus, and the phalamus. And uh as we dive into the webinar, you will hear more about it.

Then we have the thinking brain. It's a cortex especially the prefrontal cortex which is particularly evolved in us as humans. This is the newer bit only about two to three million years old. And this part is where we have the you know you you might have heard of the executive functions. is the body helps us plan, reason and calm ourselves down, regulate our emotions when stress is manageable.

So on a good day, these two parts work together beautifully. But when stress becomes overwhelming, that's that's the trick that's the tricky bits. Um like in trauma the emotional brain takes over and the thinking brain the rational part gets kind of pushed offline doesn't have the time to think through.

So that's when we react rather than reflect and that's a big part of what happened in PTSD.

The nervous system

So let's take a quick tour of how our nervous system works.

So what happens in our body when we feel stressed?

We got the central nervous system. If you look at the picture on the left, that's the brain and the spinal cord is, let's say, the main control center.

Then we have the autonomic nervous system. You have a picture on the right, which branches out from the spinal cord to the rest of the body.

Now these systems, the autonomic nervous systems runs automatically. We don't have to think about it. It just goes and it keeps everything ticking along. Uh the heart rate, the breathing, digestion, temperature, all of it.

Now the automatic autonomic sorry system has two main branches.

You see here uh you've got the sympathetic nervous system which activates us. This is our get up and go kind of system. It's the one that gets the gazelle sprinting across the savannah uh when he spots a lion.

So what happens is that the blood rushes to the muscles, the heart speeds up and digestion shuts down cuz you know who needs lunch when you're running for your life, right?

And then on the other side uh we got the parasympathetic system. Now this does exactly the opposite. It's the rest and recover mode. slowing things down, helping digestion, restoring balance once the lions has gone or the threat.

So, here is the interesting bit. Our body doesn't know the difference between a lion, let's say, and a stressful email or being late for work or a conflict or a traumatic memory. they all trigger the same biological alarm that we're going to look at um in a in a in a minute in the next slide.

So normally our body smoothly moves between these two states.

When we breathe in we activate the sympathetic so activation and when we breathe out we relax. It's the parasympathetic that kicks in.

A way I like to explain it, I read it on a um in a book which is fascinating is um why zebras don't get answers if I'm correct is is that they're like these two systems like the accelerator and the brake. So we can't press both at the same time. Um so our body constantly adjusts between between them.

So what happens in PTSD that system this body system gets stuck the body starts you know remaining in survival mode even when the threat has passed either constantly on high alert that's the hyperarousal the fight or flight state the sympathetic system or shutting down into freeze or collapse even when there's no danger the body keeps reacting as if there is danger.

And that's why it can be so hard to feel calm, to feel uh safe or fully present when we experience PTSD.

It's in other words, the body hasn't yet learned that the danger has passed and remains very easily triggered.

It's quite tricky, isn't it?

The threat response

Now, the threat response.

When something scary happens, the information traveling through our brain can take two different routes. That's what we call a shortcut or a highway.

Let's start with a shortcut, a short.

So when the brains get startled, it sends an emergency message straight to its via center. And that's the amdaala that we mentioned earlier. This part of the brain works like um an alarm system. It sends out a quick alert to the rest of the body to say something's wrong. Get ready.

And in a split second, it has to be fast. Remember, it's for survival. Stress hormones surge through the system. Heart rate jumps, muscle tense, digestion poses, and we get those sweaty pumps or goosebumps.

All of this happens even before we even had time to think. We're literally afraid before we know that we are afraid and that's what keeps us alive and you know when we're in danger.

I'm sure you all experience when you know maybe in the middle of the night you are kind of trying to sleep and at some point you hear some noise coming from another part of the of the house.

What happens? Your body reacts. You start hearing very well. You're all tense up. That's your sympathetic system kicking in. That's the saying. I don't know exactly what the this is about, but in the meantime, let's me let me get everything activated. So, we are we're on the safe side.

Now, this fast route has a cost because it's so quick. It's not very accurate. It reacts before checking the facts.

Now, that's where we, you know, we we get to the highway.

Let's talk about the highway. This is the slower more thoughtful route. So here information travels through the talamos if you see here in the middle um up to the cortex especially the prefrontal cortex. It's just the part of the brain that help us reason and uh you know make sense of things.

I may be thinking you know the system poses for a moment analyzes the situation and decides is this actually dangerous? Is this sound maybe could be you know maybe a glass moved from the sink or maybe a pipe doing a noise.

If it is uh if it is not if it is not sorry if it is a danger the cortex confirms the alarm and tells the body to stay alert. So we remain in that state.

But if it's not, it was you know the pipe or the or the glass, it sends a calming um calming signal back to the amydala to say all right darling all clear stand down and the body gradually settles back to normal.

So we are fluctuating as we said between the two systems.

Now in PTSD the balance breakdown. The amydala stays on the high alert while the prefrontal cortex our rational brake system goes quiet.

When the amigdala sends a signal to the body to become alert it also triggers the release of the stress hormone that I'm sure most of you have heard talking about is the cortisol our best friend.

So the stress hormone goes through the hypothalamus. PTI gland is in the very inner part of the brain and down to the adrenal glands and we got the cortisol release.

Normally when we are already when we already have a lot of cortisol in the body there is a feedback circuit that inhibits further release.

But if the brain continues to say to release cortisol too much of this hormone can short circuit some parts of the brain especially the hypoc campus.

The hypocmpus is a key part of the brain that organizes memories and we're going to talk about it in a minute.

When this happens, the traumatic memory doesn't get stored properly. It loses its context, becomes fragmented, and can feel like it's happening all over again. That's what people with PTSD experiences. That's what trauma is about.

So when we talk about PTSD, we're really talking about what happens when this communication between the fast emotional brain and the slow rational brain gets disrupted. It loses, you know, it loses the ability to regulate themsel. The alarm keeps ringing even when the fire is long long gone.

Um and here's a fun fact.

Um you see here from the picture that it kind of go through the eyes, right? So the eyes go through the talamos. The talamus makes sense you know organizes the sensory uh signal and then send it to the rest of the body where they have to of the brain sorry where they have to go but smell and touch bypass the thinking part of the brain all together just go that's why a certain scent or texture smell can suddenly take us right back to a moment we thought we had forgotten like our grandma perfume just to say one um the sense system goes straight to the emotional center and in just these two senses the smell and touch.

Trauma processing

Okay.

So this um is just a model to show the difference between the typical processing of an experience and what happen what gets stuck what doesn't happen with the trauma processing.

You got the sensory input, you know, through the eyes. You see someone walking dodgy or um you know, you you smell something, you smell fire. Um the signal split in the brain and then it goes through the emotional processing, right? Let's get ready.

And then it also goes the logical processing like all right, is this a real danger or is just my partner burning the dinner?

And then this information gets integrated and you get what we talk what we what we call an adaptive adaptive memory.

With trauma processing uh the event is so out of ordinary is so intense that there is no time for the logical processing.

So the memory gets stuck, the information gets lost and uh the memory gets stored in a maladaptive way. That's what keep triggering the alarm signal.

Brain injury

Now brain injury let's move move on to talk about this and uh it's same it's it's easy it's helpful to start with a simple distinction.

We often hear you know the term TBI or traumatic brain injury. This refers to an injury caused by an external force like a fall, a road trackic accident, assaults, a blow to the head or an explosion.

And then we have ADI or acquired brain injury. This stands for um you know it's it's it's kind of a broader term that includes also injuries caused by internal factors like reduced blood or oxygen supply. examples you know here on the picture you have uh stroke, hypoxia, hanoxia, brain tumors, infections such as enifolitis or menitis.

In short, ABI refers to any injury to the brain that occurs after birth. So it's not genetic.

Now it's vital to remember that every brain injury is unique. Uh they can range from mild to severe and even people with seemingly identical injuries or even twins identical twins they will have different brains because of the how the experiences shape uh their brain during their life and so they can have very different outcomes.

This is influenced by their life experience, psychological processes, many many things.

Um many events that cause a TVI like car accidents or assaults are also you know obviously psychologically traumatic and that's why we in we see that increased risk of de developing PTSD in people with brain injury. It's the nature of the of the of the injury itself of the event.

So importantly trauma symptoms could have been there already before the brain injury. We all have a history but we all have a past and they get exaggerated mutually interfering with adjustment processes when we talk about rehab rehabilitation.

So when we have both TBI and PTSD recovery gets a bit more complex but it's not absolutely not impossible.

What is trauma?

What is trauma?

The word trauma actually comes from ancient Greek and means to wound or to pierce. It was first used to describe soldiers whose armor had been pierced in battle. Their defenses were literally overwhelmed, broken down.

So today we use this term to describe a psychological wound, an emotional response to something so distressing or life-threatening that it overwhelms our ability to cope.

In the context of brain injury, trauma can obviously be both physical and psychological. the accident itself, loss of control, you know, being in intensive care units, surgery, all of these can leave a lasting imprint and the nervous system can remain in survival mode beyond the event.

The window of tolerance

The window of tolerance is a brilliant metaphor um which was firstly introduced by Den Seagull to help us understand how our nervous system manages emotions.

Think of it as the you know here the green zone is the zone where we function at our best where we can think clearly feel our emotions and respond in balanced flexible ways.

When we are inside the window we might feel stress or sad or excited but it's all manageable.

When we're pushed outside the window, either above or below, things starts to feel overwhelming.

On one side, we have hyper arousal. That's the fight orflight zone, anxiety, panic, hunger, or disconnection. And um you know, feeling constantly on edge.

And on the other side, we have the hypoarousal. That's the shutdown zone. People report feeling numb or empty.

After trauma, especially in PTSD, the autonomic nervous system, the one that we talked about earlier, can become disregulated, meaning that people are pushed out of the window, the green zone, way more easily and have trouble finding their way back

here. You know, we can see it a bit more clearly.

In a healthy nervous system, um, the one on the right, our level of arousal naturally moves up and down throughout the day.

As we said between the sympathetic system breathing in alert which activates us and the parasympathetic system breathing out calms us down which is also the reason why in breathing exercises we always say to do the outreath a little bit longer than the inb breath.

So this back and forth is completely normal. It's how we stay balanced and respond to life.

Um regulation doesn't mean being calm all the time. I always say that it means being able to stay with ourselves as emotions and the sensations comes and go.

When in PTSD the windows becomes narrower. Here on the left you see it. It means that the fluctuations are the same kind of but it takes far less stress to push to push them to push us into the either the anxiety or shut down you know above or uh below.

So we are operate people are operating outside of the window of tolerance. That's something you might have heard saying therapy helps widen the window of back again.

That's what we do by working with the body where the nervous system lives and by gently processing the emotions you know that whenever given space to move through they remain there stuck in the emotional brain they didn't travel all the way through the to the rest of the um the rational brain the cortex

The body and trauma

basan the cork you might have um heard of him is one of the leading voices in trauma and trauma research. You might know his book, The Body Keeps the Score. And if you haven't read it, I warmly really recommend it.

So he explained how the trauma fundamentally changes the way the brain, the body and the mind work together.

Trauma requires some brain key structures and perpetuates a state of chronic survival which exhausts the body from men's attention and erodess, you know, our sense of self.

The amydala, our internal smoke alarm, you remember, becomes overactive. It keeps us on alert even when we're safe. It's not working properly. It's over sensitive.

The filtering system, attention filtering system, struggles to tell what's important, what's not. Um, you know, so everyday life can feel a bit overwhelming because we don't discard unnecessary stimuli and our connection to the body, the self, what what what is called the self-sensing system can become dullled. uh we might feel numb, tense or disconnected.

So as as he puts it, trauma isn't just an event, it's the imprint it leaves on the body and the mind.

This next quote is from Peter Levine is another leading figure in trauma work and the founder of uh somatic experiencing.

We won't read it together now because I don't want to go over time, but I wanted to leave it here for you to reflect on later when you know you you go through the slides. Um I believe it captures beautifully how the body holds and release the trauma.

Reframing trauma

So reframing trauma, Peter Levan encourages encourages us to move away from labing people as victims.

Traumatic experiences are understood in this framework, not as things that happened to someone, but it's about what the body had to do to get us through it.

It's an event that carried more emotional energy than the body could handle could possibly handle at the time.

So in this terms, the body did what it needed to do. it adapted to help the person survive and you know when when they were under threat.

I think importantly having one traumatic memory doesn't necessarily mean someone is going to get PTSD. Not necessarily.

It does suggest though that the experience hasn't been fully processed. It may still be causing distress or triggering a kind of emotional switching off you know as a way of coping with what happened.

I I sometimes I put a thermometer here because I sometimes explain it to my clients with a thermometer analogy.

Um to me it's a bit like when our body gets a fever to fight to fight off an infection, a virus or a bacterium. That's hiking temperature is absolutely normal. Is a healthy protective reaction. Thank god we had it.

But with PTSD, it's as if after recovering from the flu, every time we enter in contact with a small bacterium or a virus, the body cranks the temperature straight back up to 40° every time, as if there's a major infection to fight.

The response itself isn't wrong. It's just happening too strongly and too often.

And our goal in therapy is to help bring the body's thermostat back into balance. if that makes sense.

PTSD in brief

Now, PTSD in brief, uh, PTSD is really a whole person condition. It doesn't just affect emotional thoughts. It touches every part of how someone feels and functions.

Emotions and feelings are different. There may be fear, guilt, numbness.

People might present with unusual behaviors in order to avoid the reminders. They can be more irritable or withdrawn from others.

And we often see intrusive memories, changing in thought and beliefs, sleep problems and unpleasant physical sensations are also very common.

And with for people with a brain injury, these symptoms can overlap with the neuroscychological effects of the injury itself, which makes recognizing PTSD and treating it a bit more complex.

So at the bottom you got the definition of PTSD according to the DSM5 which is a diagnostic manual of mental health disorders.

Um PTSD develops when the brain's natural recovery process get disrupted and stuck. We talked about it.

Not everyone who experienced trauma develop PTSD said that. But for some the memory stay did it intrusive and emotionally charged to the point that they severely interfere with everyday life. That's where we talk about PTSD.

Um PTSD is diagnosed by a mental health professionals and includes symptoms across four main domains.

reexperiencing the event, flashbacks, nightmares, intrusive thoughts,

avoidance, making you know the person makes active efforts to avoid memories, reminders or emotions linked to the trauma,

negative mood and beliefs. So, guilt, shame, emotional numbers, mistrust of self or others.

and hyper arousal when you know we feel an urge, easily startled, irritable or having you know um trouble sleep and and concentrating

to meet the no PTSD does need to last more than a month and cause real disruption in daily life a home a working relationship without treatment these symptoms can persist for months or even a years which is why early support make such a ments.

PTSD can touch every part of life.

Um, families often describe it as walking on eggshells, unsure how to help, or what might trigger a reaction.

Over time, this can lead to withdrawal, low mood, and a loss of confidence.

So, recognizing these effects helps us see that PTSD is not just emotional, it's a condition that reshapes how the brain and the body function in everyday life.

What can cause PTSD?

PTSD can develop after all sort of events. Road traffic accidents, assaults, switching something traumatic. The list can go on for ages.

For people with brain injuries, the trigger is often the crash or the fall itself. Uh but that's not the whole story.

Sometimes it's what happens afterwards that leaves the biggest mark.

Think about the experience of being in intensive care. tubes, machines, bright lights, strange noises, people coming and going. It's disorienting. It's frightening, especially if you're in pain, sedated, or hallucinating with delirium.

That experience alone can be traumatic and even separate from the injury itself.

Many people also experience retrograde or post-traumatic amnesia. It basically gaps in memory before or after the event. So, the story of what happened can feel incomplete or confusing.

And some other you know some people remember nothing of the accident but clearly recall waking up in hospital and realized that something was wrong for many that moment you know discovering the injuries not being able to speak or move walk feeling completely powerless that becomes the target memory that carries the emotional weight.

There can be no active memory of the accident but the body remembers and is stuck.

And of course everyone experiences different. It depends on how the injury happened, who else was involved, what the hospital and rehab experience were like.

So when we explore these stories in therapy, we're not just asking what happened cuz that's not the full thing.

We're really asking what did your body and mind go through and what emotions still need space to be understood?

Why brain injury raises risk

Why brain injury raises risk?

And let's look at the connection.

Research show that having a brain injury can make someone more vulnerable to developing PTSD. And that's for both uh neurological and psychological reason.

On the neuro side, changes in the frontal lobe. So there is a reduced um frontal regulation um can reduce the brain ability to regulate emotion. So basically the part help us come down after and regulate what we're feeling. It's not working smoothly as it's supposed to.

damage to the hypoc campus which helps us store memory memories in time and context can also u make traumat memories feel current more current rather than past.

Uh the amydala is affected so falling off the alarm to things um you know what are actually is dangerous and we also know that brain injury can disrupt the autonomic nervous system.

So the system that controls you know heart rate and arousal. So we can have exaggerated or prolonged stress response that becomes physiological. So the body stays in that survival mode for longer than it should.

On top of that psychological factors as for everybody confusion at the time of the injury, loss of control, uh all this can amplify the sense of threat or helplessness.

Last but not least, brain injury can reduce the mental resources needed to process stress and recover emotionally and make it will happen.

So in short, brain injury can both trigger PTSD and make it more complicated to recover from because it affects the very systems that help us feel safe and in control.

Distinguishing PTSD from brain injury

Now this slide here is uh just to say that distinguishing PTSD from brain injury can be tricky because some symptoms often overlap.

both can cause irritability, poor sleep, poor, you know, trouble concentrating, um, poor executive functioning.

But PTSD is usually marked by emotional reactivity. It's, you know, you got the nightmares, you got avoiding the trauma reminders, you got trauma related thoughts, while brain injury symptoms are more consistent physical linked to cognitive fatigue.

And usually a good neuroscychological assessment helps tease this apart and guide to the right support so that they are good treatment can be put in place.

Treatment

So the good news is PTSD is treatable even in um when overlaps with brain injury patients.

There are several effective therapies and the strongest evidence comes from trauma focused oh sorry trauma focused CBT and EMDR.

Um trauma focused CBT helps people safely revisit and reprocess traumatic memories and challenge unhelpful beliefs about themsel and the world. um sometimes involves exposure therapy that you might have heard of.

EMDR or eye movement desensitization processing use gentle bilateral stimulation like side to side eye movements or tapping. We can use puzzles or sounds as well um to help the brain refile traumatic experiences so that they feel it tr in truly feel in the past not in the present.

There are also other body- based approaches that people benefit from things like neuro feedback, cranioacral therapy, emotional freeotic freedom techniques.

So these all aim to calm the nervous system and help the body release the store tension essentially.

medication can sometimes support the process too but not a as a standalone treatment um but to to kind of ease the anxiety nightmares or you know to lower the stress threshold so therapy becomes more accessible you can actually lower the symptoms so you work on the problem

what is important to remember is that after a brain injury we always have to adapt the therapy uh we have we are working with uh a vulnerable brain pathways and connections have changed.

So having shorter sessions, plenty of breaks, visual supports, pacing, these are all key especially when someone is managing fatigue or memory difficulties or attention problem.

So the key message here is that with the right approach tailored to the person and the brain injury recovery is absolutely possible.

Carers and family

Caris and family play a vital role in their recovery after trauma or burn injury, often more than they realize, if I may say.

The best support is usually simple and consistent, such as listen and validate.

Just being present, acknowledging how the person feels makes a huge, huge difference.

Avoid pressure to talk before they're ready. Timing really matters. We all have different speed.

Try not to rush in with the look on the bright side. It could be worse. It's not big deal because the comments are obviously well-intentioned, but they can feel invalidating when someone's still processing what's happen what's happening. Sorry, what happened?

Especially because they don't always have an understanding of why they're feeling that way.

So, I have clients saying to me, it feels silly. I don't understand why I feel this way rationally. You know, I'm not under threat. this doesn't make sense.

They say I feel stupid. They they use they use many many words to describe it.

So give it time.

Keeping a predictable routine help the person feel safe and grounded when you know everything else feels uncertain while they're trying to understand their body, their brain, all the changes.

I always remind people to encourage professional help um and to remember that cars and family are not therapists.

Setting boundaries protect both sides, both ourselves and the person we love and prevents burnout.

And most importantly, carers and family also need care.

Supporting someone with PTSD or brain injury or both can be exhausting. So it's essential to look after your own wellbeing too cuz you are doing all that scaffolding and that holding and you know all in the frame which is really really tiring.

So whether it's through rest, peer support, professional supervision, just look for it.

Self-help strategies

And clearly alongside therapeutic interventions, there are some self-help strategies that people can use to complement therapy.

Uh these include grounding techniques to bring attction attention back to the present, naming five things you can see or feel, for example.

Um breathing exercises to regulate the nervous system. Focusing on slow exhale to cure the parasympathetic system.

Acing activities to prevent spikes and crashes.

Yoga.

Keeping a journal or a creative outlet. Um this is useful to externalize and make sense of the experience in a different way which is not verbal because sometimes in brain injury the the the language and the communication is affected.

connecting with others whether through groups, peers, trusted family.

The point here is that recovering is nonlinear. It's about rebuilding safety and confidence step by step.

Key takeaways

So key takeaways from today, PTSD is a normal response to abnormal stress that can persist.

Brain injury increases the vulnerability and complexity of the situation.

But with the right combination of psychological, medical and social support, recovery is always uh pretty much achievable if you have the right combination.

Not every brain injury equals PDSD.

Not all traumatic events equal PTSD.

And um I think that's it. I pretty said that.

Good. Uh thank you very much.