A brain injury can result in a confusing array of psychological changes. These range from subtle and temporary lapses in ability and behaviour, to a profound and permanent reduction in basic skills and loss of control of emotion and behaviour.
Sustaining a brain injury can be a devastating experience for both the individual concerned and their family and friends. The impact is all the more confusing due to the lack of public awareness of the nature and effects of brain injury. To learn that a loved one, whose life may be in danger, has sustained a brain injury is intensely distressing for the family. When the person has recovered sufficiently to recognise that he or she has sustained a brain injury, this can be both disturbing and a threat to their personal identity.
Having weathered the immediate crisis following the brain injury, there may follow a long struggle to regain physical, cognitive and social skills. The process of recovery may continue for many years, often with a remarkable degree of improvement. Specialist neurological rehabilitation facilities may be required for those with more severe injuries, but for many, even prolonged periods of intensive treatment will not ensure a restoration of previous skills and lifestyle.
Cognitive impairment
All those with a moderate to severe brain injury are likely to have some difficulties with their cognitive skills, at least in the early stages of recovery; as will some people with minor injuries. The most common cognitive problems after brain injury involve concentration, memory and general speed of thought. However, a broad spectrum of cognitive skills may be affected, including perception, language and the awareness of self and others. A set of skills known as ‘executive functions’, including planning, organisation, multi-tasking and flexible thinking, is also commonly affected and this can be particularly debilitating.
Soon after injury, whether in the hospital or home environment, the demands on the person with a brain injury can be relatively limited, and so the presence of subtle cognitive changes may not be readily apparent. Their memory of the distant past and their established prior knowledge (e.g. educational skills) may appear to be relatively unaffected. The person may therefore seem to have no obvious problems when holding general conversations about familiar topics. However, problems may later become apparent during formal neuropsychological assessment, during active rehabilitation or on returning to work.
While cognitive difficulties generally show marked improvement during the course of recovery, some degree of permanent impairment is common amongst those with a more severe injury. This can often prevent or hamper a person in returning to their previous employment, studies or lifestyle.
Memory function
Memory problems take many forms and are the major area of difficulty after brain injury for many people. Memory problems usually include a period of amnesia surrounding events that took place before and after the injury, and difficulty in remembering new information.
Retrograde amnesia
The loss of memory for events leading up to the injury is known as retrograde amnesia. People with a brain injury rarely recall the circumstances of their injuries. Retrograde amnesia may extend from just a few seconds to minutes, hours, days, weeks or even longer. In addition to the period of total amnesia, people frequently complain of incomplete or vague recall spanning days, weeks, or months before their injury. However, they may be able to recall some of this information when prompted by family or friends. In extreme cases, when the period of retrograde amnesia extends to a period of years, this is very disturbing for the person and distressing for their relatives.
Post-traumatic amnesia
The period of confusion and memory loss that follows the injury is known as post-traumatic amnesia (PTA). This covers the period of time from the injury until the person starts to regain some continuity in their memory function and retain some information. This may range from a few minutes (after a mild injury), to a period of weeks, months or years (after a very severe injury). In post-traumatic amnesia, people may be able to hold a sensible conversation about familiar subjects, such as the weather or something that has just happened, but then remember nothing afterwards.
New memories and new learning
People with brain injury commonly experience some degree of difficulty in learning and remembering new information. This ranges from occasional forgetfulness to an inability to recall basic information, such as personal and family details, current circumstances and daily routines. Many people with a severe injury report problems in learning and remembering names, messages, appointments, routes and plots of books or television programmes, etc. People with more severe memory difficulties may forget where they are going or what they are doing, and may be dependent on family members to remind them of daily activities. In contrast, memory for the long-term past (such as school, work and family history) may be well retained. More information on memory is available on our #Memory problems page.
Attention and concentration
Another common complaint is that of difficulty in attending to or maintain concentration or interest in activities. While some people with brain injury struggle specifically with tasks requiring divided attention or multi-tasking, many others find that their concentration and train of thought is easily disrupted, for example by noise or interruptions. They may have to start an activity over again or ask for information to be repeated. Difficulties with attention and concentration can have far-reaching effects on work, leisure and social activities. Such problems may be worsened when the person is tired or uninterested in the subject matter.
Speed of information processing
People also commonly experience a reduction in their speed of thought and their responses, even after a relatively minor brain injury. They may find, for example, that they are unable to take in new information as quickly as they used to. They may often find themselves left behind by conversations or television programmes, slow to read newspapers or books, sluggish in their reactions, or generally slow at work or in their leisure activities.
Language skills
While severe loss of language skills is relatively uncommon after generalised brain injury, people may have word-finding difficulties and may experience a reduction in their vocabulary. People may also experience difficulties in organising their communication and expressing themselves, especially when conveying complex ideas. More marked difficulties in understanding and expressing language are common after more localised damage to language-sensitive parts of the brain, for example after a stroke or a bleed following traumatic brain injury. People may have difficulty recognising speech sounds, identifying individual words, or breaking down the structure of sentences to extract the meaning. People may also have difficulty in selecting and expressing words or in constructing sentences. Specific difficulties with reading, writing or spelling may also occur. More information on this is available on our #Communication problems webpage.
Perceptual skills
People with severe brain injury may have problems with one or more of their senses, and/or difficulties with their perceptual skills (i.e. their ability to interpret the information they receive from their senses). The most commonly reported perceptual problems are visual - involving the ability to recognise and identify objects, faces and other visual material. These problems may be complicated by double vision, loss of co-ordination of the muscles controlling eye movements, or a reduction in the person’s field of vision. Perceptual problems are not, however, confined to vision. Parallel problems in auditory (hearing) or tactile (touch) perception may occur, whereby the person has difficulty identifying and recognising sounds or sensations.
Spatial and constructional skills
People with brain injury may perceive objects accurately, but have difficulty with their spatial skills - i.e. in judging spatial relationships between two or more objects, or between themselves and objects in their environment. This may lead to them misjudging distances (e.g. reaching out to pick something up and missing), perceiving things the wrong way around (e.g. trying to read a newspaper upside down), confusing left and right, or having difficulty in locating objects or following even familiar routes. Occasionally people may fail to respond to stimuli coming from their left or right or may ignore a particular side of their body, for example when shaving or dressing. This is known as visual neglect. There may also be problems with constructional skills (e.g. in copying or drawing, completing puzzles/ jigsaws/ models or in household tasks such as DIY). Others may retain spatial and constructional skills but have difficulty in completing complex activities, e.g. dressing or cooking, in the right order.
Executive function
People with a brain injury often experience difficulties with executive skills - that is, in planning, problem solving, reasoning, decision making, and self-monitoring. In general conversation they may lose their train of thought and go off at a tangent. Others may be inflexible in their thinking, repeating one rigid opinion and failing to appreciate other people’s points of view. This means that conversations can be frustrating and unrewarding for others, particularly when the same conversation is repeated several times. It may be hard for a person with brain injury to identify and analyse problems, think of possible solutions, make decisions, and implement coping strategies. They may also be poor at planning, monitoring and evaluating their performance, and organising their lives effectively.
Awareness and insight
The awareness of oneself and of others can be profoundly affected by brain injury. People with brain injury may be unaware of how they are presenting themselves and can lack insight into their difficulties. This is particularly common in the early stages of recovery. As people recover, they may gradually regain their self-awareness and insight into their more obvious problems (such as mobility, speech or memory), but may never achieve insight into more subtle changes in their skills or behaviour. They may, as a result, fail to pick up on hints or social cues and may therefore misjudge social situations, appearing clumsy in their social skills and inappropriate in their behaviour.
Bryce's story
“My brain injury affects me socially and makes me find day to day business taxing. I find myself frustrated noticing some deficiencies with socialising, memory and understanding small elements of my day.
“My family and friends have been vitally important for my recovery. They inspire me to want to get the most out of these circumstances."
Find out more about Bryce's story of rebuilding life after brain injury.
Behavioural and emotional changes
Brain injury can result in a wide range of emotional and behavioural changes. These reflect a combination of organic damage and psychological reactions to the injury and its consequences. Primary changes due to damage to the brain (such as irritability and impulsivity) interact with secondary reactions to these (such as frustration, loss of confidence and depression). Such reactions are similar to those experienced by other injured or stressed people, but are influenced by the cognitive, behavioural and emotional changes that arise directly from the brain injury.
While behavioural and emotional changes are very common after severe brain injury, some people with a more minor injury suffer post-concussion syndrome, which comprises a constellation of symptoms including dizziness, headache, fatigue, irritability and poor memory and concentration. This is usually short-lived, but may persist with subtle changes in cognition, behaviour or emotion, of which only the person or their close family may be aware. Where such changes are not acknowledged or appropriately managed, this can add to the anxiety of the person and their family and can lead to long-term emotional difficulties. People may appear to have recovered well after a brain injury, and yet be left with the disconcerting feeling that they are not quite the person they once were.
Behavioural changes
Behavioural changes after brain injury are many and varied. Some appear to be an exaggeration of previous personality characteristics, while others may seem completely out of character for that person.
Disinhibition
A common change early in recovery is disinhibition, that it, loss of control over behaviour, resulting in socially inappropriate behaviour. This ranges from a tendency to divulge personal information too freely, to disturbing and unpredictable outbursts of uncontrolled rage. Common complaints include a tendency to make tactless remarks, to laugh inappropriately, and to be overly familiar towards others. A major area of difficulty, especially early in recovery, is that of sexual behaviour - making inappropriate sexual advances or remarks. Abusive or crude language may cause offence and be acutely embarrassing for relatives or in social situations. Most people gradually regain control over their behaviour, but those with a severe injury may remain impulsive and/or inappropriate in their actions. A few people never regain adequate control over their behaviour, remaining unpredictable, aggressive, and reliant on others to exercise a degree of control over their behaviour.
Irritability, frustration and aggression
Perhaps the most common behavioural change after brain injury is that of increased irritability. People with a brain injury are often impatient, intolerant of others’ mistakes, and easily irritated by interruptions, such as noise from children or machinery, which disrupt their concentration. They are frequently reported to be short-tempered, for example when things do not work out as expected or where there are differences of opinion with family or work colleagues.
Many people with brain injury become frustrated by the slow rate of recovery and some also remain angry with anyone held responsible for their injury. When a build up of irritability, frustration and anger is combined with loss of behavioural control, it may result in outbursts of verbal or physical aggression. Some people with brain injury experience sudden and unpredictable outbursts of uncontrolled rage without any warning, often known as ‘episodic dyscontrol’. More information on this is available on our #Anger webpage.
Apathy and loss of initiative
In contrast with those who exhibit poor control over their behaviour or increased irritability, some people with a brain injury may become passive, unresponsive and lacking in initiative. Some people may appear unconcerned and even unaware of their difficulties, especially in the early stages of recovery. Others may appear interested and have good intentions to carry out activities, but are unable to organise themselves and initiate action. This may happen to any of us when feeling depressed, but for the person with a brain injury, this can result directly from the injury itself rather than solely as a result of depression.
Egocentricity
People may also become egocentric after brain injury, tending to be self-centred and appearing not to consider the feelings or needs of their family and friends. In adversity, it is common for anyone to tend to focus on their own needs, but this can be greatly exaggerated for a person with a brain injury. Cognitive impairments can mean that they are oblivious to, or unable to appreciate, others’ points of view, and they may be unaware of the needs of others.
Emotional changes
The emotional impact of brain injury depends upon the individual’s previous personality and coping skills, their appreciation of their own difficulties, and the family and professional support that is available to them, as well as the nature of the brain injury.
Lability
In parallel with their loss of behavioural control, many people with a brain injury experience loss of emotional control. They may react strongly and unpredictably to events which would not previously have troubled them, and may also be subject to rapid and marked swings in mood - for example, being happy and joking one minute and tearful the next.
Depression
Depression is a common emotional reaction to a brain injury. For some this may be an early reaction to the trauma of the injury and subsequently disability, whereas for others it may develop as they struggle painfully and seemingly helplessly to regain their lost skills. Commonly, depression presents itself when active treatment is complete and the person returns home, only to be confronted by the realisation that life will probably never be as it was before. The loss of former physical, cognitive, and social skills, the impact on personal relationships, and the fact that they are unable to return to their previous leisure and social activities or fulfil their former work aspirations, can be extremely hard to accept, and can understandably lead to depression.
Anxiety
Many people suffer from anxiety after brain injury, which impacts upon their daily lives and may obstruct their rehabilitation. Those with a less severe injury may be anxious early in recovery, feeling disturbed by the changes to their cognitive skills and personality. People with a more severe injury may become anxious later on, when they come to appreciate the extent of their long-term disability and feel anxious about the future. A few who suffer anxiety may become obsessional in their thoughts and actions.
Post-traumatic stress disorder
Some people may experience post-traumatic stress disorder (PTSD). This is a severe psychological reaction to a traumatic event. It involves the persistent re-experiencing of the trauma, avoidance of the stimuli which remind the person of the event, increased arousal, and a numbing of emotional responses. Loss of memory for the circumstances of the injury means that most people with severe brain injuries are not troubled by disturbing memories of the event. As such, PTSD is most commonly experienced after mild brain injuries when memories of the circumstances surrounding the injury are retained. However, some others develop a fear of circumstances similar to that of their injury (e.g. being assaulted), and a small number of people have disturbing memories of the early stages of their recovery.
Changes in self-concept
After a brain injury, people may experience marked changes in their view of themselves, that is, in their self-concept. Those with a minor injury may have the nagging doubt that they are not quite the person they were beforehand, while those with a more severe injury are confronted by complex and confusing neurological disability, totally outside the realm of normal experience. Those with marked physical disability may struggle to perform basic personal and domestic activities, while those with severe communication problems may experience immense frustration and a distressing sense of isolation. Severe perceptual or spatial disorders present a confusing and bewildering world within which it is difficult to play one’s full part. For those with reasoning difficulties, life may appear at times an insoluble puzzle. Severe memory problems may result in a disturbing lack of continuity and order to one’s life, particularly for those experiencing a long period of amnesia for events before, as well as after, their injury. Changes in behaviour and emotion, especially those involving loss of control over emotions, thoughts or actions, can be profoundly disturbing.
While frustrated by current limitations which some may see as a personal failing, people with brain injury tend initially to view such changes as temporary, being confident of a good, if not full, recovery. Often, it is only on completing treatment and returning home to familiar surroundings that they are confronted by their limitations. There may follow a gradual and painful process of realisation of their disabilities, and an appreciation that they may not, after all, recover their former skills and lifestyle. This can result in a period of depression characterised by confusion and uncertainty.
Such reactions are delayed for some people, who understandably find it hard to accept their limitations and respond with determination to make a full recovery. They may set themselves unrealistic targets, which may lead to repeated disappointment and despair.
The limited opportunities in our society for people with brain injury can create a sense of helplessness and futility, until survivors can find a new direction and meaning to their lives.
Find out more about post-traumatic stress disorder in our webinar
View video transcript Hide video transcript
Hello everybody.
Over the years I have specialised in trauma and brain injury rehabilitation, and I'm particularly fascinated by the link between the two. 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 almost makes it hard to define. So what is it? What is trauma? Why do certain people develop PTSD and others don't? Why can people with brain injury be particularly vulnerable to this?
So my aim for today is to try and give a grounded, practical overview of how our body works and some of the helpful models to understand what happens.
So here we go.
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 in the picture on the left.
Now, the emotional brain is what we sometimes call the mammal brain because we share it with all mammals. It's very old. It's around 200 million 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 limbic system. We're going to talk more about some of these structures, but just to mention a few, we've got the amygdala, the hippocampus and the thalamus. As we dive into the webinar, you will hear more about them.
Then we have the thinking brain. It's the 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. This is where we have, you know, what you might have heard of as the executive functions. It helps us plan, reason and calm ourselves down, regulating our emotions when stress is manageable.
So on a good day, these two parts work together beautifully. But when stress becomes overwhelming, that's the tricky bit. Like in trauma, the emotional brain takes over and the thinking brain, the rational part, gets pushed offline. It doesn't have the time to think things through.
So that's when we react rather than reflect, and that's a big part of what happens in PTSD.
So let's take a quick tour of how our nervous system works. What happens in our body when we feel stressed?
We've got the central nervous system. If you look at the picture on the left, that's the brain and the spinal cord. It's the main control centre. Then we have the autonomic nervous system, shown in the picture on the right, which branches out from the spinal cord to the rest of the body.
Now, the autonomic nervous system runs automatically. We don't have to think about it. It just goes on keeping everything ticking along. The heart rate, breathing, digestion, temperature, all of it.
The autonomic system has two main branches. You've got the sympathetic nervous system, which activates us. This is our get-up-and-go system. It's the one that gets the gazelle sprinting across the savannah when it spots a lion. The blood rushes to the muscles, the heart speeds up and digestion shuts down because, you know, who needs lunch when you're running for your life?
Then on the other side we've got the parasympathetic system. Now this does exactly the opposite. It's the rest-and-recover mode, slowing things down, helping digestion and restoring balance once the lion has gone, or once the threat has passed.
Here is the interesting bit. Our body doesn't know the difference between a lion and a stressful email, being late for work, a conflict or a traumatic memory. They all trigger the same biological alarm that we're going to look at in a minute on the next slide.
So normally our body smoothly moves between these two states. When we breathe in, we activate the sympathetic system, activation. When we breathe out, we relax. It's the parasympathetic system that kicks in.
A way I like to explain it, from a fascinating book called Why Zebras Don't Get Ulcers, is that these two systems are like the accelerator and the brake. We can't press both at the same time, so our body is constantly adjusting between them.
So what happens in PTSD? This body system gets stuck. The body remains in survival mode even when the threat has passed. Either constantly on high alert, that's 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.
That's why it can be so hard to feel calm, feel safe or be fully present when we experience PTSD. 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?
Now, the threat response.
When something scary happens, the information travelling through our brain can take two different routes. That's what we call the shortcut or the highway.
Let's start with the shortcut. When the brain gets startled, it sends an emergency message straight to its threat centre, the amygdala that we mentioned earlier. This part of the brain works like an alarm system. It sends out a quick alert to the rest of the body to say, "Something's wrong. Get ready."
In a split second, because it has to be fast, remember it's for survival, stress hormones surge through the system. Heart rate jumps, muscles tense, digestion pauses, and we get those sweaty palms or goosebumps. All of this happens before we've even had time to think.
We're literally afraid before we know that we are afraid, and that's what keeps us alive when we're in danger.
I'm sure you've all experienced when you're trying to sleep in the middle of the night and suddenly hear a noise coming from another part of the house. What happens? Your body reacts. You start hearing really well. You tense up. That's your sympathetic system kicking in. It's saying, "I don't know exactly what this is about, but in the meantime, let me get everything activated so 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.
That's where we get to the highway.
This is the slower, more thoughtful route. Here, information travels through the thalamus up to the cortex, especially the prefrontal cortex. It's the part of the brain that helps us reason and make sense of things.
The system pauses for a moment, analyses the situation and decides, "Is this actually dangerous?" That sound might simply be a glass moving in the sink or a pipe making a noise.
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, if it was the pipe or the glass, it sends a calming signal back to the amygdala to say, "All right, darling. All clear. Stand down."
The body gradually settles back to normal.
So we are fluctuating, as we said, between the two systems.
Now in PTSD, the balance breaks down. The amygdala stays on high alert while the prefrontal cortex, our rational brake system, goes quiet.
When the amygdala 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 of: cortisol, our best friend. The stress hormone goes through the hypothalamus, the pituitary gland in the very inner part of the brain, and down to the adrenal glands, where cortisol is released.
Normally, 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 signal the release of cortisol, too much of this hormone can short-circuit some parts of the brain, especially the hippocampus.
The hippocampus is a key part of the brain that organises 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 experience. That's what trauma is about.
So when we talk about PTSD, we're really talking about what happens when the communication between the fast emotional brain and the slow rational brain gets disrupted. It loses the ability to regulate itself. The alarm keeps ringing even when the fire is long gone.
Here's a fun fact. You can see in the picture that information from the eyes goes through the thalamus. The thalamus organises the sensory signal and then sends it to the rest of the brain where it needs to go.
But smell and touch bypass the thinking part of the brain altogether.
That's why a certain scent, texture or smell can suddenly take us right back to a moment we thought we had forgotten, like our grandma's perfume, just to give one example.
Those sensory systems go straight to the emotional centres. In particular, smell and touch can have a really powerful effect.
This is just a model to show the difference between the typical processing of an experience and what happens when trauma processing gets stuck.
You've got the sensory input through the eyes. You see someone walking suspiciously, or you smell something, you smell fire. The signal splits in the brain and goes through emotional processing, right? Let's get ready. Then it also goes through logical processing, like, "All right, is this a real danger or is it just my partner burning the dinner?"
This information gets integrated and you get what we call an adaptive memory.
With trauma processing, the event is so out of the ordinary, so intense, that there is no time for the logical processing. The memory gets stuck, the information gets lost, and the memory gets stored in a maladaptive way. That's what keeps triggering the alarm signal.
Now, let's move on to talk about brain injury.
It's helpful to start with a simple distinction. We often hear the term TBI, or traumatic brain injury. This refers to an injury caused by an external force, like a fall, a road traffic accident, an assault, a blow to the head or an explosion.
Then we have ABI, or acquired brain injury. This is a broader term that includes injuries caused by internal factors like reduced blood or oxygen supply. Examples include stroke, hypoxia, anoxia, brain tumours and infections such as encephalitis or meningitis.
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. They can range from mild to severe, and even people with seemingly identical injuries, or even identical twins, will have different brains because of how life experiences shape them over time. They can therefore have very different outcomes.
This is influenced by life experiences, psychological processes and many other factors.
Many events that cause a TBI, like car accidents or assaults, are also psychologically traumatic. That's why we see an increased risk of developing PTSD in people with brain injury. It's the nature of the injury itself and the event that caused it.
Importantly, trauma symptoms may already have been present before the brain injury. We all have a history and we all have a past. These difficulties can become exaggerated and mutually interfere with adjustment and rehabilitation processes.
So when we have both TBI and PTSD, recovery becomes a bit more complex, but it's absolutely not impossible.
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 armour had been pierced in battle. Their defences were literally overwhelmed and broken down.
Today, we use the 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, the loss of control, being in intensive care, surgery, all of these can leave a lasting imprint. The nervous system can remain in survival mode long after the event itself.
The window of tolerance is a brilliant metaphor, first introduced by Dan Siegel, to help us understand how our nervous system manages emotions.
Think of it as the green zone. It's the zone where we function at our best, where we can think clearly, feel our emotions and respond in balanced, flexible ways.
When we're inside the window, we might feel stress, sadness or excitement, but it's all manageable.
When we're pushed outside the window, either above or below, things start to feel overwhelming.
On one side we have hyperarousal. That's the fight-or-flight zone. Anxiety, panic, anger, disconnection and feeling constantly on edge.
On the other side, we have hypoarousal. That's the shutdown zone. People often report feeling numb or empty.
After trauma, especially in PTSD, the autonomic nervous system that we talked about earlier can become dysregulated, meaning people are pushed out of the window, the green zone, much more easily and have trouble finding their way back.
Here we can see it a bit more clearly.
In a healthy nervous system, 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 and becoming alert, and the parasympathetic system, breathing out and calming down. That's also the reason why in breathing exercises we always encourage the out-breath to be a little longer than the in-breath.
This back and forth is completely normal. It's how we stay balanced and respond to life.
Regulation doesn't mean being calm all the time. I always say that it means being able to stay with ourselves as emotions and sensations come and go.
In PTSD, the window becomes narrower. Here on the left you can see it. It means the fluctuations are roughly the same, but it takes far less stress to push us into anxiety or shutdown, above or below the window. People are operating outside their window of tolerance much more often.
You might have heard therapists say that therapy helps widen the window again. That's what we're trying to do by working with the body, where the nervous system lives, and by gently processing emotions that were never given the space to move through. They remain stuck in the emotional brain and never fully travel through to the rational brain, the cortex.
Bessel van der Kolk, who you might have heard of, is one of the leading voices in trauma research. You might know his book The Body Keeps the Score. If you haven't read it, I warmly recommend it.
He explains how trauma fundamentally changes the way the brain, body and mind work together. Trauma rewires some key brain structures and perpetuates a state of chronic survival, which exhausts the body, fragments attention and erodes our sense of self.
The amygdala, our internal smoke alarm, becomes overactive. It keeps us on alert even when we're safe. The filtering system struggles to tell what's important and what's not. Everyday life can therefore feel overwhelming because we don't filter out unnecessary stimuli.
Our connection to the body and to ourselves, what is sometimes called the self-sensing system, can become dulled. We might feel numb, tense or disconnected.
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, another leading figure in trauma work and the founder of 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 go through the slides.
I believe it captures beautifully how the body holds and releases trauma.
So, reframing trauma.
Peter Levine encourages us to move away from labelling people as victims. Traumatic experiences are understood in this framework not simply as things that happened to someone, but as experiences that required the body to do whatever it could to get us through them.
It's an event that carried more emotional energy than the body could possibly handle at the time.
In these terms, the body did what it needed to do. It adapted to help the person survive when they were under threat.
I think it's important to remember that having one traumatic memory doesn't necessarily mean someone is going to develop 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 as a way of coping with what happened.
I sometimes use a thermometer analogy with my clients. To me, it's a bit like when our body develops a fever to fight off an infection, a virus or bacteria. That higher temperature is absolutely normal. It's a healthy, protective reaction. Thank goodness we have it.
But with PTSD, it's as if after recovering from the flu, every time we come into contact with a small bacterium or virus, the body cranks the temperature straight back up to 40 degrees, as if there is a major infection to fight.
The response itself isn't wrong. It's just happening too strongly and too often.
Our goal in therapy is to help bring the body's thermostat back into balance, if that makes sense.
Now, PTSD in brief.
PTSD is really a whole-person condition. It doesn't just affect emotions and thoughts. It touches every part of how someone feels and functions.
There may be fear, guilt or numbness. People might present with unusual behaviours in order to avoid reminders. They can become more irritable or withdrawn from others.
We often see intrusive memories, changes in thoughts and beliefs, sleep problems and unpleasant physical sensations.
For people with a brain injury, these symptoms can overlap with the neuropsychological effects of the injury itself, which makes recognising PTSD and treating it a bit more complex.
At the bottom you've got the definition of PTSD according to the DSM-5, which is a diagnostic manual of mental health disorders.
PTSD develops when the brain's natural recovery process gets disrupted and stuck.
We talked about this earlier. Not everyone who experiences trauma develops PTSD. But for some people, the memory stays vivid, intrusive and emotionally charged to the point where it severely interferes with everyday life. That's where we begin to talk about PTSD.
PTSD is diagnosed by a mental health professional and includes symptoms across four main domains.
Re-experiencing the event through flashbacks, nightmares and intrusive thoughts.
Avoidance, where the person makes active efforts to avoid memories, reminders or emotions linked to the trauma.
Negative mood and beliefs, such as guilt, shame, emotional numbness or mistrust of themselves or others.
And hyperarousal, where someone feels on edge, is easily startled, irritable, or has trouble sleeping and concentrating.
To meet the criteria for PTSD, symptoms need to last more than a month and cause significant disruption in daily life, at home, at work or in relationships.
Without treatment, these symptoms can persist for months or even years, which is why early support makes such a difference.
PTSD can touch every part of life. 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.
Recognising these effects helps us understand that PTSD is not just emotional. It's a condition that reshapes how the brain and body function in everyday life.
PTSD can develop after all sorts of events. Road traffic accidents, assaults, witnessing something traumatic. The list can go on for ages.
For people with brain injuries, the trigger is often the crash or the fall itself. 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 experiencing delirium.
That experience alone can be traumatic, even separate from the injury itself.
Many people also experience retrograde or post-traumatic amnesia. Basically, gaps in memory before or after the event.
The story of what happened can feel incomplete or confusing.
Some people remember nothing of the accident but clearly recall waking up in hospital and realising that something was wrong.
For many, that moment of discovering the injury, not being able to speak, move or walk, and feeling completely powerless becomes the target memory that carries the emotional weight.
There may be no active memory of the accident itself, but the body remembers and remains stuck.
Of course, everybody's experience is different. It depends on how the injury happened, who else was involved, and what the hospital and rehabilitation experience was like.
So when we explore these stories in therapy, we're not just asking, "What happened?" because that's not the full picture.
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.
Let's look at the connection.
Research shows that having a brain injury can make someone more vulnerable to developing PTSD, and that's for both neurological and psychological reasons.
On the neuro side, changes in the frontal lobe and reduced frontal regulation can reduce the brain's ability to regulate emotion. Basically, the part that helps us calm down and regulate what we're feeling isn't working as smoothly as it's supposed to.
Damage to the hippocampus, which helps us store memories in time and context, can also make traumatic memories feel current rather than past.
The amygdala can be affected too, so the alarm system becomes more sensitive to things that aren't actually dangerous.
We also know that brain injury can disrupt the autonomic nervous system, the system that controls heart rate and arousal. This can lead to exaggerated or prolonged stress responses. The body stays in survival mode for longer than it should.
On top of that, there are psychological factors. Confusion at the time of the injury, loss of control and uncertainty can all 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, making recovery more difficult.
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.
This slide is really here to show that distinguishing PTSD from brain injury can be tricky because some symptoms often overlap.
Both can cause irritability, poor sleep, trouble concentrating and difficulties with executive functioning.
But PTSD is usually marked by emotional reactivity. You've got the nightmares, the avoidance of trauma reminders and trauma-related thoughts, while brain injury symptoms are often more consistent and linked to cognitive fatigue.
Usually, a good neuropsychological assessment helps tease this apart and guide people towards the right support so that appropriate treatment can be put in place.
The good news is that PTSD is treatable, even when it overlaps with brain injury.
There are several effective therapies, and the strongest evidence comes from trauma-focused CBT and EMDR.
Trauma-focused CBT helps people safely revisit and reprocess traumatic memories and challenge unhelpful beliefs about themselves and the world. It sometimes involves exposure therapy, which you may have heard of.
EMDR, or Eye Movement Desensitisation and Reprocessing, uses gentle bilateral stimulation such as side-to-side eye movements or tapping. We can use sounds or puzzles as well. The aim is to help the brain refile traumatic experiences so that they truly feel in the past rather than in the present.
There are also other body-based approaches that people benefit from, such as neurofeedback, craniosacral therapy and emotional freedom techniques. These approaches aim to calm the nervous system and help the body release stored tension.
Medication can sometimes support the process too, but not as a standalone treatment. It may help ease anxiety, nightmares or reduce the stress threshold so that therapy becomes more accessible. In other words, it can lower the symptoms enough for people to work on the underlying problem.
What is important to remember is that after a brain injury we always have to adapt therapy. We are working with a vulnerable brain where pathways and connections may have changed.
Having shorter sessions, plenty of breaks, visual supports and careful pacing are all important, especially when somebody is managing fatigue, memory difficulties or attention problems.
The key message here is that with the right approach, tailored to both the person and the brain injury, recovery is absolutely possible.
Carers and family play a vital role in recovery after trauma or brain injury, often more than they realise.
The best support is usually simple and consistent.
Listen and validate. Just being present and acknowledging how the person feels can make a huge difference.
Avoid pressure to talk before they're ready. Timing really matters. We all move at different speeds.
Try not to rush in with comments like, "Look on the bright side", "It could be worse" or "It's not a big deal". These comments are usually well-intentioned, but they can feel invalidating when somebody is still processing what has happened.
This is especially true because people don't always understand why they're feeling the way they are.
I have clients who say things like, "It feels silly", or "I don't understand why I feel this way. Rationally I know I'm not under threat."
They'll say, "This doesn't make sense. I feel stupid."
People use lots of different words to describe it.
So give it time.
Keeping a predictable routine can help the person feel safe and grounded when everything else feels uncertain and they're trying to understand their body, their brain and all the changes they are experiencing.
I always remind people to encourage professional help and to remember that carers and family are not therapists.
Setting boundaries protects both ourselves and the person we love, and it helps prevent burnout.
Most importantly, carers and family also need care.
Supporting somebody with PTSD, brain injury, or both, can be exhausting. You're often providing a lot of scaffolding and holding things together, which is really tiring.
So whether that's through rest, peer support, professional supervision or something else, it's important to seek support for yourself too.
Alongside therapeutic interventions, there are some self-help strategies that people can use to complement therapy.
These include grounding techniques to bring attention back to the present, such as naming five things you can see or feel.
Breathing exercises can help regulate the nervous system. Focusing on a slow exhale can activate the parasympathetic system.
Pacing activities can help prevent spikes and crashes.
Yoga, keeping a journal or having a creative outlet can also be helpful. This can help people externalise and make sense of their experiences in a different way that isn't purely verbal, particularly because language and communication can sometimes be affected by brain injury.
Connecting with others, whether through groups, peers or trusted family members, can also be important.
The key point is that recovery is non-linear. It's about rebuilding safety and confidence step by step.
So, the key takeaways from today.
PTSD is a normal response to abnormal stress that can persist.
Brain injury increases vulnerability and adds complexity to the situation.
But with the right combination of psychological, medical and social support, recovery is very often achievable.
Not every brain injury leads to PTSD.
Not every traumatic event leads to PTSD.
I think that's it. I think I've pretty much said everything.
Good. Thank you very much.
Work, social and family changes
Many people with brain injuries face major changes in their work, leisure and social activities, and in their family relationships.
Occupational changes
The combined effects of physical, sensory, cognitive, behavioural, and emotional changes mean that many people with severe brain injury will be unable to return to previous work, except perhaps in a reduced capacity. For some there will be the opportunity to re-train for alternative work or to work in a supported capacity. Others may undertake voluntary work, or attend a sheltered workshop or Headway group.
For those who may be able to return to work following a brain injury, it is important not to rush back too soon, underestimating the effects of fatigue and subtle cognitive changes. It is often possible to organise a phased return with reduced responsibilities to avoid getting overloaded too early.
Leisure and social activities
Many people with brain injuries do resume their former leisure and social activities, although they may find that they have lost the edge in their performance in sports, or that they no longer quite fit in with their friends as they did before. Those with severe injuries may find that former hobbies and sporting activities are ruled out because of physical disability, slowed reactions, or reduced concentration. Some people who have marked cognitive impairment may lack the interest and initiative to pursue former activities.
Some existing friendships tend to fade away after brain injury with the person struggling to contribute as before and some friends feeling embarrassed by their disability and any difficulties in social interaction. However, both existing friends who are able to accommodate the effects of brain injury and new friends post-injury provide vital support.
People may find themselves socially isolated and dependent upon their family until they are able to rebuild their social lives. Families are often very resourceful in organising leisure and social activities, but this can put an extra strain on family members until the person starts to make new friends.
Family relationships
Brain injury can be a major source of stress for close family members. The shock of the initial injury, and the anxious wait for signs of recovery in the early stages, are acutely stressful. The family then share in the long and often painful struggle to regain lost skills. Throughout, the family is a vital source of comfort, reassurance and support. Family members may also have to assume the role of carer for the dependent person and, later, perhaps take on the role of therapist in retraining lost skills. This can be a source of friction for the injured person and their relatives. Families may also experience a similar sense of social isolation to the person with the injury.
Ultimately, the family is faced with the difficult task of adjusting to the many physical and psychological changes in the person with a brain injury, particularly the changes in personality. It is these latter effects which tend to place the greatest strain on family members.
Parents may naturally resume the role of carer, but find it hard to allow the person more independence as recovery takes place. Brothers and sisters may find that their injured sibling now looks to them for leisure and social activities. Spouses may find the role of carer or therapist irreconcilable with that of sexual partner. They may feel that the altered personality and behaviour of the injured person is no longer attractive or compatible with their own.
Those with children may find themselves torn between the needs of their children and those of their partner. The children themselves are likely to be confused and distressed by any strange or unpredictable behaviour on the past of the parent with a brain injury. Parents may therefore have additional task of protecting children from the effects of the injury and helping them to understand and adapt to the changes in their injured parent. More information on this is available on Children.
Readjustment after brain injury is perhaps most difficult for partner relationships, particularly where there are marked changes in the personality of the injured partner. All carers, whatever their relationship to the person with brain injury, may feel isolated and trapped, but a spouse may feel in a ‘social limbo’, still living with a partner, but one with whom they no longer enjoy their previous leisure, social and sexual lives.
Many families therefore encounter marked changes following brain injury. However, that is not to suggest that all families will experience significant problems. Many show great resilience in adapting to such changes, often with little or no support. Some make the required adjustments quite naturally and may feel closer as a result, while others may struggle and need help in finding a positive way forward.
Psychological services
Psychological services can help people with brain injuries and their families throughout the course of recovery, from acute care and rehabilitation to resettlement and long-term support.
The types of psychological needs outlined in this booklet are generally dealt with by clinical psychologists, but are also appropriate to other professional groups, such as nurses, occupational therapists, psychiatrists, social workers, speech therapists, and teachers. Unfortunately, clinical psychology is a small profession within the NHS and only a small number of specialists (known as clinical neuropsychologists) work with people who have a neurological illness or injury. While most regional neurosurgical centres and neuro-rehabilitation services have access to specialist neuro-psychological services, some areas have to rely on general clinical psychology services.
Expert psychological advice may not therefore be readily available in the acute hospital, but most areas should be in a position to provide at least some of the psychological services outlined below.
Cognitive assessment
As people with brain injury regain consciousness, they generally experience a period of disorientation and confusion. Nursing staff on the ward may request help from a clinical psychologist in managing this confusion and in promoting the early recovery of cognitive skills, through a structured programme of graded orientation exercises.
As the person improves, a formal neuropsychological assessment of cognitive skills is often required. Such an assessment is likely to include tests of general intellectual abilities, memory and learning skills, and may also include tests of attention, speed of information processing, and executive skills.
The assessment of intellectual ability may include basic education tests (such as general knowledge, arithmetic, vocabulary, word reading) and various reasoning tasks to assess the ability to apply this knowledge to new problems.
Assessment of memory function is likely to include recall, learning and retention of both verbal material (such as stories and lists of words) and visual material (such as geometric shapes, faces or objects).
More specialised tests of other areas of cognitive function, such as attention, executive function, perception and language, might be included depending upon individual need.
Cognitive rehabilitation
A formal cognitive assessment should identify the extent of any impairment, as well as areas of strength on which to draw in rehabilitation. A range of rehabilitation strategies may then be adopted, depending on the specific nature of problems and the stage of recovery. This may start with orientation exercises and education, and progress to the development of strategies to manage difficulties with cognitive skills (such as attention, memory, or perception), or to compensate for lost skills through the use of external aids.
As the likely extent of long-term problems becomes more apparent, the focus is likely to shift to alternative ways of organising and approaching tasks in order to cope with the difficulties that remain.
Re-assessment may be helpful both in monitoring progress, reviewing rehabilitation strategies and goals in the light of improvement and, later, in guiding resettlement plans.
Behavioural management
Early on in their recovery, people with brain injury often become restless and agitated, or exhibit disinhibited or aggressive behaviour. Ward staff may seek psychological advice about the management of such behaviour. In some cases a psychiatric opinion and medication may be required to contain agitated, disruptive, or aggressive behaviour. Where such problems persist, a specific behaviour modification programme may be required. This involves staff and relatives working together to systematically discourage disruptive behaviour and actively encourage positive behaviour. In extreme cases, there are a few units that specialise in the management of very severe behavioural problems.
Social skills training
While severe behavioural problems affect a small proportion of people with brain injury, many more experience difficulties with their social skills and relationships due to a combination of cognitive, behavioural and emotional changes.
Social skills training may be of value in raising self-awareness and social awareness, as well as providing a forum for peer support. It can also help people to appreciate the inappropriateness of some of their conversation and behaviour, and the need to be more controlled and positive in their social activities. This can help people to rebuild their confidence, both in maintaining their established relationships and in making new friendships.
Psychological counselling
People with brain injuries benefit from being given feedback and advice about the nature of their psychological difficulties. This is especially important where there is a tendency for the person to underestimate the extent of their difficulties, and to overestimate future recovery. In the early stages of recovery, this belief may protect people from becoming depressed and serve as a powerful motivating function. However, continued reliance on unrealistic expectations of recovery may impede both progress in rehabilitation and adjustment to long-term disability.
A detailed explanation of the nature of the person’s difficulties, and guidance about the likely extent of recovery, can help them gain a more realistic outlook, and so help them make appropriate plans for the future. This is not to suggest that people should give up hope of further recovery, but rather that there is a need to get on and make short-term plans on the basis of current capabilities.
Psychological counselling may also help in evaluating re-employment options and getting back into social and leisure activities. The family should be included as fully as possible in such counselling. Relatives usually benefit from detailed feedback about the results of formal assessments, the nature and implications of acquired disability, and some explanation of the rationale and goals of treatment. They often seek advice about the management of cognitive and/or behavioural problems, and may assume the role of co-therapist in reinforcing treatment strategies at home. They too may benefit from guidance about what to expect in terms of further recovery, and from help in making appropriate plans for the future.
Individual psychotherapy
Some people, understandably, feel devastated by the effects of their brain injury. Where people do suffer marked depression or anxiety, psychological therapy or psychiatric treatment may help them through a difficult phase. However, it is not only people who are acutely distressed who benefit from psychotherapy. Unsurprisingly, in the confusion of the present and the uncertainty about the future, people often cling to the past following their brain injury. Some people attempt to carry on as before, unable to accept the changes that have occurred, and may continue to judge themselves by the pre-injury standards that they can no longer meet. For others, the preoccupation with what they have lost may cloud their appreciation of the positive attributes and potential that remain.
Psychotherapy can help people to re-appraise their new situation. With support and guidance, they can often be helped to move forward to explore their new selves, and search for a new direction and purpose to their lives.
Family therapy
Family members face a similar process of adjustment following brain injury. As the person improves, regains their independence and resumes former roles, family relationships can naturally revert to their previous pattern. However, for those with permanent disability, some changes in family roles and relationships may be inevitable.
Many families adjust well to such changes, and some report feeling closer as a result. Where changes do cause problems, family therapy can help with resolving the conflicts that have arisen. Children may also benefit from help in understanding and coping with the changes in their parent.
Where families find the changes too great to cope with, therapy can help them move forward with the minimum of recrimination and guilt.
The information on this page was written by Dr Andy Tyerman, Consultant Clinical Neuropsychologist.
This information was last reviewed in 2018.
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