Abstract
This article explores the concept of the “Perfect Storm” in the brain. The “Perfect Storm” in the brain occurs when a person is struggling with both physical damage to the brain and PTSD simultaneously. Through my clinical research project, “Listening to the Brain/Recovering the Brain/Mind,” I came to understand that all physical trauma to the brain is also traumatic to the individual and therefore a case of PTSD. Physical damage to the brain, including a TBI, stroke, seizures, infections, dementia, major mental illness and C-PTSD, causes the brain to “run” like a slow computer. This is extremely frustrating for the person because they then have a lot of difficulty processing their world both internally and externally. At the same time, PTSD causes the brain to speed up its functioning via stress hormones and the HPA axis. The result is “crazy making” for an individual, but this is seldom recognized. After laying out the theory, a case history is included that demonstrates how this issue develops and how it can be treated.
Keywords: TBI; PTSD; Concussions; Brain/Mind; Brain damage
Let’s look at the
details of the “perfect storm”
First, the
physiological symptoms. The Concussion Legacy Foundation in Boston looks at the
4 Baskets of Symptoms following a concussion and post-concussion syndrome. (3)
I believe this paradigm is of great value when addressing all trauma to the
brain. The 4 Baskets of Symptoms include:
·
Physical
Aliments
·
Cognitive
Decline
·
Multiple
Problems Dealing with the Person’s emotional states and their social
interactions
·
Constant
Sleep Disturbances
On my own, I have added
the value of an Apple Watch (or the equivalent) App for sleep and dreams. Through
this process of tracking nightly sleep and dreams, I have been able to learn a
lot more about a person at a much deeper level. Amazingly, I have been able to
predict major issues for the next day including seizures, blackouts, major
depression and panic attacks. Quite fascinating and helpful!
Second, what is the
psychological damage that leads a person to experience PTSD? When someone
experiences a traumatic event, the mind responds by shifting into survival mode
where brain chemistry is altered and the brain/mind begins to function
differently. The immediate effects are confusion, disorientation, dissociation
and increases in anxiety and depression. While the longer-term effects include
flashbacks, avoidance and hypervigilance. The brain’s fear circuits are
activated, leading to physical and emotional changes in the brain/mind. And in
addition, higher level functions like reasoning and emotional regulation lose
their effectiveness in the person’s life4.
The impact of trauma on
an individual is serious business, but I don’t believe it is taken seriously
enough by medicine nor by our society. In my experience, trauma drives all
forms of pain and suffering. Over time, trauma alters brain structures like the
hippocampus and the PFC (pre-frontal cortex), impacts memory and emotional
regulation and affects the individual’s ability to feel safe in the world. Again,
this is a “tall order” of problems impacting the individual’s functionality on
so many levels. And I believe we need to do a better job of recognizing and
treating trauma whether it is coming from a psychological place, damage to the
brain or both as is the case here.
Let’s take a deeper
look at the impact of trauma on an individual5.
The immediate and short-term effects of trauma push the brain/mind into
survival mode including:
·
A
state of shock and denial
·
Emotional
and physical dysregulation
·
Hyperarousal
of the nervous system
·
Disorientation
and confusion
The long-term responses
of the mind involve:
·
Intrusive
thoughts and memories
·
Avoidance
of anything related to the traumatic event
·
Increased
hypervigilance
·
Increasing
difficulties with emotional regulation
·
Significant
changes in perception
·
Concerns
about a foreshortened future
As you can see from the
above, there are significant changes in the neurobiology of the brain. Particularly
with the fear circuitry in the brain, the PFC (prefrontal cortex), the
hippocampus and the makeup of the neurotransmitters in the brain. Overall, the
brain/mind remains in a constant state of reactivity, rather than returning to
a more restful, responsive state. In summary, traumatic events have the ability
to physically alter brain functioning and structure in 3 major areas of the
brain6.
The amygdala which
triggers the fear response in the brain.
The PFC is responsible
for decision making and emotional regulation. It can be either impaired or
under active, making it difficult to control the brain’s fear response and calm
the body’s stress response.
The hippocampus
controls memory storage, works to distinguish past from present, creates
fragmented memories under stress, will have difficulty discerning safety from
past traumas and contributes to intrusive thoughts and flashbacks.
When I pull all this
together, the “Perfect Storm” in the brain looks like this:
There are unwanted and
repeated memories of a life-threatening event or events.
There are flashbacks
where the event or events are re-lived and the person may lose touch with
reality.
There is the avoidance
of persons, places, things, sounds or sights that are reminders of past trauma.
Feelings of detachment
from people, even family and emotional numbness.
Shame about what
happened and what was done.
Survivors guilt with
the loss of friends, family or comrades.
Constant hypervigilance
and alertness for threats.
At the same time, the
brain is physically injured and the normal processes in the brain/mind for
repair, recovery and healing don’t work well enough or even at all. Overall,
the individual loses their normal functionality and they find themselves
struggling to exist day to day.
Exploring a Case
How does this all get
played out in a patient’s life?
Ms. L grew up with an
alcoholic mother who was physically and emotionally abusive from age 5 until
she left home at age 19. Her mother’s physical abuse included punching and
slapping her daughter, which probably included at least some sub-concussive
blows (which over time do cause significant problems just as “straight
concussions do). At age 19 her car was broadsided by a driver who apparently
did not see her and pulled onto the highway colliding with her car. Following
the accident, Ms. L was hospitalized for over a week, going in and out of a
coma. She did recover but with virtually no treatment or follow up for either
the trauma and abuse or the severe concussion she had sustained. Here we have
the evidence that this was already the “Perfect Storm” in the brain. Physical
damage colliding with emotional damage.
From here she found a
good paying job, got married and then divorced and held herself together
through an eating disorder: bulimia. This is the way she managed her
depression, anxiety and stress load. Eventually she got into psychiatric
treatment and was on medication for over 12 years. The medication helped her
cope by lowering her anxiety and keeping her relatively calm day in and day
out. But the medication was not addressing her PTSD, her TBI and the “Perfect
Storm” in her brain. After 12 years of being on Tramadol and Prozac, she
decided to get off the medication. Following this decision her symptoms
exploded and emotionally out of control she came to see me. By the time she had
arrived in my office, she was experiencing the “Perfect Storm” in the brain
with no understanding of exactly what this was all about. She was experiencing
daily panic attacks that flooded her mind so she couldn’t concentrate on her
life. She was depressed about everything. At the same time, she was also
experiencing blackouts during which she temporarily lost consciousness and
would find herself lying on the floor somewhere in her townhouse. On several
occasions she blacked out while she was walking down the steps from her bedroom
to the first floor. She could easily have broken her neck on one of these
blackouts on the steps. Here again we see emotional damage (depression and
panic attacks) clashing with physical damage. Where each set of symptoms
magnifies the other set of symptoms. What is the way out here, the exit?
I have found that the
treatment of the “Perfect Storm” requires addressing both sets of symptoms
simultaneously. This is not easy work for the clinician because it involves
being in “three places” at the same time, mind, brain and their continual
interaction. With this challenge in mind, I set up the following treatment
program for Ms. L7.
Nutrients for the
brain, specifically to address damage to the mitochondria (the tiny energy
factories in the nerve cells).
Stimulation to the
brain on a daily basis. I suggest music with noise-cancelling headphones. A
total immersion schedule for each day (like a full-time job).
Creating daily flow
experiences8.
Neuro-Psychoanalytic
sessions 2-3 times per week to process the recovery from the injury.
Weekly chiropractic
treatment for the health of the nervous system.
Paying close attention
to diet and exercise.
And most recently I
have added the use of an Apple Watch with the sleep and dreams app (or an
equivalent), to track the individual’s rhythm of sleep and dreams. Very, very
helpful in tracking exactly where a patient is physiologically and
psychologically.
In Summary
I have found that it is
the healing relationship between doctor and patient, the matrix, the holding
environment, that is the most powerful ingredient in the healing process. Because
the patient is entering into a relationship where he or she is free to
verbalize their experiences with someone who understands what they are going
through. They are not waiting for something to be done to them; they are
actively engaged in the healing process. Where they are encouraged to put their
difficult, confusing, disorienting, dissociating, painful experiences into
words. And over and over again, I have seen this process work to heal brain
injuries (see “The Complex Architecture and Healing of Traumatic Brain
Injuries” 2023). What I sense here is that it is the healing of the Self that
is most crucial to the recovery process. My patients spend way more time
talking about their personal lives and not that much time talking about their
brain injuries. I did not expect this, but I see this process in every one of
my patients. And over time they do get better! (See “The Complex Architecture
and Healing of Traumatic Brain Injuries,” Cambridge Scholars Publishing 2023)9.
References
1.
TBI and PTSD: Navigating the Perfect Storm.
3.
Concussion Legacy Foundation in Boston.
6.
Bremner JD. Traumatic Stress: Effects on the Brain. Dialogues in
Clin Neurosci 2006;8(4):445-461.
8.
Csikszentmihaly M. Flow: The Psychology of
Optimal Experience (book). Harper Perennial Modern Classics 2008.
9.
Reynolds LJ. The Complex Architecture and
Healing of Traumatic Brain Injuries (book). Cambridge Scholars Press 2023.