PTSD 101 offers a range of 18 relevant and timely topics related to post-traumatic stress and trauma. The goal is to develop or enhance practitioner knowledge of trauma and its treatment. Continuing education (CE) credits are available for most courses. There is no need to register in order to take a course. And there is no charge for either the courses or for CE credits.

Attention:  Effects include difficulties in maintaining attention, shifting attention from one activity to another, suppressing one's own preoccupations, and screening out distractions.

 

Suggestions: Keep sessions short and focused. Cue people when they seem stuck on prior topics or have lost the topic. Gradually lengthen the amount of time as abilities permit. Make eye contact frequently to maintain attention. Make learning fun. Make sure the environment has few distractions.

Memory:  Short-term memory problems are common among people with brain injuries. Holding onto several pieces of information while thinking through each item may be difficult. Other common problems include remembering to complete tasks at specific times and recalling recent experiences. The memory of pre-traumatic events is often intact after the initial stages of rehabilitation.

Suggestions: Preview and review information. Use consistent terminology and presentation format.  Present material in a way that makes previously presented information easy to recall. Speak concisely. Include in each session some material that was covered in the previous session.  Use overheads and flip charts. Print rather than write. Use pictures and symbols for non-readers. Ask participants to use "memory books" or other notebooks during sessions. Point out information they might want to record.  Help participants make note cards or signs to cue thoughts and actions. These signs can be placed in conspicuous spots in their rooms. Participants can choose the phrases to be used, then design and make the signs. Make audiotapes or videotapes of sessions for participants.

Language:  Often people with brain injuries lose the ability to express ideas or to understand others. Many cannot quickly find the words to express themselves. They may have lost the ability to speak, or may speak in a disorganized fashion. People with cognitive disabilities are often uncomfortable speaking or reading in front of groups.

Suggestions: Speak slowly and clearly, but do not exaggerate inflection. Use concrete terms. Teach the meaning of new words before using them. Use age­appropriate words: Treat adults like adults. Encourage people to ask questions. If you are not sure they understand, ask questions to check comprehension.  When you ask questions, begin with those that require short answers. Create an atmosphere where people are comfortable refusing to comment or read aloud. Be patient and encouraging when they need time to express their point. Do not pretend to understand if you cannot follow a person's comment. If you think you understand, ask "Do I have this right?" and paraphrase what they have said.

Reasoning and Judgment:  Brain injury often reduces the ability to make inferences. Thinking may be concrete, so that idioms and humor are interpreted incorrectly. This may lead to confusion and misinterpretation. Impulsivity may limit the ability to work on problems. People may find it difficult to picture the consequences of their acts. They will need help in distinguishing appropriate from inappropriate behavior, and some basis for reflecting on the propriety of what they have said or done.

Suggestions: Use simple, concrete terms. Avoid idioms and subtleties. Be clear and direct. Use problem-solving exercises that reflect the situations in which participants encounter "cues" for drinking or drug use. Role-play exercises and discussion of scenarios can be helpful.  Avoid confronting people with brain injuries about their substance use, particularly in groups. Build decision-making skills by identifying and weighing short- and long-term consequences of actions. Encourage people to postpone decisions until they have more facts. Reply to their assertions in a concrete, non-judgmental way. Encourage people to read instructions and use cue-cards to strengthen reasoning skills. For example:

Emotions:  Emotional problems after brain injury can include irritability, frustration, dependence on others, insensitivity, inflexibility, anxiety when confronted, lack of awareness of one's impact on others, overreacting to stress, and heightened emotionality.

Suggestions: Try to understand what the person may be experiencing. Keep a non-threatening, non-judgmental attitude and approach. Be positive in giving directions. Make sure non-verbal messages do not contradict verbal messages. Meet resistance with empathy and reflection, rather than confrontation.

This article appears courtesy of the Rehabilitation Institute of Chicago and the Illinois Prevention Resource Center. No reuse or copying of this article may be made without the prior written consent of the Rehabilitation Institute of Chicago.

 
Blast-related attacks can cause TBI (Traumatic Brain Injury) or MTBI (Mild Traumatic Brain Injury). According to the Defense and Veterans Brain Injury Center (DVBIC), "Blast injuries are injuries that result from the complex pressure wave generated by an explosion . . . Air-filled organs such as the ear, lung, and gastrointenstinal tract and organs surrounded by fluid-filled cavities such as the brain and spinal cord are especially susceptible to primary blast injury (Elsayed, 1997; Mayorga, 1997). The overpressurization wave dissipates quickly, causing the greatest risk of injury to those closest to the explosion."

Though there is much that is unknown about brain injuries, a study of returning soldiers done at Walter Reed Medical Center in 2003 by the DVBIC determined that 61 percent of the soldiers who had sustained blast-related attacks had brain injury. P. Steven Macedo, a neurologist and former doctor at the Veterans Administration (quoted by Ronald Glasser in a March 2007 Washington Post article), estimated that at least one-third of all veterans who had served in Iraq or Afghanistan likely had sustained brain injury.

With the nearly 2 million soldiers, sailors, airmen, and marines that have served in Iraq or Afghanistan to date, that estimate would mean approximately 670,000 returning heroes are suffering from a brain injury. This is far more than the mere 12,274 reported cases of combat-related TBI as of March 2007. Such a drastic discrepancy in numbers would indicate, perhaps, that current military and Veteran's Administration screening and diagnostic procedures are not adequate.
 
It is also possible that the majority of our heroes are being diagnosed with PTSD (Post Traumatic Stress Disorder) when they should actually be receiving a diagnosis of TBI, MTBI, or a combination of PTSD and brain injury. Many symptoms of brain injury, mild or otherwise, mirror symptoms of PTSD. Individuals experiencing either injury typically experience one or more of the following: memory loss, difficulty concentrating, shortened attention spans, slower thinking processes, irritability, difficulty sleeping, depression, and impulse control problems. With so many shared symptoms, it is impossible for many, even trained professionals, to determine from which ailment (or both) a soldier is suffering.
 
It is necessary, however, in order to ensure proper long-term care of our nation's heroes for medical providers to do the appropriate testing in order to determine if brain injury exists. This is paramount because, according to the Brain Injury Association of America (BIAA), brain injury causes and accelerates many diseases including respiratory, circulatory, digestive, and neurological diseases. Without proper initial care, veterans will not receive follow-up screenings and treatment to prevent or mitigate further harm.
 
Our family's personal experience with TBI/MTBI screening through the Veteran's Administration medical system has not been entirely favorable. My husband sustained more than twelve blasts (a combination of RPGs and IEDs) while serving in Iraq. His neurological symptoms following one attack fell directly under the diagnostic criteria for brain injury (available on the BIAA's Web site at www.biausa.org) because he had an intermittent loss of consciousness for a period of time following the blast. He received one initial screening at our local VA outpatient clinic followed by one "second-level evaluation" at our regional VA hospital. The second evaluation was so unprofessional and seemingly dependent on the clinician's opinions, that I sought counsel from the BIAA. It was through them that I learned that my husband did, indeed, at the very least have a MTBI and should receive follow-up care and testing under "civilian" care guidelines. However, based on the opinion of the VA clinician, my husband's mental, behavioral, and physical changes have been attributed only to PTSD.
 
There are many current military and VA procedures and policies that will have to be adapted and improved in order to properly care for and diagnose our many returning heroes. The current level of care given to soldiers in regards to brain injury is definitely an example of this. I hope that, if enough veterans and family members stand up and ask for more, we will make the road ahead easier for our returning brothers and sisters.
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Neurological Symptoms of TBI include memory loss; concentration or attention problems; slowed learning; and difficulty with planning, reasoning, or judgment.
 
Emotional and Behavioral Consequences of TBI include depression, anxiety, impulsivity, aggression, and thoughts of suicide.
 
Physical Symptoms of TBI include nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, quickness to fatigue, lethargy, or other sensory loss.
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See also Ronald Glasser, "A Shock Wave of Brain Injuries," Washington Post, April 8, 2007. Accessible at http://www.washingtonpost.com/wp-dyn.
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