PTSD and Survivor’s Guilt

Survivor’s Guilt a Lingering Problem after CO Poisoning

Survivor’s Guilt and other Anxiety related symptoms interact with brain damage deficits to significantly complicate recovery after carbon monoxide poisoning. This blog is a followup to last weeks blog on brain damage and mood disorders.

By Rebecca Martin

When I think back over recounts of accidents over the years, the incidence of PTSD and survivor guilt have often been components which seem to be some of the more serious aftereffects of any traumatic event. For instance, we see drivers hesitant to be behind the wheel following a car accident, workers reluctant to return to a job following job-related  event,  or children hesitant to return to school after an incident of high carbon monoxide levels.

Many times, PTSD is apparent following an accident or event and not necessarily in only those activities directly related to the causal event itself. Survivor guilt is a serious component of PTSD following a traumatic event which may have taken others’ lives but not one’s own. Both of these disorders have something in common with or major depressive disorder (MDD): the patient is often repeatedly urged by those closest to them to move on or get over it. Like many of the aftereffects of traumatic brain injury, what can’t be seen is often minimized  or dismissed.

One way that CO survivors deal with anxiety and survivor’s guilt is to being hypervigilant about having Carbon monoxide detectors every where they are.

The American Psychiatric Association describes PTSD as the following:

“Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.” https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

When discussing brain damage we are looking at two different issues in general. The actual injury itself and the symptoms which follow. We categorize the injury in terms of the actual physical changes which occur at the time of the accident or event. We traditionally look at symptoms as very separate disorders brought about subsequently by the brain damage event. However, advancements in our understanding of brain function are  showing that many of the cognitive, emotional, psychiatric and functional symptoms following a TBI have an organic root as well.

PTSD was once thought of something that soldiers suffered in wartime and was referred to as “shell shock” or “combat fatigue”. It is estimated that 35% of soldiers who suffered a mild brain injury in combat also experience PTSD. But, roughly 3.5% of people in America will suffer from some form of PTSD in their lifetime. This means that approximately 8 million Americans have PTSD during any given year.

It is very normal for us to have residual effects after any traumatic event, whether physical or emotional. It may be hard to perform daily activities. We can have unsettling memories, feel on edge, and suffer from sleep disturbances. We may avoid people or things which remind of us of the event. These feelings can appear immediately after an event or long after. A good example would be those who experienced abuse and suppressed those feelings for a long period of time only to relive them much later. PTSD can also come and go as daily life sails on smoothly or reaches rough waters along the way. It is only when PTSD causes problems with coping with daily life and perseveres over a long period of time that we think of it as serious.

PTSD Impacts Day to Day Function

People with PTSD are often impacted when it comes to employment, school,  tasks of everyday living and relationships. Often traumatic incidents involve dissociative experiences during the event. “I felt like I was watching it happen from the outside”, “It felt like time stood still”. This disassociation can continue as feelings and memories are suppressed for self-protection. This can lead to a distancing from friends and family members who eventually feel shut out of the person’s life. Offers to help are often refused and it is highly likely that the person may not be aware of the extent of the change in their behavior. Isolation follows.

In an article by Marilyn Lash, MSW, Brain Injury Journey Magazine, it is described as a “perfect storm” when TBI and PTSD combine. Things which were once safe and familiar become terrifying and threatening. But it is equally challenging to separate those issues specific to TBI from those issues specific to PTSD as they are similar. But they are not identical and there can be overlap and interplay between the two.

TBI (or other brain damage) is a neurological disorder, while PTSD is a mental disorder, but the two can interact in ways that reinforce the deficits which occur when both are present following an accident. One of the common causes of the two occurring in conjunction is car accidents. During a car accident we might see the mechanisms of PTSD emerge in our adaptive survival response; the familiar fight or flight reflex. It becomes maladaptive if it continues once the threat has been removed.

“The scientific community once believed that alterations of consciousness associated with TBI precluded formation of a trauma memory, making it improbable for PTSD to develop following TBI. Experts, however, now recognize that PTSD may develop following TBI due to several factors: implicit (unconscious) encoding of affective and sensory experiences (e.g., sights and smells) associated with the traumatic event, conscious encoding of some aspects of the event, reconstruction of the trauma memory from secondary sources (e.g., family, other observers), and memory of circumstances surrounding the event that also may be psychologically traumatic (e.g., sights at the scene of an accident after consciousness was regained). When psychological trauma is ongoing (e.g., military combat, domestic violence), PTSD may develop in response to the broader series of events, even if the specific event leading to TBI is not remembered.” https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.17090180

So while we may wonder how altered consciousness or a loss of consciousness might impact our traumatic memories of an event, it is clear that PTSD is a real possibility even in these instances. When we speak of a mild brain injury there are some complications when separating the causes for common symptoms which may initially present in both mild traumatic brain injury and PTSD. There may be difficulty discerning the causality of the symptoms as being from physical damage or from psychological stress. This is especially true in those instances where there has been no loss of consciousness to definitively point to a mechanical reason for the presented symptoms. This difficulty can continue after the mild brain injury due to the overlap and interplay of TBI and PTSD. We must reiterate that a mild brain injury differs from post-concussive syndrome in that the former usually resolves satisfactorily in a shorter period of time while the latter continues for a longer period of time or indefinitely. In this respect, mild brain injury refers to the physical damage which occurred at the time of the event or developed subsequent to the event.

Important in this distinction is the observations that during the acute phase those symptoms of mild brain injuries commonly associated with such an occurrence (cognitive, emotional, behavioral and physical)  were easily observed during the first week post-injury but psychiatric or mood disorders were more easily tracked after three months had lapsed, including those of PTSD.  At that point, an experienced clinician is needed to discern which symptoms are attributable to which. As stated previously, these symptoms are similar, but not identical.

For instance, due to PTSD, one might experience hypervigilance to threats related to the triggering incident while the presence of a TBI might cause a person to perseverate on those perceived threats to self in a disproportionate manner, to the exclusion of other thoughts. A person with TBI will experience cognitive fatigue because it is harder to think and learn due to physical deficits while someone with PTSD may experience fatigue due to sleep disturbances related to memories of the trauma itself. A person with a TBI might have experienced amnesia prior to or during the event, while the person with PTSD might be plagued with memories of the event reliving the event over and over. The important issue is that many of the treatments for overlapping symptoms of TBI and PTSD are identical.

One issue to look at is the incidence of suicide. The presence of PTSD, like depression, increases the risk of suicide. We have witnessed this in the military population where suicide rates have risen. The assumption that PTSD is going to be a factor after any brain injury stemming from a traumatic event is a safe assumption.

Survivor’s Guilt after Brain Damage

One component to PTSD is something we refer to as “survivor’s guilt.” This is such an enigmatic human emotional state: That one can feel personal regret and guilt over surviving a situation which may have significantly injured or killed others is a hard to grasp concept. As a cancer survivor I am very familiar with the term and the seriousness of survivor’s guilt. And just as it is common among cancer survivors, it is also common among crash survivors or witnesses to any traumatic event.

“In a 2018 study, researchers surveyed people who were receiving treatment from a traumatic stressclinic in the U.K. They found that 90% of participants who had survived an event when others had died reported experiencing feelings of guilt.”

Survivor’s Guilt Can Cause Helplessness and Isolation

Much like other psychiatric disturbances related to trauma, survivor guilt can lead to feelings of helplessness and disconnection, lack of motivation, problems sleeping, social isolation and ultimately, thoughts of suicide. And like depression it can lead to a world view that perceives the world as a threatening and unfair place. One can experience PTSD secondhand upon being apprised of horrific events and so can survivor guilt come from being told the circumstances of one’s accident by others. One might be in a multiple vehicle accident and suffer milder injuries but experience survivor guilt upon being informed that others perished in the same accident. Questions as to why one survived when others did not, what might have been done to prevent the accident, or how they responded during the event can become all-consuming. When we add in a TBI, those thoughts can become disruptive to normal functioning.

Survivor’s guilt is not always comprehensible but it is a recognized response to trauma. It is an internalized response to a traumatic event that seems to be hard-wired into us, as humans, in order to support societal living. Like PTSD, it can pass after a short period of time or persist for years.

I can explain the lingering impact of survivor’s guilt as a cancer survivor. Recently a good friend passed from cancer. It’s been some time since I struggled with survivor guilt but this loss of a friend brought up the seemingly unconnected emotions I associate with survivor’s guilt; depression, guilt, fear, questioning the fairness of the world, irritability, anger, lack of appetite. I also imagine PTSD like this, manageable until something triggers the thought processes which throw us off course. But what if those thought processes persist over time and interfere with our ability to enjoy life? And what if a TBI is present and exacerbating coping mechanisms? What recourse is available for survivor’s guilt in those circumstances?

As I stated previously, it is important to determine which symptoms are attributable to the mechanics of TBI and which to the mental issues related to PTSD. And where those two things overlap, and what common modality of treatment is beneficial in both instances.

Self-Medication Magnifies Struggles

One major difference is seen in the instance of substance abuse. After a TBI, the effects of alcohol are magnified and ultimately can increase the risk of further brain injury. The best solution is to avoid alcohol entirely. Those who suffer from PTSD are prone to self-medication and substance abuse as a means to cope with depression and stifle the symptoms of PTSD. It goes without being said that this usually results in further problems. The common ground here is that substance abuse is not the solution for either issue regardless of their interconnection.

While there are studies showing that TBI may differentiated from PTSD with some accuracy using SPECT (single-photon emission computed tomography) this does not address what treatment is most effective when there is evidence of both in a single patient.

“In fact, the treatments for PTSD may be harmful or, at best, not helpful in the case of TBI. The pharmacological treatments for PTSD include the serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, mood stabilizers and atypical antipsychotics. While some evidence suggests antidepressants may be helpful for those with chronic TBI, the prescribing of benzodiazepines to those with TBI can impede function or even be dangerous.” https://www.hmpgloballearningnetwork.com/site/behavioral/article/tbi-and-ptsd-appear-similar-treatments-must-differ

It is thus important that experienced clinicians provide a detailed analysis of symptoms in order to determine which are exclusive to each component and which are overlapping in such a way as to benefit for similar treatments. Of course one of the first questions when diagnosing PTSD is as to whether the person has ever had a TBI. Experienced clinicians, gathering accurate information and enlisting the support of friends and family can help devise a treatment plan that addresses both concerns. The biggest barrier to effective treatment is a perception among physicians that TBI is not treatable. The next barrier is the perception among patients that PTSD is not treatable. These outdated perspectives do much to impair successful treatment of TBI in conjunction with PTSD.

“Anybody who receives a concussion from an accident can also experience PTSD afterward —whether it was a fall, a car crash, or a bomb blast,” says Michael “Micky” Collins, PhD, an internationally renowned expert in concussion and the director of the UPMC Sports Medicine Concussion Program. “Because many symptoms of PTSD overlap the symptoms of concussion, such as headache, fatigue, dizziness, and anxiety, it can be difficult to determine if the patient has a concussion, PTSD, or both. So, it is critically important for someone who has experienced a traumatic injury to get a comprehensive evaluation by a medical provider trained in diagnostic measures for both concussion and PTSD.” https://share.upmc.com/2020/12/complex-concussions/

Therefore, it is of utmost importance, whenever there is suspicion of PTSD, to rule out or address the possibility of a TBI. In the absence of a confirmed diagnosis of a concussion, or carbon monoxide poisoning, proper imaging and testing by neuropsychologists and other neurological system experts is important. On the flip side, PTSD cannot be ruled out in the event there was a change in consciousness or amnesia at the time of the event.

According to the Psychological Health Center of Excellence (formerly Deployment Health Clinical Center) the treatments for co-occurring PTSD and TBI may include:

• Psychosocial interventions involving exposure to trauma memory and/or cognitive restructuring have a strong clinical evidence base for treatment of PTSD.
• Cognitive behavioral therapy (CBT) demonstrates positive treatment responses in patients with mild, moderate, and severe TBI and also in patients with no history of TBI. CBT has been shown to be effective in targeting psychosocial trauma symptoms as well as decreasing symptoms of acute stress disorder (ASD), depression, and non-specific post-concussion symptoms.
• Current evidence suggests that pharmacological treatment of PTSD in patients with comorbid TBI is best approached similar to that of PTSD alone. Clinicians should be aware that potential medication side effects might increase the risk of TBI-associated problems such as cognitive deficits, sensory and balance problems, and seizures.
• Treatment recommendations for concussion are symptom based and most are based on standard clinical care rather than strong research evidence in randomized clinical trials. In general, the management of mild TBI symptoms is categorized as either non-pharmacologic (first-line treatment) or pharmacologic (second-line treatment). The concussion/mild TBI guideline provides specific recommendations for treating post-traumatic headaches, dizziness and disequilibrium, tinnitus, visual dysfunction, sleep disturbances, behavioral symptoms, cognitive symptoms, fatigue, persistent pain, hearing difficulties, smell (olfactory) deficits, and nausea.
• Because of the potential for co-occurring medical and psychiatric conditions, it is generally best to develop a collaborative care treatment strategy to address the symptoms of PTSD and concussion simultaneously. https://www.pdhealth.mil/news/blog/meeting-challenge-co-occurring-posttraumatic-stress-disorder-and-mild-traumatic-brain-injury

Those who have had brain injuries due to other causes, such as carbon monoxide poisoning, are not exempt from a risk of co-concurring TBI and PTSD. Phobias about further carbon monoxide exposure can occur. We have seen children reluctant to return to a classroom in the aftermath of a school evacuation. Hypervigilance can be in evidence after a carbon monoxide event in the home. In the event that others perished in the event, survivor guilt can also be an issue, especially if family members were involved. In these cases as well, it is important to establish that there is a comorbid brain injury in order to provide effective treatment and not to assume that the psychological impact is the sole concern.

As in all brain injuries, it is often the family and close circle of friends who can provide the most clues into the patient’s mental state and functioning and when coupled with all-inclusive medical care; relief can be found. Whether ii is through pharmaceutical means, therapy or the development of coping skills, there are avenues for hope after a traumatic experience.