Because head traumas are by definition traumas, the high comorbidity of PTSD and TBIs could be related to a shared etiology (Bahraini et al., 2014). For example, combat exposure can simultaneously cause physical trauma that causes TBI and psychological trauma that develops into PTSD. Some researchers debate the shared etiology perspective, suggesting that the amnesia central to TBI classification would prevent the re-experiencing aspects of PTSD (Alway et al., 2016). Rates of PTSD do appear to be higher in mild TBI samples compared to moderate to severe TBI; however, PTSD has been diagnosed across the range of TBI severity (Ponsford et al., 2018). Even without memory of the traumatic injury, individuals may reconstruct narratives about the event that result in intrusive memories and the re- experiencing of symptoms (Alway et al., 2016). Additionally, traumatic memories may be encoded in unconscious memory, triggering physiological arousal symptoms regardless of conscious perception (Alway et al., 2016). There has been shown to be a higher frequency of delayed- onset PTSD in individuals with TBI (Ponsford et al., 2018). TBIs may also confer risk of or vulnerability to future traumas. Impairments to frontal regions of the brain involved in executive function and emotional control may induce behavioral impulsivity and risk-taking that increase the likelihood of traumatic experiences and subsequent Suicide The suffering and pain associated with traumatic experiences and PTSD can result in increased suicidal ideation and suicide attempts. Individuals with PTSD are 14 times more likely to have attempted suicide than people without the diagnosis (Rojas et al., 2014). One longitudinal nationwide study of 3.1 million people in Sweden found that individuals diagnosed with PTSD were twice as likely to die by suicide (Fox et al., 2021). The link between PTSD and suicidality is found across trauma types, including combat, physical/sexual abuse, and natural disasters (van Minnen et al., 2015). The potential for suicide is compounded when individuals are affected by more than one PTSD comorbidity (e.g., MDD and substance use disorder; Rojas et al., 2014). As with other problems concurrent with PTSD, there is more than one plausible theoretical explanation, particularly given that both PTSD and suicide risk factors are related to aspects that involve behavior, emotion, cognition, and physiology (Rugo-Cook et al., 2021). In some cases, PTSD symptoms may cause suicidal thoughts and behaviors (Hudenko et al., 2021; van Minnen et al., 2015). Intrusive memories, frequent re-experiencing of trauma, and the inability to shut off physiological reactivity may leave individuals feeling so exhausted and helpless to relieve symptoms that they consider something that was previously unthinkable (Hudenko et al., 2021). In other instances, the cognitive-affective impairments of PTSD (e.g., shame, guilt, and negative self-appraisals) may account for the suicidal ideation (van Minnen et al., 2015). Also, certain coping styles deployed to alleviate trauma symptoms, such as suppression, may intensify suicidal behaviors (Hudenko et Insomnia Sleep problems are direct symptoms of PTSD, but research suggests that they “tend to become independent problems over time that warrant sleep-focused assessment and treatment” (Gehrman, 2022, p. 1). Werner and colleagues (2021) suggest that a fear of sleep can develop as a result of concerns of loss of control/safety associated with sleep as well as a fear of re-experiencing trauma during nightmares. Poor sleep hygiene, a key factor in the development of insomnia, could be a direct result of behaviors designed to cope with trauma symptoms, such as leaving lights on at night or using substances before bed (Gehrman, 2022).
PTSD (Bahraini et al., 2014). Practitioners should be aware of the similarities between PTSD and TBI symptoms. When assessing for trauma symptoms, they should obtain detailed injury histories and consider neurocognitive tests. Case Example Peng was in a serious car crash that resulted in a severe concussion. He had been discharged from the emergency department without additional treatment for the brain injury beyond resting and monitoring his symptoms. Two months after the accident, Peng entered therapy to treat his PTSD symptoms. He was not able to drive without feeling completely flooded by fear and would become stressed any time his wife went driving on her own, worrying about her safety. When he saw cars going by, he would experience a quick flashback of his accident and notice a slight throb in his head. Peng was also more reactive and irritable in his interactions with his wife. Peng was referred to a neurology specialist, and the approach to his trauma treatment became integrative and interdisciplinary. He received medical treatment for his TBI, and after a few months, his irritability, impulsivity, and headaches subsided. Although he still experienced anxiety and avoidance in relation to driving, Peng was able to slowly desensitize his fears and eventually drive again. al., 2021). Finally, particular traumas (e.g., sexual abuse), even without the presence of PTSD, increase suicide risk, so it is possible that both the suicidality and PTSD are rooted in the same traumatic experience but occur independently (Hudenko et al., 2017). Given the complexity of these factors, it has been recommended that suicidal ideation as it relates to PTSD be considered using fluid vulnerability theory (Rudd, 2006), a diathesis–stress perspective that views suicide risk as a fluid and dynamic process (Rugo- Cook et al., 2021). This perspective suggests that individuals with PTSD may have risk factors specific to PTSD that then activate and broaden other risk networks that could activate an acute period of suicidality (Rugo-Cook et al., 2021). Case Example Tim, a 10-year-old, was referred for therapy because he had expressed thoughts about killing himself and he frequently drew dark images in his notebook that worried his teacher. Tim’s teacher knew he had a trauma history (he had seen two of his brothers die in a gang shooting), but she was not sure if his suicidal thoughts were related to that traumatic grief or something else. Sessions revealed that Tim’s PTSD symptoms were underlying his suicidal ideations. He was experiencing cognitive-appraisal distortions related to the trauma, feeling shame and guilt for not protecting his brothers and a negative sense of self, believing that his brothers were so much better than he was and that he should have been the one to die. Reframing and restructuring Tim’s negative appraisals reduced his negative sense of self and alleviated his suicidal symptoms.
Practitioners could consider treating insomnia first and then engaging in trauma treatment once sleep patterns have stabilized; however, practitioners should be mindful that insomnia may persist even after trauma symptoms subside (Werner et al., 2021).
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