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Domino Effects of TBI and PTSD by Marilyn Lash, MSW

Combined effects of TBI and PTSD

TBI and PTSD do not stack neatly like dominoes.

Dominoes was a favorite game as a kid – matching the dots on the plastic rectangles to form meandering chains across the table. Then I could line them up vertically and with one tap, the whole chain went down one by one in an impressive cascading slide. The descent may have looked orderly, but the result was disaster – now all I had was a mess.

I was reminded of this domino slide when I was thinking about the

Dominoes falling are like the cascading effects of TBI and PTSD.

combined effects of TBI and PTSD in many returning veterans and service members. While each diagnosis has specific symptoms, those living with or caring for someone with PTSD and TBI know that it’s the interaction between the two conditions that make it so difficult to live with and hard to manage.

When I ask wounded veterans and their caregivers what symptoms are having the greatest effect on their daily lives, difficulty sleeping is always a response. It’s a perfect example of the domino effect – here’s why.

Sleep disorders are common among persons with TBI. It may be difficulty falling asleep, staying asleep, waking early or late because the “normal” sleep cycle has been disturbed. Now take a look at what happens with PTSD. Intrusive memories and flashbacks often flood in at night so that sleep is constantly interrupted. The veteran with PTSD often dreads going to bed because of recurrent nightmares. Their sleeping partners describe nights of sweats, tossing and turning, and agitation with the wounded veteran often escaping to the couch. Now add the PTSD symptom of hypervigilance to this mix. This state of over alertness can make it even harder for the veteran to relax and enter a sleep state. One veteran recently told me, “I only get about 2 hours sleep a night.”

We all know what it’s like to not get a good night’s sleep. We know that fuzzy headed feeling, the dull headache and the slowed thinking. But for most of us, a good night’s sleep refreshes us and we’re back to our A game. But what if this never happens?

Overlapping effects of TBI and PTSD

That’s where the domino cascade starts. Among the overlapping effects of TBI and PTSD are anxiety, depression, slowed cognition or thinking, and substance abuse. The effects of sleep disorders often increase depression and lead to using alcohol and self-medication in attempts to control anxieties, reduce chronic pain, and block memories. Each night can become a “living hell” as the war is relived. With cognition already impaired, now the effects of little or interrupted sleep on memory, judgment, organization, and initiation are magnified. The irritability that is often described as a “short fuse” by family members can quickly escalate into physical aggression or verbal abuse. The effects of these bad nights now spill over onto family members. Spouses and children often describe their mornings as “walking on eggshells” in attempts to avoid arguments and keep calm with the goal of getting off to school or work without further conflicts.

So it’s not nearly as simple as “a bad night’s sleep.” Life is not as easy as picking up the pile of fallen dominoes and putting them back in order. This cascade for the effects of TBI and PTSD illustrates and underscores the important of treatment, not for individual symptoms but for the management of the complex interplay of PTSD and TBI.