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Posttraumatic Stress Disorder after Traumatic BrainInjury and Interpersonal Relationships: Contributionsfrom Object-Relations PerspectivesGiles Yeatesa

a Community Head Injury Service, Buckinghamshire NHS PCT, Aylesbury, U.K.Published online: 09 Jan 2014.

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Posttraumatic Stress Disorder after Traumatic Brain Injury and Interpersonal Relationships: Contributions from Object-Relations Perspectives

Giles Yeates (Aylesbury, UK)

Posttraumatic stress disorder (PTSD) has been identified in survivors of traumatic brain injury (TBI), sustained from road traffic ac-cidents, assaults, or industrial accidents. This article reviews the small literature on this population, which is predominantly charac-terized by integrations of cognitive neuropsychology and cognitive behavior therapy. While these perspectives have been applied to identify etiological processes and treatment options, one insufficiently specified domain in this literature is the role of interpersonal relationships. This includes interpersonal etiological mechanisms and social outcomes, but also therapeutic process for PTSD after TBI. In response, object-relations psychoanalytic concepts of symbolizing (Segal, 1957) and containing–contained (Bion, 1962) mechanisms are applied. These concepts are used to consider the aforementioned factors while permitting close conceptual links to neurological and cognitive vulnerabilities for this clinical group. This article finishes with a therapeutic application of these concepts, from the perspective of a neurorehabilitation team.

Keywords: PTSD; TBI; object relations; interpersonal; containing–sustained.

Giles Yeates: Community Head Injury Service, Buckinghamshire NHS PCT, Aylesbury, U.K.Correspondence to: Giles Yeates, Community Head Injury Service, Jansel Square, Bedgrove, Aylesbury, Buckinghamshire, HP21 7ET, U.K. (email:

GilesYeates@buckspct.nhs.uk).Acknowledgment: The author would like to thank Nigel King for helpful comments on earlier drafts of this article.

Prevalence of PTSD after traumatic brain injury

It is estimated that every year between 225 and 335 people out of 100,000 suffer traumatic brain injury (TBI) in industrialized countries such as the United Kingdom (McMillan & Greenwood, 1991). TBI can be defined as a sudden, nonprogressive insult to the brain, causing neurological damage. TBI most commonly re-sults from road traffic/industrial accidents or assaults. The sequelae of TBI include physical, cognitive, and emotional difficulties, with the likelihood of the latter increasing in the post-acute period (Williams & Evans, 2003).

While the early studies of posttraumatic stress disor-der (PTSD) co-occurring with TBI reported incidence rates of close to 0% (Mayou, Bryant, & Duthie, 1993; Sbordone & Liter, 1995), subsequent larger-sample studies outline a different picture. These studies point to a difference in incidence rates for mild TBI ver-sus moderate–severe TBI groups. In mild TBI, an incidence of 11–24% has been reported across studies

(Gil, Caspi, Ben-Ari, Koren, & Klein, 2005; Harvey & Bryant, 1998, 2000; McMillan, 1996), and incidence of some aspects of PTSD symptomatology within this group has been reported to be 33–48% (Bryant & Harvey, 1999; Hickling et al., 1998; Mayou, Black, & Bryant, 2000; Middleboe, Andersen, Birket-Smith, & Friis, 1992), depending on neuropathology and time since injury.

These authors noted that such incidence rates are comparable to or even higher than groups who have experienced trauma through similar events but where no TBI has been sustained. Recent studies of American soldiers returning from Iraq and Afghanistan have ex-plored this further (Hoge et al., 2008; Schneiderman, Braver, & Kang, 2008). These findings suggest that during combat, loss of consciousness (LoC) for up to a few minutes or other postconcussive indicators are associated with higher rates of subsequent PTSD symptomatology than where there has been no LoC or alterations to cognition.

For moderate to severe TBI, different incidence

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rates have been reported, depending on sample and measurement methodology used. A rate of 27% was reported by Bryant, Marosszeky, Crooks, and Gurka (2000), although King (2008a, 2008b) comments that this sample was unrepresentative of typical severe TBI populations. Less replicable findings have taken this figure upwards to 61% (Grigsby & Kaye, 1993; Hib-bard, Uysal, Kepler, Bogdany, & Silver, 1998; Ohry, Rattock, & Solomon, 1996). Studies using more rep-resentative community samples have yielded rates of 11–18% (Greenspan, Stringer, Phillips, Hammond, & Goldstein, 2006; Williams, Evans, Needham, & Wil-son, 2002). One study comparing TBI groups classified as severe, moderate, and “complicated mild” (Glasgow Coma Scale Score <12, and an abnormal CT scan re-sult) yielded a consistent rate of 5.6% across all groups (Bombardier, Fann, Temkin, & Esselman, 2006).

In considering the variability across these stud-ies, some authors have noted that some measurement paradigms risk a false diagnosis of PTSD within this sample (McMillan, 2001; Sbordone & Liter, 1995). Sumpter and McMillan (2005) have shown that the use of self-report scales serves to overdiagnose PTSD in severe TBI groups (the use of these instruments yielded incidence rates of 44–59%, whereas the use of a structured interview schedule produced a rate of only 3%). Others warn against a general lack of con-trol samples in this literature (McMillan, Williams, & Bryant, 2003).

Etiological mechanisms of PTSD following TBI

Despite methodological critiques, these findings col-lectively mount an increasing challenge to earlier con-ceptualizations of PTSD as an incompatible outcome following coma and organic amnesia associated with TBI (Bontke, Rattock, & Boake, 1996; Sbordone, 1992). This traditional position was based initially on empirical findings supporting the incompatibility of the two conditions (Mayou, Bryant, & Duthie, 1993). In addition, prevailing theoretical positions argued for such incompatibility (Sbordone & Liter, 1995).

However, studies have since demonstrated the same group of PTSD symptoms experienced by those with and without TBI: fear of death, loss of control (McMil-lan et al., 2003), avoidant coping (Harvey & Bryant, 1998), and external attributions of causality and blame (Williams, Williams, & Ghadiali, 1998; Williams et al., 2002). Further support can be found in a com-parable acquired, nonprogressive neurological group. Incidence of PTSD has also been reported in survivors of stroke or transient ischemic attacks (Bruggimann

et al., 2006; Sembi, Tarrier, O’Neill, Burns, & Fara-gher, 1998). Currently, four etiological mechanisms underpinning PTSD following TBI have been iden-tified within integrated cognitive neuropsychological and cognitive-behavioral frameworks (Evans & Wil-liams, 2009; King, 2008a, 2008b; McMillan, Williams, & Bryant, 2003).

First, some survivors of TBI have no or only minor alterations of consciousness, permitting full recall of the incident in a similar manner to those who have PTSD without TBI (Horton, 1993). This may occur in mild TBI or in the initial stages of an open head injury (e.g., following a penetrating bullet or sharp-object wound; Evans & Williams, 2009).

Second, although significant alterations to con-sciousness are a component of many cases of acute brain injury, a significant proportion of survivors (27% of a TBI sample; Williams et al., 2002) are left with partial recall (Creamer, O’Donnell, & Pattison, 2005) or with “islands” of memory concerning the incident or the time before or after the incident (e.g., fragmented impressions of being in hospital connected to feeding tubes during the acute phase), rather than a complete absence of representation (King, 1997; McMillan, 1996; Silver, Rattock, & Anderson, 1997).

These “islands” are often affectively charged. Clini-cal neuropsychologists orientated to a cognitive frame-work have linked these to the development of negative attributions around the accident, regarding self and world (Williams et al., 2002). While the presence of memory islands in a TBI sample was not found to predict the development of PTSD, Williams and col-leagues (2002) found the affective quality and mean-ing of the representation to be predictive. Contrasting examples include the retention of a negatively charged image of a friend dying versus a snapshot of a medic providing reassuring comments at the scene (Williams et al., 2002). Such islands are qualitatively different from intrusions experienced by trauma survivors in the absence of brain injury. In the case of TBI, accompa-nying semantic or episodic information to place the re-called material within a wider context is comparatively less available or accessible.

A third mechanism can exert influence in the ab-sence of any explicit, declarative memory at all (Lay-ton & Wardi-Zonna, 1995). This is consistent with neurocognitive and psychoanalytic perspectives that do not stipulate a necessary role for explicit memories within traumatic etiology with or without TBI (Brewin, Dalgleish, & Joseph, 1996; Layton & Krikorian, 2002; Layton, Krikorian, Dori, Martin, & Wardi, 2006; Yovell, 2000). In a series of 105 cases of mild TBI, the presence or absence of amnesia for the traumatic

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event did not differentiate PTSD incidence within the sample (Bryant & Harvey, 1999). Traumatic memories in TBI have been shown to exist outside of conscious awareness, at the level known within cognitive neuro-psychology as “implicit” memory (e.g., Markowitsch, 1998).

Brewin, Dalgleish, and Joseph (1996) describe these as “situationally accessible memories,” unable to be intentionally retrieved but automatically activated in response to stimuli that are situationally related to the incident. They may have been encoded at the implicit level during the initial period of altered conscious-ness, via fear-conditioning association learning. This learning is neurologically mediated through frontal cortico-amygdalar circuitry (Alexander, Fiegelson, & Gorman, 2005a; LeDoux, 1999). Activated later, post-TBI, where declarative recall is absent, these memories may be experienced as flashbacks, a sense of traumatic reliving, increased psychological distress, physiologi-cal arousal, and somatic sensations (Bryant et al., 2000; King, 2001; McMillan, Williams, & Bryant, 2003; Mc-Neil & Greenwood, 1996).

These three mechanisms have been identified as es-sential to the etiology of posttraumatic states by both cognitive (Brewin, Dalgleish, & Joseph, 1996) and psychoanalytic commentators (Freud, 1920; Yovell, 2000). In addition, a fourth etiological mechanism emerges from the incomplete or nondeclarative quality of Mechanisms 2 and 3. This is the later reconstruction of original component memories or sensations. These are often formed within a cohesive narrative of the event, but via third-person and media accounts of the incident, later integrated into first-person recall (Bry-ant et al., 2000; Harvey & Bryant, 2001). The resulting script may have no veridical link to the actual sequence of events during the trauma, and it may have a quality of alienness or “otherness.” Using this as a resource to fill in memory gaps may be inherently ruminative, in-trusive, and traumatic for survivors (Harvey & Bryant, 2001; McMillan, 2001).

Other trauma mechanisms may not be directly asso-ciated with encoding or retrieval mnemonic operations, but may be related to comorbid neuropsychological deficits of other kinds. King (2002) described a com-bination of executive impairments and PTSD in a case of TBI where perseverative (uncontrollable repetitive) thinking interacted with previously avoided memories . This material was recalled with accompanying in-creased arousal, and the contents perseverated in the mind and resulted in an unremitting and very distress-ing continual reexperiencing of trauma over a period of 7–10 days, necessitating hospital admission.

One evidence-based psychological treatment of

choice for PTSD (Foa, Keane, & Friedman, 2000; NICE, 2005) is cognitive behavior therapy (CBT; Ehlers & Clark, 2000; Rothbaum, Meadows, Resick, & Foy, 2000). This approach has been directly adapt-ed to respond to the neuropsychological observations above. CBT for PTSD usually employs controlled ex-posure/reliving of the traumatic memories while reduc-ing avoidant behavior. Significantly, these elements are interwoven with the cognitive restructuring of the individual’s appraisals, attributions, and meanings regarding the interrelationships between symptoms, memories, self, and world pertaining to the traumatic event and thereafter. This approach has been the first to be applied to PTSD following TBI (Bryant, Moulds, Guthrie, & Nixon, 2003; King, 2001, 2002; McGrath, 1997; McMillan, 1991; McNeil & Greenwood, 1996; Middleboe, Andersen, Birket-Smith, & Friis, 1992), with adjunct strategies employed to address concurrent cognitive difficulties in attention, memory, and execu-tive domains (Evans & Williams, 2009; King, 2002; Williams, Evans, & Wilson, 2003).

The role of interpersonal factors in the TBI PTSD literature

Cognitive-behavioral approaches informed by cogni-tive neuropsychology have been a notable success in brain injury rehabilitation. These ideas and data have challenged initial rejections of comorbid PTSD and TBI and have validated survivors’ experiences. They have been a key resource in the theorizing of the in-terplay of PTSD and TBI sequelae. This knowledge has been applied by clinicians to respond to specific cognitive deficits alongside standard interventions. Is there, therefore, anything more to add to this specialist literature? Are there any aspects of the phenomenology or outcomes associated with this clinical group that re-main unacknowledged by these existing approaches?

One area of ambiguity may be revealed in the CBT PTSD literature. The CBT formulation of PTSD has followed the focus of the DSM-IV (APA, 1994) criteria in identifying altered relationship of self and world as a core component, with the world (and stimuli within it) being attributed as unpredictable and threatening in nature (Ehlers & Clark, 2000). This features in PTSD TBI studies, with some commenting on the affective quality of traumatic memory fragments and altered roles of self and external events within these (King, 1997; McNeil & Greenwood, 1996). Alternatively, the role of negative external appraisals in posttrauma attri-butions has been reported by authors (Williams, Evans, & Wilson, 2003; Williams et al., 2002).

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While this altered self–world feature is undoubt-edly present in most PTSD presentations, the concept may be more usefully specified. For example cognitive studies on attribution in non-TBI PTSD have identified that those survivors who attribute external blame for the incident and its consequences are focusing spe-cifically on other people. This group are more likely to develop PTSD (Kushner, Riggs, Foa, & Miller, 1992) and demonstrate increased distress 6 and 12 months after the incident (Delahanty et al., 1997). Attribu-tions of external causality involving others have also been demonstrated as being positively correlated with PTSD symptomatology in a TBI sample (Williams et al., 2002).

The cognitive-behavioral studies on PTSD following TBI describe survivor recall of a “lorry emerging from a side road on a collision course” (McMillan, 1996), of the “distress of others involved in an accident” (Mc-Millan, 1996), and of a girlfriend dying in the accident (Williams et al., 2002) and not being able to help her (Williams, Evans, & Wilson, 2003). Additionally an assault survivor is reported to struggle with prolonged feelings of guilt for the death of a friend in the same incident, despite his complete lack of declarative recall (McNeil & Greenwood, 1996). In another case, the car that had knocked one person down was remembered by that individual as reversing to “finish me off” when it was actually reversing to help him (King, 1997). These are themes of self or others intentionally or unintention-ally causing, or passively allowing, harm to persons.

Additionally, the absence of a survivor’s own de-clarative memories of trauma, and the subsequent reli-ance on accounts from another/third-person, has been implicated as an etiological mechanism. Elements of these adopted accounts have been identified as intru-sive rather than containing semiotic structures (Harvey & Bryant, 2001). The combination of interpersonally negative islands of memory and (unintentionally) psy-chologically toxic alternatives provided by others im-plicates the interpersonal dimension as etiologically relevant.

When considering the objectively documented na-ture of incidents leading to TBI, malevolent actions, in-tentions, or responsibility of self or other often feature. The survivor may have been injured as a result of the actions of another driver (intentional or otherwise), a purposeful assault, or the neglect or human error of an industrial colleague or superior (Bell, 1998; Layton et al., 2006). Perhaps, in addition, the survivor may have inadvertently caused the death of a significant other in the same incident (e.g., in a car crash) or may experi-ence guilt through the very fact of his or her survival when others have died.

This social, interpersonal theme continues in the psychological consequences and untreated outcomes of PTSD following TBI. Social contexts such as crowds become a source of anxiety and are avoided (Williams, Evans, & Wilson, 2003), and social roles and relation-ships are altered or restricted (McGrath, 1997; Wil-liams, Evans, & Wilson, 2003). Survivors’ fears have been documented as involving others, such as fears for family after an individual was assaulted (Williams, Evans, & Wilson, 2003). Reciprocally, successful CBT treatment of PTSD symptoms was reported to resolve these fears for family members (Williams, Evans, & Wilson, 2003) and result in significant others noticing the survivor’s “old personality returning” (McGrath, 1997). While these interpersonal indicators of PTSD are either briefly or indirectly commented upon in these studies, an observational lens attending to the interpersonal in this client group can highlight further qualities and features.

Much of the phenomenology reported in the cogni-tive TBI PTSD literature may be of interest and open to redescription or reinterpretation by psychoanalysts. However, it is this interpersonal dimension of etiol-ogy and experience during PTSD and TBI that will be explored in the remainder of this article. As a neurore-habilitation clinician, the author has found elements of psychoanalytic theory invaluable in conceptualizing key interpersonal processes and intersubjective quali-ties within PTSD work following TBI. These ideas will be discussed below, leading on to a consideration of interpersonally focused neurorehabilitative and thera-peutic responses.

Psychoanalytic theories of posttraumatic states

Within psychoanalytic theory, trauma is conceived of as an undermining of a function protecting the men-tal apparatus. The internal world is flooded with un-manageable excitation and excessive stimuli (Freud, 1920). In addition to this, ego mechanisms usually employed to manage, filter, and manipulate such input are rendered inoperational as a result of the traumatic experience. Freud first conceived of the interrelation-ship between a traumatic experience and this protec-tive function as an “extensive breach being made in the protective shield against stimuli” (1920, p. 31), this shield being a metaphorical mental “envelope or membrane” (p. 27). This was later relabeled as a “skin” (Bick, 1968) and considered to be essential to mental functioning.

Using this metaphor, the breach of the skin is con-

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sidered to be a piercing or wound (hence the Greek root of the word traumatic; Garland, 1998a). This wound then allows all excessive stimulation to flood in to the defenseless mind, invading and populating it with repetitive, bad contents, with the qualities of “foreign bodies” (Freud, 1893). As a result of this pro-tective skin being undermined during trauma, coping processes such as denial are also unavailable to the individual, who is unable to patch up the wound.

The metaphor of a skin has some value, approaching the posttraumatic subjective qualities of fragmentation and uncontrollability of internal events (intrusions). It also accounts for the avoidance strategies that indi-viduals desperately employ to avoid mentally reexpe-riencing traumatic representations or stimuli. It is the author’s opinion that the “islands of memory” reported in some TBI survivors who have PTSD are even more appropriately described by Freud’s “foreign bodies” than by intrusions in other PTSD groups. This is due to the relatively greater lack of contextual or semantic information to place such impressions within a mean-ingful context. In addition, survivors’ decreased execu-tive/attentional resources are insufficient to adequately manage the contents of working memory. This results in TBI survivors’ later distress in trying to reconstruct meanings or narratives around these impressions (Mc-Millan, 2001).

However, this concept of a protective layer is also limited by an abstract nonspecificity that remains elu-sive in both etiological research and therapeutic prac-tice. In integrating Freud’s formulation of trauma with his seminal paper on mourning (Freud, 1915), post-Freudian object-relations authors have arguably pro-vided the specificity needed. This lineage was taken up by Melanie Klein’s (1940) notion of the developmen-tal internalization, through “good-enough” caregiving (Winnicott, 1965), of a protective and protected good object alongside bad objects. This Kleinian depressive organization, the nodal point of subsequent ego forma-tion, can be altered through adverse later life circum-stance. The loss of a good protecting object and the simultaneous alteration of personal agency in this loss are associated with a dominance of paranoid-schiz-oid relations (Garland, 1998a). A necessary condition for progress to adaptive ego functioning is an active process of mourning to access the depressive position once more.

This account was furthered by Hannah Segal (1957) to highlight the foundation of developed symbolization as a specific aspect of the internalized relationship from caregiver interactions. While previous psychoanalytic considerations of mnemonic and symbolic processes in traumatization existed (Kardiner, 1941), they were

similar in metaphor and scope to the current cognitive neuropsychological theories mentioned above (Brewin, Dalgleish, & Joseph, 1996). These are focused on an isolated individual and their psychic functions. For the purposes of this discussion, Segal’s contribution is to take Kleinian theory and frame symbolization as an inherently interpersonal, intersubjective process.

The resultant view of developing symbolic and re-flective function is commensurate with Vygotskian theory (Vygotsky, 1978) and with more recent in-tersubjective accounts of reflexivity and mentalizing development (Fonagy, Steele, Steele, Moran, & Hig-gitt, 1991; Fonagy & Target, 1996, 1997; Target & Fonagy, 1996). It is the caregiver’s ability to think “about” something that is internalized by the infant in normal development. Correspondingly, the infant becomes equipped to represent, symbolize, and trans-form symbolizations of concrete experience. He or she can recognize these symbolizations for what they are, separate from lived experiences.

Using Segal’s work in response to trauma referrals, Garland (1998a, 1998c, 1998d) has observed how in serious trauma there is a simultaneous undermining of this ability to symbolize alongside altered interper-sonal relations. The survivor can no longer distinguish the real from representation or phantasy, reliving the trauma as if it were happening all over again. Interper-sonally, the individual experiences and responds at the level of the concrete. He or she finds traumatic stimuli in both self and others and copes through projecting what is bad, overwhelming, and unmanageable into those around him or her.

Defining the caregiving function further while plac-ing greater emphasis on the interpersonal process, Bion (1962) elaborated this transmission of symbolization to an “alpha function.” A necessary developmental pro-cess, this is the “containing” function of the caregiver, reciprocally positioning the infant as the “contained.” Bion (1967a, 1967b) notes that the “good-enough” caregiver takes in “beta elements” projected by the infant: unintegrated sensations, fears and phantasies of annihilation, destruction, and rage. In their raw form, these elements are too overwhelming, threatening, and unmanageable for the infant.

In containing these and not responding to their at-tacking quality, the caregiver translates and metabo-lizes these, a process of “reverie” (Bion, 1962). These are transformed into “alpha elements”—symbolized and manageable versions of the former, able to be thought about. It is this receptive and metabolizing/processing quality that is internalized through develop-ment. Esther Bick’s (1968) account of a psychic “skin” similarly prioritizes carer–infant interactions as the

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interpersonal dimension through which this psychic organ is developed. An infant with undifferentiated sense of self–other boundaries or personal coherence requires these intact qualities in the caregiver as a pre-liminary step to the later acquisition of these faculties him/herself.

Through this reformulation, Freud’s (1920) protec-tive shield or skin is now an interpersonal function and relationship, structuring ego development and charac-terizing self–other interactions. It is this perspective that specifies traumatic sequelae as a simultaneous col-lapse of internal subjectivity and translation of this into particular relationships (Garland, 1998a). The ability to think about the trauma is impossible, and the prior-ity is to respond to others that have largely become threatening (Garland, 1998a, 1998c). Reciprocally, the invaded subjectivity of the survivor, populated with bad objects, leads to the inevitable concrete projection of this content into others. In doing so, this threatens and/or “spoils” those others in the process (Garland, 1998d).

Neuropsychoanalytic formulations of PTSD after TBI

Using these object-relations concepts, a psychoanalytic framing immediately makes sense of the interpersonal threat themes in the discourse and experiences of TBI survivors who also have PTSD. In addition, interper-sonal outcomes are understandable, such as crowds causing anxiety, alterations to family identificatory processes (relatives defining “personality change”: McGrath, 1997; Yeates, Gracey, & Collicutt-McGrath, 2008), and loss of social roles (McGrath, 1997; Wil-liams, Evans, & Wilson, 2003).

When considering the issue of overlapping cogni-tive, emotional, and interpersonal alteration in this group, specific observations can be made. A chronic undermining of the containing–contained dynamic can be seen to be both a biopsychosocial consequence and a maintaining core mechanism of a range of processes in comorbid TBI and PTSD. These include the initial trauma experience (and any changes in consciousness associated with this), altered neurological and cogni-tive function, and altered reactive emotional process and subjective experience. In addition, this is related to a change in the interpersonal meaning of significant others and/or the reaction of others to some or all of these difficulties.

The value of the “containing–contained” and simi-lar object-relations concepts is that the above levels of change can be seen to derive in part from a unified

process rather than from separable, interacting bio-logical, psychological, and social factors. Patterns of influence and change unique to some of these three levels are acknowledged (and discussed below). How-ever, conceptualizations of a core mechanism acting at all three dimensions can approach the particular subjective qualities and processes associated with this group.

Neurobiological changes forming the material pa-rameters of affective change in PTSD have been dis-cussed by other authors. Significantly for this paper, these discussions have identified simultaneous altera-tions to subjective and interpersonal experience as a concomitant of this neurobiological process. In a debate concerning the affective systems subserving the qual-ity of anxiety experienced in panic disorder and PTSD, some authors speculated for the latter an involve-ment of nonsocial fight–flight/FEAR survival systems (Panksepp, 2005; Watt, 2005) mediated by amyg-dala involvement (Alexander, Fiegelson, & Gorman, 2005a). Crucially, others have argued that the socially embedded experience of PTSD may be subserved by both the FEAR and PANIC/separation-distress systems in Panksepp’s (1998) typology (Alexander, Fiegelson, & Gorman, 2005b). The latter mediating anxiety state may be intimately concerned with the presence, ab-sence, or actions of others (Panksepp, 1998).

Alterations to these systems occur in PTSD with-out TBI (Alexander, Fiegelson, & Gorman, 2005a). Amygdalar activation and corresponding rise in corti-sol levels has been shown to undermine the structural and functional properties of the hippocampi in states of high anxiety, causing subsequent declarative memory dysfunction (Bremner et al., 1995; for a full neuropsy-choanalytic discussion, see Yovell, 2000). Current neu-roscientific and psychotherapeutic accounts highlight how amygdala-dominated fear processing without dominant hippocampal involvement in learning can result in the subjective recall of concrete, rigid, terrify-ing images that are difficult to think about/elaborate or modify (Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000; LeDoux, 1999; Yovell, 2000).

However, the neuroanatomical circuitry subserv-ing all of these relevant systems (brainstem, medial temporal and frontal cortices; Panksepp, 1998) are all known to be frequently damaged in most forms of TBI. This is via diffuse axonal injury, if not direct and profound cortical damage (Adams, Graham, Murray, & Scott, 1982). This significantly greater disturbance may feature in TBI as a corresponding change in how self–other relations may be felt and experienced. Intru-sive, rigid images of malevolent others may be present without the symbolic and mnemonic elaboration of

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the complex good and bad qualities of any individual or relationship. This can prevent a growing sense of adjustment and security with others. A felt secure base within certain key relationships may be undermined through damaged attachment neural systems.

The emerging social neuroscience literature has highlighted that following frontal, insula/somatosenso-ry, and temporal cortical damage, acquired difficulties have been noted in relation to empathy. These include deficits in emotion recognition, in understanding the mental states of others (e.g., Baird et al., 2006; Blair & Cipolotti, 2000), and in other forms of social inference (McDonald, 2002).

Baron-Cohen (1997) presents an evolutionary psy-chological perspective on the inherited necessity to mindread others to maximize interpersonal gain and reduce social harm. It follows that impaired mental-izing functions will alter a survivor’s social landscape of threat (for supporting evidence, see Fonagy et al., 1991). Clinicians working with such presentations have noted that this poor social competence increases social isolation and associated feelings of loneliness, depression, anxiety, irritability, and reduced self es-teem and confidence (McDonald, 2002). Collectively, all of these factors may overdetermine the emergence of malevolent relationship experiences post-injury.

One further common neuroaffective change re-ported in comorbid cases of PTSD and TBI involv-ing fronto-limbic damage is a subjective dullness, or numbness (Lishman, 1998; McMillan, Williams, & Bryant, 2003). Indeed, bilateral amygdala damage can result in a loss of subjective anger or fear response and a corresponding inability to recognize negative emo-tions such as anger or fear in others (e.g., Adolphs, Tranel, & Damasio, 1998; Adolphs, Tranel, Damasio, & Damasio, 1994; Baird et al., 2006; Blair & Cipolotti, 2000; Park et al., 2001). Perhaps this may feature as a unique version of an empty and incapable container of emotion reported in any PTSD survivor where a failure of Bion’s (1962) mechanism has been reported (Gar-land, 1998a).

Alterations to cognitive function (including that broader than or different from the sequelae of the emotional systems described above), subjective expe-rience, and interpersonal relations are reported in most PTSD TBI studies. However, a connecting process has not been sufficiently articulated. Sensory and informa-tion-processing-based problems such as noise sensitiv-ity, attention, processing speed, and working memory (Lezak, 1995) are ubiquitous in cases of TBI where PTSD is not present. However, it is suggested here that the traumatized subjective response to such problems is more acutely focused on the agency of other persons

as producers of noise and on overwhelming quantities and flow of social information.

The traumatic incident and its later recall may have established a persecuting or persecuted positioning of others. This may be notable where the responsibility of one person for the suffering or death of another is implicated in the incident. This may be significantly maintained by the individual’s constant experience of noise, sights, words, and information coming in too fast to manage. Within our social world, other indi-viduals are often the cause of, or are associated with, these stimuli. This could be the flow of social infor-mation, manageable to others, or an accidental but subjectively harmless noise. These would all be imme-diately experienced by the TBI survivor as attacking stimuli. Through later consideration, these others may seem neglecting, uncaring, and unsympathetic to the survivor’s difficulties (by implication, an active attack; Klein, 1940).

A few survivors of TBI with whom I have previ-ously worked often struggled with both acquired noise sensitivity and PTSD. Some were continually preoc-cupied with staff accidentally banging doors some distance away down a corridor of the rehabilitation unit. These were experienced as persecutory attacks within what is supposed to be a therapeutic environ-ment. Therefore, the presence of cognitive deficits and their interaction with social environmental factors is a constant perpetuation of the interpersonal dynamic initiated within the trauma.

The cognitive-behavioral language of external attri-butions (Williams, Evans, & Wilson, 2003) describes aspects of this process. However, the emphasis on declarative, intentional cognitive process may not be appropriate to the more automatic and affective quality of threat experienced in relation to others. If disrupted brainstem–limbic–medial frontal circuitry is a feature of these presentations, as described above, then a lan-guage with less reliance and/or emphasis on cognitive process is required. Furthermore, the reciprocal pro-cess of the survivor subjectively threatening/damag-ing/spoiling others within these cycles is missed by an attributional paradigm.

If the application of object-relations formulations of posttraumatic phenomena can link sensory, pro-cessing, and attentional deficits with altered interper-sonal meaning, then additional contributions can be made regarding symbolization. Prioritized by Segal (1957) as an essential feature of a containing, protec-tive mechanism, this process can be heterogeneously undermined through cognitive deficits in abstraction, reasoning, executive functioning, visual representa-tional, and language abilities, arising from TBI (Lezak,

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1995). Following Segal, the loss or alteration of these abilities will result in a corresponding difficulty in rec-ognizing, responding to, or managing traumatic mate-rial in a reflective, symbolic form (Langer, 1999). Both Bryant (2001, p. 941) and Evans and Williams (2009, p. 234) have noted that acquired difficulties in memory and attention will restrict a survivor’s ability to employ coping strategies to manage posttraumatic stress dif-ficulties. This increased cognitive vulnerability has also been extended to the survivor’s reduced ability to manage any additional pre-injury traumatic material (McMillan, Williams, & Bryant, 2003).

Interpersonally, this will manifest as a need to cope in the concrete, communicating and managing anxiety and pain through projective and projective identifica-tory mechanisms (Klein, 1940). King’s (2001) ob-servations of implicit learning during the traumatic incident alongside a lack of declarative recall is a unique consideration of this latter point. The corre-sponding subjective experience is described by King as sensory/visceral impressions without cognitive con-tent. This echoes Freud’s (1914) original description of repetition phenomena, some purely sensory, that make up transference patterns in therapy and are com-municated as primitive projections within interper-sonal relationships. Even a more complex process such as identification has recently been conceptualized as involving both autobiographical, explicit recall and implicit procedural acquisition of others’ habits (Olds, 2008).

Some contemporary support for applying this think-ing to psychological therapy for TBI survivors has been provided by Turnbull, Zois, Kaplan-Solms, and Solms (2006). These authors documented the develop-ment and shifting of transference in psychoanalytic psychotherapy with a densely amnesic client who was unable to declaratively recognize the therapist in each session. The transference process was considered to be a product of implicit learning.

Finally, in considering the social realm itself, loss of pre-injury social roles (Williams, Evans, & Wilson, 2003) is significant. This could be a consequence of other cognitive and physical problems, or perhaps the social consequence of the aforementioned altered in-terpersonal processes. Family therapy formulations of trauma have emphasized the role of social positioning during and after trauma in determining different cours-es of recovery within a traumatized group or commu-nity (Papadopoulous, 2002). Prior to or following TBI, a specific social or family role (often involving caring for others) may have a psychologically structuring function. The disruption to, and inability to resume,

such a role may prevent access and use of a culturally constructed containing–contained mechanism. This failure may be one further perpetuation of the subjec-tive and interpersonal effects of the trauma experience (for case discussion of loss of social role and concur-rent alteration to object relations in TBI without PTSD, see Yeates et al., 2008).

In summary, an object-relations perspective on PTSD after TBI can contribute over and above existing cognitive-behavioral formulations. These contributions are the attention to interpersonal etiological processes and outcomes and the creation of tight conceptual links between these and neurological, cognitive, and subjec-tive factors. This analysis and language can no doubt be retranslated within CBT frameworks. However, the value of an object-relations psychoanalytic formulation can be extended to guide unique directions in treatment to respond to interpersonal sequelae. This therapeutic application is discussed below.

Prioritizing interpersonal factors within rehabilitation responses

Cognitive-behavioral approaches to PTSD after TBI focus on facilitating the survivor’s reprocessing of traumatic memories—that is, cognitive restructuring (meaning reconstruction, reappraisal, and reattribu-tion). In addition, there is a targeted reduction of avoid-ant behavior and teaching of alternative strategies to manage the physiological basis of anxiety (King, 1997; McGrath, 1997; Williams, Evans, & Wilson, 2003). Additionally, compensatory rehabilitation strategies for memory, attentional, and executive impairments are included (Williams, Evans, & Wilson, 2003). Single-case evaluations have provided preliminary evidence for the efficacy of these approaches (e.g., Williams, Evans, & Wilson, 2003).

So what can an object-relations psychoanalytic ap-proach offer to neurorehabilitative practice? Taking the preceding line of focus within this paper, a psycho-analytic formulation and therapeutic relationship can be used by the survivor to make sense of simultaneous disruptions to mental life, social roles, and interper-sonal relationships. The latter may include tensions with rehabilitation staff. While a formal provision of psychoanalytic psychotherapy would be well-placed to offer this clinical response, this is fairly unlikely to be offered within the majority of worldwide neuroreha-bilitation centers, notably in the United Kingdom. For this reason, the consideration of therapeutic responses below is from the perspective of clinicians offering

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differing psychological therapies (such as CBT) and the wider rehabilitation team making use of these psy-choanalytic ideas.

In identifying the direction and key mechanisms of therapeutic change for this client group, the advantages of the protective function as an interpersonal dynamic over an abstract “skin” or shield become clearer. If a central therapeutic aim is to restore a containing–con-tained function within and between the survivor of TBI and others, then the initial focus is on the immediate re-lationships with clinicians and the psychological tools codeveloped within these interactions.

An important initial step would be to fully assess the survivor’s subjective experience of relationships and significant others, including clinicians. This would provide a map of a changing territory of interpersonal safety and threat around the survivor. Assessment of social communication such as social comprehension, emotion recognition, perspective taking, mentalizing, and social inference would provide some useful links to neuropathology and influential neuropsychological parameters. Similarly, knowledge about any intrinsic changes to a survivor’s experience of emotion and embodiment will inform subsequent therapeutic en-counters.

The TBI survivor needs to be equipped to have the means to move from his or her immediate responses to threatening stimuli, to discriminate between the time of the trauma and the current, social, environment. This would facilitate both the later acquisition of strategies to maintain this distinction and authorship of contem-porary meanings regarding self and world. This would include the development of new (or resumption of old) social relationships. A clinical response using the con-taining–contained concept would foster the likelihood of this first step by attending to the transference within sessions. Exploring and naming the moments when the therapist or others become the persecuting bad object is paramount. Neuropsychology would inform this process, suggesting the level of complexity the survivor can symbolize and/or process regarding oth-ers and relationships. Key questions would concern the availability for that survivor of a full representational palette of others’ qualities, attributes, and intentions. It is necessary to discern whether these can be thought about and held alongside each other. Similarly, it is important to know what key interpersonal or intersub-jective information is missing or is inaccessible to the survivor.

For the TBI survivor, the therapeutic process en-tails an emerging awareness of his or her subjective responses to the appearance of the bad object, such as a

flooding of unmanageable anxiety, suspicion, or anger (trauma-related material, beta elements). Reciprocally, this would also involve the therapist experiencing the intersubjective effects of the survivor’s concrete cop-ing: projections and projective identification to ex-pel the bad contents of the survivor’s internal world (Garland, 1998b). This process develops through the clinician noticing the pattern and the corresponding feelings in the countertransference, containing this, and symbolizing this in her or his responses (Segal, 1957). These therapist’s impressions, developed into a psychological formulation and shared in visual, con-versational, or narrative form, will often be the first symbolic tool for the survivor post-injury. The medium of formulation should be informed by a neuropsy-chological identification of strengths and weaknesses. Nonpsychotherapeutic clinicians such as occupational therapists or speech and language therapists could use the containing formulation as a point of reference when their discussion of compensatory memory or planning strategies becomes threatening or overwhelming for the survivor of TBI.

Beyond the immediate interpersonal process and functional adaptation work, longer term goals of psy-chological therapy for survivors often develop into themes of salient adjustment to life post-injury. These include permanent alterations to self, identity, and rela-tions with others. From an object-relations perspective, this adjustment process will necessitate a process of reparation (e.g., Klein, 1935). The individual works via a containing process, toward an ambivalent holding of both good and bad objects side by side in his or her internal world and in his or her relations with others, without the bad being a threat to the good.

Compensatory approaches to cognitive dysfunc-tion, couched within a therapeutic relationship, can be thought of not only as isolated skills learning, but as co-constructive symbolic activity. The acquisition and meaning of these psychological tools, codeveloped with a (caregiving) other (Vygotsky, 1978), resembles the pretraumatic developmental formation of a con-taining–contained function. The memory, attentional, and executive strategies and compensatory devices described by Williams and colleagues (Evans & Wil-liams, 2009; Williams, Evans, & Wilson, 2003) in their CBT approach can all be seen as supportive of renewed symbolic, representational processes. Such external re-sources may permit more elaborate, contextually en-riched representations of others to be shared between the survivor and therapist. These may evolve more integrated, whole objects to be used in the survivor’s interpersonal world.

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With regards to implicit learning processes for sur-vivors, the therapist’s countertransference and then the survivor’s own awareness of the transference can be used. These are sources of information to be used to identify and label sensory-based anxiety states proce-durally learned through the trauma experience (King, 2001). In the absence of explicit recall, these feel-ings can be contained, described, symbolized, and reconstructed through both education and reflective processes.

However, the cognitive-behavioral and object-re-lations approaches do differ in practice. The latter prioritizes at least some level of in-session relational process work as a necessary precursor to the effective introduction and acquisition of cognitive compensatory strategies. Interestingly, this prioritization of a caregiv-ing relationship as a vehicle of change in trauma may make both developmental and neurobiological sense. Both early and contemporary considerations of anxi-ety at the neurological systems level have highlighted social caregiving as a key influence on an organism’s later self-soothing (containing?) regulatory abilities (Alexander, Fiegelson, & Gorman, 2005b; Freud, 1926 [1925]).

Focusing on memory neurobiological systems in PTSD without TBI, Yovell (2000) describes important modifications to standard psychoanalytic technique to compensate for compromised hippocampal function from elevated cortisol levels during times of emotional arousal. Yovell suggests that therapists should “strike while the iron is cold” (p. 179): interpretation should be saved for periods of emotional calm in sessions with these analysands. This adaptation again prioritizes the containing timing of the caregiving therapeutic en-counter as a key mechanism of change. For Yovell, this change is at a therapeutic level and is also creating the right conditions for hippocampal regeneration. Follow-ing Olds (2008) and the observations of Turnbull and colleagues (2006), the implicit learning/memory foun-dations of identification make the therapeutic use of this process as a point of both containment and growth a serious possibility with TBI survivors, even where explicit memory is partially or severely compromised.

Conclusions

A specific contribution has been outlined for key ob-ject-relations concepts in the literature on PTSD after TBI. The work of Klein, Segal, and Bion has evolved a formulation of a containing–contained, symbolizing interpersonal function, building on Freud’s (1920) ear-lier notion of a breached protective shield in trauma.

When applied to posttraumatic experience (Garland, 1998d), these concepts both alert the clinician to in-terpersonal etiological processes and also permit new avenues of intervention within this work. In reha-bilitative responses to PTSD following TBI, the valu-able contributions of cognitive neuropsychology and cognitive-behavioral therapy can be supplemented by an object-relations formulation. Links can be made between the traumatic process, subjective alteration, concurrent cognitive deficit, and the evolution of a threat located in the relationships between survivor and significant others post-injury. Therapeutic responses can be guided by a containing, interpersonal process. This can then be used to form symbolic, interactional “scaffolding” where cognitive compensatory strate-gies can be introduced to consolidate further symbolic activity. These resources can be used to develop more flexible, integrated representations of significant others and key relationships.

Future publications would be useful to substantiate some of these theoretical considerations. Neuropsy-chologically adapted psychoanalytic therapy case re-ports on PTSD after TBI would be welcome, as would future research into interpersonal pre- and post-injury influences on the etiology and outcome of PTSD in this clinical group.

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