PTSD, TBI, and MDD can all impact decision making and lead to risky behaviors. PTSD may cause aggression, numbness, and lack of care. TBI can impair decision making and emotional processing. MDD can cause feelings of worthlessness and hopelessness. Having multiple conditions makes resisting risky impulses even harder. To reduce risk, identify goals, strategies, and specific tactics like avoiding triggers and using healthy coping skills like journaling or relaxation. Learning about oneself helps recognize unsafe choices and change behaviors to stay safe.

1. How PTSD, TBI and MDD Impact Decision Making
Johanna England
RISKY BUSINESS

2. WHAT IS “PTSD”, ANYWAY?
• Our bodies are made to react quickly in stressful situations. Have you heard the term
“fight or flight”?
• Traumatic stress is a normal reaction to an abnormal situation.
ektherapies.blogspot.com

3. (Something is potentially dangerous.
We are being shot at (unconditioned
stimuli), while helicopters continuously
hover above (conditioned stimuli).)
(A healthy, adaptive response to
danger that keeps us alive.)
(Our response to the conditioned (neutral) and unconditioned (aversive) stimuli of a dangerous
situation. The sound of a helicopter is now associated with being shot at. Do we run? Fight? Hide?)
(Over time, if nothing bad happens when we
are exposed to stimuli, fear extinction
happens. Helicopter noise is no longer
stressful. Exposure therapy is an attempt to
create fear extinction.)
(The brain is unable to decide that
conditioned stimuli is not a threat. The
sound of helicopters is a stressor
[“trigger”] that causes a fear reaction. )

4. Symptoms of PTSD:
 Reliving the event through nightmares, flashbacks or “triggers”
 Avoiding situations or people that remind you of what happened
 Negative changes in beliefs and feelings
Numbness (having a hard time “feeling” things, like love or compassion)
Difficulty trusting others
Anger
Forgetfulness
 Hyperarousal
Feeling jittery or irritable
Having difficulty concentrating
Being easily startled
 Risky or aggressive behavior
Fighting
Aggressive or unsafe driving
Risky sexual behavior
www.ptsd.va.gov

5. TRAUMATIC BRAIN INJURY – “TBI”
• Traumatic brain injuries are caused by head injuries. Injuries vary and could be mild, as in
a concussion or very severe, as in a gunshot wound to the head.
• TBI can cause a wide range of functional short or long-term changes affecting:
• Thinking (memory and reasoning)
• Sensation (touch, taste, and smell)
• Language (communication, expression, and understanding)
• Emotion (depression, anxiety, personality changes, aggression, acting out, and social
inappropriateness).
http://www.cdc.gov/traumaticbraininjury

6. MAJOR DEPRESSIVE DISORDER – “MDD”
• Major Depressive Disorder is a fancy term for depression that lasts for a long time.
• Depression is often a symptom of both PTSD and TBI. If it lasts for a while and causes
problems of its own, it gets its own diagnosis of MDD.

7. What kinds of problems does depression cause?
 Feeling sad, worthless or unlovable
 Loss of interest in sex or other pleasurable activities
 Having crying spells, sometimes for no obvious reason
 Agitation, restlessness, irritability, and/or angry outbursts
 Trouble thinking, concentrating or making decisions
 Unexplained physical problems, such as muscle aches or headaches
 Frequent thoughts of death or suicide
 Reckless behaviors – are sometimes a warning sign of suicidal thoughts

8. Did you notice that MDD, PTSD and TBI can all contribute
to “risky” or reckless behavior?
http://bblmedia.com

9. All of these conditions are associated with risky behavior, but
probably for different core reasons.
PTSD – Risk behaviors may be a result of aggression in some people (aggressive
driving, starting fights) or “numbness” that produces an “I don’t care” attitude (unsafe sex)
TBI – Risk behaviors could be due to impairment in the parts of the brain that control our
impulses and help us make good decisions (unsafe sex, starting fights, unsafe driving –
really any unsafe or illogical behavior). Changes in the parts of the brain that process
emotions can also lead to reckless behavior. Physical problems caused by TBI could
indirectly impact decision making by producing feelings such as extreme frustration.
MDD – Risk behaviors in depression could be related to feelings of worthlessness or
hopelessness. Risky or reckless behavior caused by depression is a warning sign for
suicidal feelings.

10. Consider this…
A person may have one, two or all of these three conditions at once. What type of impact
might that have on behavior? Is it more difficult to resist the impulse to do something risky
that comes from one source (such as MDD alone) or from several sources (such as MDD
+ PTSD + TBI)?

11. STAYING SAFE
Identifying risk reduction strategies
and tactics

12. If I want to reduce my risk of harm, the first step is complete honesty with myself. Is
there anything I do that is reckless? Do I keep myself safe? How could I be safer?
I can ask myself – “When is the last time I regretted doing something?” Regret can
be a good indicator that we have made a risky or reckless decision. Thoughts like:
“Why did I sleep with her without a condom? I don’t even know her!”
“Why did I gamble? I don’t have the money for my rent now!”
“I can’t believe I drove drunk last night. I don’t even remember the ride home!”
“Why didn’t I lock up my gun. My son played with it and could have been killed!”
“Why did I start that fight with her ex? Now she won’t even talk to me!”
are good indicators that something went wrong and I need to decide what could have been
done differently. I need a strategy!

13. A strategy is a broad plan to achieve a goal.
I will reduce my risk of contracting HIV or other STIs
by being sexually careful.
A tactic is a specific action taken to build a strategy.
To reduce my risk of contracting STIs, I will wear a
(new) condom every time and be choosy about my
sexual partners.

14. To develop a strategy, first decide on a goal.
My goal is to stop getting into fights.
Then decide on a broad way to meet this goal.
I am going to stop getting into fights, by avoiding going to places that are
triggers for me. (No more Fight Club!)

15. But what if I don’t follow my plan and go somewhere
unsafe for me? Or what if I get triggered by surprise?

16. Five Steps for Positive Decision Making in Any Situation
Step 1: Say the problem without blaming anyone.
• Instead of, “Paul is making me so mad, I want to hit him.” Say, “I’m feeling really aggravated
and aggressive right now.”
Step 2: Brainstorm several possible solutions (at least three).
• I could leave.
• I could try telling Paul, as calmly as possible, that I don’t like what he is doing.
• I could go outside or to the restroom to practice calming coping skills.
Step 3: Briefly go over the good and bad points of each solution.
• If I leave, I remove myself from the situation, but I am still angry.
• If I try talking to Paul, maybe it will make things worse, but it could fix the problem.
• If I try using my coping skills to calm down, it might not work, but it could help a lot.
Step 4: Pick a solution that will have a happy ending for all.
Step 5: Try out the solution. If it works, great! If not, have fun going through the process again.

17. Did you say “coping skills”?
Yes! Healthy coping skills are so important! Each and every single person in this room
needs them. Seek out help with learning about them and finding which ones work for you.
Ask your Dr. or therapist to help you! Healthy coping skills can help you get through
ANYTHING!
Two kinds of healthy coping skills. They work together and we need both.
Avoidant coping skills – Listening to music, doing art, exercising, relaxation
Processing coping skills – Writing about feelings in a journal, expressive art with the intent
to release feelings, talking to a trusted person about feelings
Imagine you are running a race. Processing is the hard work. It’s the running. Avoidance is
the part where you take a break, recharge and get ready to do more hard work. Most
people enjoy avoidance and tend to neglect processing. Avoidance isn’t all that helpful
without processing, because we’ll be “stuck” without the ability to run.

18. Oops! Wait a minute! We can use unhealthy coping skills, too. Smoking and overeating are
very common examples. Abusing drugs or alcohol are also common ways to cope with
feelings in a harmful way.
Sex can be healthy or unhealthy. Safe sex with a loving partner can be a terrific, healthy
coping skill. Sex that is not safe, 100% consensual or that makes you feel bad about
yourself is an unhealthy coping skill.
depositphotos.com

19. In conclusion, the most effective way to keep ourselves safe is to learn about ourselves. If we
can recognize what causes us to make unsafe choices, we can work on changing that
behavior. These are steps you can take to keep yourself safe:
 Attend all medical and therapy appointments faithfully. This is an investment in yourself.
 Take medications as prescribed. If your medications are bothering you, or if you feel you
no longer need them, talk to your doctor. Don’t just stop taking them!
 Talk to your therapist about coping skills. Be interested and involved in your treatment.
 Work on making strategies to reduce risks with tactics that will help you be successful.
 Believe that YOU are worth protecting!