Adjustment to Trauma
The consequences of trauma are varied and can be detected in different ways. Visibly, one can see the physical disability or perhaps an obvious impairment in function. At a slightly less visible level, a traumatic experience can result in psychological effects, such a anger, intrusive thoughts, emotional numbing, depression, and anxiety. The most hidden consequences of trauma can include a difference in the way a traumatized person organizes and uses new and existing information as well as a reorganization of existing belief structures and ways of thinking.
Most people fortunately experience trauma as a transient disruption. They experience a temporary upheaval of the trauma or injury but maintain their overall health and can still function in work, home, and social relationships. This is known as resilience. With resilience, the patient travels a trajectory of recovery in which psychopathology resolves and the patient returns to a pre-injury level. Resilience also reflects the ability to maintain a stable equilibrium in spite of highly disruptive events associated with loss.
In this section, we will describe the various disruptions in psychological functioning that follow trauma as well as the resilient responses that can follow a traumatic injury. We will highlight aspects of traumatic events, the characteristics of survivors, and the environments that influence the risk of disruption caused by trauma. We also hope to impress upon those who care for the traumatized patient that trauma can bring out the best in human behavior, such as strength, courage, forgiveness, and growth.Definitions of Traumatic Events
Psychological trauma is a psychic or behavioral state that results from mental or emotional stress or physical injury. Events that lead to post-traumatic stress disorder are usually extreme, severe, harmful, or threatening that they demand extraordinary coping efforts. A traumatic event usually subjects people to extremes of fear, horror, vulnerability, uncertainty and loss of control.
According to the definition of psychological trauma, nearly all patients seen in an acute hospital setting for trauma, including their friends, and family and some of the staff have experienced some type of psychological trauma. This would include:
- Individuals who have been injured or exposed to a recent, sudden, unpredictable event
- Individuals who have been injured by a prolonged, repeated stressor
- Individuals who have experienced prolonged duress associated with a chronic illness, causing a feeling of being traumatized but without a specific traumatic event
- Individuals exposed to “vicarious trauma”, such as the healthcare providers who treat trauma patients and those who witness traumatic events but are not injured by them
Some terms to become familiar with include “depression” and “post-traumatic stress disorder”. Depression describes a number of psychological experiences after trauma, including having a distressed and tearful mood, agitation, sadness, and being upset. There are many diagnoses that are more likely to occur after psychological trauma including major depressive disorder, adjustment disorder, and post-traumatic stress disorder.
In a major depressive disorder episode, there is more than just having a depressed mood, distress, and anhedonia. Other symptoms include:
- Depressed mood
- Diminished pleasure or interest in activities (anhedonia)
- Increased or decreased appetite
- Insomnia or increased amount of sleep
- Psychomotor agitation or retardation
- Decreased concentration
- Decreased energy
- Feelings of guilt or worthlessness
- Recurrent suicidal ideation
- Preoccupation with death
A patient must have 5 of the nine symptom, one of which must be depressed mood or anhedonia. The symptoms have to be present for at least two weeks. They must also impair functioning and not be caused by another medical condition or medications.
A diagnosis of major depression can be done through self-report measures or through detailed clinical history that includes an assessment of the above symptoms.
Post-traumatic stress disorder or PTSD is usually reserved for the actual anxiety disorder caused by the experience of trauma. The criteria used in diagnosing PTSD include the following:
- Exposure to a traumatic event in which something was witnessed or observed that was horrifying
- The traumatic event is persistently re-experienced such as having recurrent distressing recollections of the event or feeling as if the actual event were occurring (flashbacks)
- Persistent avoidance of stimuli associated with the trauma
- Numbing of general responsiveness not present before the trauma
- Persistent symptoms of increased arousal
- Having the symptoms for at least one month
This means that PTSD cannot be diagnosed in the first month following the trauma. There are a number of self-report measures of post-traumatic stress symptoms. They can provide worthwhile information regarding post-traumatic anxiety and its severity. Some people have post-traumatic symptoms and yet do not meet the full criteria associated with the disorder.
Another anxiety disorder associated with stress is the “acute stress disorder”. This describes an anxiety disorder characteristic of an acute psychological reaction to trauma that is not only intrusive, avoidant and with arousal symptoms but has dissociative symptoms. This involves having a detachment from one’s thoughts or body or feeling that external events are unreal. These patients experience being in a daze, emotional numbing, and difficulty recalling aspects of the trauma. It is similar to PTSD but emphasizes the dissociative symptoms that can occur after a trauma. It has a maximum duration of 4 weeks after the traumatic event.
Some people experience a post-traumatic growth, which is described as having an increased appreciation for life, feeling increased personal strength, changes in life priorities, gaining positive spiritual changes, experiencing improved relationships, and finding a new meaning and purpose in life. This suggests that positive changes can come from adverse life experiences, which is sometimes under-recognized when thinking of trauma recovery.Theoretical Approaches
In recent years as society has become more sensitive to the impact of trauma. Health professionals have become better in treating the psychological disorders that come out of trauma while losing sight of the more prevalent phenomenon or resilience.
There are three different ways to look at trauma and the responses to trauma. They include the following:
- Behavioral Theories. According to these theories, trauma responses are learned by observing the behaviors of others and then reinforcing those behaviors in the individual. The patient may be rewarded with sympathy, attention or care in response to a certain reaction to trauma. These types of responses can become deeply ingrained and rarely deliberate. In using this theory, the treatment involves gradually re-exposing the patient to the feared stimulus while managing the fear and anxiety. Over time, the trauma survivor is able to tolerate the feared stimulus.
- Psychodynamic Theories. This involves having the unconscious mind keep anything that is too difficult, unpleasant, or threatening from the conscious mind. The patient alternates between having intrusive thoughts of the trauma with numbing or avoidant thoughts. As the person learns to cope with the experience, the intrusive thoughts and numbing behaviors should go away. The experience can be less distressing and can better be tolerated.
- Cognitive theories. This is based on the idea that human beings have the basic need to make sense of the world and to assign meaning to life experiences. Exposure to trauma can shatter or violate one’s own invulnerability or worth as well as the belief in the safety of the world. The goal of treatment is to find acceptable meaning in the trauma on both an emotional and thinking level. Some people search for meaning but are unable to find a satisfactory resolution. Some feel they need more information after all factual information has been provided. Others continue to have intrusive thoughts and some continue to make unfavorable comparisons between life as it is and life as it might be if the traumatic event had not occurred. They blame themselves for the trauma or see themselves as victims with little hope that things will improve or change.
What is a normal reaction to just having sustained a life-threatening, life-altering injury? What is the normal response to undergoing extensive medical and rehabilitative interventions after an injury? What is a normal reaction to having a disability as a result of trauma? There is perhaps no “normal” way to react to trauma and everyone has their own unique response.Physical Responses
In the initial hours and days following a trauma, individuals may experience physical symptoms such as sleep difficulties, fatigue, nightmares, changes in appetite, muscle tension, hyperarousal, exaggerated startle response, and somatic complaints as part of a reaction to the traumatic event. As many as 50-75 percent of patients hospitalized with an acute burn injury have trouble falling or maintaining sleep and about a third have nightmares. It is impossible to tell the difference between psychological effects of the trauma versus the effects brought on by the injury, such as pain, lack of mobility, and medical treatment.Emotional Responses
The majority of people do not experience significant long term emotional distress, even after a significant injury. Some people experience short term distress. The patient may feel anxiety, fear, helplessness, depressive symptoms, sadness, anger, guilt, irritability, despair, or anguish. Many survivors also experience dissociative symptoms, such as emotional detachment, numbing, or an absence of emotional responsiveness. Patients describe feeling as if they are in a dream, a daze, or a stupor. They may have amnesia for the event. Medications can contribute to these symptoms. Positive emotions such as joy, humor, and hope have also been seen in the newly injured trauma survivor.Cognitive Responses
These include things like difficulty concentrating, easy distractibility, and memory difficulties. Intrusive thoughts about the trauma itself are also common. Some may feel as if they were back in the traumatic situation. The individual may be preoccupied or ruminate about the traumatic event. Thoughts of the world being an unsafe place are also seen in the newly injured patient.Behavioral Responses
There are many behavioral changes that can be seen in the traumatized patient that are not necessarily associated with a poor outcome. There may be social withdrawal or isolation. It can be difficult to physically withdraw within the confines of the hospital environment but may show up as reducing interactions with others or limiting the environment itself. Avoidance can occur, which can take on different forms, including avoidance of feelings, avoidance of reminders of the trauma, or avoiding any discussion of the event. They may avoid medical procedures because they remind the patient of their trauma. Others may respond by talking frequently about the trauma, including the events leading up to, including, and after the event.Prevalence of Psychopathology during the Acute Phase
Across all injury categories, depressive symptoms were reported by a sizable number of those who had experienced a recent trauma. Nearly half of all individuals had a significant degree of depressive symptoms at one month after a severe traumatic brain injury. Fifteen percent of these patients have severe depression. Only a few studies exist regarding the prevalence of acute stress disorder after a traumatic injury. It appears that acute distress disorder occurs in about 20 percent of survivors of traumatic injury.