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Psychological reactions to trauma: signs and symptoms

Ashley Conway
BSc(Psychol) PhD(Psychol)
Chartered Counselling Psychologist
Harley Street
London

People suffering from psychological trauma may experience more complex  effects on their mental health than anxiety or depression. Ashley Conway explains how to identify the features of trauma, and what to look out for when treating a patient who has been traumatised

Dealing with psychological trauma can bring difficulties above and beyond those associated with other psychological problems, such as anxiety or depression. There may be a number of reasons for this. Often, where there has been a trauma, there will also be a complex mixture of elements of anger, guilt and blame, as well as sadness and fear. To compound matters, many traumatic events (physical assault, sexual assault, road traffic accidents, terrorist incidents) may involve criminal proceedings and impending court cases.

Some individuals (particularly in cases of sexual and/or violent assault) may find the court process itself traumatising. Where there are criminal proceedings or civil litigation involved (for example, a compensation claim), precise language is important. This puts an additional pressure on clinicians. We must be extra careful in these circumstances to use the correct language and terms when talking to patients or writing about their presentation.

This is the first of two articles on trauma. Part one will deal with identifying the features of trauma, and the psychological problems associated with it. It will also discuss some of the signs and symptoms that might lead us to suspect that a psychological trauma is underlying a particular presentation. These may not be obvious, but might be very important. Part two (to be published in a later edition of Nursing in Practice) will address the practical implications of working with patients who have been traumatised.

Defining trauma
First, we need to decide what constitutes a trauma. This may seem like common sense, but sometimes it is not. To be defined as a trauma for a diagnosis of post-traumatic stress disorder (PTSD), the event must involve threatened death or actual serious injury to the patient directly, or such an event being witnessed by the patient.1 Events that many of us would consider being traumatising, such as being fired after 20 years in a job, or a spouse leaving after many years of marriage, do not fit this criterion, so being aware of definitions for accurate diagnostic labels starts at the very beginning. Symptoms that occur in reaction to trauma are usually divided into three groups, as described below.

Re-experiencing the trauma
This might include recurrent and intrusive recollections of the event, recurrent distressing dreams about the event (in children this may be generally frightening dreams without specific reference to the traumatic incident), and acting or feeling as if the traumatic event were recurring. In its extreme form, this last symptom may include features of dissociation, where the usually integrated functions of consciousness, memory and perception are disrupted. Flashbacks would be an example of this phenomenon. It is important to note that flashbacks are different from ordinary memory. Flashbacks involve re-experiencing the event, as if the individual were back there in that moment, and they may occur in any sense – sight, sound, smell, touch taste (I would also add endogenous physiological stimuli, such as palpitations, breathlessness or specific pains).

A soldier who had completed three tours in Iraq and Afghanistan was talking to me about an injury to his face. He suddenly got up and looked in the mirror on the wall. He opened his mouth and stared at what he saw. I did not ask him what he was doing (this is effectively a request for a rational explanation), but I did ask him what was happening to him (a request for a description rather than an explanation). He replied that he was checking to see if he had blood in his mouth.

He was not remembering that he had blood in his mouth at the time of the trauma, he was feeling it and tasting it, as he was talking to me about the events. He was having a flashback, so he needed to check in the mirror, because without doing so he could not know whether his mouth was full of blood or not. Further demonstrations of symptoms in this category include intense psychological distress or physiological reactivity on exposure to reminders of the traumatic event.

Avoidance
This is not a very surprising symptom. If a traumatic experience has occurred in a specific environment, there is a strong desire to avoid re-exposure to that environment. It is a simple survival mechanism – if you feel very threatened in one situation, do not go back there. This may involve places or situations. For example, a patient who was injured in the London tube bombings on 7 July 2005 avoids travelling on the underground. This creates a significant inconvenience when living in London, but it is still possible to travel around by other means.

Further problems may arise when the avoidance generalises – a patient who nearly drowned becomes fearful of going swimming, then going in boats, and eventually crossing bridges over water. This kind of generalisation can obviously seriously restrict someone's life, when every journey has to carefully planned, and occasionally abandoned because of a bridge.

Avoidance may also include thoughts, feelings and conversations about the traumatic event. There may be amnesia for some aspects of the trauma. Memory of the trauma may be unreliable, incomplete, fragmented or disordered in time. This does not tell us anything about the veracity of the history provided by the patient.

Many authorities believe that memory works differently during trauma, and it may be that it works differently for a single traumatic episode (such as an accident or a terrorist event) and ongoing trauma (repeated abuse in childhood or being a prisoner of war). This cutting off from thoughts and feelings may be associated with a generally diminished responsiveness to the external world, including a sense of detachment from other people, and a reduced ability to experience intimacy in all its forms.

Increased arousal
This will often involve sleep problems, possibly including nightmares, hypervigilance, an exaggerated startle response, irritability and difficulty in concentrating. A patient who worked as a bank cashier was held up at gunpoint. At work, two weeks later, he found himself making mistakes and being short-tempered and rude to customers. Both things were uncharacteristic of his normal behaviour, and were almost certainly part of his post-trauma reaction.

Interestingly, the traumatic reaction is typically worse when the stressor is inflicted deliberately by humans – so an individual who has received injuries in a skiing accident is less likely to suffer a traumatic reaction than an individual who received comparable injuries in a violent assault.

Other factors to consider
Age and cultural differences may influence presentation. Children may describe various physical symptoms such as stomach or headaches, or show signs of anxiety, such as bed-wetting. In cultures where admission to nightmares or anxiety is equated with weakness or mental illness, presentation may be more somatised (typically breathlessness, chest pain, palpitations, dizziness, exhaustion, aches and pains).
Pre-existing psychological problems, such as anxiety or depression, probably make individuals more vulnerable to develop post-traumatic reactions. High levels of social support probably decrease this likelihood. Following trauma there is also an increased risk of developing an associated psychological disorder such as panic attacks, agoraphobia, depression and somatisation disorders. "Self-medicating" with alcohol or other drugs is quite common, and this can obviously develop into a problem in its own right.

For a formal diagnosis of PTSD, a number of very specific criteria have to be met, including the nature of the trauma, and a selection of the symptoms outlined above, with the duration of symptoms more than one month. The reaction may have onset delayed, for months or even years before symptoms appear.

Although it may be important for lawyers, clinically, of course, it is not particularly relevant whether a patient exactly meets all of the necessary diagnostic criteria for PTSD. Many patients may have serious reactions to trauma that do not fit these specific diagnoses, but nevertheless have a real need for skilled help. I have worked recently with a patient who was seriously injured in a terrorist incident that was covered by the world's media. He obsessively sought out all the film that he could find of the event, and would watch it over and over again. No avoidance there then, but an idiosyncratic response from a patient who was deeply traumatised.

Conclusion
Working with trauma is demanding for the clinician. This field is complex, but fascinating. It is also potentially very rewarding. With good therapeutic support (see part 2 in a future issue of Nursing in Practice) patients do get better, and good awareness of signs and symptoms of a traumatic reaction is the first step in helping a patient to recover.

Reference
1. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders IV-TR. Washington: APA, 2000.

Further reading
Rosen GM (ed). Post-traumatic Stress Disorder: Issues and Controversies. John Wiley and Sons Ltd. Chichester, 2004.