Since ancient times, trauma has been one of the most frequently used words in medicine. It is Greek in origin, meaning ‘physical wound'. Today, traumatology is the branch of medicine that studies and deals with physical injuries. However, from the late XIX century, Freud extended its meaning to include not just physical but also psychological wounds emerging from what he called a traumatic event.
During and after WWI, the term ‘mental trauma’ was widely used to describe the psychological scars left in those returning from the front. Soon, doctors and psychologists learned that many people suffered a similar cluster of mental and physical symptoms despite having never been on a battlefield. A wider concept of trauma was born. Trauma played a central role in psychoanalysis. Freud thought the symptoms seen in patients were the consequences of mental mechanisms trying to keep the memories of those traumatic events away from the conscious mind. In his view, the aim of psychological trauma treatment was to dig deep in the patient’s mind, bring the traumatic events to the surface and confront them. The principle of reality would prevail and the conflict would be resolved.
It was a simple and logical idea that fitted perfectly well with the psychoanalytic theory. However, it didn’t take long to realise that trauma was a lot more complex and that pushing patients to recall painful events from the past only brought more suffering.
Instead of relief, patients feel intense anxiety remembering the event that resulted in psychological trauma. Upsetting memories and flashbacks and the overwhelming feeling of helplessness would be repeatedly triggered by unrelated circumstances. Many people lose interest in daily life and feel emotionally numb and detached from others.
Anxiety, panic attacks and depression persist long after the events. It is not unusual to turn to alcohol or drugs in an attempt to control the overwhelming feelings. Insomnia resulting from excessive anxiety and depression, and total or partial amnesia of the traumatic events are very common. This results in a certain level of impairment of cognitive functions.
The symptoms usually manifest soon after the events but in some cases, they can take weeks to emerge slowly, in a pervasive way. Patients report having good days when the symptoms almost disappear, and bad days when all of a sudden they return, stopping them from living a normal life. Today, this symptomatic constellation is known as post-traumatic stress disorder (PTSD).
Over time a mixture of despair, anger and hopelessness leaves persistent scars in people. Depending on the predominant symptoms they showed during the first psychiatric assessment, patients can be diagnosed with borderline personalities, bipolar disorders, alcohol or drug misuse disorders, or post-traumatic stress disorder.
PTSD is one of the most incapacitating anxiety disorders; it is not suitable for a single line of treatment. Sometimes anxiety or depression can be the main reason people seek treatment. Over the years I have seen many patients treated for alcohol or drug dependence when the underlying condition was PTSD. In those cases, removing the addiction could result in severe depression or anxiety, because addiction was the only defense they could put up to control the overwhelming feelings, very difficult to express in words.
There are a variety of therapeutic interventions to help people with PTSD.
Individual and/or family therapy are the foundations of any therapeutic approach.
Most patients also need medication to help them sleep and control anxiety or depression. Cognitive behavioural therapy (CBT) has been proven beneficial for minor symptoms of PTSD. Eye movement desensitisation and reprocessing (EMDR) is a new neuropsychological technique that is known to benefit patients as well.
Dr Oscar D'Agnone, MD, MRCPsych.