When you’re faced with a sudden serious medical situation, it’s normal to feel panicked. In most cases, you have no choice but to deal with the panic and your health problem. But even after dealing with the event, a percentage of patients will later develop “medical trauma,” which can be enormously disruptive not only to their lives but to their healing.
Bottom Line Personal asked Lawson Wulsin, MD, author of the forthcoming Toxic Stress: How Stress Is Making Us Ill and What We Can Do About It, what to know about this kind of trauma and how to manage it…
What it is: Medical trauma is a pattern of lingering psychological distress extending beyond the normal healing period of a medical event. Example: For most surgery patients, the wounds heal and the psychological distress recedes. But a few people will continue to have psychological repercussions in a way that impairs their functioning. In that regard, medical trauma can be thought of as a form of post-traumatic stress disorder (PTSD). But medical trauma is not “just” PTSD. It’s often more complex and difficult to diagnose than other forms of PTSD because it is wrapped up in the medical issue itself. If you’re in an awful car accident but walk away unscathed, you could develop PTSD, but it is purely psychological, requiring no physical recovery. Medical trauma can become a snake eating its own tail—the psychological trauma interferes with physical healing and, since trauma often manifests in physical ways, may cause a confusing pile-up of medical issues.
Symptoms: One of the tricky things about diagnosing trauma is that humans can repress traumatic experiences for months, years, even decades. That can make it difficult to connect the trauma to medical events from the relatively distant past. Trauma manifests in two opposing ways…
Hyperarousal is an emotional overreaction consisting of flashbacks, nightmares and reliving the trauma either through explicit memories or the re-experiencing of a sensation associated with the traumatic event.
Psychic numbing is a coping mechanism marked by a flattening of emotions and withdrawal from other people.
The same patient can experience both sets of symptoms or may lean more one way than the other. Psychological numbing is harder than hyperarousal to recognize in oneself or a loved one.
Who is susceptible? We know surprisingly little about who develops medical trauma and why. But we do know that somewhere between 20% and 30% of people exposed to the same event will develop a traumatic psychological reaction. That’s in line with other forms of PTSD.
We also know that trauma thrives on surprise. The less prepared we are for a situation, the more likely we are to later experience trauma. Example: Imagine a passive patient who ignores her doctor and signs a consent form without understanding what it says, then awakens from surgery to find her left foot gone. Besides the normal psychological burden of such an event, she may feel shock, betrayal, anger and injustice, making the situation even harder to process.
People with any kind of psychiatric history, including depression, anxiety and addiction, are more likely than others to develop medical trauma. We also know that people who have experienced prior traumas are more susceptible. That runs counter to the popular notion that we get tougher the more we endure. Instead, our bodies and minds “keep score” and eventually reach a breaking point. Given trauma’s strange incubation period, it can sometimes be difficult to sort out which of a series of shocking events has triggered the PTSD.
Common causes: Just about any surprising or painful medical event—emergency bypass, colostomy, chronic infection, miscarriage—can produce medical trauma. The following examples illustrate just how varied such events may be…
Implantable cardioverter-defibrillators (ICDs): People with certain heart arrhythmias have ICDs placed in their bodies that send a jolt of electricity to restart the heart if it enters cardiac arrest. If you’ve ever witnessed defibrillation, you know that this is no tiny shock—it comes out of nowhere, and it hurts…and it requires follow-up with a medical team to figure out why it happened and what needs to be done. About one in five ICD recipients will develop medical trauma after a defibrillation event. Yes, the device saved his life, but now he is dreading another jolt that could come at any time while reliving the horror of the last one. The best ICD clinics around the country offer counseling to help patients manage the psychiatric aspects of living with the ICD.
Surgery and anesthesia: Although people undergoing urgent or high-risk surgeries are slightly more likely to develop medical trauma, even routine and elective surgeries can trigger trauma later on. Experts aren’t sure whether the trauma is associated with the operation itself, the anesthesia or both. But patients who experience the horrifying condition called “intraoperative awareness,” in which they’re awake and alert during the surgery but unable to communicate with the medical team, are particularly prone to traumatic reactions.
Delirium: This condition, which can be brought on by infections, liver failure or brain injury or because of a toxic reaction to anesthesia, is a fairly common problem in hospitals. The patient endures a terrifying form of brain failure in which she is disoriented, loses control of her behavior and cannot communicate. She may engage in impulsive, thrashing and violent behaviors. She won’t remember most of it, but as she emerges from delirium, she becomes aware of what kind of state she has been in. Most people recover just fine, but some will have recurrent nightmares and be unable to stop thinking about the delirium. The horror of their helplessness can combine with shame and embarrassment about how they must have appeared to others. They may ruminate during the daytime, replaying scenes in their head, terrified about ever becoming delirious again. Family members who have experienced delirium should be closely monitored for such behaviors in the weeks after the episode so that the trauma can be treated.
Prevention: Unfortunately, there’s no way to guarantee that you or someone you love won’t ever experience medical trauma. But we can take what little we know about trauma’s causes and use it to reduce our risk.
Given that medical trauma appears more often in people with psychiatric histories and those who have experienced trauma in the past, medical professionals should ask screening questions before undertaking procedures that could trigger a trauma response. But since few doctors do this, you should report any personal history and voice any concerns about developing trauma. Also speak up if you’ve experienced intraoperative awareness or delirium.
Because surprise tends to exacerbate the trauma response, enter medical situations with your eyes wide open. Taking control of the situation, being your own advocate, asking questions, making lists, calling specialists—anything proactive you do to make yourself more informed and more in control will provide a psychological buffer against trauma.
Treatment: Trauma is treatable, but since we can’t erase the past and we can’t cure trauma—we can only manage it. The gold standard for managing trauma is a branch of cognitive behavioral therapy called cognitive processing therapy (CPT). Over the course of weeks and months, the therapist helps the patient identify situations that trigger trauma. He learns alternative ways of thinking about the situation that triggered the reactions. By recording thoughts and story-building, the patient begins to construct a narrative about the events that gives him control over his emotional life and physical reactions to his feelings. Ultimately, the patient will be able to think about the traumatic event without re-experiencing the old emotions and feelings of threat. Some patients will need medication to help this process along.
Outside of formal therapy, there are exercises people can do to help manage trauma. Meditation is one of the best ways to quell the hyperarousal symptoms of medical trauma. It doesn’t have to be anything fancy. Meditation in the form of dance, singing or chanting works, and apps such as Headspace can be helpful.
One of the best antidotes to psychological numbing is exercise. Someone in that numbed state likely won’t feel like exercising, but just taking a short walk can begin to make a difference.
