Psychological trauma - Signs and Symptoms

An overview for Human Services Professionals

by Tom Cloyd, MS, MA - Counselor / Psychotherapist - Cedar City and St. George, Utah , Utah (435) 272-3332 - email: tc (AT) tomcloyd (DOT) com (please read about content licensing)

Informal screening for psychological trauma produces results

Individuals with undetected, untreated psychological trauma disorders usually do poorly when we try to assist them in our work in health care, vocational or occupational counseling, or general mental health care. Even when an individual is known to be a trauma victim, all parties involved too often fail to realize that most individuals with Posttraumatic Stress respond well to treatment.

However, failure to recognize the problem assures that no treatment will occur, so that problem must be addressed first. It is critical that we improve our ability to detect who is likely to have such a disorder, so that they may be formally assessed and, if necessary, treated. With treatment, individuals with psychological trauma disorders generally improve dramatically (many recovering fully). They will then respond far better to educational, health care, and all manner of other human services support efforts.

So, what should we watch for in the people we serve, as indicators of a possible psychological trauma problem?

Signs of trauma - your first clue

Personal history is the major source of signs to which we should pay attention. In fact, the known or suspected presence in a person's history or one or more traumatic events is essential. Without having established at least a reasonable suspicion of this, one cannot go further with the idea of a psychological trauma disorder as a cause for dysfunction in a client/patient's life.

How to think about client/patient history

There are two histories. History is what happened to someone, but there are always objective and subjective aspects to this. Objective experience sets up the conditions for trauma, but only subjective experience traumatizes. The individual must have had a grave subjective - emotional - experience at the time of the objective event(s), or soon afterwards, for trauma to have occurred.

History is never enough, and may be completely irrelevant. History qualifies an individual for, but does not confirm a diagnosis of, a psychological trauma disorder. History can, at most, suggest the need for further investigation. Most people with a traumatic event history do not develop a trauma disorder, and fewer still have such a disorder by the time we see them. We need merely to be careful to detect those who do. History from which an individual has recovered is of little or no interest to us. What really interests us is what's happening now with an individual, as a result of their history.

History may be unrecoverable. Because early childhood experience can most definitely cause the emotional overload which can lead to enduring psychological trauma, it, too, is of great interest to us. However, childhood memory before about age 7 to 10 is notoriously unreliable or even completely unrecallable. This doesn't mean that it doesn't exist, but just that it cannot be reliably recalled. So, if you have other reasons to suspect a trauma disorder, but no known history to qualify the individual for such a disorder, do not abandon the idea without careful consideration. Professional consultation will often be needed at this juncture.

The history that matters is the history in the person's brain. We should never contest a client's reported history, for any reason. For our purposes, if they "remember" it, it's "history". People can remember and be traumatized by events that simply could not have happened to them - this is well documented. Belief, not fact, is what makes something real, psychologically. Beyond this, we need not, and should not go.

History can mislead. History is merely the story we tell ourselves about the past. Sometimes people assemble a story that is simply wrong, in an attempt to make sense of their present disturbed state of mind. Over time, they can easily come to believe their own story, which may deviate gravely from actual events. Children can do this easily, and then tell the story as adults, with complete belief. Our only concern should be the connection of their "history" to present client dysfunction. Errors in history often take care of themselves, in the course of treatment.

What to look for

Be aware, again, that the following are merely indicators - "red flags" - which tell us that we need to know more about the person we are trying to assist. (This list is not intended to include all possibilities, but merely the ones most likely to be seen.)

A word of caution about getting history: Contact with history can disturb a client. If they avoid certain details, there's probably a good reason. In seeking additional information, respect reluctance to disclose, and note this as a very good sign that there's something painful being hidden. It's best to show obvious carefulness and compassion [2].

• Client/patient report of an event which was a "big deal" for them at the time. They will either tell you it bothered them, or give supporting history indicating serious emotional reaction at the time.
• Client/patient report of an event which YOU think ought to have been a "big deal" for them at the time. The client/patient may not initially indicate to you that the event affected them, but a little common sense on your part can be very helpful here. Feelings can be hidden. "Emotional numbing" may be how the individual survives day to day. For example, it is not reasonable for someone to report that their mother died when they were 5, and for you to assume that this wasn't a problem just because no emotion is shown when you are given the report. Consider probing a little further, recalling that your purpose at this point is merely to get at how they reacted at the time of the event or soon after. Relative to this historical concern, remember the problem of unrecallable personal history mentioned above.
• Report of an event in client/patient records which suggests emotional trauma. Medical records indicating treatment for an assault, or an auto accident, for example, clearly indicate the possibility of a traumatic event that may be associated with the physical injury.
• History of adult victimization. Adults who repeatedly experience violent attacks (physical, sexual) were very often trauma victims earlier in their life. They get into victimizing situations because they've always been victimized and don't know how to protect themselves.
• History of substance abuse or dependence of any kind. Most, if not all, such abusers are self-medicating - using these substances as a short term solution to a mental problem they're experiencing. The great majority of these mental problems are trauma related, upon careful examination. And...all of this applies to the other compulsive behavior problems we see - abuse of work, exercise, food, sex, credit, and so on. There are many ways to get short-term relief from chronic bad feelings. We need to question why the "chronic bad feelings" are there in the first place, which questioning will usually lead us to something traumatic.
• History of instability in intimacy or work relationships. Traumatized individuals often have difficulty with trust, or with authority, or simply with the kind of steady focus needed to follow instructions, make plans, and follow through on them. Their history will show this.
• History of overt self-abuse attempts or acts. This is a major "red flag", and includes people who attempt suicide in any way. or those who deliberately injure their bodies (cutting, burning, etc. - but not as a part of some kind of group initiation rite, as with certain gangs).

Symptoms of trauma - definite indicators

Given a known or suspected history of traumatic event(s), then, with enough symptoms, showing themselves in the right pattern, a formal diagnosis of one of the psychological trauma disorders may be made. The statistically most common such diagnosis is Posttraumatic Stress Disorder - the most grave of the formal Anxiety Disorders described in the DSM-IV [1]. Even without qualifying for this diagnosis, however, a person's function may still be seriously compromised due to posttraumatic stress symptoms.

How to determine the presence of symptoms

1. Look for them in any pre-existing records or reports you have available for review. (Example: Case notes from another worker, indicating hyper-emotionality in response to certain questions.)
2. Look for them in the client/patient's current behavior and expression. Look for restless eyes, or restless feet or hands. Traumatized people are scared, and can show that in a lot of ways.
3. Ask the person. Individuals who are trying hard to "keep their act together" in public will still tell you about other times, when they are definitely less in control of their feelings, thoughts, and experiences. This is undoubtedly the best way to determine symptom profile.

Formal symptom list

Posttraumatic symptoms fall into three classes. If any of these are reported or observed, investigate further.

Re-experiencing event(s)

• Traumatic event(s) are re-experienced in any one of these ways:
• Thoughts or images which disrupt normal thought or activity (for example - "flashbacks").
• Repeated bad dreams (with early childhood trauma, the dreams may be very formless).
• Feeling or acting as if the traumatic event(s) were happening again (for example - a firecracker goes off and a vet "hits the deck").
• Experiencing either (a) distinct mental distress (fear, panic, etc.) or (b) strong physical stress reactions (racing heart, blood pressure elevation, etc.) in response to anything which reminds the individual of what happened to them. These reminders could be either purely mental or objective and physical in nature.

Avoidance

Trauma-related stimuli are physically avoided, and general responsiveness is numbed, in any three of the following ways:

• Attempts to avoid of feelings, thoughts, or talk about the event(s).
• Attempts to avoid activities, people, or places which relate to the event(s).
• An inability to recall some important aspect of the event(s).
• The experience, after the event(s), of marked loss of interest or involvement in activities formerly important to the individual.
• Feelings of isolation or detachment from other people.
• Inability to experience any of the basic feelings.
• An expectation that their life will be more brief or clearly less rewarding than that of other people.

Hyper-reactivity

Response to various stimuli is markedly increased, subsequent to the traumatic event(s), in an two of the following ways:

• Sleep disturbance (difficulty getting to sleep or staying asleep).
• Anger outbursts, or irritability.
• Poor concentration.
• Unusual levels of watchfulness or vigilance.
• Distinct startle responses.

Notes

1. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4^th ed. Utah, D.C.

2. You can say something like, "Do you feel comfortable telling me a little more about the time of your father's death?" If they start at any point to become emotionally disturbed, note the subject that is troubling, and if possible say something like "I can see that this is a difficult subject for you. Let's talk about something else, OK?" (Pause for reaction - but not too long.) "Could you tell me more about (and here you can change the subject as distinctly as possible)?"