Session by Jonathan Tomlinson
Blog post by Dr Katie Burgass
Trauma is an issue that has been raised at many of the sessions we have covered through the Trailblazer scheme so it was extremely useful to have a session solely focussed on this area. We started by discussing examples of complex and difficult to manage patients we have encountered, those that can present with many and often difficult to explain medical symptoms. Jonathon spoke about how he had identified common problems between these patients such as pain, fatigue, IBS, palpitations, dyspnoea, dyspepsia and incontinence. These symptoms all are associated with sympathetic (arousal) or parasympathetic (reduction) activity.
We discussed the theory of “Hypervigilance”. The limbic system (that controls our emotion, motivation, learning and memory) is linked to the brainstem which controls the vagus nerve in charge of our parasympathetic and sympathetic drives. If there is trauma in early life, people often struggle with self-regulation between “arousal” and “reduction” states. As a result they can develop symptoms through the parasympathetic or sympathetic drive, that could therefore be interpreted as symptoms of undischarged traumatic stress. In addition to this the limbic system and brainstem have no link to the prefrontal lobe (involved in decision making, planning and behaviour) so any actions coming from it are reflexes. The patient has no control over these symptoms.
Patients suffering with symptoms of hypervigilance often use methods that result in dissociation and disconnection to try and regain a level of control. Examples are self- harming, using drugs or isolating themselves. It is also worth noting the impact of trauma can be variable between different individuals. Trauma is the symptom, not the event.
We also discussed the impact of childhood trauma as well as resulting in physical and mental health difficulties, can often result in shame. “Unlike guilt which is the fear of doing something wrong, shame is the guilt of feeling you are a bad person”. This can be crippling to a person.
So how best to approach a consultation if you feel someone has suffered from this in the past? And when you have, where do you go next with it? Recovery is all about reconnection.
The 5 areas Jonathon suggested focussing on were:
1. Relationships – building a meaningful connection with another human being, this could be done using social prescribers to access voluntary or support groups.
2. Biology – encouraging healthy behaviours, addressing diet and weight, smoking cessation and drug use, rationalisation of medications.
3. Body – encouraging physical and mental exercise, creative activities, using outdoor spaces and connecting with nature.
4. Mind – dealing with emotions, accessing support through talking therapies and mental health teams
5. Social security – without this 5th element it is very difficult to start addressing the other 4. Having financial security and appropriate, safe accommodation is a priority.
Once someone feels secure in the environment can they start addressing changes within themselves. As doctors we often strive to find the “science” behind our patients presentations, so hearing a theory around the impact of trauma on physical health based within a neuroscientific context was extremely interesting.
Practical tips I picked up from the session:
– Look at the problems list and consolidate.
– Acknowledge when things have become chronic. Looks for symptoms of “hypervigilance” as explained above.
– If you feel a patient may have suffered from trauma in the past allow time to build rapport and a relationship before addressing this. “Where do you think your anxiety comes from?” is often a helpful question to ask as an opener.
– Acknowledge the cause of the symptoms, this will empower patients.
– Look at the 5 areas to be focussed on for recovery. Make a plan together, addressing things at a pace the patient in comfortable with.
– Make a crisis plan for if things were to go wrong, involve family / friends and other professionals. Focus on triggers and coping mechanisms as well as sources of support. Write the plan down. Review it after each crisis. Don’t change medication during a crisis.
There are many patients I encounter at work that I am sure have experienced trauma in their past. I now feel more equipped to address this with them, the difficulty, as always in general practice, is finding adequate amounts of time and space to spend with these vulnerable patients within the busy day.