Understanding Trauma Beyond the Physical
By Dr. Judith Freedman, Consultant Psychiatrist
Trauma often is a feature of personal injury and of clinical negligence, but it is not uncommon for only the physical trauma to be recognised, while the psychological trauma remains unnoticed by the victim, as well as by others.
For severely injured people, the focus in the initial stages is on their physical survival and recovery, and the psychological symptoms might not emerge or be noticed until sometime after the event. In cases of historic sexual abuse, the posttraumatic symptoms may not emerge until years after the abuse.
This is a brief guide to the presentation and diagnosis of traumatic disorders, designed to help solicitors know when to request a psychiatric assessment and to help you understand what the report might say.
To put this into perspective, the life-time prevalence of PTSD in the UK population is one in 10 people, with those at highest risk being victims of rape and other sexual assault, physical assault, and accidental injury. [1]
There has been debate as to whether PTSD can be related to experiencing serious illness, childbirth, or medical treatments, including, but not limited to, negligent outcomes. Presently, there seems to be acceptance that some people do develop PTSD in the aftermath of such medical events. [2]
Recognising PTSD
The most frequently recognised traumatic disorder is Posttraumatic Stress Disorder (PTSD). Description of this disorder evolved from work with combat veterans and sexual violence victims. Traumatic symptoms were noted in soldiers over several centuries, but awareness of them increased during both World Wars.
Initially, the condition was referred to as “shell shock”. In the 1990’s, Professor Judith Herman described traumatic symptoms in victims of sexual violence and recognised that their presentation was similar to that of the combat veterans who were suffering from traumatic symptoms. [3]
Meanwhile, in the 1980’s, the Diagnostic and Statistical Manual for psychiatric disorders and the World Health Organisation’s International Classification of Diseases began developing standardised descriptions, first just for adults and then adding children.
The current versions in DSM 5 (2013) [4] and in ICD-11 (2018) [5] have some differences, but largely, they are similar in requiring that the person has been exposed to a horrific and threatening event, including learning that a traumatic event occurred to a family member or friend, and that their symptoms have continued for a month or for several weeks.
This timescale acknowledges that the majority of people who have a traumatic experience will recover psychologically within the first weeks following the event and will not develop PTSD.
The diagnostic codes set out a range of symptoms that are present for adults who have an ongoing disorder after the trauma. (I will not include children here, although there is a large degree of overlap with adult presentation.)
Expert Witnesses need to establish the presence of a sufficient number of these symptoms to make a diagnosis of PTSD.
The symptoms have to cause significant distress, such as associated hyperventilation or heart pounding, and they must have been present for more than one month. In brief, the key symptoms relate to re-experiencing, avoidance, and hypervigilance, as follow:
Intrusive Memories/Re-experiencing:
- Repeated intrusive memories of the traumatic event(s), such as flashbacks or intrusive memories; the distinction between these is that in a flashback, a person re-experiences the trauma as if it is actually happening, while an intrusive memory also is distressing and not willingly brought to mind, but it is experienced as a memory, not a re-occurrence.
- Nightmares related to the traumatic events, which cause distress during the dream and upon awakening.
Avoidance:
- The person tries to avoid reminders of the trauma, commonly by switching off television programmes and films or avoiding media stories that might trigger memories.
Alternations in Cognition and Mood:
- Not being able to remember important aspects of the traumatic event(s).
- Blaming oneself and/or mistrusting others.
- Persistent fear, anger, guilt, or shame.
- Decreased interest in activities.
- Feeling detached or estranged from others.
- Inability to experience positive feelings.
Arousal and reactivity/Hyper-vigilance:
- Irritability and angry outbursts.
- Reckless or self-destructive behaviour.
- Hypervigilance; sometimes people describe always looking over the shoulder.
- Exaggerated startle response, usually to loud noises.
- Concentration problems.
- Disturbed sleep.
Although Anxiety and Depression are not symptoms of PTSD, they often are associated with it, risk factors for developing PTSD include previously suffering childhood trauma (also known as developmental trauma), previous episodes of PTSD, and lower socioeconomic status. Overall, women are more prone to presentation with PTSD, but this might be related to women rather than men being more likely to report psychological difficulties.
Once a person has had a period of PTSD, they are at increased risk for developing PTSD to a further traumatic event, this is one reason why it is important for Expert Witnesses to have access to the person’s full set of medical records. The significance of such records was apparent when I assessed a person for a personal injury claim, and I discovered from their GP records that they had suffered a previous episode of trauma. When I asked about these different episodes, the person told me that their intrusive memories were related to the recent trauma, but their nightmares were related to the previous trauma, this is an unusually complex presentation, but probably not unique.
Complex PTSD:
You may receive expert reports that include the new diagnosis of Complex PTSD (CPTSD). This diagnosis was established over decades of work with PTSD sufferers and concern that some of them, particularly people who experienced prolonged traumas, had more complex and enduring presentations, particularly in the areas of emotional regulation, self-identity, and relational capacities.
This led the ICD-11 to create separate diagnoses of PTSD and CPTSD, moving some of the PTSD symptoms from the DSM-5 to this new category.
To make the diagnosis of CPTSD, a person first must show symptoms of PTSD, including exposure to a trauma, re-experiencing the event, avoiding traumatic reminders, and having a sense of current threat (hyper-vigilance). The diagnosis of CPTSD then is based upon having additional complex difficulties.
MIND set out a useful list of symptoms of CPTSD: [6]
Difficulty controlling your emotions.
Feeling very angry or distrustful towards the world.
Constant feelings of emptiness or hopelessness.
Feeling as if you are permanently damaged or worthless.
Feeling as if you are completely different to other people.
Feeling like nobody can understand what happened to you.
Avoiding friendships and relationships, or finding them very difficult.
Often experiencing dissociative symptoms such as depersonalisation or derealisation.
Physical symptoms, such as headaches, dizziness, chest pains and stomach aches.
Regular suicidal feelings.
There is a significant degree of overlap between CPTSD and borderline personality disorder (BPD), but it is possible to distinguish between these two conditions. Often, people with BPD will have a developmental history of instability, which can be traced through their life, starting before the index trauma. Also, people with BPD are more likely to attempt suicide and self-harm. However, people with BPD are vulnerable to developing PTSD if they suffer a traumatic event, so the distinctions can be difficult to make.[7]
Why this is Important:
Expert witnesses in psychiatry routinely screen for traumatic disorders when we assess people who are making personal injury or clinical negligence claims.
Often, this is because we are instructed to comment on the possibility of a traumatic disorder, but there are many instances in which the victim and hence their legal team are aware only that they are suffering from anxiety and/or depression.
I have spoken with people who have felt embarrassed about their traumatic symptoms and kept them hidden from others, as well as trying to dispel their own self-awareness of the distress they cause.
They are relieved to find that what they are experiencing is a recognised disorder and that treatment is available for it, being able to talk about the symptoms can begin to alleviate the self-blame they have experienced.
There is treatment available for people with PTSD and with CPTSD; although the treatments are not presently evidence-based, many people report finding them helpful. The treatment usually is trauma-focussed cognitive behavioural therapy.
People with CPTSD are likely to need a longer course of therapy, medication, usually with a combined anti-anxiety and antidepressant medication, such as an SSRI, may be helpful.
Some people have had significant disruption in their lives and will benefit from longer-term psychotherapy after the CBT.
Some local mental health services in the NHS have trauma teams, but more of this work is available in the private sector, this means that the sooner in a case that funding for treatment can be secured, the better chance there is of a good outcome for a person who is suffering from PTSD or CPTSD.
About the Author
Dr. Judith Freedman is a distinguished psychiatrist with extensive experience in psychotherapy and forensic psychiatry. She holds a fellowship from the Royal College of Psychiatrists and has been actively involved in providing expert witness testimony in family, civil, and criminal court cases. Her work often focuses on complex PTSD assessments and issues surrounding physical, sexual, and emotional abuse.
Dr. Freedman has previously held significant positions such as the Psychiatrist in Charge at the Adolescent and Family Treatment Unit at McLean Hospital and served as an instructor in the Department of Psychiatry at Harvard Medical School. She is also the convenor of the Consortium of Expert Witnesses to the Family Courts, underscoring her pivotal role in shaping legal considerations related to psychiatric evaluations in the UK.
Her contributions to psychiatry are further highlighted by her extensive publications, which cover a range of topics from family dynamics to the psychological impacts of trauma. Dr. Freedman is recognized for her deep understanding of the interplay between mental health issues and their legal implications, making her a respected figure in both the medical and legal communities
To request her CV or for any medico-legal matters she can be reached at judithfreedman@inneg.co.uk
References
[3] Herman, Judith Lewis (1997) [1992]. Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political Terror. New York: BasicBooks. ISBN 978-0-465-08730-3.
[4] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
[7] Cloitre, Marylène, ICD-11 complex post-traumatic stress disorder: simplifying diagnosis in trauma populations. The British Journal of Psychiatry (2020) 216. 127-131. doi:10.1192/bjp.2020.43
