Wounds from Psychological Trauma (Nursing)

00:01 There are wounds from trauma that people experience, whether they experienced it as a child, as an infant, as a young person, as an adult, or as an older senior person.

00:17 So we think about trauma in two ways.

00:20 There can be that "capital-T" trauma, which is something like 9/11.

00:26 Some horrific event.

00:29 That occurs and makes us think that we're going to die.

00:33 Or there can be the "small-T" traumas, the traumas that happen day, after day, after day, like bullying.

00:43 Like, the effects of racism.

00:50 Like having to deal with a mental illness, and not being able to get the help you need, and having people look at you in a different way.

01:01 So, we want to understand that when we have those kind of wounds, our body wants to protect us.

01:14 And so it does, either escaping or it defends us.

01:21 So, if we can't escape, and we can't defend, and I'd like you to think about children who are dependent on their adult caretakers, they can't escape, nor can they defend themselves.

01:39 So, when those two responses are unavailable, that active defense mechanism becomes passive.

01:50 It becomes the freeze, submit, because otherwise, I might die.

02:00 What happens in those moments, if we cannot defend ourselves, is that our brain, because it is so complex, it starts fragmenting things.

02:13 We don't want to think that we gave in to the uncle, who sexually assaulted us, at the age of four.

02:23 We have to go to Christmas every year and he's there.

02:28 And so what our brain does, is it fragments it.

02:33 And it helps us to dissociate or step outside of ourselves, and be able to say that happened to her, it didn't happen to me.

02:44 Frequently, when you're talking to a person who has had to have that submit response to trauma, you will find that they have dissociation.

02:56 And we see the dissociation.

02:59 We see the person as they are talking, where my uncle would walk into the room, and I would see his silhouette in the doorway.

03:14 And you have to say to the person, "Are you still here with me? Because I'm Dr. Marshall, and you're in my office, and you're safe here." Are you with me? Because they have now dissociated on me.

03:27 They've left intellectually and emotionally my office, and they are now that four-year-old lying in the bed, seeing that silhouette, as clear as if it was happening in the moment.

03:40 So, we know that the instinctive physical body reaction is going to be that fight or flight.

03:48 But when that's unresolved, when we run away, or we put up a fight against someone, sometimes our body memorizes, that terrible moment, and we have actual physical impulses that remain memorized in our body, even though it's not experienced.

04:17 So, what does that mean? That means that when we are hoping to defend ourself, we might internalize, what if? What if I was able to do this? What if I was able to do that? Even though we're not able to actually engage in that self defense, that what if sense, remains in our body because every cell in your body responds.

04:48 If you've ever been sitting in a nice quiet place and someone drops a tray of food and you jump.

04:56 It's not just your head that's jumping.

04:58 It's every cell in your body is reacting to the crash of that tray on the floor.

05:06 And it may be minutes later that you start feeling that your heart slows down.

05:14 So, sometimes, that moment of, what if I get up? and what if I stand up, and I shout out? or I call my mother? Sometimes that happens in a moment, and we become reactivated.

05:33 Our autonomic nervous system becomes activated anew.

05:38 Our heart starts beating really fast.

05:41 We start sweating.

05:43 We have pupillary changes, getting ready for the attack.

05:47 Our mouth dries up.

05:50 We might start trembling, a sense of panic comes over us.

05:56 And we know that there are overwhelming odds that we cannot do this.

06:02 This is reactivation. This can happen at any time.

06:06 As I was saying with that one patient who starts telling me about her uncle, she's in my office, she's safe in my office.

06:15 And yet, in that moment, her whole autonomic nervous system was becoming reactivated.

06:23 Survivors of trauma have symptoms.

06:26 They recall a feeling, or they stopped talking.

06:32 They may have depression.

06:35 They may have irritability.

06:38 They may have loss of interest in doing any of the things that they want to do.

06:45 They may find that they can concentrate.

06:49 A sense of numbness comes over them.

06:53 Maybe they feel unreal, or out of their body.

06:55 Like they're watching something happen to themselves, even though they know what's actually happening to them.

07:04 When we ask people, "Well, what about the next three years or five years? What do you see?" There's a loss of a sense of what the future might hold for them.

07:13 There's a replacement of hope for the future with a kind of hopelessness.

07:20 They feel ashamed and worthless.

07:25 When you ask them about memories of their childhood, or memories of college, little or no memories will actually come up.

07:33 But they will tell you about their nightmares, or about their flashbacks to a moment in time.

07:42 Meeting new people, or trusting people is very difficult.

07:47 They are hypervigilant.

07:48 They're always waiting for the next thing to happen.

07:52 They have a very difficult time trusting people.

07:57 We find that oftentimes, people who go on with PTSD, chronic PTSD, they find that they have chronic pains.

08:05 They have back pains, they have hip pains, they have headaches, shoulder pains, myalgias.

08:14 And they don't know who they are anymore.

08:15 They have a loss of the sense of, who am I? We see generalized anxiety all the time, with panic attacks that are not infrequent.

08:30 In order to cope with all of these feelings, this constellation of feelings, they're more likely to try and help themselves cope through maladaptive behaviors, like substance abuse, or through eating disorders.

08:48 Usually, there is a high level of insomnia.

08:53 Also, when you're talking to them, they will say, "I am so overwhelmed.

08:58 My emotions are just drowning me out." And self-destructive behaviors like drinking and driving, or smoking.

09:09 Because what does it matter, anyway? So, if we take a minute now, and we think about the symptoms that emerge in PTSD, this irritability, the depression, the anxiety, the substance use.

09:27 Each one of these symptoms actually can be a diagnosis of a different mental illness.

09:36 When we see the constellation, however, we need to take a moment, we need to take a breath, And we need to ask the patient, "So tell me, is there anyone in your life who you are or were afraid of?" And if they say, "Oh, yeah, I'm really afraid of my mother.

10:01 Even now in her 90s, she's is hell to live with." And then you say to them, "Is there anyone now or during your lifetime you were ever afraid for?" And they say, "Oh, my sister. My mother used to beat her senseless." Well, you have now just with two questions, Who are you afraid of? Who are you afraid for? You've been able to identify that there is the possibility that this person presenting with this constellation of symptoms, actually is a survivor of trauma, and needs to be treated for post-traumatic stress disorder.

10:49 Trauma causes disorganized attachment.

10:54 Especially if this trauma is happening as a person is a child or youth.

11:01 The person is continually asking themselves, is it really safe to be attached? Is it safe to care about something? Or someone? So what do we think happens? When a parent figure is creating safety versus danger, what do you think we might see? If early attachments are safe. If a child cries, and the person taking care of them comes in and comforts them, that child learns to trust being taken care of.

11:41 And as they grow and mature, they're able to engage in comfortable kinds of relationships, because relationships are safe.

11:52 But when the adult caregiver is constantly either not taking care of them, ignoring them, when a child is crying, and instead of being held they're screamed at or perhaps hit, that creates an internal struggle, because that baby, that child is yearning to be attached, is needing as a human being, to be held, to feel safe.

12:25 But at the same time is learning that that is not safe.

12:29 To call another person into its life, is to call danger and pain into its life.

12:39 With the parent or caregiver that provides safety, the adult grows up, learning it's safe to be close to others.

12:48 And it's even safe to be by myself.

12:51 I'm okay. I am a complete and worthy person that people can love.

12:59 I want to be close. I don't want to be alone.

13:03 I like when people are around me.

13:06 And so, my impulse, and my belief system says, "It's okay to attach to another person.

13:14 It's alright to be close.

13:16 I can trust other people with my emotions in my heart." But for that child who knew only danger, that child grows up with the real story that they believe, a schema that says, it is not safe to be connected to others.

13:37 It is unsafe to have to depend on anybody else.

13:41 You better watch out. Don't you trust anyone else? And so that person when an attachment starts to occur, their impulse is that fight or flight.

13:55 Get away from that closeness.

13:58 Don't allow people in because you know what's going to happen.

14:03 Remember, this is the idea of the trauma being codified, being codified so deep, that we are not aware.

14:12 We're not thinking, Oh, it's not safe to trust.

14:15 We just know if we have been mistreated as babies, our patients know, don't let this nurse get close to you because as soon as you do, it is a problem.