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Trauma Informed Care

Session by Jonathan Tomlinson

Blog post by Dr Katie Burgass

Trauma

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 5 th 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.