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July TOWS-UNDERSTANDING AND DEALING WITH TRAUMA-Dr Yewande Oshodi Ms Titi Tade & Dr Arit Esangbedo


What exactly is Trauma?

Trauma can be perceived as highly upsetting, emotional, overwhelming events that may involve actual or threatened death, serious injury or sexual violence.

People may react in different ways to traumatic events. Ranging from relatively mild distress that is fleeting to severe disruptions that makes it difficult to cope or function.

In our context several examples abound as we will hear from other speakers

The burden of trauma, related conditions and its signs and symptoms

Trauma has long been one of the leading health problems worldwide. It is said to be the fourth leading cause of death amongst children, adolescents and young adults in the United States.

According to an article by Mariana et al 2019, it is estimated that fifty percent of all deaths occur within minutes of the injury either at the scene or en route to the hospital. For every person killed by injury, around 30 times as many people are hospitalized and 300 times as many people are treated in hospital emergency rooms and then discharged.

The mortality rose from 35% in a high-income setting to 55% in a middle-income setting, to 63% in a low-income setting. This percentage is said to be higher now because of the COVID-19 pandemic.

The statistics on trauma exposure and trauma related disorders in Nigeria are not fully known. The loss of productivity due to death and disability from injury represents a significant loss of economic opportunity in all countries. The treatment and rehabilitation of injured people represent a large proportion of many national health budgets, and

the recent kidnappings, herdsmen crises, Endsars proteststressors all suggest there have been high levels of trauma experienced within our population. By extension the rates of trauma related disorder are likely to be on the increase. This will be a good research focus for consideration. It is very likely people in our communities are struggling with various degrees of trauma. Traumatic experiences are on the rise in Nigeria and the world also the daily onslaught of information on social media. Coupled with the resurgence as seen by the closure of Unilag hostels yesterday.

Types of Trauma:

-Sexual Assault- which may include groping, forced kissing, rape, sexual harassment etc. women and girls are 4times more likely to experience attempted or complete sexual assault than me.


-Child Maltreatment- which can be informs of neglect, physical , sexual, emotional/psychological


-Domestic violence- This can be physical, sexual or emotional. DV can be willful intimidation, physical assault, battery, and or other abusive behavior perpetrated by an intimate partner against another. -Pattern of control can be In forms of threat, intimidation, isolation, financial control, use children to gain control, asserting male dominance, etc.

-Traumatic loss

-Medical trauma

-School violence


-War related trauma such as terrorism (which we are currently experiencing in our country), refugee/war zones

There were so many stories of people that were experiencing trauma due to even watching the Endsars protests via social media

-Racial trauma such as the systemic racism(white supremacy) amongst black indigenous people of colored , such as what just happened in the football match between Italy and England, were all the black players were called all manners of racial slurs because the English felt they were responsible for making them lose the match.

-Natural Disasters such as earthquakes, flooding, building collapse hurricanes and pandemics. Over the past one year,pandemic has created a lot of traumatic experiences to the people of the world. Experience of sudden loss of a loved one, fears of infection and death heightened the trauma.

-A note on Emotional/Psychological Abuse. This is a non-physical form of abuse used to isolate and manipulate a person. it can be as traumatizing as physical abuse.

-Simple Trauma which refers to one defined traumatic event eg. Rape.

-Secondary trauma stress which is symptoms and signs of trauma occurring to one as a result of another’s traumatic experience. It presents like PTSD with the cluster of symptoms of avoidance, hyper arousal, and re-experiencing the events. It is common mostly in healthcare professionals and any other professionals who work with abused children; and therapists who support sexual assault survivors eg. Doctors, nurses, social workers, lawyers and even the eyewitnesses for the end-SARS protest are all experiencing secondary trauma.You can agree with me that this COVID-19 pandemic has left a lot of us traumatized secondarily,

It appears there are many negative experiences that people pass through in the the course of their lives and may never realise that it may actually have left them traumatised.

Possible Outcomes and Impact of Trauma

Impact of trauma depends on some factors; viz

• The age at which the trauma occurred. In children the impact and outcome may be grave, say a child who watches his father beat up the mother may himself become violent when older.

• The time elapsed since exposure, in this situation war veterans may experience PTSD months or years after a war.

• The nature of the trauma. For example the impact and outcome of systemic racism will include ‘racial battle fatigue” unemployment, illnesses/early death and so on.

Note: The secondary Trauma that healthcare workers face is also often mixed so health care workers awareness and self-care is important. Though most healthcare workers are usually the last to seek help for such trauma as they feel it comes with the job which is not true.

Common Symptoms and Signs Associated with trauma

• Emotional Problems which can manifest as depression, self-blame/harm, guilt, shame, grief, confusion, pre-violence attitude, PTSD.

• Physical problems which can be somatic complaints such as crawling sensations on the body, headaches, feeling ill etc.

• Behavioral Problems which can manifest as poor anger management, attention seeking behavior etc.

• Cognitive Problems can be manifested as problems with concentration and problem solving skills, disorganized behavior.

• Social Problems which can be manifested as withdrawal, distrust in relationship etc.

We can’t talk about symptoms and signs of trauma without a few notes on Post-traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD).

Quite a number of people present with complaints of crawling sensation. So, this is a masking of the actual problem. Though a person may experience some of these symptoms listed not necessarily all.


Diagnosing Post Traumatic Stress Disorder (PTSD).

PTSD is intense, prolonged and delayed reactions to intensely stressful event. E.g. Natural disasters, wars, rape, fires etc.

International Classification of Diseases 10 diagnosis of PTSD includes:

1. Evidence of Hyper arousal(insomnia, irritability);

2. Avoidance (numbness, detachment, decrease interest in activities, avoid things that cause one to remember).

3. Re-experiencing of symptoms(flashbacks, nightmares, intrusive images)must have occurred within 6months of event or delay between event and symptoms is 6months. Symptoms cause severe social functioning problems and significant distress.

4. Evidence of the trauma.

5. Evidence of all 3 features of hyper arousal, re-experiencing symptoms and avoidance.

According to the book DSM V, PTSD is diagnosed if symptoms have been present for greater than 1month, but if less than a month then the diagnosis becomes Acute Stress Disorder. It also adds Persistent negative alterations in cognition and mood as the fourth symptom.

Acute Stress Reaction/Disorder

This is the immediate and brief responses to sudden intense stressors in any person who doesn’t have any psychiatric disorder at the time.

Considering the ICD definition, response should start within a few minutes if not immediate to 1hour of exposure to stressors. It begins to diminish after not more than 48hours.

Meanwhile, DCM definition, response should be while or after experiencing the stressors. It last for at least two days and goes no more than 4weeks, symptoms may be that of anxiety, depression, or both anxiety and depression.

Children and Trauma.

We all know children are very unique and may not respond to traumatic experiences like adults.

Children Experience trauma in varied forms similar to those listed earlier such as in the image I will now post here;

Fig: 1:









Trauma in Children could emanate from any of these items above,

Bullying is increasingly going on in our secondary schools traumatizing children...and we only start seeing the outcomes in university. Let's watch out for bullying and parental neglect as common routes of traumatizing children.

Another important concept to be highlighted in discussing child trauma, is complex trauma. Complex trauma is a term relevant to children and it describes both

- children's exposure to multiple traumatic events—often of an invasive, interpersonal nature and

-The wide-ranging, long-term effects of this exposure.

These events are severe and pervasive, such as abuse or profound neglect.

Complex trauma commonly occurs with repeated trauma against a child, this includes all forms of child abuse, neglect, adverse childhood experiences, community violence – domestic and family violence, civil unrest, war trauma or genocide, cultural dislocation, sexual exploitation and trafficking.

Complex trauma is a further complicated type of trauma, triggering stress hormones and may also worsen the mental health outcomes unlike a single event trauma.

Research has shown that the presence of Adverse childhood experiences (ACE) have been linked to poor mental and physical health outcomes long term.

Trauma In childhood if not managed really can dictate the course of the lifespan of the mental/physical health of the trauma survivor

So a child may have reactions that impact his/her daily life after a traumatic event, these responses are called child traumatic stress. These reactions may show up in different ways, such as changes in child’s behavior (such as being more irritable, withdrawn, or acting younger than his/her age), difficulties in interactions with others, problems or changes in sleeping or eating patterns, or school performance.

The signs and symptoms of traumatic stress look different in each child and at different ages. See this table below.


Table 1:




In essence, this is to say that following a trauma exposure the developmental age would dictate the expression.

Another key point would be regarding the diagnosis made in trauma survivors.

Apart from the ASD and PTSD mentioned earlier it is also important to know that younger children may develop Attachment disorders.

These are also trauma related disorders and could also result following trauma experiences such as neglect, abandonment and inconsistent parenting.

This long term could further result in some personality disorders with self-harming behaviors.

A useful tip known as the “Three E’s of Trauma” may present a useful framework for caregivers in understanding the trauma in relation to children.

The 3 E's are:

Event

Experience

Effect.


-Was there an Event?

-How did the child perceive it?

-What are the effects observed since the event?

This way we can be more deliberate in observing and seeking for help for children that have experienced trauma.

DEALING WITH TRAUMA

When trauma occurs, it can seem overwhelming but there are different ways to cope and deal with it and the emotional after effects that it leaves behind. Some ways to cope with trauma are:

1. Accepting that a traumatic event has occurred. Do not try to deny, avoid or belittle the pain that you or your loved one is going through, they are all normal reactions to trauma.Acceptance is key and always the first step in recovery and healing.

2. Do not blame yourself but rather focus on dealing with the issues and emotions that you are experiencing such as tackling resentment you feel towards your partner in cases of emotional abuse, the anxiety, guilt or fear that you may feel. You can do these by

• Accepting there are things you cannot control

• Identify and track your stressors so you understand how you react to them

• Develop healthy habits i.e. healthy diet and exercise.

• Get adequate Rest and relax to recharge yourself.

• Be mindful and also try meditation.

3. Try to resolve the day to day issues because the process helps you to gain confidence in your ability to solve the bigger issues that you face.

4. In cases of emotional or physical abuse, do not rationalize the abusive behaviour of the abuser. This is what makes many abuser go scot free. The abuse survivor often self blames or is shamed, sadly so because the abusers behaviour is rationalised over.

5. Do not self-isolate or avoid people, it may only make things worse

▪ Sharing the experience with someone that is trusted may help but do not feel pressured to share if you are not ready.

▪ Engaging with people may provide some feelings of respite and safety.

▪ Become engaged in healthy community activities such as volunteering.

6. If after trying all of these you are still struggling with the effects of the trauma, then It may mean it is time to seek professional help. So how do we know when it’s time to seek help?

When to Seek Help:

There certain signs that point to when one should seek professional help after trying to cope on your own for a while. They can be:

• Use or increase in alcohol consumption and drugs to try to cope

• Difficulty functioning at work, school or in your daily life generally.

• Still experiencing severe fear, anxiety, nightmares and flashbacks

• Avoiding situations that are similar to the traumatic event at all cost

• Increased self-isolation and self-exclusion from family, friends etc

• Binge Eating/Excessive dieting

• Suicidal thoughts or other self-harming behavior

Professionals that can be of assistance;

The most important thing about finding a professional who can help with dealing with trauma is making sure that the person is qualified to give the kind of help that is needed.

That may mean going through established organizations such as government mental health facilities or Non-profit organizations such as SURPIN, MIND-Trust, MANI, ASIDO Foundation e.t.c. to get a therapist. In addition the Cece Yara Foundation and Mirabel center can assist with help for rape survivors.

Qualified professionals will use evidence based strategies that work such as CBT, Trauma focused CBT, supportive psychotherapy amongst others. In some cases medication may need to be prescribed by the Psychiatrist depending on the presentation.

An unqualified professional will do more harm than good.

The following are professionals that can help with trauma:

Psychiatrists, psychologist, Medical/clinical social Workers, trained trauma therapist and mental health counselors.

Conclusively, trauma is a mental health disorder so try to ignore or suppress it, so please if you or a loved one are experiencing trauma reach out to any of the above mentioned professional bodies for help.

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