Accessing deep knowing after iatrogenic trauma
Vol 11 #4 February 2, 2022
Associate Clinical Professor, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]
Apart from the normal range of imperfect upbringing, with its mixture of good-enough parenting and caregiver lapses, this college student denied any major developmental trauma like neglect or sexual abuse. I believe she would have eagerly revealed any of that if it had occurred, as she was willing to share a lot and was looking for answers from this consultation. During the hour that the intake lasted, I could still not pinpoint the issue, or trauma, that could have been at the root of such polymorphous Angst in the form of recurrent depression, generalized anxiety since adolescence, social anxiety, eating disorder, body dysmorphia, recently diagnosed OCD, sense of overwhelm, and alcoholism in this woman at the portal of emerging adulthood. There was no shortage of aspects of her phenotype that she disliked, even though she did not present dysharmonious or potentially stigmatizing features. Given her field of study, she was very reliable and good at providing clinical info. It sure impressed me throughout our conversation, but it might also have misled me. While most people come to our clinic to get a medication, she was simply seeking understanding and “analysis” of her problems. Very mature and insightful, I thought.
But that didn’t change the fact that I was contemplating a table full of dispersed puzzle pieces. It was relatively late, after hours, but I proceeded with what I would in hindsight call a mixture of discipline and intuition. We had covered a lot of ground, but my questionnaire for intake always includes a brief core medical history that consists of asking about seizure disorder and head trauma. This was the question I had had no time to ask yet. I took the extra few seconds, even if I was over the 60 minutes allocated for the session, and even if I could tell she was getting mildly exhausted after having been engaged the whole time. I felt the same but couldn’t resist the growing need of uncovering the truth.
“Any history of seizure disorder or head trauma?”
She could have simply answered “no”, because she technically had experienced none. But I am thankful she somehow sensed the relevance of mentioning that she had meningitis at six months that was complicated by subdural hematoma… I was transfixed. Imagining a baby, undergoing neurosurgery for evacuation of the product of a brain bleed. Suddenly, it all made sense. What I have noticed in my years of clinical practice and supervision of residents who see just as many patients with medical or iatrogenic trauma as I do is that those medical events matter. They can be traumatic, especially when they happen to young children who must suddenly undergo separation from caregivers while undergoing intrusive procedures. This is double trauma: psychological and to the body. Even when only one facet of it occurs, it can affect the other (psychological trauma can generate somatic responses, and trauma to the body can lead to anxiety and cognitive distortions). And when this happens pre-verbally, it takes longer to realize its impact and heal, because it is so overwhelming at the time, and the lack of language delays the processing. In my young patient’s case that day, all her symptoms (concerns saturated with “shoulds” and around fitting in, about being accepted, sensitivity to rejection, filling a void with alcohol etc) stemmed from insecure attachment in my opinion. Being in a strange, frightening environment like an operating room, then neurosurgery intensive care disrupts the attachment between parent and child that needs to be maintained 24/7 at such a young age. Skin-to-skin contact is needed from birth on for many years. I have heard other stories of seemingly inexplicable separation anxiety (such as the story of a teenage girl so anxious that she needed to co-sleep with her parents. After digging, it was discovered that she was born prematurely and had to be in the NICU for a while).
In conclusion, symptoms do not occur in a vacuum. Family history or genetics are rarely sufficient to explain mental disorders. Something in the environment typically triggers the vulnerability that is contained in the genotype. The person telling you a story might not remember the facts of the diseases but there is certainly a deep knowing that must be decoded and brought to light by the listener, by the provider. What an incredible privilege.
This encounter took place at the end of a stressful and painful day, and just confirmed once again that this is really a captivating, rich and rewarding field. It is like a form of labor and delivery. We push the interview a little more, we invite the patient to push harder from the recesses of memory, from the scripts contained in the body, from the symbolism of the complaints. We must also remind the patient to “breathe”, be mindful and attend to body sensations that arise as some questions are potentially triggering. And once the “baby” is born again, it is never too late to attend to those needs that were abruptly put on hold when destiny struck. An effective healing journey can finally start, and developmental aspects of the person can be taken where they were left off for optimal and holistic growth.