Traumatic Injuries May Leave Invisible Scars

Traumatic injuries from workplace or home incidents, car crashes and physical assaults can produce psychological scars that linger long after the physical wounds have been treated and healed. In particular, symptoms of posttraumatic stress disorder have a high prevalence among survivors of accidents and nonsexual assaults.

Surgeons, nurses and others can start patients down the road to psychological wellness by identifying and referring patients who may require psychological consultation. This early intervention - often taking the form of a few simple questions asked at the right time - is becoming a routine practice in many institutions as those who treat damage to the body are teaming up with those who treat the emotional impact of the injury.

"The injuries that most people think about when they call them 'traumatic' are usually either very serious injuries involving significant tissue, soft tissue, or structural injury, or they are serious from the standpoint of feeling very helpless from sustaining an injury that was not expected," said Mark D. Rusch, PhD, Associate Professor and Rehabilitation Psychologist at the Medical College of Wisconsin.

Dr. Rusch, on staff in the Department of Plastic and Reconstructive Surgery, stressed the importance of making the connections between traumatic injuries and posttraumatic stress disorder, which has been associated with increased risk for other disorders including depression, phobias, panic disorder and substance abuse.

Many factors appear to increase an individual's risk for posttraumatic stress following an injury, including a history of psychiatric disorder, previous trauma, substance abuse, parental divorce and separation from parents, and physical or sexual abuse. Individual "patient variables" help explain why one person may survive severe injuries with minimal psychological disturbance while another may exhibit serious posttraumatic stress symptoms after a slight industrial accident.

Loss of Control a Key
"For people who have what appear to be very minor sudden impact injuries, you might ask why that would provoke a traumatic response," said Dr. Rusch. "The answer is that if a person during or immediately after the injury experiences a profound sense of helplessness, loss of control, loss of power, loss of ability to deal with the situation, that's what makes it traumatic. So it's not necessarily the extent of injury.

"That's really what constitutes the type of situation that might lead to a serious psychological reaction like posttraumatic stress disorder, which is an anxiety disorder. The incident itself provokes a sense of loss of control and loss of ability to deal with the situation, helplessness. That would explain why a fingertip injury could produce the same level of posttraumatic stress as, say, an arm amputation."

A patient's perception of the degree of risk to life during the injury-producing event is critical information but not necessarily a predictor of the degree of psychological trauma that may follow, Dr. Rusch said. "For example, someone who sustains a fingertip injury in a machine at work does not experience a fear of dying," he said. "However, if that person believes that as a result of that injury they are at risk for subsequent injury at work, the person is going to be highly reluctant to go back and do that type of work in that factory.

"What we've found is that when people believe that the cause of their injury is related to either something outside of themselves, like equipment, maintenance at work, shoddy repair work, factors outside of their immediate control, they're more likely to be reluctant to go back and work in that environment. And that makes sense if the risk is high. There is some evidence to suggest that people who attribute the cause of their injuries to factors outside of their control are also more likely to experience at least longer-term post-traumatic stress. Again, it's the issue of control."

It's taken a long time for treatment providers to embrace the idea that even minor injuries can lead to major psychological problems, Dr. Rusch noted. Until fairly recently, he said, "They've all been lumped into the same group and told 'OK, you're better, go back to work.' What we've also found is that people who realize that they were injured because of a lapse of judgment, working too fast and not paying attention, or doing something to the equipment to jury-rig it so that they could work faster, are less likely to be reluctant to go back to that same job because they know what they can do to prevent future incidents."

Questions Establish Connections
Questions about the circumstances of the injury event, the patient's response to the event, and the patient's thoughts after the event are effective tools for medical staff people to use prior to calling for psychological consultation.

"Initially, they simply have to ask the injured individual some questions," said Dr. Rusch. "We typically ask people to tell us what happened, how they felt, if they panicked at the scene. Some people will say that they were deeply shaken, but that they gave instructions to coworkers as to what to do to get their hand out of the machine, or help them get out of the car in the case of a motor vehicle crash. So they in retrospect realize that they had kept their head and maintained their sense of control.

"Others will say that they lost control. Some faint, some run from their machine yelling and screaming, they tell of coworkers having to hold them down. Those reactions are indicative of a potentially more difficult response later on. It's important to know if a person thought he or she was going to die, if that thought went through his or her mind at the time. That truly would contribute to a feeling of loss of control and helplessness.

"I've interviewed numbers of people who recall, as they're trapped in a car waiting to be extricated, thinking they were going to die. It's an extremely threatening thought, and for those who remember it vividly it's a very powerful memory that they have. And it's not always corrected by the new information the patient has. As they're telling me the story, it's like they're not really making the emotional connection that they didn't die. In treatment we help them make that connection. They're aware of it intellectually but it's not really having an impact on how they feel about what had happened to them. We help them make the emotional connection, which is very powerful and very necessary."

Other things that early intervention questioning can discover about a patient's posttraumatic symptoms, Dr. Rusch said, are if they're having flashbacks, if they're seeing the incident happen over again, if they're having a hard time keeping it out of their thoughts, if other things are reminding them of what happened, and if they're having repetitive, intrusive unwanted thoughts about it.

Talking it Out, Person-to-Person
"If I ask somebody to tell me what happened and they say 'well, I really don't want to talk about it,' that's an indication that that person may have a more difficult time down the road," said Dr. Rusch. "Now, that doesn't mean that someone should be forced to talk about what happened. We don't do that. But it's an indicator that we will probably have to pay more attention and be mindful of the fact that the person is already avoiding thinking about something that arouses a great deal of distress and anxiety."

Dr. Rusch said that he is seeing growing awareness about the value of early psychological treatment process among surgeons and others. "I can say a lot about Froedtert Hospital, because this is where I work," he said. "There are several psychologists who work in this institution who are frequently called upon by plastic surgeons, trauma surgeons and orthopaedic surgeons to see patients in the hospital.

"These surgeons, and the physician's assistants and nursing staffs, have all become very well informed and very aware of the possibility of intense psychological reactions to some of these injuries. And they're very quick to get us involved on the inpatient level. I think that here, because it's a trauma center, there is an even greater sense of the need for that kind of treatment. Any institution that deals with patients who have been injured by any means needs to at least screen for the symptoms, because in doing so it helps the patient realize that some of what may be very puzzling reactions are really, in a sense, quite normal.

"If the institution doesn't ask, if some representative like the nurse or physician's assistant or the physician doesn't ask, then sometimes the patient thinks 'well, I'm having these very weird reactions but I don't know if anybody would understand this if I told them about it. Maybe they'll think I'm crazy. Maybe they'll think I'm weak, or a complainer, so I'm not going to say anything.'

If someone on the staff asks about flashbacks or nightmares or other symptoms, Dr. Rusch said, "that alone can alert the patient to the fact that this probably is normal and that these people know what to do about it. Here it's systematic in the sense that just about everybody working with traumatically injured patients will take a moment or two to ask about those kinds of symptoms. It's part of what they do. There isn't a set protocol, there's not a list of questions that everybody asks, but there's usually one or two members on the team who take it upon themselves to quietly ask those questions."

Dan Ullrich
HealthLink Contributing Writer

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