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In recent years, there has been a growing awareness of the negative psychosocial impacts of various medical events, which has led to an increased attention on medical trauma. While the COVID-19 pandemic may have contributed to this, there has been research over the last few decades seeking to understand potentially traumatic medical events and their outcomes, including posttraumatic stress disorder (PTSD). Medical trauma includes potentially traumatic events related to life-altering or life-threatening medical events, such as pain, injury, serious illness, medical procedures or other frightening treatment experiences.
Current understanding of medical trauma is firmly rooted in existing foundational knowledge of trauma and trauma-related disorders. Conceptual models, such as Price et al.’s (2016) Integrative Trajectory Model, Edmondson’s (2014) Enduring Somatic Threat and Murray et al.’s (2020) applications of Cognitive Therapy for PTSD resulting from Intensive Care Unit admission, have each contributed to understanding of medical trauma. These models highlight the unique contributors to medical traumatic stress, including aspects of the illness experience and care environment, interactions within the healthcare system, and long-lasting or permanent somatic experiences that elicit cues of the medical trauma. Medical trauma is a layered and complex type of trauma exposure that can be described by four conceptual components: 1) compromised body integrity; 2) psychophysiological responses; 3) interpersonal and healthcare environment experiences; and 4) confrontation with mortality and related existential/spiritual crises. These experiences are further compounded by “secondary crises” that can precipitate and/or perpetuate distress related to medical trauma including relational (e.g., role disruption), physical (e.g., acquired disability), spiritual/existential (e.g., change in self-perception), developmental (e.g., missed milestone), occupational/financial (e.g., loss of employment) and avocational impacts (e.g., loss of hobby; Flaum Hall & Hall, 2016).
Birk et al.’s (2019) systematic review of early interventions to prevent PTSD following life-threatening medical events and Cordova et al.’s (2017) conceptual paper on PTSD and cancer each provide insightful considerations into PTSD as a diagnosis resulting from medical trauma. In short, not all medical events can qualify for a Diagnostic and Statistical Manual of Mental Disorders-5th Edition (American Psychiatric Association, 2013) diagnosis of PTSD given current definitions of a Criterion A stressor which limits qualifying medical events to those that are experienced as “sudden and catastrophic.” As a result, many people who experience medical trauma may not necessarily qualify for a PTSD diagnosis despite the presence of clinically significant PTSD-like symptoms. In these cases, patients may meet criteria for an adjustment disorder with the medical event as the qualifying stressor. The 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11; World Health Organization, 2019) explicitly names acute life-threatening illness as a traumatic stressor and provides heart attack as an example. While not explicitly referenced in the ICD-11, the qualification of an “acute life-threatening illness” may also disqualify serious life-altering illnesses like Inflammatory Bowel Disease (IBD) from a PTSD diagnosis despite research suggesting approximately one third of patients with IBD will experience clinically significant PTSD symptoms as a result of their disease experience, surgical intervention and/or disability (Taft et al., 2019). Although diagnostic considerations can vary depending on the medical stressor (i.e., whether the stressor is considered Criterion A), existing literature is beginning to demonstrate the potential benefits of trauma-informed and trauma-focused interventions to address the psychosocial impacts of many types of medical events (McBain, 2020).
Currently, there are no validated measures designed specifically to identify medical traumatic stress. However, clinicians may use a combination of strategies including self-report measures and clinical interview to assess for exposure to medical trauma and its impacts as they would for any other type of trauma exposure. For example, they could ask about exposure to frightening medical experiences, diagnosis of any chronic illnesses or ongoing health concerns. Health-related Quality of Life measures, such as the Secondary 7 – Lifestyle Effects Screening (S7-LES; Hall & Flaum Hall, 2017), the 36-Item Short Form Health Survey (SF-36; Brazier et al., 1992) or the Psychosocial Adjustment to Illness Scale (PAIS; Derogatis, 1986) can help clinicians identify if a patient is experiencing distress or difficulty with adjustment as it relates to a medical event or current health. Once exposure to medical trauma has been verified, validated PTSD symptom measures such as the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) can be utilized to identify clinically significant symptoms resulting from the medical trauma.
Because we know where and when medical trauma may happen, healthcare professionals have a unique opportunity to prevent or mitigate the impact of medical trauma. For many, experiences of medical trauma, including traumatic medical conditions and aspects of the medical environment, are compounded by discrimination and bias experienced within the healthcare system (e.g., discrimination resulting in delay of diagnosis or care). Applications of universal preventative approaches including the implementation of culturally sensitive, trauma-informed care in healthcare settings may help to reduce the risk of exposure to distressing patient-provider interactions that are often cited by patients and their families as a source of medical trauma. Secondary prevention measures including the early identification of distress and targeted brief intervention may also serve to aid in a public health approach to addressing medical trauma. Mental health professionals embedded within inpatient and outpatient healthcare settings may help to increase identification of those experiencing medical traumatic stress, provide brief intervention to facilitate adjustment and support linkage to appropriate mental health services. However, research is ongoing regarding the most effective way to intervene early with this population (Birk et al., 2019).
Medical trauma has largely been neglected in the field of traumatic stress, with clinicians and researchers rarely acknowledging its existence. One reason for this is the continuation of silos within mental health training, which limit the transfer of knowledge that could aid in the identification and intervention of medical trauma (McBain et al., 2022). However, preliminary work to develop trauma-focused interventions specifically for medical trauma has shown promise (e.g., Murray et al., 2020). Despite this progress, there is a significant gap in the literature regarding the application of evidence-based psychotherapies for PTSD, such as Prolonged Exposure (Foa et al. 2019), Cognitive Processing Therapy (Resick, Monson, & Chard, 2017) and Eye Movement Desensitization and Reprocessing (Shapiro, 2019) to PTSD resulting from medical trauma.
Further research is necessary to inform the appropriate adaptation of current evidence-based treatments to address the unique biopsychosocial factors that lead to development and maintenance of PTSD symptoms among medical trauma survivors. Effective treatment of PTSD following medical trauma is unlikely to require a significant overhaul in how clinicians approach treatment. For instance, clinicians can consider implementation of assessment of distressing medical events into existing intake or assessment procedures and bolster foundational trauma-focused psychoeducation to include medical trauma and its consequences. Evidence-based treatments for PTSD are equipped to address medical-trauma related symptoms (e.g., therapeutic exposure, cognitive restructuring) and the process of treatment would be familiar to trauma-trained clinicians. In other words, the unique clinical considerations for medical trauma primarily arise from the trauma-related content to be targeted in therapy versus fundamental changes in the therapeutic process itself. For example, processing trauma memories primarily characterized by sensory impressions and strong physical sensations, therapeutic exposure focused on somatic cues, Socratic dialogue focused on unique medical trauma-related cognitions (e.g., internalized ableism; threat of reoccurrence) and behaviors (e.g., preoccupation with checking vitals) that may be elicited by medical trauma. Clinicians’ ability to appropriately address the unique considerations of medical trauma in PTSD treatment requires understanding of the fundamentals of a patient’s disease experience and treatment (e.g., common symptoms, interventions) while contextualizing these experiences within an ecological framework. Clinicians should approach this work with cultural humility by limiting reliance on patients to educate and inform about their illness. Instead, clinicians should seek to understand patients’ experiences through independent information gathering (e.g., disease specific organizations, literature databases) and consultation as necessary then by verifying this information with individual patients.
To learn more about educational initiatives on and resources for medical trauma, please visit the ISTSS Medical Trauma webpage at: https://istss.org/public-resources/friday-fast-facts/fast-facts-medical-trauma.
About the author
Sacha McBain, PhD is a clinical psychologist and assistant professor at the University of Arkansas for Medical Sciences (UAMS). Dr. McBain developed and leads the Trauma Surgery Psychology Consult Service at UAMS, Arkansas’ only Level 1 Trauma Center. This service is designed to address the psychosocial needs of trauma patients during hospitalization. Dr. McBain’s expertise and interests include traumatic medical events, implementation of trauma-informed and trauma-focused care practices in acute and critical care settings, and preventive and early interventions for traumatic stress sequelae and related concerns. She has completed training in community health and prevention research and implementation science in order to skillfully engage in highly partnered interdisciplinary trauma-focused program development and evaluation efforts.
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