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Intense or Prolonged Psychological Distress

Jamie Marich, Ph.D., LPCC-S, LICDC-CS, RMT, edited by C. E. Zupanick, Psy.D.

Exposure to reminders or cues associated with a traumatizing experience can trigger symptoms of severe psychological distress such as depression, panic attacks, and even hallucinations. Each of these signs of psychological distress are also symptoms of other psychological disorders. For instance, panic attacks are a hallmark symptom of several types of disorders, particularly the class of disorders called Anxiety Disorders. However, people who have experienced traumas may have a panic attack in response to some reminder of the trauma. For instance, some female domestic violence survivors report panic attacks whenever they hear a man's raised voice. If a clinician was evaluating a domestic violence survivor, without knowledge of this abuse, they could easily misdiagnose her with an anxiety disorder when a trauma-related disorder would better explain her anxious symptoms.

Because there is so much symptom overlap in mental health diagnoses (and physical diagnoses as well) it is important to consult competent professionals. If you suspect you have experienced trauma, abuse, neglect, or other adverse life experiences, you should be sure to raise these concerns with your mental health provider. This is often difficult to do because it's so difficult to talk about the trauma, neglect, abuse, stress, etc. It becomes something you tend to keep to yourself. But here is an example of when you must be courageous and tell your treatment professional. You can also ask to be referred to a trauma specialist. Sometimes trauma specialists are able to ask questions more sensitively, making it easier for you to discuss at your own pace. Keep in mind, you only have to tell as much as you can and still feel in control. For instance, you could simply say, "I have some bad memories from the past, but I don't want to talk about them right now." The point here is that this is not the time and place for secrets.

There is another group of overlapping symptoms that can also lead to misunderstanding and/or misdiagnosis on the part of the clinician. These group of symptoms are called psychotic symptoms. Some examples are hallucinations, (seeing or hearing things that are not there), and delusions (such as believing you are a famous hero or character). When clinicians spot these sort of severe symptoms, they typically and immediately begin to consider a group of disorders called psychotic disorders. The distinction between trauma disorders and psychotic disorders is not about diagnostic labels. The medications to treat trauma-driven disorders, and the medications to treat psychotic disorders, are vastly different.

Once the clinician has gathered together several diagnostic hypotheses, they look for reasons that refute those hypotheses. Then, the final question might be, "Which diagnosis best explains the symptoms that were observed and reported? Since clinicians must use both their own observations, and the self-report of the therapy participant, it becomes clear that self-reports must be as thorough and accurate as is possible. When someone feels unable to be completely honest with a health care provider, a good response is something like, "I don't want to answer that question right now, but maybe we can come back to it later." The alerts the clinician that they may not have all the facts yet.

Here is an example of what can happen with misdiagnosis. Consider Bob, a gentleman who was in and out of psychiatric hospitals and institutions for the better part of his adult life. His primary complaint was always that he was depressed. According to Bob, whenever he got depressed, "The voices tell me to kill myself." The usual treatment was to hospitalize Bob and put him on a heavy dose of medication. Still, after 25 years he really hadn't show any great improvement.

Luckily for Bob, he bumped into two trauma-informed clinicians at the emergency clinic in one of many facilities where he received care. These two trauma-informed clinicians asked Bob to talk about the content of his voices. He revealed the voice was his father's- the same father who was his primary abuser. His father told him things like, "I wish you were never born," or "You are a worthless piece of ----!". The trauma-informed therapists thought this was an important detail, one that might change his diagnosis. Perhaps this is not a psychosis. So, they approached treatment differently, considering these symptoms might be trauma driven, maybe a sort of flashback. Once Bob's problems began to be addressed as trauma, he was able to manage and eventually eliminate the voices. We will discuss these treatment strategies in the Treatment chapter.

Children describe similar experiences and are too quickly diagnosed with ADHD or Conduct Disorder.

 


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