Importance of methodological considerations in documenting psychological trauma

Abstract

The documentation of psychological trauma is obviously a challenge to clinicians while they are diving deep into remote events related to their clients or patients. The potential role of psychological trauma in the early developmental stages, and even the existence of adverse childhood experiences, is important to prove, yet it is difficult to do so. A diverse range of methods have been applied, all of which presumably benchmark a big therapeutic step; however, these enthusiastic methods frequently do not last for long. While hypnosis supporters, Freudian and Neo-Freudian disciples can be acute enough to enhance and uncover suppressed memories, modern psychiatry relies mostly on diversely structured interviews. Functional magnetic resonance and its related subtleties might help, but the questions that remain unanswered are numerous and confusing. Connecting early experiences with long-term memory while identifying psychological trauma its importance for the individual’s growth trajectory; thus, it remains an intriguing issue.

Key Words: Psychological trauma, Adverse childhood experiences, Post-traumatic stress disorder, Self-reporting, Hypnosis, Magnetic resonance imaging

Core Tip: The documentation of psychological trauma is a delicate issue with important clinical, ethical and legal implications. Interviews, self-reporting, hypnosis and recent sophisticated imaging techniques have been proposed and tried. While each method has intrinsic advantages and drawbacks, it is important for scholars to specify their chosen approach while denoting the value and limitations of the findings.

INTRODUCTION

Remote psychotrauma, especially in the early stages of human development, deserves special attention with regard to later psychiatric morbidities. This issue has long since been of particular value as even ancient authors highlighted the role of stress and trauma in the aftermath of catastrophic life events.

Of interest might be that early sources grant no time delay between psychotrauma and its effects on the human psyche. However, months or possibly years may be required for the full picture of posttraumatic stress disorder to arise; this might be true for Homer’s Odysseus, who experiences flashbacks and intrusive memories of lost friends while in captivity on Calypso’s island, although the legendary author sketches no clear timelines. This notion of time and relativity is older than Einstein’s discovery.

Macbeth demonstrated the full picture of psychotrauma soon after the killing of his rival[1]. Charles IX experienced hallucinations and nightmares the day after the Saint Bartholomew massacre: […] the solitary hours of Charles IX were rendered terrible by a repetition of the cries and groans which assailed his ears during the massacre of Saint Bartholomew[2].

Therefore, it is clear that in remote historical settings, the timeline of psychotrauma following a stressful event is different from what it seems to be in current lines of thought. The immediacy of reaction(s) is disputable but remains present.

Self-reporting and structured interviews

The form of trauma reporting in a structured interview differs from the self-reporting found in most available questionnaires; however, the authors generally speak through their characters as if the experiences were their own. Trauma reporting recently transcended the necessity of a close relationship between the physician (therapist) and the patient (client), as questionnaires can be completed online as well. Thus, the effects of psychotrauma might be communicated via the internet[3].

It is clear, however, that patient interviews and self-reports have limitations. Memories of remote and early traumatic experiences are often suppressed or erased. Furthermore, identifying participants whose responses are likely dishonest or unreliable is challenging[3]. Documentation requires objectivity; hence, the value of an interview remains restricted. Even when equipment and staffing are adequate, different issues (for example, retraumatization) might lead to the loss of information[4].

Hypnosis and psychoanalysis

The advent of hypnosis and psychoanalytical methodologies provided new perspectives for obtaining the requested information. In 1889, Oppenheim elaborated on some of Erichsen’s ideas and coined the term ‘traumatic neurosis’. Another French author (Brissaud) pushed the notion further and spoke of ‘sinistrosis’[5]. While Erichsen (1866) proposed an organic nature of traumatic events, the London surgeon Page argued in 1885 that it was not physical injuries but rather fright, fear, and alarm that caused the disorder he termed “nervous shock”[6,7]. These views and those of other contemporaries prompted Charcot’s pupil, Sigmund Freud, and his apostles to dig deeper into the traumatic unconscious[8,9].

The milestone Freudian publications, namely, ‘Interpretation of dreams’ (1900) and ‘Beyond the pleasure principle’ (1920), shed unprecedented light on the internalization of psychological trauma and its elaboration, although not everyone—perhaps even less his contemporaries—shared Freud’s opinions[10,11].

Criticism aside, hypnosis was developed before the nineteenth century, yet French scholars maintain its worth; Janet referred to hypnosis as ‘influence somnambulique’[12]. Nevertheless, apart from the intrinsic problems of hypnosis, hypnotherapy and all other subtleties of the technique somehow failed to stand the test of time. The changed status of awareness in hypnosis leading to profound relaxation and free production of recollections of remote traumas (if present) does not necessarily serve as documentation of trauma. Mnestic lacunae, confabulations and inconsistent statements arise, even with an experienced therapist. To add more to the controversy, Dreikurs suggested, “Hypnosis will not continue as a therapeutic procedure, despite its present tremendous appeal and increasingly wide use”[13].

Functional neuroimaging and biochemistry

Neuroimaging and neurochemistry have made significant progress in the last half-century. This progress has had clear implications in psychiatry, clinical psychology and psychotrauma.

Structural magnetic resonance imaging studies on traumatized children and adolescents have revealed abnormalities in numerous brain regions[14]. An impressive number of structures seem involved or imputed. The amygdala has been the focus, with measurements of its volume; the same is true for the hippocampus, brain cortex and limbic system as a whole[15,16]. Most studies have focused on children and childhood trauma, therefore encompassing an age range when important developmental changes occur. This bias is unneglectable but is not the only factor involved. Individual, racial and ethnic changes in volumetric parameters could also alter imaging findings. Researchers have strived to draft reliable and accurate methodologies; however, dilemmas remain.

Psychotrauma has an important effect on the brain's neurotransmitter systems. Therefore, a search is warranted for biochemical markers of trauma, in spite of their delicate and dynamic equilibrium. The hypothalamic pituitary adrenal axis is clearly relevant in stress responses; additionally, several neurotransmitters appear to be involved, such as serotonin and amino acids[17]. Interestingly, some biological therapies have tried to prevent post-traumatic stress disorder symptoms; an example is administering intranasal oxytocin, which is a hypothalamic hormone with a wide range of neural effects[18].

Table 1 summarizes some of the novelties and drawbacks intrinsic to most of the abovementioned methodologies. In a nonexhaustive approach, authors have tried to focus on the main characteristics of each technique, which obviously have numerous and specific features.

Table 1 Documenting psychological trauma.

Methodology	Advantages	Disadvantages
Self-reporting, structured interviews and questionnaires	Online surveys possible	Interviewer dependent
	User friendly	Participant motivation
	Therapeutic alliance	Low response rate
	Culturally shaped	Risk of retraumatization
	Standardizing of results
	Quantifiable
Hypnosis and psychodynamic/psychoanalytical approach	Recall of suppressed memories	Mnestic lacunae
	Recollections of remote traumas and of adverse childhood experiences	Confabulations
	Person centered	Inconsistent statements
	Potentially of treatment value	Potential for false memories
	Exploring the subconscious	Unsuitable for psychotic patients
MRI (functional neuro-imaging)	Objective data/findings	Methodology still not well standardized
	Reproducible	Ethnic and age-related changes to be considered
	Images availability and storage of high quality	Relatively costly

MRI: Magnetic resonance imaging.

CONCLUSION

The theme of psychological trauma and its long-term after-effects is of particular interest in neuroscience. However, this issue still needs systematization. Documenting a psychologically remote and traumatic event might be problematic but of high value when medico-legal and forensic issues are at stake, even with the unfortunate result of retraumatization[19].

When producing results, clinicians must clearly report the methodology used for documenting psychological trauma. By doing so, everyone should clearly understand the limitations of the findings without raising unnecessary doubts about their validity.