The trouble with trauma, besides its obvious discomfort, is that many people equate trauma and its symptoms with full-blown Post-traumatic Stress Disorder (PTSD). If you’ve been traumatized, then you must have PTSD. The real story is actually quite different. Trauma manifests in many different ways, at many different levels—and each manifestation can be inhibitive.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), clinically valid PTSD must cover 6 categories of diagnostic criteria, 4 of which contain several different symptoms. In fact, out of 21 total possible symptoms, a minimum of 10 symptoms must be present in order to be diagnosed with PTSD. If a patient exhibits 7or 8 symptoms, then technically the patient does not qualify for PTSD, but rather, has what is known as, sub-syndromal PTSD. For example, consider the following symptom (taken from the DSM-IV, category C of diagnostic criteria for PTSD): Efforts to avoid activities, places, or people that arouse recollections of the trauma. This symptom can lead to withdrawal and isolation. People don’t want to leave their house. They miss work and/or other activities of importance. They become homebound.

Another diagnosis, Simple Phobia, easily accounts for half of the MVA patients that I treat. People are too afraid to drive or be driven. Imagine being too afraid to drive—how utterly debilitating! Again, this does not qualify as full-blown PTSD but you can see how imposing it becomes in one’s life. Sometimes it can be severe, like the case of one woman who literally would not get into any moving vehicle. She finally had to drug herself up because she had to get to the next state in order to help her ill mother.

Panic attacks are another example of a symptom that can profoundly disrupt one’s life. A patient had come to me, a young man in his twenties, who was experiencing panic attacks after being in a motor vehicle accident. Clearly, panic attacks are a powerful, visible symptom of trauma and should not be taken lightly. He described attacks that would erupt seemingly out of nowhere, not connected to being in a car or any other obvious stress trigger. The attacks would abruptly stop him from whatever he was doing, leaving him extremely short of breath, very anxious, cold, sweaty palms, and unable to function. He literally would have to sit down and ride it out, hoping not to pass out. He never knew when they would hit. And they were hitting him almost daily. That aspect alone scared him enough to go to therapy.

Often panic attacks occur when one encounters a trigger, a reminder of a traumatic event. Ironically though, this patient presented with a mystery. His latest attack occurred when he was alone at Mt. Tabor, walking around calmly taking photographs. There was no one around, no sudden, loud noises, nothing unusual. He was not thinking about accidents or automobiles. He was feeling happy and peaceful. Suddenly he was stricken with an attack and had to sit down or he would have fainted.

The intake session, and several subsequent sessions revealed that he had been watching in his rear-view mirror while the car behind him rammed into him. During this brief time, the patient, unawares, had been holding his breath. This pose or stance is what got “frozen” or “stuck” in him, physically and emotionally. He simply was not breathing. Not breathing creates loss of oxygen, which then creates panic. He didn’t need to get triggered by an outside stimulus—he simply had unconsciously adopted this pose and then suffered panic attacks at any given time.

The therapy then consisted of him voicing/articulating the sequence of the accident. When he stopped breathing, as he had done during the real accident, I loudly told him, “Breathe” as he told about the actual impact. The deep breath finally freed him from his locked up pose.

The following week he reported vastly fewer attacks. He was reminded to keep checking himself to make sure that he was breathing fully. The next week he was done to no panic attacks.

Trauma hits in different ways and in different intensities. Most manifestations can be ripe for therapeutic treatment.

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Beverly Schwartz, LCSW
Spring 2010
SOMA Trauma Therapy, LLC

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For survivors of motor vehicle accidents (MVAs), the choice to get back in the car or truck is often a difficult, emotionally wrenching and psychologically complex decision. And they find it impossible to just go on, not only with normal driving, but also with many routine aspects of their lives as a whole.

In many ways driving has become safer with dual airbags, seat belt laws, child car seats, traction control devices and the like. Yet none of these protect against the acute stress and frequently chronic or long-term effects of surviving an MVA – even when there are no physical or visible signs of injury. The symptoms suffered by MVA survivors are fairly predictable; fear of driving, anxiety, poor sleep, irritability, reduced joy, body aches, fatigue, relationship and sexual difficulty, and preoccupation with the accident. These symptoms may emerge within hours to months after an accident. More severe symptoms in the aftermath of an MVA include depression, panic attacks, inability to work, social isolation, guilt and shame, and full-blown Post-Traumatic Stress Disorder (PTSD). There are over three million MVA survivors annually in America, about 1 percent of the population. Yet getting help for the emotional impact remains elusive.

Take the case of Lisa, 43, mother of two, who was taken to the hospital for observation and discharged several hours later after an MVA. Lisa was severely shaken up though her injuries did not appear serious. But her mind kept racing back to the accident. At work she felt unusually tired, struggled to concentrate, and felt disengaged from her tasks. At home, she had trouble sleeping, had frequent headaches, was irritable with the kids, short-tempered with her husband, and generally felt guilty. Driving became an ordeal.

Three weeks after the accident her condition worsened. Crying jags, nightmares and anxiety added to the fatigue, restless sleep, neck pain and headaches she was already suffering. Her doctor gave her medication for sleep. Over the next several months physical therapy, anti-depressant medication, pain medication for her neck, and massage therapy were added to her treatment regimen. Four months after the accident Lisa began psychological counseling. Her constant anxiety interfered with her confidence to drive and motivation at work. She was becoming isolated socially and could not explain what was happening to her. Lisa had lost her drive.

Lisa learned in therapy that her symptoms were a normal reaction to an extreme situation. She was not crazy, oversensitive, selfish, weak, a drama queen, or playing the victim. Her situation finally began to make sense. In time, with acceptance of her self and her condition, she was able to resume joyful activities. She still had moderate anxiety driving but was coping reasonably well.

Lisa’s case may be called typical though in fairness each MVA survivor’s experience is unique. Key elements to successful treatment include finding ways to talk about the impact of the traumatic event, using effective tools to relax, processing traumatic memories, returning to normal activities, and developing a sense of self free of trauma. Unfortunately, these objectives are often elusive because traumatic reactions to an MVA remain misunderstood, treatment may not be started in a timely manner, medical professionals may not identify symptoms, and survivors may not implement treatment recommendations.

An important aspect of trauma is that the mind and body are deeply connected through our biochemical and neuromuscular system to process events, both new and old. When there is trauma, our responses form the basis of the fight, flight or freeze response, part of the primitive adaptive wiring central to our survival. The system is masterful. The problem with trauma is that this ingenious brain-body system develops a hair trigger reaction to perceived threat even when there is no actual danger. The program in our brain designed to protect us may backfire by overcompensating. This leads to alarming, enduring mistakes in perception and reactive behavior. And years of struggle for some survivors.

The road to recovery does not have to be long or painful. Proper treatment, particularly with a clinician well versed in treating trauma, and familiar with the unique impact and subtle course of MVA issues, can make the difference between prolonged emotional turmoil and regaining the sense of self the accident displaced.

Soma Trauma Therapy specializes in healing both the cognitive (thinking) process and the neurophysiological (body) disturbance associated with trauma. Soma’s short-term-trauma-therapy helps clients achieve pre-accident functioning in 10-15 sessions compared to 30 or more treatments of conventional talk therapy. Soma coordinates care with other providers to maximize support and efficient use of resources. Soma helps clients regain their drive.

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Michael Alter, LCSW
SOMA Trauma Therapy, LLC

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Psychological trauma defies physical detection: You cannot see it in an X-ray or an MRI; you cannot feel it during a medical examination. You can only experience it personally, both viscerally and emotionally, or witness the outward manifestations, the troubled signs of trauma. “I can’t sleep, I am exhausted, I’m anxious all the time, and I am scared to get into a car”. Or, “I can only be in a car if I am driving, I don’t remember where I put things, I can’t stop thinking about the accident, and I don’t want to leave my house”. Yet another, “I feel so depressed, I am fighting with my kids/spouse/friends, I am usually not this irritable, and I wake up almost every night from nightmares about the accident”. There are countless variations.

Head trauma or minor brain damage intensifies trauma symptoms; partly because it vastly worsens or creates the cognitive difficulties and because it produces its own pain—the perennial headache. These symptoms seem to take the longest to subside and can be quite debilitating. Postconcussional Disorder and Mild Neurocognitive Disorder are often the psychiatric diagnoses given to head trauma victims.

Often trauma symptoms take 3-4 months before they emerge. Or, people will resist, fighting back the symptoms thinking that it will go away, or they try to manage them without success. Undeniably trauma does sometimes work itself out. However, when 6 months have rolled by and things are not getting any better, something is amok. I once had a client who took 9 months to come to therapy. Prior to the accident, he enjoyed many years of being a top salesman in his field, pulling in six figures annually. (Imagine a modern-day Don Draper of “Madmen”). Then one day, while watching in his rear-view mirror, he was rear-ended. He couldn’t remember if he had hit his head, didn’t remember the actual impact, nor could he remember exiting from his vehicle. He had blacked out. Three days later he started getting constant, severe headaches. Headaches that were so bad they eventually prevented him from sleeping, prevented him from working, and forced him to the ER for pain relief. By the time he came to trauma therapy, he had been through just about every pain treatment the doctors could think of. Nothing was working. Not being a pain specialist, I simply did what I always do with new clients: Took him through a guided imagery, breathing/relaxation exercise. Within 2 minutes he fell asleep. He slept through the rest of the session. Before he left, I instructed him to do the exercise on his own each night. When he returned the following week, he reported that upon leaving my office, he noticed, that for the first time in months, he did not have a headache. Unfortunately it only lasted for a couple of hours, but he also said that his sleeping had improved significantly. The end of the story is not so neat and compact. Due to a history of what he said were serious childhood traumas that he did not want triggered, he dropped out of treatment. He was afraid of losing control. Still, the moral of the story is: Unnecessary pain and suffering is not worth it, and is treatable.

Attorneys with whom I have consulted sometimes wonder how an ordinary car accident can cause trauma. After all, isn’t Post-traumatic Stress Disorder (PTSD) reserved for those who have fought in wars, or were tortured, or were the victim of a heinous crime? First, not all trauma is PTSD. There are varying levels—some which require longer, in-depth treatment, others that can be resolved within a few sessions. There have been many cases that needed only 4-8 sessions to get past the driving phobia that many people develop. Would that have been considered full-blown PTSD? No. But driving phobias are just as viable and worthy to treat. We certainly wouldn’t want hundreds of people driving around terrified, white-knuckled at the steering wheel, and so anxious and hyper vigilant that they practically cause that which they are trying to avoid.

Secondly, trauma cannot be measured only by the external, material event that occurred. There is an internal process at work as well. I had a client who, while driving on the freeway, was hit, which somehow caused his vehicle to change direction and head towards a huge, semi-truck. As the vehicle rapidly approached the truck, the client watched, horrified and terrified, as his car actually went under the truck. Somehow the vehicle stopped and the client was able to walk out of his car virtually unscathed, at least physically. What he presented in therapy was a man riddled with trauma symptoms: unable to sleep, daily nightmares, obsessed with the accident, obsessed with how he came out alive, depressed, unable to drive, extremely anxious, not wanting to leave his house. What he vocalized is that while he watched himself go under the truck, he truly, genuinely, absolutely thought that he was going to die. It is the perception of danger that accounts for how the mind will process or not process the traumatic event.

Trauma, and its manifestations, is really not mysterious. It is when we avoid acknowledging it because we tell ourselves, or we have been told, “Hey, you didn’t get hurt too badly”, that we really feel the pain.

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“Trial Lawyer”
Winter 2010
Oregon Trial Lawyers Association
Brain Injury Issue

Beverly Schwartz, LCSW
SOMA Trauma Therapy, LLC

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