The Trauma of Medical Illness

Severe and life-threatening illnesses are traumatic events. Although this remark may not sound novel, the idea of illness as traumatic has not been given much attention in the psychodynamic literature or in general psychological and psychiatric literature. It was only as recently as 1994 that the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) referred to life-threatening illness as a traumatic event for consideration in the diagnosis of Post-Traumatic Stress Disorder. Additionally, as mentioned in Chapter 1, within classical psychoanalysis, there has been relatively little emphasis on “real events,” including the effects of adult onset trauma. However, modern psychodynamics recognizes that reactions to adult onset traumatic events are different and unique, with the power to shape adult development, potentially as forcefully as childhood events. Patients experiencing major medical illnesses may have reduced capacity for symbolic thought due to the physical demands of their illness and stress associated with mortality. In the first part of this chapter I will address clinical work with patients who present with less access to symbolic thought and concrete thinking. Second, I will discuss additional sequelae of traumatic illnesses. Traumatic events such as severe life-threatening illness can cause post-traumatic stress disorder (PTSD) or its symptoms in many people, though the diagnostic criterion of PTSD doesn't fully convey the extent of feelings or suffereing in those who have experienced traumatic medical illnesses. Physicians refer many patients with major illness for therapy, yet the fundamental premise of therapy, thinking about one's experience, can feel overwhelming. Avoidance, a primary symptom of PTSD, makes reflection difficult. I will provide suggestions for clinical management, followed by observations on the interaction of past traumatic experiences in the presence of traumatic illnesses, non-life-threatening illnesses and age-related bodily changes. Finally, I will discuss the ways in which physical slowing down related to illness and aging, which are experienced by many as a type of loss and its associated disappointment, can be a stimulus for psychological symptoms in those with traumatic histories. For people who use their bodies to avoid thinking and feeling, aging and illness mean the end of physical and mental distractions. Patients who use hypomanic defenses, which can also include ways of thinking which create distractions to avoid feelings of guilt and sadness, or who are excessively active to keep troubling thoughts and feelings at bay, can develop disturbing psychological symptoms. Additionally, for some patients who have relied excessively on somatic modes of functioning (often present in those who have experienced early trauma), being more somatically focused takes place because adequate access to thoughts are not possible. Illness and aging can end a relationship with the body that has served a soothing function, and loss of the body as a soothing object has serious consequences. Especially for patients with traumatic histories, this can result in intrusive memories of past trauma, which creates intense psychological distress. I will discuss these dynamics further and implications for therapeutic interventions.