Published online Sep 20, 2023. doi: 10.5662/wjm.v13.i4.166
Peer-review started: April 18, 2023
First decision: June 1, 2023
Revised: June 10, 2023
Accepted: June 27, 2023
Article in press: June 27, 2023
Published online: September 20, 2023
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 me
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.
- Citation: Vyshka G, Elezi F, Mana T. Importance of methodological considerations in documenting psychological trauma. World J Methodol 2023; 13(4): 166-169
- URL: https://www.wjgnet.com/2222-0682/full/v13/i4/166.htm
- DOI: https://dx.doi.org/10.5662/wjm.v13.i4.166
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. 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.
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.
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.
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. 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.
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’. 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’. 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”.
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. 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. 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.
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.
|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|
|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|
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.
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.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Neurosciences
Country/Territory of origin: Albania
Peer-review report’s scientific quality classification
Grade A (Excellent): 0
Grade B (Very good): B
Grade C (Good): C
Grade D (Fair): D
Grade E (Poor): 0
P-Reviewer: Dimopoulos N, Greece; Masaru T, Hungary; Tang F S-Editor: Ma YJ L-Editor: A P-Editor: Xu ZH
|1.||Cairns K. Caring for the carers: Preventing and managing secondary traumatic stress. Responses to traumatized children. In: Hosin, A.A, edits. Responses to Traumatized Children. Palgrave Macmillan, London. 2007; 186-199. [Cited in This Article: ]|
|2.||De Boismont AB. Hallucinations; or The rational history of apparitions, visions, dreams, ecstasy, magnetism and somnambulism. Philadelphia: Lindsay and Blakiston. 1853; pp. 305-313. [Cited in This Article: ]|
|3.||Frewen P, McPhail I, Schnyder U, Oe M, Olff M. Global Psychotrauma Screen (GPS): psychometric properties in two Internet-based studies. Eur J Psychotraumatol. 2021;12:1881725. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 4] [Reference Citation Analysis (0)]|
|4.||Borgschulte HS, Wiesmüller GA, Bunte A, Neuhann F. Health care provision for refugees in Germany - one-year evaluation of an outpatient clinic in an urban emergency accommodation. BMC Health Serv Res. 2018;18:488. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 15] [Cited by in F6Publishing: 16] [Article Influence: 3.2] [Reference Citation Analysis (0)]|
|5.||Mayer E. The traumatic neuroses with special reference to their medico-legal relations. JAMA. 1917;12:958-964. [Cited in This Article: ]|
|6.||Jongedijk RA, Boelen PA, Knipscheer JW, Kleber RJ. Unity or Anarchy? A Historical Search for the Psychological Consequences of Psychotrauma. Rev Gen Psychol. 2023;23:1-17. [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)]|
|7.||Kirmayer LJ, Young A, Hayton BC. The cultural context of anxiety disorders. Psychiatr Clin North Am. 1995;18:503-521. [PubMed] [Cited in This Article: ]|
|8.||Pérez-Rincón H. Pierre Janet, Sigmund Freud and Charcot's psychological and psychiatric legacy. Front Neurol Neurosci. 2011;29:115-124. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 2] [Article Influence: 0.2] [Reference Citation Analysis (0)]|
|9.||Levine HB. Psychoanalysis and trauma. Psychoanalytic Inquiry. 2014;34:214-24. [DOI] [Cited in This Article: ] [Cited by in Crossref: 18] [Cited by in F6Publishing: 11] [Article Influence: 1.2] [Reference Citation Analysis (0)]|
|10.||Emery PE. The inner world in the outer world: the phenomenology of posttraumatic stress disorder from a psychoanalytic perspective. J Am Acad Psychoanal. 1996;24:273-291. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 7] [Cited by in F6Publishing: 7] [Article Influence: 0.3] [Reference Citation Analysis (0)]|
|11.||Soreanu R. Something Was Lost in Freud's Beyond the Pleasure Principle: A Ferenczian Reading. Am J Psychoanal. 2017;77:223-238. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 9] [Cited by in F6Publishing: 4] [Article Influence: 0.7] [Reference Citation Analysis (0)]|
|12.||Haule JR. Pierre Janet and dissociation: the first transference theory and its origins in hypnosis. Am J Clin Hypn. 1986;29:86-94. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 26] [Cited by in F6Publishing: 25] [Article Influence: 0.7] [Reference Citation Analysis (0)]|
|13.||Dreikurs R. The interpersonal relationship in hypnosis. Some fallacies in current thinking about hypnosis. Psychiatry. 1962;25:219-226. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1] [Cited by in F6Publishing: 1] [Article Influence: 0.0] [Reference Citation Analysis (0)]|
|14.||Rinne-Albers MA, van der Wee NJ, Lamers-Winkelman F, Vermeiren RR. Neuroimaging in children, adolescents and young adults with psychological trauma. Eur Child Adolesc Psychiatry. 2013;22:745-755. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 42] [Cited by in F6Publishing: 43] [Article Influence: 4.3] [Reference Citation Analysis (0)]|
|15.||Preçi S, Vyshka G. Measuring the Amygdala; Otherwise Recycling Lombroso Theories One and Half Centuries Later. Anthropol. 2014;2:e120. [DOI] [Cited in This Article: ]|
|16.||Ben-Zion Z, Korem N, Spiller TR, Duek O, Keynan JN, Admon R, Harpaz-Rotem I, Liberzon I, Shalev AY, Hendler T. Longitudinal volumetric evaluation of hippocampus and amygdala subregions in recent trauma survivors. Mol Psychiatry. 2023;28:657-667. [PubMed] [DOI] [Cited in This Article: ]|
|17.||Rana BM, Hassan K, Ali S. Biological markers of psychological trauma: A review. Pak Armed Forces Med J. 2010;60:289-299. [Cited in This Article: ]|
|18.||van Zuiden M, Frijling JL, Nawijn L, Koch SBJ, Goslings JC, Luitse JS, Biesheuvel TH, Honig A, Veltman DJ, Olff M. Intranasal Oxytocin to Prevent Posttraumatic Stress Disorder Symptoms: A Randomized Controlled Trial in Emergency Department Patients. Biol Psychiatry. 2017;81:1030-1040. [PubMed] [DOI] [Cited in This Article: ]|
|19.||Gutheil TG, Bursztajn H, Brodsky A, Strasburger LH. Preventing “critogenic” harms: Minimizing emotional injury from civil litigation. J Psychiatry Law. 2000;28:5-18. [DOI] [Cited in This Article: ] [Cited by in Crossref: 15] [Cited by in F6Publishing: 15] [Article Influence: 2.1] [Reference Citation Analysis (0)]|