Thoughts On Trauma and PTSD

Writers, in general, find inspiration by things that happen around us. As a doctor (who happen to have an interest in writing), things that happen around me are things that happen to my patients or to my colleagues or to myself.

Lately, we have a couple of PTSD cases in our ward. One of my patients developed PTSD after being involved in a relatively minor road traffic accident. 

Just a few weeks ago, I was asked to present a topic on psychological management of patients with Burn Injury and one of the subtopic that I covered in my talk was PTSD among war veterans living with blast injuries.

And just yesterday, one of my colleagues had a minor accident on the way to work, and she jokingly said, “Oh no, I hope I don’t develop PTSD like our patient.”  She is one of the funniest person in my department but part of me feel worried if she might not be joking about her worries on developing PTSD. She admitted to me once that she is the OCD and anxious type. 

It reminded me of my own impending PTSD last year (I use the word ‘impending’ because I never actually developed one. But I could have developed one, I think, if I didn’t straight away get a grip on myself and took steps to prevent it from developing. One of the steps I took was by refusing to talk about it or mentioning it to anyone other than to my family members who knew about it. And I continued doing my daily routine as though nothing serious had ever happened to me. My method worked because Alhamdulillah, I don’t have PTSD).

All in all, I feel like this is PTSD month for me and therefore this is what I am inspired to write about.  

***

If you have read the non-fiction book ‘Shrinks: The Untold Story of Psychiatry’ by Jeffrey A. Lieberman (The Former President of American Psychiatric Association and one of the key contributor to the development of DSM III, a dramatically and drastically more systematic manual than the previous DSM I and DSM II), you will find a very interesting chapter that he wrote on how unique, personal and mysterious the development of trauma can be. 

download

Why does trauma occur in some people and not in others? And how come the development of trauma has nothing to do with the scale of danger involved? Jeffrey A. Liberman related two events that had occurred in his life; one incident was life threatening (he was held at gun point by a robber in his house), and the other was just a minor accident (he accidentally dropped an air conditioner from a multi-storey building and the air conditioner almost hit the doorman downstairs but in the end, no one was actually injured) and yet he developed PTSD over the minor accident rather than the one that might cost his life. 

Below was his own thoughts regarding how puzzling the development of trauma can be:

“What is it about traumatic events that produce such intense and lasting effects? Why does trauma occur in some people and not in others? And how do we account for its seemingly unpredictable incidence – after all, it seems rather counterintuitive that dropping an air-conditioner elicited PTSD-like effects, while a violent home invasion did not. During the latter episode, I was assaulted and my life was in genuine danger; during the air conditioner’s plunge, I never faced any physical hazard. Was there some critical factor that determined how my brain processed each event?”

When I read this particular chapter of the book, I remember thinking that “PTSD is so fascinating.”

Out of all 265 diagnoses in DSM-5, all of them are defined without any causes being explicitly referenced, EXCEPT for substance use disorder and PTSD. While we all know that drug addiction is due to actual effect of  chemical reaction leading to neural changes in your brain, PTSD is a psychological reaction to an event that produces lasting changes to a person’s mental state and behaviour. Like substance use disorder, the cause for PTSD was clear cut (unlike other diagnoses in DSM-5). Before the event, a person was mentally healthy. After the event, the person is mentally wounded. (and treating a mental wound is a whole new headache that is not as straightforward as treating a physical wound. A mental wound is something you cannot see directly. In a sense, it is like ‘benda ghaib’ that you cannot fully grasp. How do you treat a ‘benda ghaib’? It is so difficult and it can be so frustrating sometimes, trust me).

 ***

Until now, it remains a mystery to me as to why I was able to move on with my normal routine after I was involved in a major MVA last year, but in contrast, I was an emotional wreck after the passing away of my ex-classmate many years ago. 

I was very emotionally affected after the death of my ex-classmate when I was 18 years old. Something about mortality scared me as a teenager. The unpredictability of death – that it could occur to someone as young as my ex-classmate in a sudden manner – shocked me out of my complacence about life in this world. I never had to think about death before. Intellectually, I knew it could happen to anyone at any age. But spiritually, emotionally, I was just a teenager who was enjoying life and didn’t think about mystical, existential stuff like that… until the death of my ex-classmate. I was not in any danger when the news of her death was informed to me. I remember feeling shocked but I was not affected straightaway. So I could not understand why a few days later I found it difficult to sleep and this continued for months. (But my appetite was intact, Thank God. Maybe NOTHING can ever reduce my appetite. Haha).

Last year in Ramadan 2016, I had made plans to visit my sister on the weekend. We were going to meet in Tanjung Malim and we were going to hang out in KL to have some sisterly fun times. On Friday, right after my sahur meal, I made that journey to see her. It rained heavily that morning. I ALMOST did not fasten my seat belt when I started my journey. In general, I didn’t like wearing seat belt. I felt that it limited my movement and made me feel very uncomfortable to drive. But I don’t know why on that day, I decided  to fasten my seat belt. Something about the heavy rain  gave me pause and made me decide  to err on the side of caution. (I thank God for that decision every day of my life and I never again drive anywhere without fastening my seat belt.) 

I had just passed the Pendang area on the PLUS highway when I accidentally hit a big puddle of rain water while driving in high speed and all of a sudden, I lost control of my car and it spun around so many times and then it actually went into the air before it flipped over and I ended up upside down inside the car. While the whole thing was happening, my mouth only said “Ya Allah, Ya Allah, Ya Allah.” (Seriously, I could not remember the complete syahadah at that time. I guess, the complete syahadah is something I associate with dying in bed rather than while struggling with my car).  As my mouth kept uttering the name of God, my mind kept thinking that “I am going to die soon.” Then I thought of what my family members would feel. And then I remember thinking “Well, at least,  I die in the month of Ramadan.” But a glimmer of hope inside my head also said “If not death, then at the very least, you might end up in ICU.” I thought about intubation, brain injuries and chest tubes while struggling with my car.

 

I have never experienced such an absolute loss of control over anything before in my life. That was the first and only time that I truly felt that my whole fate was out of my hands (even though, when you think about it, your whole life is NEVER in your hands. You are never in complete control. Everything has been written.)

Alhamdulillah. Alhamdulillah. Alhamdulillah. I did not sustain any fractures. I did not even sustain any bruising. Not even an abrasion. I was upside down in the car a few seconds after the whole crazy movement ceased and I thought to myself “I am alive!” I still remember the song that was playing on the radio at that time while I was digesting the fact that I was alive. (It was an arabic, Amr Diab song.)

Suddenly, an elderly stranger broke the window of my car, and pulled the door open and lifted me out of the wreckage. He thought I couldn’t walk, so he just lifted me up without asking whether I could walk myself. (I remember thinking “Hopefully I am not too heavy for you.” haha) I tried to tell him that I could walk, that I sustained no injuries. But he didn’t hear me due to the heavy rain. And I was too exhausted to shout twice. I would forever be indebted to him. He was such a kind-hearted man.

He was so surprised that I was unharmed. He said, “Ingat mesti dah pengsan, patah riuk dah.” I reassured him that I was fine. I thanked him very much for helping me out of the car and for going back inside my car to retrieve my handbag, and my phone. A few people also stopped by my car to help. 

“Nasib baik kebetulan tak ada kereta lain waktu tu.” said the kind uncle. 

Yup, it was a major accident involving me and the divider only. Thank God that I did not cause any injury to anyone else. (I don’t think I could live with that.) It was because I hit the divider that had caused my car to stop spinning. But unfortunately instead of stopping, it went into the air and flipped over. And the most miraculous thing is the impact from the collision did not even trigger the air bag to deploy. If it did, I would surely have some remarkable injuries on my face.

I called my father to tell him that I was involved in an accident. I didn’t tell him how bad it was over the phone. (In my experience, whenever I was involved in an accident – even when it was not my fault – somehow he would blame my driving. I must be driving too fast, he would say. But seriously, other than this particular major accident which only involved me and a highway divider, the other accidents were not my fault… all the police reports confirmed that. How would my fast driving cause other drivers to make mistakes in their own driving? In the previous two accidents I was involved in, the other drivers themselves had admitted that it was their mistakes. My own NCB was not affected in any accidents I had had before this one) 

While waiting for him to arrive, I prepared myself mentally to be scolded by him. (Because unlike the others, this one must be my fault. I can’t exactly blame the highway divider, right? I must have lost control of my car because I hit the big puddle of water, isn’t it? So this IS my fault. And I knew I would surely ‘kena leter’). But to my surprise, my father did not say anything after he saw the condition of my car. Perhaps, after seeing how bad the accident was, he was too shocked to the point of speechlessness. Or maybe he was just relieved that I escaped without any injuries.

Because he did not scold me as I had expected, I actually burst out crying right there and then. I was holding myself really well before that. I did not burst out crying until he arrived in front of me without a word. Perhaps when I saw how very uncharacteristic the behaviour of my father was, it then really hit me that I could have died. I could not remember the last time I cried in front of my father prior to this incident. It must be many many years in the past since I have cried in front of anyone. See? Even I was behaving uncharacteristically on that day. Haha.

My father eventually made a joke “Sejak bila Kak Ngah jadi pelakon stunt, buat lagak ngeri ni?”

I laughed in the midst of tears.

On the way back home, me being a PSY MO, I thought about PTSD. I have seen a few patients who stopped driving after being in an accident. I have seen patients who have panic attack while driving. I was afraid that I might develop such symptoms. Which would be so troublesome, because I don’t want to have to depend on other people to get me to places I could so easily drive myself. That kind of dependency, resulting from unreasonable out-of-control fear, would limit my freedom. And I really love driving. Despite what my father always said, I think I am a skilful driver. (It is just that my skill is so good that it belongs in the race track. Haha.)

I started to formulate ways on how to prevent myself from developing PTSD. I didn’t know whether or not it would work, but I had made all these plans inside my head as my father was driving me home. 

1)Start Driving Again Straight Away

In one of the books I read, the protagonist develops fear of horse riding after she fell from her horse in one of her practice session. Her tutor had told the protagonist, “You should have gotten back on the horse straight away after your fall. Everybody knows that the longer you wait to get back on your horse after a fall, the harder it is to regain your confidence.” So based on that principle that I remember reading from a Sweet Valley High novel, I decided to straightaway drive my father’s Ford Ranger a few hours later in order to go to the workshop and retrieve some of my leftover stuff from my wrecked car.

My father and my mother offered to accompany me to go to the workshop since it was so soon after the accident (2 hours post-MVA!) but I told them that I had to do this by myself. I had to drive by myself because I wanted to be able to drive by myself for the rest of my life. I don’t know whether there is a window period, within which time, you must create a new experience to undo the bad ones. (this was just my theory, at that time. Not sure if it is scientifically proven or true. Haha) So, I decided to hasten the process of driving again after my accident. Alhamdulillah, I was fine. No anxiety (well, maybe just a little) and no panic attack whatsoever.

 

2)Start on your normal routine straightaway

I stayed at my parents’s house on the day of my accident to please my mother (because my mother was remembering how my cousin had passed away one day after his accident despite being discharged from A&E with no detected internal bleeding. His passing away was a shock to the whole family.) But the next day, I told them that I wanted to go back to my own house. I wanted to see whether I can stay at home by myself after the accident. Having my own space to relax and read and escape from noise and hectic environment is important to someone like me. Being able to enjoy my solitude without fear and anxiety is imperative to an introvert like me. We need our alone time in the same way we need our basic physiological needs (well, maybe not in the same way we need oxygen, but almost in the same way we need food and drinks.) I need to be able to do that. And I wanted to test my ability to do that straightaway. My mother did not approve of my plan but my father had no objection. I think my father understood the practicality of my decision… it was just as practical as my decision to start driving straightaway.

At the end of the day, we must control our anxiety and our fear by facing it head on and moving on. We must prove to ourselves as soon as possible after an event that there is nothing to be anxious about and nothing to fear. The sooner you get the ‘testing and proving phase’ done and over with, the sooner it stops having any power over you. 

Even though I had no injuries, no scratch and no abrasion whatsoever, the muscles all over my body started to ache slightly and felt a bit stiff the day after the accident. My mother suggested for me to take a leave on Sunday. But I decided not to do that. I wanted to get on with my routine as though nothing traumatic has happened. In my normal life, I get to work on Sunday, and therefore I MUST go to work on Sunday as usual.  Routine, routine, routine… my main aim was to get back to my normal routine.

The muscle ache? I just pretended  as though I had a heavy work out at the gym. 😉

 

3) I kept my accident a secret from everyone at work and even from my best friend.

On Sunday, they asked me why I was driving my father’s Ford Ranger instead of my usual Toyota Rush. I told them that I had an accident (I didn’t tell them that it was bad and it scared me shitless when it was happening. Hahha).

A few weeks later when they still saw me driving my father’s Ford Ranger, they commented that the workshop where I sent my car took too long to repair the car. I simply shrugged my shoulder and said “Yeah, I don’t know why they took so long. Maybe insurance issues or something.” I ended up getting back my car after 3 months of repair work. And my friends kept saying “Why does it take so long?” 

Hmmm… 

I just didn’t feel like talking about it. I was studying for my Part A MRCPSYCH exam at that time and I had read that debriefing was not recommended for PTSD. In my mind, I felt like talking about it might be like some sort of mini-debriefing and therefore I simply avoided talking about it by making it a secret. I think it worked.

(Deep inside, maybe I kept it a secret because I was afraid people would comment or tease me about my driving skill like my father always does. I am quite touchy about my driving. I hated it when guys think women are bad drivers. I think I am a good driver and I don’t want anyone else to think otherwise. Haha.)

 ***

So Alhamdulillah, I can really tell you that I did not get any PTSD/anxiety/fear of driving/ fear of rain/ panic attack after the accident. In fact, when I compare the emotional impact between this accident and the death of my ex-classmate, I can honestly tell you that  I was more affected by the death of my ex-classmate than this accident. I had no trouble sleeping at all after the accident.

It was weird. But as Jeffrey A. Lieberman had said, development of trauma is such a mystery. Does it have anything to do with our brain processes while the trauma was happening or our brain processes after the trauma has happened? Our amygdala, hippocampus, and our prefrontal cortex are all involved in the pathophysiology of trauma. But when do they start forming the ‘traumatic memory loop’? Why do some people never develop that loop despite whatever traumatic experiences they have gone through?

Until now, I am still wondering. Could it be that I had prevented any development of PTSD (traumatic memory loop) by normalizing my life as much as possible right after the accident? Maybe somehow, I had stopped the process of ‘traumatic memory loop’ formation by tricking my brain into thinking that everything was normal and the next day was just another day. 

Whatever it was, one of the things I told my colleague after learning about her accident was, “You must drive straightaway.”

Because it helped with me. So hopefully, it helps her too.

In the whatsapp group, all of us were sharing the pictures of our previous encounter with road traffic accidents. And needless to say, my picture won the prize of the most horrifying accident to ever happen to any of us. And then it occurred to me, “Wow, I finally talked about my accident after all these months,”

***

With my colleague’s accident, I remember again all the thoughts I had about my own accident in the aftermath.

I had thought, “Maybe I didn’t deserve a Ramadhan death, after all. I am not that good as a person.” (God, that sounds depressing but unfortunately, it is the truth. I have that much insight about my impatience and my lack-of-tact and diplomacy.)

I had thought that “Well, maybe God saved me because He loves me and He wants to give me a chance to repent and do as much good as possible while I still live.” (This sounds less depressing. Hahha)

After nearly tasting death, you realize that things that happen in this world are so insignificant that you should not stress yourself about it at all. Nearly tasting death gives you a strange sense of freedom. You knew that the most stressful thing that can happen to you is death.  And if that is the worst thing and you have nearly encountered it, what makes you think you cannot handle the rest of the other life stressors that may come your way in the future? Life is one struggle after another …so don’t be afraid, stick to your principles, speak the truth and do what is right no matter how much it would compromise your position because ‘in this world’ is your only chance.  Death can happen at any time. And thoughts of death renders everything else in this world meaningless. But paradoxically, it can motivate you rather than pull you down, if you have the right methodology in thinking about it.

I remember thinking about miracles and guardian angels after the accident. In Islam, we know about the Hafazah angel…

For each one are successive [angels] before and behind him who protect him by the decree of Allah . Indeed, Allah will not change the condition of a people until they change what is in themselves. And when Allah intends for a people ill, there is no repelling it. And there is not for them besides Him any patron. (Quran 13:11)

According to Wikipedia, The Arabic term al-mu’aqqibat (commonly encountered in the definite plural, Arabic معقبات “those who follow one upon another”) is a term occurring in the Quran (Q.13:11) which some Islamic commentators consider to refer to a class of guardian. Therefore also these Angels are also called al hafathah (الحفظة) which means the guarding angels. They protect us from the harm of evil jinn and shaytan (شيطان).angels who keep people from death until its decreed time.

In Islamic tradition a guardian angel or watcher (angel) (raqib “watcher”) is an angel which maintains every being in life, sleep, death or resurrection. The Arabic singular for mu’aqqibat would be a mu’aqqib “a person which follows.” These angels are included in the hafazhah (“the guards”) and the concept of the guardian angel in Islam is similar to the concept of the guardian angel in some Jewish and Christian traditions.

At the end of Ramadhan last year, I reflected about my remarkable experience by writing a poem entitled ‘Hafazah’. In that poem, I was meeting that guardian angel  when I make it to heaven and we were having a conversation. Hahha. It was a fanciful poem but it was deeply felt.

The month of Ramadhan has always been special to every single practicing Muslim out there. It is the month of miracle. I knew that before. Intellectually, I believe that. But now God let me emotionally experience the miracle. It was a blessing, actually. And so, I have nothing else to say but Alhamdulillah.

 

Hafazah

Katakanlah nanti suatu hari
Kita bertemu sekali lagi
Jasad, jisim, jirim ukhrawi
Bukan di sini, di syurga abadi
Akankah kau aku kenali?
Akankah aku kau dekati?
Akankah kau aku hampiri?
Lantas berkata dengan lirih,
“It was you then, wasn’t it?
In the world once you’d saved me,”
Akankah kau menjawab kembali,
“No problem, dearie, you don’t owe me,
It was my job, so I did it. 
The ink has dried, the pen is lifted.”  

Akankah aku berkata pula
“Sudah lama ingin berjumpa,
mengenali dia gerangan mana,
menjaga aku tika bahaya,
mengiringi ku dalam duka,”
Kemudian kau akan ketawa,
“No problem dearie, you don’t owe me,
It was my job, so I did it. 
The ink has dried, the pen is lifted.”

Akankah aku melirik padamu,
Lalu dengan suara esak tersedu
Mengucapkan puisi dalam sendu
Yang kau balas dengan menyeru.
“No problem dearie, you don’t owe me,
It was my job, prescribed by God 
So I did it, not for you
I swear, nothing else is true,
It wasn’t your time, or it would be done”

Atau mungkin kita tidak akan berjumpa,
Kerna layakkah aku menapak ke syurga?
Mencarimu di sana adakah terdaya?
Mungkin madah ini takkan termakna
Hanya tinta beku coretan pena
Catatan kaku selama-lamanya.

5/7/16, 30 Ramadhan 1437

5.30 pm

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