Post-traumatic stress disorder (PTSD) is more common in the dying, their families and the bereaved than you might think. Dr Louis Heyse-Moore, a retired consultant in palliative medicine, counsellor and writer, explains how recent advances in the treatment of PTSD may be relevant to improving support for the dying.
He was an old, white-haired, stocky, Polish man dying of cancer. He lapsed into an agitated confusion. He was back in his Second World War concentration camp. The other patients were his fellow inmates and we hospice staff were the guards. He saw a woman who had recently died. No surprise; it happened all the time in the camp. This was my first encounter as a young doctor with post-traumatic stress disorder (PTSD) and I had no idea what to do.
Years later, I trained in Somatic Experiencing (SE), a trauma therapy. It was a queue of Aha! moments. Our mammalian body holds the key. Our life feels threatened; our physiology reacts − adrenaline, a racing heart, muscles primed to fight or flee. If we can’t, our nervous system freezes.
The stage is set for PTSD with its unholy mix of hyperarousal (flashbacks and nightmares) and hypoarousal (dissociation, depression and avoidant behaviour). How does this apply to palliative care?
In several ways:
- The immediate Traumatic Stress (TS) of a terminal illness − gnawing pain or incurability. PTSD from previous medical input − a diagnosis of cancer, a big operation, time in the Intensive Care Unit or toxic chemotherapy.
- Reactivation of past PTSD − war veterans (as above) or developmental trauma from child abuse (violence, neglect, rape).
I thought back over my time in palliative medicine. I recalled many patients. It was hidden in plain sight: PTSD. There was Barbara with her nightmare of a demon staring at her and her terror every time I mentioned cancer or dying. And Vivian, her colon cancer successfully resected, who couldn’t understand her depression until childhood memories of violence and sexual abuse surfaced. There were many more.
My colleagues said PTSD was rare in palliative care. In a study of clients referred to me by a hospice for counselling because of bereavement issues, I found 33 per cent had PTSD. (1) Alici et al (2) found 17 per cent of veterans had PTSD-related symptoms in their last month of life.
Why is this important? Because new understandings in neurophysiology have enabled PTSD therapy to leap forwards in recent years. Hospice patients could benefit from this. How? Tune into the body. Listen to its language: sensations, symptoms, emotions. PTSD affects the emotional and reptilian parts of our triune brain. Talking cognitively isn’t enough.
I’d like to tell you more about SE: about Xanthe, troubled by memories of a sexual attack, whom I watched in awe as she discharged her frozen trauma energy by gently shaking and trembling and left the session with a ton weight lifted from her shoulders; about grounding, bringing a person out of a traumatic terror trance; about carefully titrating the amount of suffering worked with to prevent overwhelm; about resourcing to help stabilisation; about unfreezing and restoring body defences. I’d like to tell you more, but there isn’t space. So maybe try the resources below …
Oh, and by the way, Somatic Experiencing works, as a recent study from Israel shows. (3)
- Heyse-Moore, LH. ‘Is Psychological Trauma in Palliative Care Underdiagnosed and Undertreated?’ Abstract. 1st European Conference on Somatic Experiencing, Denmark. 2015.
- Alici, Y, Smith, MS, Hien, L et al. ‘Families’ Perceptions of Veterans’ Distress Due to Post-Traumatic Stress Disorder-Related Symptoms at the End of Life.’ Journal of Pain and Symptom Management. 2010: 39(3): 507-514.
- Brom, D, Stokar, Y, Lawi, C, et al. ‘Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study.’ Journal of Traumatic Stress. 2017; 30(3): 304-312.
Notes: Patient details have been anonymised.
All photos were taken by Louis Heyse-Moore.
Links and Resources
- Heyse-Moore, L. ‘Trauma and the Dying.’ Therapy Today. 2016; 27(2): 18-21.
- Levine, P. Waking the Tiger: Healing Trauma. Berkeley, California: North Atlantic Books. 1997.
- Levine, P. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, California: North Atlantic Books. 2010.
- Somatic Experiencing Trauma Institute.
- Somatic Experiencing Association UK.
- SOS Internationale – the official training body for becoming a Somatic Experiencing Practitioner in the UK – provides simple, practical, and effective tools to address the symptoms of trauma.
- Contact Dr Louis Heyse-Moore DM FRCP MBACP by email.