1 Images of Trauma David Healy Images of Trauma was published in 1993. A good time for a book on trauma. It was originally entitled Images of Uncertainty but the marketing department in Faber thought trauma would work better. Shortly afterwards Faber got out of books of this kind to focus on their core market – poetry, plays and highbrow fiction. The marketing consultants must have gotten to them. One consequence was they never produced a paperback version of Images. The version reproduced here comes from the word files sent to Faber supplemented with scanned pages converted from PDF to word for the references and introduction along with images. There are likely some differences to the final published version. In assembling the material, I was worried the message might deviate from the message in Shipwreck of the Singular. This is the book I have least confidence in. To my surprise, despite a 30 year gap there is a lot of consistency. 2 INTRODUCTION Consider the following clinical cases. A nineteen-year-old girl is admitted to a psychiatric unit. She seems miserable and depressed. Sustained and vigorous treatment with ECT, a variety of antidepressants and combinations of antidepressants, as well as treatment with neuroleptics, do nothing to alleviate her condition. Finally, after a year of treatment, despite little change and repeated suicide attempts, she was discharged from hospital. lt transpired that this girl had been multiply abused on two separate occasions in what appeared to have been organized abuse. At no point during her stay in hospital was she questioned about sexual abuse. These aspects of her care were first stumbled on many years later by friends watching her nightmare. Subsequently under hypnosis, she gradually pieced together a story of considerable trauma, for which she had been amnesic for ten years. Since childhood Steven had suffered from nightmares and sleepwalking. This became a particular problem when, in 1935, he was hospitalized because of an infection. To prevent him from sleepwalking about the ward in the middle of the night his hands were bound behind his back. On one such occasion he awoke and, in a half-conscious state, found himself tied down. Although he could not untie his hands he was still able to evade his bodyguard and escape into the surrounding countryside. He returned a few hours later. Some ten years later, Steven was again admitted tb a hospital - this time in an attempt to cure recurrent sleepwalking. One evening at about midnight the nurse saw him struggling violently on his bed, apparently having a nightmare. He was holding his hands behind his back and seemed to be trying to free them from some imaginary bond. After carrying on in this way for about an hour he crept out of bed still holding his hands behind his back and disappeared into the hospital grounds. He returned twenty minutes later, awake. As the nurse put him to bed she noted deep weals like rope marks on each arm, of which Steven, until then, seemed unaware. The next day the marks were still visible. 3 Steven's physician believed that the marks were stigmata caused by reliving the traumatic event of a decade earlier. To test this, he caused Steven to relive that experience under a hypnotic drug. While reliving the experience Steven writhed violently on the couch for about three• quarters of an hour. After a few minutes weals appeared on both fore• arms. Gradually these became deeply indented and finally blood appeared along their course. Next morning the marks were still clearly visible. A sixty-year-old woman was admitted to hospital following the death of her husband. She had many signs of depression - poor sleep, loss of appetite, loss of interest. But she was unlike most depressed subjects in that she did not know where she was and seemed to forget shortly after being told. She seemed not to know that her husband had recently died, claiming that he was alive somewhere - probably away doing some important business. That he had left her did not appear to bother her. When her children visited, she paid no heed to them. When she did engage others it was to tell them that the car park was sinking or that the main hospital building had burnt down or that the Red armies were coming. A course of electroconvulsive therapy substantially improved her, but whenever she went out with her children for the weekend she came back worse. A meeting with the family indicated that, while they all appeared to love her, none was happy to have her come to live with them. Finally one of her children took her home for a month's trial period but brought her back after a week as her mother had begun to act bizarrely - wandering around claiming she had no head, and hiding in wardrobes. Back in hospital her bizarre behaviour failed to resolve, and further courses of electroconvulsive therapy (ECT), antidepressants and neuroleptics had no beneficial effects. Her general disorientation led to her being transferred to a ward for demented women. There she could often be found standing up against the wall in a crucifixion posture for hours. She sometimes claimed she was blind, and indeed when walking around she often bumped into things. But on such occasions her eyes, typically, were closed. Despite all this, when taken out on ward outings to a nearby shopping centre, she, uniquely among the group, was apprehended for shoplifting. This and other incidents left ward staff certain that she was not demented, that she knew all that was going on around her. And on occasional days she could be perfectly lucid and engage in conversation entirely appropriately. She has now been in hospital for several years. A young boy of eight 'goes off his feet' abruptly. Later that day he is seen by a psychiatrist because his GP thinks the condition is probably hysterical. In discussion with the psychiatrist, it turns out that the boy's father had promised to bring him to the cup final. He was not able to keep his promise, but the final was drawn and there had to be a replay. Again, the father promised to bring the son and again let him down. When faced with the prospect of telling his friends his legs gave way. He walked out of the psychiatric consultation. In contrast Estelle, aged twelve, while wearing a new dress one day got into an argument with a friend which ended in her being pushed over backwards. She fell and soiled her dress in a most embarrassing way. She came home and tried to conceal the shame. The following day she began to lose the power of her legs. She remained paralysed until healed by hypnosis eight years later. A fifty-five-year-old woman was in court to testify about a road accident. Having talked at great length when asked to she later interrupted further proceedings to let the court know about something she had just remembered. An irate magistrate ordered her to shut up. She did - for over a year. Why she later recovered was not very clear to subsequent therapists. A man in his sixties due shortly to retire from a sales job loses his job because the business goes bankrupt. He has to sell his car. He could retire and supplement a rather meagre state pension with donations from his children. However, he has always worked and feels obliged to keep on doing so. He finds factory work nearby doing unskilled labouring in uncongenial surroundings. His family notice 4 that he begins to become withdrawn and unhappy. After two years it becomes too much for him and he quits. Thereafter he sits at home all day doing nothing. This provokes anger and concern at home. His general practitioner refers him to a psychiatrist who diagnoses depression and tries him on antidepressants, to no avail. Shortly after this visit he begins to have difficulties walking. His gait becomes more and more peculiar, especially the left leg, which he drags after him while hopping forward on his right leg. His left arm sticks out at an odd angle. When asked what is wrong, he complains of a pain in his knees. He has several falls which lead to hospitalization for suspected minor strokes or epilepsy. But no abnormality is discovered. He is sent home unchanged. His voice then begins to fail, at first slowly, but the failure is progressive so that after a few months it has almost completely disappeared. He can still communicate by writing. When asked why no one has been able to find anything wrong with him he writes, because they have not looked hard enough. The man has by now been almost aphonic for over a year. No one knows how to help him. He seems condemned to remain at home in this odd state until he dies. Finally, an attractive twenty-year-old girl is brought into hospital seriously depressed. She has stopped eating. She sleeps poorly, if at all. Her answers to all questions are that she has killed people, she is a murderer, and she will be executed. She always looks distracted, at times appears to be having visions and on occasion is seen to walk backwards. Neither antidepressants in large doses nor neuroleptics make any difference. ECT is considered, as she is seemingly delusionally depressed. However, the nursing staff feel there is something different about this lunacy and suggest diazepam instead. She responds rapidly to a moderate dose of this and is normal within a few days. Subsequent discussions reveal that the episode began following an argument with her family about whether she should be going ahead with a marriage scheduled for a few weeks later.