Adult survivors of child abuse

• Abuse frequently has lifelong effects, with some effects remaining hidden due to delayed disclosure or disbelief from others.
• Forms of Abuse: Multiple types often occur together, compounding the adverse effects on mental and physical health.
• Statistics: The Australian Institute of Health and Welfare estimates significant reductions in mental health disorders (e.g., depressive and anxiety disorders) and self-harm if childhood abuse was eliminated.

2. Health Consequences of Childhood Abuse

• Mental Health Impacts: Strong associations with depression, anxiety, PTSD, substance misuse, suicidal tendencies, and risky behaviors.
• Physical Health Impacts: Increased risk of chronic conditions such as arthritis, ulcers, migraines, obesity, diabetes, and cardiovascular disease.
• Biological Mechanisms:
  • HPA Axis: Alters stress response mechanisms, affecting physical and mental health.
  • Neuroplasticity: Abuse influences neural changes, potentially impacting therapy response.
  • Epigenetic Changes: Exposure to trauma may alter gene expression, affecting immunity and stress resilience.
  • Inflammation: Early trauma linked to inflammatory conditions and potential bidirectional relationship with mental illness.

3. Survival Mechanisms and Behavioral Adaptations

• Substance Misuse: Often used as a coping mechanism (alcohol, smoking, drug use).
• Risky Behaviors: Includes gambling, physical inactivity, and disordered eating, potentially maladaptive if they avoid dealing with trauma.
• Psychological Mechanisms:
  • Dissociation: A common response, particularly in those abused at younger ages or with feelings of helplessness, leading to disconnection from emotions and thoughts.
  • Emotional Dysregulation: Presents as strong, fluctuating emotional responses and impaired cognitive function when emotionally triggered.
  • Alexithymia: Difficulty in identifying and describing internal emotional states, often leading to frustration and miscommunication in clinical settings.

Emotional Dysregulation:

• Definition: Difficulty in managing or responding to emotional experiences in an adaptive way.
• Presentation:
  • Intense physical and emotional reactions.
  • Emotions that are heightened, fluctuate quickly, and can be unpredictable.
  • Commonly triggered when in a hypervigilant or heightened state of awareness.
• Cognitive Impact:
  • Emotional triggers can impair cognitive function.
  • Challenges arise in understanding or regulating emotions effectively.
• Dissociation:
  • A defense mechanism where a person may ‘disconnect’ from their thoughts, emotions, physical sensations, or sense of self.
  • Often used by individuals under extreme distress as a form of escape or self-protection.
• Mood State Incongruence:
  • Emotions may not align with the subject being discussed.
  • Difficulty in identifying or articulating emotional states (referred to as alexithymia).
• Adaptive Dissociation:
  • For some, particularly adult survivors of trauma, dissociation is a persistent mechanism activated under stress.
  • This may hinder the development of self-reflective practices and adaptive coping mechanisms.
• Mindfulness as an Intervention:
  • Can help re-engage individuals with their internal and external sensations.
  • Aims to reduce dissociation by fostering awareness of present-moment experiences.

4. Risk of Revictimization and Additional Trauma

• Increased Vulnerability: Adult survivors have a higher risk of experiencing victimization and violence.
• Implications for GP Care: Trauma-informed therapies are recommended to manage potential violent or self-harming behaviors.
• Intergenerational Trauma: Patients with childhood abuse histories may struggle with boundaries and might unintentionally perpetuate cycles of abuse without proper support.

5. Protective Factors for Resilience

• Positive Experiences: Success in academics, sports, social activities, and supportive friendships promote resilience.
• Internal and External Supports: Cognitive strengths (e.g., intelligence) and psychological resilience (e.g., temperamental stability) can buffer adverse outcomes.
• Role of GPs: GPs can advocate for these protective factors, especially in families where abuse or trauma has been present.

6. Prevalence and Vulnerable Populations

• National Statistics: Around 13% of Australian adults report childhood abuse, with one in four girls and one in eight boys affected by sexual abuse.
• Gender Differences: Girls have higher vulnerability to sexual abuse, whereas boys are more often affected by physical abuse.
• Vulnerable Groups: Those with backgrounds of intergenerational trauma (e.g., Aboriginal and Torres Strait Islander communities) or parents with substance abuse are at heightened risk.

7. General Practice Presentations

• Common Symptoms and Conditions:
  • Anxiety
  • panic attacks
  • chronic depression
  • obesity
  • eating disorders
  • personality disorders
  • chronic pain
  • substance abuse
  • saucidality
  • chronic pain
  • STD
  • self-hram
• Complex PTSD:
• Patients may exhibit
  • hypervigilance
  • flashbacks
  • re-experiencing
  • avoidance behaviors
  • dissociation
  • mimicking or compounding other mental health disorders.
• Somatic Presentations:
  • Unexplained GI symptoms
  • chronic pain
  • recurrent STDs may indicate trauma, requiring a sensitive inquiry into trauma history.

Complex Trauma and Patient Presentation

Understanding trauma-related behaviors through this lens reduces stigma and allows for compassionate, contextualized care.

• Avoidance and ‘Resilience’:
  • Overworking can act as an avoidance strategy, similar to coping through disordered eating, substance use, or gambling.
  • When this becomes maladaptive, it can prevent addressing emotional and interpersonal issues.
• Doctor–Patient Relationship:
  • Misunderstandings in communication can lead to conflicts, especially if the patient feels unheard or misinterpreted.
• Self-Esteem and Trust:
  • Survivors often struggle with low self-esteem and trust issues, particularly if betrayal occurred from a trusted figure.
  • They may experience a false sense of blame for their abuse, complicating their self-perception.
• Cognitive Impairments:
  • Heightened distress can impact concentration and memory, further affecting daily functioning and self-worth.
• Attachment Issues:
  • Without stable attachment models in childhood, survivors may have difficulties with interpersonal relationships in adulthood.
• Underlying Shame:
  • Profound shame often drives many symptoms and behaviors, particularly in trauma survivors.
• Multiple Diagnoses:
  • Survivors frequently accumulate various diagnoses, such as depression, anxiety, PTSD, and borderline personality disorder, leading to potential stigma and discrimination.
• Long-term Impact:
  • The trauma effects can be lifelong if untreated. Influencing factors include abuse type, duration, family support, disclosure responses, and ongoing experiences of abuse.
• Triggering Events:
  • Specific life events, such as marriage, childbirth, reaching a certain age, the death of an abuser, or sensory triggers (like smells), can precipitate PTSD flashbacks.
• Discussing Childhood Trauma:
  • Patients may not voluntarily disclose trauma unless prompted; however, health professionals may hesitate to ask, fearing it will complicate consultations.
  • Patients generally appreciate sensitive inquiries regarding adverse childhood experiences, but insensitive questioning can re-traumatize.
• Trauma-Informed Care:
  • A trauma-informed approach involves actively considering trauma in patient presentations, validating experiences, and providing a safe environment.

Adverse childhood experiences with proven physiological impacts5
Disconnection	Invasion	Loss of safe caregiver
Physical neglect(a) Emotional neglect(a) Non-verbal emotional abuse(b) Peer physical bullying(b) Emotional abuse(a)	Physical (including intimidation) abuse(a) Sexual abuse(a) Witnessing violence against siblings(b)	Absent parent(a) Intoxicated (alcohol or drugs) parent(a) Mentally unwell parent(a) Incarcerated parent(a) Witnessing interparental violence(a) Witnessing violence against siblings(b)
a. Direct evidence4,50,51 b. Direct evidence13

Role of General Practitioners in Trauma-Informed Care

• Trauma-Informed Approach:
  • Safety: Ensure patients feel physically and emotionally secure in consultations.
  • Trustworthiness: Establish consistent, transparent interactions with clear boundaries.
  • Choice and Empowerment: Involve patients in decisions to support autonomy and control.
  • Collaboration: Work in a team-based model, referring to mental health specialists as needed.
• Boundaries: GPs must model strong boundaries, crucial for patients with histories of boundary violations, and avoid re-traumatization by respecting emotional and physical space.

Identification and Screening for Past Abuse

• Signs and Symptoms: Somatic symptoms, mental health disorders, substance misuse, suicidality, or risky behaviors may indicate a history of trauma.
• Inquiry and Disclosure: Patients rarely disclose without being asked. When asking, GPs should avoid leading questions and instead gently probe with open-ended questions about childhood or family dynamics.
• Case-Finding: GPs should maintain a trauma-informed lens in all consultations, recognizing that re-traumatization risks can increase in insensitively handled inquiries.

Triggers for PTSD Symptoms in Adult Survivors

• Life Events: Marriage, childbirth, their child reaching a certain age, or the death of the perpetrator may provoke traumatic memories.
• Other Triggers: Specific locations, smells, or media representations related to the trauma can trigger flashbacks or anxiety.
• GP Approach: Recognize potential triggers and help patients develop coping strategies or refer to appropriate therapy.

Support and Follow-Up in General Practice

• Supportive Approach: Acknowledge the patient’s experience, validate their feelings, and encourage hope for recovery.
• Multidisciplinary Referrals: Patients benefit from coordinated care involving mental health services, with GPs acting as facilitators.
• Encouragement of Long-Term Engagement: Many survivors need extended, empathetic support, especially if unwilling or unable to access mental health services independently.

Management

1. Approach to Consultation

• Understanding and Listening: It’s essential to approach each consultation as an opportunity for the patient to share their story, which may be challenging due to the nature of trauma and the patient’s readiness. GPs may need to navigate their own experiences or preconceptions to avoid misalignment with the patient’s goals.
• Patient-Led Solutions: Allow the patient to guide their narrative, focusing on person-centered solutions that resonate with them individually.
• Financial and Time Constraints: These factors can hinder the ability to offer support fully. GPs should be mindful of setting realistic time frames and expectations for ongoing sessions.

2. The Process of Telling the Story

• Role of the GP: Listening attentively is therapeutic and can empower the patient. The GP’s role includes balancing empathy without becoming overly engaged in the patient’s distress, which might keep the patient emotionally stagnant.
• Learning to Cope: Adult survivors with severe trauma may lack foundational coping skills and may need to learn, not re-learn, these strategies. Dissociation or disconnection from feelings may mean they are still working on reconnecting with their thoughts and emotions before managing them.
• Clues of Dissociation: A lack of coherence in the patient’s story, missing information, or unusual emotional responses (too much or too little) may indicate dissociation. Recognizing this can help GPs approach the narrative with sensitivity.

3. Handling Emotional Reactivity

• Hyperarousal and Hypo-arousal: Sudden emotional responses can signify that certain topics are emotionally triggering. During such instances, it’s vital to ensure the patient feels safe and supported, helping them remain grounded in the conversation.
• Balancing Empathy: Too little empathy may hinder rapport, while too much can prevent the patient from progressing. Acknowledge the patient’s feelings but maintain focus on gathering necessary details and advancing the discussion constructively.
• Checklist for Coherent Storytelling: Use a checklist to ensure key elements of the patient’s history are not missed, as trauma survivors may provide information in non-linear, overwhelming, or fragmented ways.

4. Setting Expectations and Session Structuring

• Multiple Sessions: Complex cases often require multiple sessions to build trust and understand the patient’s experiences. Setting this expectation early can relieve pressure on both the GP and the patient.
• Prioritizing Impact Over Specifics: While specific trauma details may emerge, understanding its overall effect on the patient is often more beneficial. Focus on the psychological, social, and functional impact rather than explicit details of the trauma.

5. Navigating Emotional Dysregulation and Relational Challenges

• Emotional Dysregulation: Table 13.1 outlines signs of emotional dysregulation, which can derail the consultation. Recognizing these signs enables the GP to respond effectively, guiding the patient back to a manageable state.
• Relational Difficulties: Patients may face complex relationships with family, friends, or even the GP, particularly if they’ve had prior negative experiences in healthcare. Maintain clear, respectful boundaries to support therapeutic engagement.

6. Acknowledging Social and Environmental Influences

• Broader Influences on the Story: Social, cultural, economic, and psychological contexts are integral to the patient’s experience and recovery process. Attending to these dimensions can enrich the consultation, providing insights into factors that may aid or hinder the patient’s healing journey.

Managing risk, therapy options, pharmacotherapy

1. Managing Risk

• Suicide and Self-Harm Risks: Childhood trauma increases the risk for suicide and self-harm, and some survivors may be at risk of harming others.
• Risk Assessment: A thorough risk assessment should be part of the management plan, especially when handling complex trauma histories.
• Resources for Suicide Prevention: Sane Australia’s suicide prevention guide and the resource “Suicide Prevention and First Aid for GPs” offer guidance on safety planning and suicide management.

2. Therapy and Treatments

Psychological Therapy

• Effectiveness: Psychological therapy has proven benefits for reducing PTSD, depression, and anxiety symptoms in adult survivors.
• Trauma-Focused Therapies: Trauma-centered therapies (e.g., EMDR, cognitive processing therapy) are particularly effective for reducing depression and dissociation, although anxiety reduction may vary.
• Therapy Options:
  • Individual Counseling: One-on-one therapy offers a safe, controlled environment to process trauma.
  • Specialist Services: Referral to mental health specialists, such as trauma-trained psychologists, can provide targeted support.
  • Group Therapy and Self-Help: Group therapy allows for shared experiences, while self-help groups can provide ongoing peer support.
• Adaptability and Sensitivity: Therapy should match the survivor’s stage in recovery. Some may find sharing re-traumatizing, while others find it therapeutic.
• Choice and Empowerment: Providing treatment options reinforces the survivor’s autonomy, helping counteract disempowerment from past abuse.
• Emerging and Experimental Therapies: Approaches like exercise and social integration are low-risk and may benefit emotional and physical health, though further research is ongoing.

Specific interventions for common symptomatology

Table 13.1 https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/specific-abuse-issues-for-adults-and-older-people/adult-survivors-of-child-abuse

Common symptomatology seen in victims/survivors of childhood trauma, linked to intervention5
Symptom type	Common symptomatology seen in victims/survivors of childhood trauma	Targeted intervention
Somatic symptoms	Medically unexplained symptoms Syndromes such as irritable bowel syndrome, chronic fatigue and fibromyalgia Chronic pain Consequences of maladaptive coping (eg substance abuse, eating disorders) May be associated with strong emotional states	Validation of the patient’s physical distress and appropriate investigation Psychoeducation regarding the psychological awareness of the link between symptoms and situation
Emotional dysregulation	Irritability and chronic hyperarousal Recurrent or chronic suicidal ideation Self-harm Maladaptive coping strategies (eg addictions, eating disorders)	Distress regulation(a) Psychoeducation regarding the psychological awareness of the link between distress and situation
Interpersonal instability	Re-enacting unhelpful relationships from the past (eg becoming abusive themselves, or partnering with an abusive partner)Poor parenting skills	Modelling of appropriate attachment Offering a stable and supportive therapeutic relationship
Avoidance	Gaps in the history-taking or the story Diversion or distraction associated with a specific theme Behaviours associated with avoidance. These may include substance use, eating disorders or disruptive behaviours. Avoidant behaviours may also be traditionally considered as ‘positive’ behaviours until they become maladaptive. An example could include distraction into work rather than addressing the issues most triggering the emotional distress.	Validation and acknowledgement of the patient’s distress and what they have been able to achieve Supportive therapy to build on other resiliences Exposure therapy, once the patient is ready  Note: If a person is using avoidance as a coping mechanism, they may be feeling too overwhelmed at this time. Go slow. Engaging the patient may require identification of what they are avoiding, drawing links between the distress and current management style (avoidance) and exploration of alternatives. This should be patient-centred, or otherwise risks alienating the patient.
Re-experiencing and dissociation	Post-traumatic stress disorder symptoms, including nightmares, flashbacks and re-experiencing Flashbacks may be predominantly emotional (ie feeling acutely distressed, anxious or fearful for no apparent reason and with no obvious narrative)Dissociation, where victims/survivors lose track of time and place, or have an intense experience of depersonalisation or derealisation	Distress regulation Exposure therapy
Disorders of memory	Fragmented memories from childhood	Psychoeducation Distress regulation
Shame	Poor sense of self, including beliefs that they are fundamentally defective, toxic or worthless	Establishment of values and appropriate goal setting(b)
Further ways to manage distress regulation are considered in Asking difficult questions – Identifying a person’s strengths and supports (refer to Box 13.3). Achieving a sense of purpose or meaning is an important aspect of self-actualisation. This concept is known by various names in different forms of psychotherapy. For example, in cognitive behavioural therapy, it can be called ‘schema therapy’. In acceptance and commitment therapy, it can be the ‘values’ and ‘goal setting’ arms of therapy. The goal of psychodynamic therapy is for the patient come to an understanding of their sense of purpose or meaning through exploration of their self-belief within a consistent, respectful and empathic therapeutic relationship. Self-actualisation and changing belief settings may only be possible once other needs, such as safety and security, are met.

Pharmacotherapy

• Adjunctive Role: Medications, such as SSRIs or anxiolytics, can help regulate emotions but should be used alongside therapy, not as a replacement.
• Guidelines: The Australian guidelines on treating PTSD and complex PTSD emphasize combined therapeutic approaches for managing acute stress, PTSD, and dissociation.

3. Self-Care for GPs

• Avoiding Burnout: Compassionate work can be demanding; support from systems and colleagues is crucial.
• Evolving Role: As GPs’ skills and personal circumstances evolve, so can their involvement in complex trauma cases, shifting the balance of hands-on care with shared responsibility within a healthcare team.
• Team-Based Approach: Trauma care benefits from a multidisciplinary model where peer support, mentorship, and supervision help mitigate clinician burnout and maintain professional well-being.

4. Ongoing General Practice Care

• Sensitive Procedures: Survivors may find certain procedures (e.g., cervical screening) particularly distressing. Providing choices and reinforcing continual consent are vital.
• Continual Consent Technique: During procedures, the GP should communicate each step and check in with the patient’s comfort, allowing them the freedom to pause or stop at any point.
• Physical Symptoms and Trauma Triggers: Some symptoms, like a sore throat or pelvic pain, may be rooted in past abuse experiences, requiring an understanding and cautious approach to avoid re-traumatization.

5. Referrals and Team Care

• Referral Resources: Referrals should be tailored to meet the survivor’s needs and comfort, with options for gender preferences if desired. The Blue Knot professional support line (1300 675 380) offers guidance and a referral network.
• Types of Referrals:
  • Experienced GPs: Colleagues trained in trauma care can offer ongoing support.
  • Mental Health Specialists: Psychologists, psychiatrists, or psychotherapists with trauma experience provide targeted therapy.
  • Social Workers and Counsellors: Specialized support for addressing social and environmental factors affecting recovery.
  • Sexual Assault Services: Specialized services for those with childhood sexual trauma, if locally available.
• Follow-Up and Continuity: Allow the patient to continue seeing the GP as part of the care team, even during ongoing therapy, offering stability and continuity in their journey.