Narrative Medicine Corner
Contribution by Madeline Mori (Western)
Accessible Text Version
We all carry scars with us that serve as reminders of specific events in our lives. For some, this may be a scar from a laceration from falling off a bike, or a burn on our hand from putting something in the oven. We might look back on these moments and laugh at our stupidity or look back fondly at the memories and the time of life that our scars evoke.
Unfortunately, there are many people who carry scars throughout life that are a constant reminder of dark times in their lives. Many times, these scars are not physical, but are still an ever-present reminder of an experience that changed their life. In medical school, I learned about adverse childhood experiences (ACEs), defined as “potentially traumatic events that occur in childhood,” including experiencing or witnessing violence, abuse, neglect, “having a family member attempt or die by suicide,” and also includes “aspects of the child’s environment that can undermine their sense of safety, stability, and bonding,” like being raised in a home with “substance abuse, mental health problems, [and] instability”. ACEs are shown to have a dose response relationship with many adverse health outcomes later in life, impacting one’s medical, psychological, and social health, including increased rates of mood disorders, anxiety disorders, substance abuse, impulse control disorders, suicide, heart disease, diabetes, stroke, chronic pain, financial and job problems.
Though I rationally understood this to be true, it wasn’t until I went through my psychiatry clerkship at an inpatient psychiatric unit that I really understood this on an emotional level. There, as I spoke to my patients daily, slowly unpacking and understanding why they were in the unit, I was able to see the relationship of ACEs and mental health disorders. For example, a patient who came in for stabbing themself had a long history of abuse and neglect from their parents. Another patient with borderline personality disorder and binge eating disorder had a history of sexual abuse from a family member.
It became evident to me that these patients carry their scars with them wherever they go, affecting the way they interact with others, affecting the way they go about their life and perceive the world. While physical scars can sometimes fade and disappear, is it possible for these psychological scars to heal and fade into the background?
As future emergency physicians, we will undoubtedly come across many patients who have experienced ACEs in their life and may be in the ED as a result of them. How can we best address and help these patients? Of course, in the moment, we can provide a place where our patients feel safe and listened to. We can help our patients work through their trauma and help them with coping mechanisms. We can provide pharmacological treatment. But more importantly, how can we prevent this from happening in the first place?
In California, 33% of children aged 0-17 have experienced 1-2 ACEs and 9% have experienced 3+ ACEs. According to the Institute of Medicine and National Research Council, ACEs are the “most preventable” cause of serious mental illness, drug and alcohol abuse in women, and HIV high risk behavior. Putnam et al found that the “absence of childhood adversities was protective… significantly decreas[ing] an individual's risk for subsequent adult mental illness”.
Especially in the ED, which serves as a safety net for many people in the community, we must adopt a public health approach to identify and prevent ACEs by screening for and following evidence-based treatment and prevention. Hopefully, as future medical professionals, we can break the cycle of ACEs causing negative health outcomes for our patients and future generations. Let us be a place that supports our patients as they heal from their scars, while also supporting community programs so that these ACEs never happen in the first place.
Disclaimer: I am in no way an expert on this topic, but wanted to share some of my thoughts here. Feel free to respond to the newsletter with your thoughts on the matter!
For more information, check out these resources:
- TED Talk by Dr. Nadine Burke Harris: How Childhood Trauma Affects Health Throughout a Lifetime
- ISTSS
References:
3. https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf
4. IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press.
5. Putnam KT, Harris WW, Putnam FW. Synergistic Childhood Adversities and Complex Adult Psychopathology. Journal of Traumatic Stress. 2013. 26:435-442.
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[Included in our Q4 newsletter. Editor: Tiffany Fan]
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