What is Trauma?

Trauma is a person’s emotional response to a distressing experience. Few people can go through life without encountering some kind of trauma. Unlike ordinary hardships, traumatic events tend to be sudden and unpredictable, involve a serious threat to life—like bodily injury or death—and feel beyond a person’s control. Events are traumatic to the degree that they undermine a person’s sense of safety in the world and create a sense that catastrophe could strike at any time. Parental loss in childhood, auto accidents, physical violence, sexual assault, military combat experiences, the unexpected loss of a loved one are commonly traumatic events.
Trauma describes a type of injury, which can be physical, sexual, or emotional/psychological. Alterations in arousal, reactivity, mood, anxiety, thoughts, and behaviors can occur following traumatic experiences.

Types of Trauma

Acute trauma reflects intense distress in the immediate aftermath of a one-time event and the reaction is of short duration. Some examples include a car crash, physical or sexual assault, or the sudden death of a loved one.
Chronic trauma can arise from harmful events that are repeated or prolonged. It can develop in response to persistent bullying, neglect, abuse (emotional, physical, or sexual), and domestic violence.
Complex trauma can arise from experiencing repeated or multiple traumatic events from which there is no possibility of escape. The sense of being trapped is a feature of the experience. Like other types of trauma, it can undermine a sense of safety in the world and beget constant, and exhausting, monitoring of the environment for the possibility of threat. Click here for more information about Complex Trauma
Vicarious trauma arises from exposure to other people’s suffering and most commonly occurs in professions that are called on to respond to injury and mayhem (e.g., physicians, nurses, first responders, firefighters, and law enforcement). 
Adverse Childhood Experiences (ACE) cover a wide range of difficult situations that children either directly face or witness while growing up, before they have developed effective coping skills. ACEs can disrupt the normal course of development and the emotional injury can last long into adulthood. The loss of a parent; neglect; emotional, physical, or sexual abuse; and divorce are among the most common types of Adverse Childhood Experiences.

Effects of Trauma

Distressing events activate an area of our brain called the amygdala. The amygdala is responsible for detecting threats and responds by sending out an alarm signal to multiple body systems–this results in our “fight or flight” response. The sympathetic nervous system stimulates the release of adrenaline (epinephrine), noradrenaline (norepinephrine), and stress hormones (e.g., cortisol) that prepare the body to fight, run, or freeze. Short-term fear, anxiety, shock, and anger/aggression are all normal responses to trauma. Such negative feelings dissipate as the crisis abates and the experience fades from memory, but for some people, the distressing feelings can linger, interfering with day-to-day life.
Sufferers of long-term trauma may develop emotional disturbances, such as extreme anxiety, anger, sadness, survivor’s guilt, disassociation, the inability to feel pleasure (anhedonia), or PTSD (post-traumatic stress disorder). The amygdala become hyperactive, its over-reaction to minor perturbations leading to an outpouring of stress hormones. Living in defense mode, and vigilant to the possibility of threat, people may experience ongoing problems with sleep or physical pain, encounter turbulence in their personal and professional relationships, and feel a diminished sense of self-worth.
Positive psychological changes after trauma are also possible when people acknowledge their difficulties and see themselves as survivors rather than victims of unfortunate experience. These can include building resilience, the development of effective coping skills, and development of a sense of self-efficacy. Some people may undergo post-traumatic growth, forging stronger relationships, redefining their relationship with new meaning and/or spiritual purpose, and gaining a deeper appreciation for life. It may sound contradictory, but post-traumatic growth can exist alongside PTSD.

Trauma is the “Great Mimicker” of Psychiatric Disorders

Those who’ve experienced trauma throughout their lives often have a “disorder” called “survival mode.” Clinically, we call this Post Traumatic Stress Disorder (or Complex Post Traumatic Stress Disorder). Unfortunately, the symptoms of post-traumatic stress can disguise itself and lead to misdiagnosis.
Disorders such as Borderline Personality Disorder, Obsessive compulsive disorder, Eating Disorders, Body Dysmorphia, Attention Deficit Hyperactivity Disorder, Depression, Generalized Anxiety Disorder, Dysthymia, and panic disorder may be manifestations of post-traumatic stress. This highlights the importance of recognizing symptoms and signs of Post-Traumatic Stress Disorder (PTSD) and Complex Post Traumatic Stress Disorder (C-PTSD).

Post-Traumatic Stress Disorder (PTSD)

What are common signs and symptoms of Post Traumatic Stress Disorder (PTSD)?

Exposure to actual or threatened death, serious injury, or sexual violence in the following ways
  • Directly experiencing the traumatic event(s).
  • Witnessing, in person, the event(s) as it occurred to others.
  • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Intrusion symptoms such as
  • Recurrent, involuntary, and intrusive distressing memories of of the traumatic event(s).
  • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (on a continuum).
  • Intense or prolonged psychological distress at  exposure to internal or external cues.
  • Marked physiological reactions to internal or external cues.
Avoidance symptoms such as
  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely with the traumatic event(s).
Negative alterations in cognitions and mood such as
  • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
  • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
  • Markedly diminished interest or participation in significant activities.
  • Feelings of detachment or estrangement from others.
  • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked alterations in arousal and reactivity such as
  • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  • Reckless or self-destructive behavior.
  • Hypervigilance
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Other symptoms that might occur include
  • Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
  • Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
  • Panic Attacks

Terms Used Throughout History to Describe what we now call PTSD:

  • Irritable Heart (Jacob DaCosta, 1871)
  • Soldier’s Heart
  • Effort Syndrome
  • Neurocirculatory Asthenia
  • Compensation Neurosis
  • Shell Shock
  • War Neurosis
  • Battle Fatigue
  • Vietnam Syndrome

Quick Facts about PTSD

  • The highest rates of PTSD occur among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide
  • Combat is the most common traumatic event for men
  • Rape/sexual assault and physical assault are the most common traumatic events in women
  • Natural disasters (earthquakes, storms, floods), terrorist attacks, mass killings, and child abuse are also common traumatic events
  • PTSD has a familial pattern
  • If left untreated, 30% of patients with PTSD will experience remission, 40% will develop mild symptoms, 20% will develop moderate symptoms, and 10% will develop severe symptoms

Good Prognostic Factors

The following are associated with better outcomes and responses to currently available treatments
  • Rapid onset of post-traumatic symptoms
  • Short duration of post-traumatic symptoms
  • Good functioning prior to the traumatic event
  • Strong social support
  • Absence of substance use or other psychiatric disorders

Risk Factors

The following, when present, are risk factors for developing Post Traumatic Stress Disorder
  • Life-threatening traumatic event (i.e., intensity or severity of traumatic event)
  • Longer duration of traumatic event (s)
  • Proximity of traumatic event(s)
  • Childhood trauma
  • Borderline/antisocial/dependent/paranoid personality traits
  • Inadequate support system
  • Female gender
  • Recent stressful life changes
  • Recent excessive alcohol intake

NOTE: PTSD is more likely to occur in individuals who are single, divorced, widowed, socially withdrawn, or in lower socioeconomic statuses 

Traumatized individuals may be at increased risk for developing the following

  • Depression
  • Bipolar Disorder
  • Panic Disorder
  • Social Phobia
  • Generalized Anxiety Disorder
  • Alcohol Abuse/Dependency
  • Substance Abuse/Dependency
  • Cerebrovascular disease
  • Congestive Heart Failure
  • Peripheral Vascular Disease
  • Myocardial Infarction (heart attacks)

Neurobiological Alterations

  • Hypothalamic Pituitary Adrenal (HPA) Axis Dysregulation (altered cortisol levels and biological rhythms)
  • Decreased volume of the hippocampus has been reported in combat veterans
  • Noradrenergic (Norepinephrine), Opioid, Glutamate, GABA, and Endocannabinoid dysregulation
  • Sleep disturbances such as decreased REM latency (i.e., decreased time between falling asleep and the first Rapid Eye Movement Cycle). 

Treatment

Medications

Selective Serotonin Reuptake Inhibitors (e.g., Sertraline, Paroxetine, Citalopram, Escitalopram, Fluoxetine) and Serotonin Norepinephrine Reuptake Inhibitors (e.g., Venlafaxine, Duloxetine) are first line medications for post-traumatic stress disorder. Prazosin is often used for trauma-related nightmares. Propranolol (Inderal), Clonidine, Valproic Acid (Depakote), Buspirone (Buspar), Mirtazapine (Remeron), Trazodone (Desyrel), Amitriptyline (Elavil), and Nortriptyline (Pamelor) may also be prescribed.  Medications primarily target intrusive thinking, ruminations, negative thoughts, mood reactivity, hypervigilance, aggression, irritability, impulsivity, insomnia, muscle tension, and panic attacks. 

The algorithm below is from the Psychopharmacology Algorithms Project at the Harvard South Shore Psychiatry Residency Training Program

Project Leader: David Osser, MD

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Psychotherapy

While medication can be very important in the treatment of post-traumatic stress disorder, psychotherapy is equally (if not more) important and strongly recommended. Exposure therapy, mindfulness-based therapies, cognitive behavioral therapy, psychodynamic psychotherapy, psychedelic assisted psychotherapy, eye movement desensitization reprocessing (EMDR), family therapy, and group therapy are used to varying degrees. 

Neuromodulation

Modalities such as neurofeedback, Transcranial Magnetic Stimulation (TMS), and ketamine infusion therapy are recommended if medication and traditional therapy are not beneficial (or only partially beneficial).

Emerging Treatments

  • Ketamine Infusions
  • Ketamine Assisted Psychotherapy
  • MDMA with guided psychotherapy
  • Psilocybin
  • Psychedelic Assisted Psychotherapy
  • Cannabis
  • Transcranial Magnetic Stimulation (TMS)
  • Electroconvulsive Therapy (ECT)

Complex Post-Traumatic Stress Disorder

Becoming a Chameleon: A Common Story of Trauma

As young children, we develop a sense of “self” through the interactions we have with the important trusting figures in our lives. Our sense of self evolves by exploring a variety of ideas, personalities, sexualities, genders, etc. By “trying on” different identities, we formulate a coherent sense of who we are. We learn about our bodies and how they relate to our feelings. We learn what trust means and who we can and can’t trust. As children, we are like sponges of information. And we don’t know any different.
Normally, our sense of self develops within a safe environment. But when there is no safety or security and our innocence is turned against us and our curiosity is made out to be a burden, we do what any normal, innocent child would do–we hide. We dissociate into pieces and parts. We learn to be who we need to be to remain safe. We become chameleons. We learn that our worth is dependent upon our productivity, on our external appearance, on how much money we have, how popular we are, and how much our friends and significant others love us.
It’s no wonder medicine is often ineffective. That’s because there is NOTHING inherently wrong with us at all. That doesn’t mean we aren’t feeling pain, depression, anxiety, fear, etc. And it doesn’t mean medicine wouldn’t be helpful. But it is important we remind ourselves that nothing is inherently wrong with us. When we are hurt by those who are supposed to protect us, we not only hide who we are, but we hide within our thoughts. And we hide from ourselves.
By doing so we regain some of the control we lost at an early age. We live in our heads because it’s the only safe place to live. Our own bodies aren’t even safe. We hide from ourselves and neglect ourselves because we were taught to fear ourselves–that being ourselves is dangerous. So, we try to control everything. EVERYTHING.
Our obsessiveness and neuroticism aren’t a problem or a disorder. They are normal responses to learning that being ourselves is dangerous. Countless times we hear ourselves saying “I don’t know how I feel.” That’s because we are exhausted. We are burned out. We’ve been made to believe that being ourselves and showing love for ourselves is selfish and BAD.
We “fight” (i.e., overreact with anger and aggression), we “flight” (i.e., run away or avoid), and/or we “freeze” (i.e., dissociate) when confronted with anything that might threaten our safety and security that we work so hard to maintain. Part of healing from trauma is recognizing these reactions and using coping skills to rewire our brains. 

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
  2. Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences.Sixth Edition.
  3. Bear, Mark F.,, Barry W. Connors, and Michael A. Paradiso. Neuroscience: Exploring the Brain. Fourth edition. Philadelphia: Wolters Kluwer, 2016.
  4. Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
  5. Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
  6. Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  7. Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  8. Mendez, M. F., Clark, D. L., Boutros, N. N. (2018). The Brain and Behavior: An Introduction to Behavioral Neuroanatomy. United States: Cambridge University Press.
  9. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  10. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  11. Neuroscience, Sixth Edition. Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White. Oxford University Press. 2018.
  12. Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. 2nd ed. Sunderland, Mass.: Sinauer Associates, 2010.
  13. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  14. Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  15. Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th Edition.
  16. Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia.

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