Introduction to PTSD and Trauma

William Harryman, MSC, NCC, MS

What Is Trauma?

Psychological trauma is the unique individual

experience of an event or enduring conditions in

which: “The individual’s ability to integrate

his/her emotional experience is overwhelmed

or the individual experiences (subjectively) a

threat to life, bodily integrity, or sanity.”

(Pearlman & Saakvitne, 1995, p. 60)

• Saakvitne, K. W. et al., Risking Connection®: A Training

Curriculum for Working with Survivors of Childhood Abuse, to be

published by Sidran Press in January, 2000.

What Kind of Trauma? • “Big T” Traumas

• Childhood abuse (sexual, physical, emotional)

• Childhood neglect (physical, emotional)

• Prolonged combat experience

• Refugee camps

• Natural disasters

• Severe accidents

• “Little t” traumas

• Broken bones

• Humiliation and ridicule

• Empathic failures in infancy

• Prolonged bullying

• Feeling left out

• Feeling not cared for

Symptoms as Adaptations

All trauma symptoms are adaptations to survive the

trauma

• Traumatic events end, the person's reaction persists

• The intrusion of the past into the present: re-experiencing

• Intrusion may present as distressing intrusive memories, flashbacks,

nightmares, or overwhelming emotional states

• Hypervigilance, dissociation, avoidance, and numbing are examples of

coping strategies that likely were effective when the trauma was

happening (or in the immediate aftermath) but now interfere with the

person's ability to live the life s/he wants.

Symptoms represent the client's attempt to cope

the best way they can with overwhelming feelings

Developmental Disruptions

• Severe trauma can disrupt basic developmental

tasks

• Developmental tasks underway when the

trauma happens can help determine what the

impact will be

• Disruptions can include: • lack of self-soothing

• the world is an unsafe place

• hard to trusting others

• poor executive function

• more easily exploited

Developmental Disruptions

as Symptoms • Disruption of developmental tasks results in adaptive

behaviors (as we noted above)

• The mental health system views these adaptations as

"symptoms," for example:

• disrupted self-soothing is labeled as agitation

• the disrupted ability to see the world as a safe place looks

like paranoia

• distrust of others is interpreted as paranoia (even when valid)

• disruptions in executive function for decision-making can look

like psychosis

• avoiding/preempting exploitation is called self-sabotage

A Brief Explanation of the

Neuroscience of Trauma

Trauma: Neurological Effects

• During traumatic

experiences, some

regions of the brain

show increased levels of

stress hormones

• One of those stress

hormones is cortisol

• Cortisol shrinks the

hippocampus

• Cortisol enlarges the

amygdala

Trauma Rewires the Brain

• Images are stored in

the right side of the

limbic system

• When recalled:

• Broca’s area is

disengaged (no

verbal translation

of inner

experience)

• Right visual cortex

is highlighted

(experience is

relived)

Trauma and PTSD

Symptoms, Risk, Resilience

What Is PTSD?

• PTSD is a type of anxiety disorder that occurs

“post-trauma,” or after being exposed to some

kind of traumatic event

• Four clusters of symptoms make up a PTSD

diagnosis: • Re-experiencing

• Avoidance (and Emotional Numbing)

• Hyperarousal

• Dissociation

• PTSD is more common than you might think, and PTSD

does not discriminate based on age, sex, or

racial/ethnic background

Re-experiencing Symptoms • Frequent upsetting thoughts

or memories about a

traumatic event.

• Recurrent nightmares.

• Acting or feeling as though

the traumatic event were

happening again, a

"flashback."

• Very strong feelings of

distress when reminded of

the traumatic event.

• Strong physical responsive,

such as experiencing a surge

in your heart rate or

sweating, to reminders of the

traumatic event.

Avoidance Symptoms • Avoiding thoughts, feelings, or

conversations about the

trauma

• Avoiding places or people that

remind you of the trauma

• Difficulty remembering

important parts of the

traumatic event

• Loss of interest in important

and once positive activities

• Feeling distant from others

• Difficulty with having positive

feelings, such as happiness or

love

• Feeling as though your life may

be cut short

Emotional Numbing Symptoms

• Emotional numbing

symptoms are those

symptoms that reflect

difficulties in

experiencing positive

emotions:

• A loss of interest in

important, once positive,

activities and interests.

• Feeling distant from others.

• Experiencing difficulties

having positive feelings,

such as happiness or love

Hyperarousal Symptoms

• Hyperarousal refers to

experiencing high

levels of anxiety:

• Having a difficult time falling

or staying asleep.

• Feeling more irritable or

having outbursts of anger.

• Having difficulty

concentrating.

• Feeling constantly "on guard"

or like danger is lurking

around every corner.

• Being "jumpy" or easily

startled.

Dissociative Symptoms

• The DSM-5 (Diagnostic and Statistic Manual of Mental

Disorders) has added a “dissociative sub-type” for

PTSD.

• Dissociative symptoms were present in 14.4% of

subjects interviewed by WHO (2013)

• Another study (2012) found 25% of their sample could

be characterized by high derealization and

depersonalization symptoms (types of dissociation)

• Individuals who qualify for the dissociative subgroup

show more comorbid Axis I disorders and more

significant history of childhood abuse and neglect

Dissociation

The more betrayal involved in the trauma, the

more psychogenic amnesia (inability to

remember the trauma) and dissociative

symptoms occur

Degrees of Dissociation

Day dreaming/

Highway

hypnosis

Dissociative

Identity

Disorder

Link Between Trauma and PTSD

• Trauma and PTSD go hand-in-hand.

• A number of traumatic events are connected to PTSD,

such as combat, rape, natural disasters, and motor

vehicle accidents.

• To be diagnosed with PTSD, a person must have

experienced some kind of traumatic event.

• Not all events are connected with the same level of risk

for developing PTSD - the level of risk connected with a

particular event is not the same for men and women.

Risk Rates for Men • For men, rape is the traumatic event most likely to be

connected with PTSD

• Approximately 65% of men who said rape was the most

upsetting traumatic event developed PTSD

• Other traumatic events likely to lead to PTSD:

• combat (38.8%)

• childhood neglect (23.9%)

• childhood physical abuse (22.3%)

• being sexually molested (12.2%)

• Men who experience rape and seek help tend to seek

out multiple sources of support

Risk Rates for Women • As with men, rape is the traumatic event most likely to

be associated with PTSD for women

• Approximately 45.9% of women who said rape was their

most upsetting traumatic event developed PTSD

• Other traumatic events that are highly connected to

the development of PTSD for women were:

• being threatened with a weapon (32.6%)

• sexual molestation (26.5%)

• being physically attacked (21.3%)

• childhood physical abuse (48.5%)

• childhood neglect (19.7%)

Why Do Some People Get PTSD and

Other People Do Not?

• Risk factors for PTSD

include: • Living through dangerous events

and traumas

• Having a history of mental illness

• Getting hurt, or fear of being hurt

• Seeing people hurt or killed

• Feeling horror, helplessness, or

extreme fear

• Having little or no social support

after the event

• Distress after the event: loss of a

loved one, pain and injury, or loss

of a job or home

Some People Do Not Experience PTSD

• Only 25-35% of those exposed to trauma will develop

PTSD, and of those, only 20-35% display persistent

symptoms

• Resilience factors that may reduce the risk of PTSD

include:

• Seeking out support from other people, such as friends and

family

• Finding a support group after a traumatic event

• Feeling good about one’s own actions in the face of danger

• Having a coping strategy, or a way of getting through the bad

event and learning from it

• Being able to act and respond effectively despite feeling fear

• Possessing a “secure” attachment style in childhood

PTSD and Attachment

Attachment and PTSD John Bolwby, father of Attachment Theory

• Innate psychobiological system (the attachment behavioral

system)

• Infants seek proximity to caregivers (attachment figures)

• Evolutionary system to protect infants from threats and reduce

distress, when the attachment bond is “secure”

Mary Ainsworth: mother of attachment theory • A Strange Situation: defined “secure,” “anxious,” and

“ambivalent” attachment styles

Mary Main: Adult Attachment Inventory • Added a 4th attachment style to the original three, the

“disorganized” style

Attachment Styles Child and caregiver behavior patterns before the age of 18 months

Attachment

pattern Child Caregiver

Secure –

About 2/3 of

adults

Uses caregiver as a secure base for exploration. Protests

caregiver's departure, seeks proximity, and is comforted on

return, returning to exploration.

Responds appropriately, promptly and

consistently to needs.

Avoidant Little affective sharing in play. Little or no distress on

departure, little or no visible response to return, ignoring or

turning away with no effort to maintain contact if picked up.

Child feels that there is no attachment; the child is "rebellious"

and has a lower self-image and self-esteem.

Little or no response to distressed child.

Discourages crying and encourages

independence.

Ambivalent/

Resistant

Caregiver not a secure base. Distressed on separation with

ambivalence, anger, reluctance to warm to caregiver and

return to play on return. Preoccupied with caregiver's

availability, seeking contact but resisting angrily when it is

achieved. In this relationship, the child always feels anxious

because the caregiver's availability is never consistent.

Inconsistent between appropriate and

neglectful responses. Generally will only

respond after increased attachment

behavior from the infant.

Disorganized Stereotypies (compulsive behaviors) on return such as freezing

or rocking. Lack of coherent attachment strategy shown by

contradictory, disoriented behaviors such as approaching but

with the back turned.

Frightened or frightening behavior,

intrusiveness, withdrawal, negativity, role

confusion, affective communication errors

and maltreatment. Very often associated

with many forms of abuse towards the

child.

Disorganized Attachment

• Disorganized attachment: Activation of incompatible

“approach–avoidance” systems, creating confusion

• Caregiver is both a “haven of safety and a source of

fear”

• (Main & Hesse, 1990)

• Distressed child seeks proximity and contact with the

attachment figure, but the caregiver's frightening

behavior generates fear and escape behaviors

• (Cassidy & Mohr, 2001; Hesse & Main, 2006)

• Caregivers of disorganized infants often have histories

of childhood trauma and unresolved loss

• (Lyons-Ruth et al., 2003; Solomon & George, 1999)

PTSD & Disorganized Attachment

• Longitudinal correlates of early disorganized

attachment include dissociative and externalizing

behaviors

• These overlap with the two of the four symptom

clusters for diagnosing PTSD

• PTSD avoidance symptoms include dissociative

behaviors, such as emotional numbing or isolating

• With the addition of a “dissociative subtype” for PTSD, there

may be a realignment of the symptom clusters

• PTSD hyper-arousal symptoms include externalizing

behaviors, such as irritability or outbursts of anger

• Both dissociative symptoms and externalizing symptoms

are commonly seen in traumatized individuals

Why This Matters . . . • Trauma-Informed Therapy

• Client Needs: Mirroring, Idealization, Twinship (Heinz

Kohut), manifested in the following ways:

• Relational: Therapeutic efficacy is based on the quality of the

relationship

• Intersubjectivity: There is not simply a client and therapist,

there is also the shared internal space created through

relationship

•Unconditional Acceptance: The client’s feelings are validated

and mirrored by the therapist

•Appropriate Boundaries: Acceptance of feelings ends with

aggression, violence, manipulation, or intoxication

• Repairing Empathic Failures: Therapists are human and make

mistakes, repairing these failures with the client models this

skill for them to learn, and assures them that the therapist will

not abandon them

Discussion and Questions?