PowerPoint Presentation

Introduction to PTSD and Trauma

William Harryman, MSC, NCC, MSWhat Is Trauma?Psychological trauma is the unique individual experience of an event or enduring conditions in which: The individuals 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.A Phenomenological Definition of Trauma We say, Ill see you later, or a parent says to a child at bedtime, Ill see you in the morning These absolutisms (a kind of nave realism and optimism) allow us to function in a world experienced as stable and predictable Emotional trauma shatters all absolutisms Trauma is a catastrophic loss of innocence that permanently alters ones sense of Being-in-the-world (Heidegger) Existence is revealed as random and unpredictable and there is no real safety or continuity of being After trauma, the world is fundamentally incommensurable, there is a deep chasm between the traumatized and others in which an anguished sense of estrangement and solitude takes form

(Robert Stolorow, Trauma and human existence: Autobiographical psychoanalytic, and philosophical reflections, p. 16)What Kind of Trauma?Big T TraumasChildhood abuse (sexual, physical, emotional)Childhood neglect (physical, emotional)Prolonged combat experienceRefugee campsNatural disastersSevere accidentsLittle t traumasBroken bonesHumiliation and ridiculeEmpathic failures in infancyProlonged bullyingFeeling left outFeeling not cared for

Symptoms as AdaptationsAll trauma symptoms are adaptations to survive the traumaTraumatic events end, the person's reaction persists The intrusion of the past into the present: re-experiencingIntrusion 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 feelingsDevelopmental DisruptionsSevere trauma can disrupt basic developmental tasksDevelopmental tasks underway when the trauma happens can help determine what the impact will beDisruptions can include:lack of self-soothingthe world is an unsafe placehard to trusting otherspoor executive functionmore easily exploited

Developmental Disruptions as SymptomsDisruption 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 agitationthe disrupted ability to see the world as a safe place looks like paranoiadistrust of others is interpreted as paranoia (even when valid)disruptions in executive function for decision-making can look like psychosisavoiding/preempting exploitation is called self-sabotageA Brief Explanation of the Neuroscience of Trauma

Trauma: Neurological EffectsDuring traumatic experiences, some regions of the brain show increased levels of stress hormones

A couple of those stress hormones are cortisol and adrenaline

Stress hormones shrinks the hippocampusStress hormones enlarge the amygdala

Trauma Rewires the BrainImages are stored in the right side of the limbic system

When trauma is recalled: Brocas area is disengaged (no verbal translation of inner experience)Right visual cortex is highlighted (experience is relived as though it is happening NOW)

When images are emotionally intense, they are more powerfully encodedTrauma memories can influence behavior even if the person has no visual memory of the trauma

How the Brain Processes Trauma A Metaphor: The Cook, the Smoke Detector, and the Watch Tower~ Courtesy of Bessel van der Kolk The cook is the Thalamus: It stirs all of the input from our perceptions into a fully blended autobiographical soup, an integrated, coherent experience of this is what is happening to me From the thalamus, the blended information goes to the amygdala and to the frontal cortex Joseph LeDoux: the pathway to the amygdala is the low road, and the pathway to the frontal cortex is the high road it takes a few milliseconds longer for information to take the highroad Processing by the thalamus breaks down in trauma Images, sounds, smells, and touch are encoded as isolated, dissociated fragments normal processing disintegrates time freezes, and the present danger feels like it will last foreverAmygdala The Smoke Detector The amygdala identifies whether incoming experience is relevant to survival It is assisted by the nearby hippocampus, which relates new input to past experience Under threaten, the amygdala immediately activates the stress response to prepare for action Because the amygdala is faster than the frontal cortex, it makes a decision before we are even aware of the danger

Trauma increases the risk that the amygdala will see danger where none exists hypervigilanceThe Medial Prefrontal Cortex The Watch Tower The medial prefrontal cortex (MPFC) is the seat of executive function the ability to read a situation, predict outcomes, and assess our choices As long as we are not too triggered, the MPFC can override the stress response system and restore equilibrium In PTSD, the balance between the amygdala and the medial prefrontal cortex shifts radically We are startled easily and become jumpy We become enraged by small frustrations We freeze if someone touches us We react from child-like ego states when triggeredTrauma and PTSDSymptoms, 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 eventFour clusters of symptoms make up a PTSD diagnosis:Re-experiencing Avoidance (and Emotional Numbing)HyperarousalDissociation

PTSD is more common than you might think, and PTSD does not discriminate based on age, sex, or racial/ethnic backgroundRe-experiencing SymptomsFrequent 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 SymptomsAvoiding thoughts, feelings, or conversations about the traumaAvoiding places or people that remind you of the traumaDifficulty remembering important parts of the traumatic eventLoss of interest in important and once positive activitiesFeeling distant from othersDifficulty with having positive feelings, such as happiness or loveFeeling 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 SymptomsHyperarousal 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 SymptomsThe DSM-5 (Diagnostic and Statistic Manual of Mental Disorders) has added a dissociative sub-type for PTSDDissociative 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 DefinedDissociation as a process:Overwhelming experience is split off and fragmented (the thalamus is unable to process it) Emotions, sounds, images, thoughts, and physical sensations take on a life of their own

Dissociation as an experience: Depersonalization: A subjective sense that one is changed, has become vague, dreamlike, less real, or lacking in significance feeling unreal as a person Derealization: A subjective experience of unreality of the outside world, what one sees lacks vividness or emotional coloring, as seen through a fog, or a veilDepersonalization and Derealization tend to co-occurDissociationThe 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 hypnosisDissociative Identity DisorderLink Between Trauma and PTSDTrauma 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 MenFor men, rape is the traumatic event most likely to be connected with PTSDApproximately 65% of men who said rape was the most upsetting traumatic event developed PTSDOther 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 WomenAs with men, rape is the traumatic event most likely to be associated with PTSD for womenApproximately 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 traumasHaving a history of mental illnessGetting hurt, or fear of being hurtSeeing people hurt or killedFeeling horror, helplessness, or extreme fearHaving little or no social support after the eventDistress after the event: loss of a loved one, pain and injury, or loss of a job or home

Some People Do Not Experience PTSDOnly 25-35% of those exposed to trauma will develop PTSD, and of those, only 20-35% display persistent symptomsResilience factors that may reduce the risk of PTSD include:Seeking out support from other people, such as friends and familyFinding a support group after a traumatic eventFeeling good about ones own actions in the face of dangerHaving a coping strategy, or a way of getting through the bad event and learning from itBeing able to act and respond effectively despite feeling fearPossessing a secure attachment style in childhoodPTSD and Attachment

Attachment and PTSDJohn Bolwby, father of Attachment TheoryInnate 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 secureMary Ainsworth: mother of attachment theoryA Strange Situation: defined secure, anxious, and ambivalent attachment stylesMary Main: Adult Attachment InventoryAdded a 4th attachment style to the original three, the disorganized styleIn the 1970s, Ainsworth devised a procedure, called A Strange Situation, to observe attachment relationships between a caregiver and child.In this procedure of the strange situation the child is observed playing for 20 minutes while caregivers and strangers enter and leave the room, recreating the flow of the familiar and unfamiliar presence in most children's lives. The situation varies in stressfulness and the child's responses are observed. The child experiences the following situations:Parent and infant are introduced to the experimental room.Parent and infant are alone. Parent does not participate while infant explores.Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.First separation episode: Stranger's behavior is geared to that of infant.First reunion episode: Parent greets and comforts infant, then leaves again.Second separation episode: Infant is alone.Continuation of second separation episode: Stranger enters and gears behavior to that of infant.Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.Four aspects of the child's behavior are observed:The amount of exploration (e.g. playing with new toys) the child engages in throughout.The child's reactions to the departure of its caregiver.The stranger anxiety (when the baby is alone with the stranger).The child's reunion behavior with its caregiver.On the basis of their behaviors, the children were categorized into three groups, with a fourth added later. Each of these groups reflects a different kind of attachment relationship with the caregiver.

Attachment StylesChild and caregiver behavior patterns before the age of 18 monthsAttachmentpatternChildCaregiverSecure About 2/3 of adultsUses 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. AvoidantLittle 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/ResistantCaregiver 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.DisorganizedStereotypies (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 AttachmentDisorganized attachment: Activation of incompatible approachavoidance 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 behaviorsThese 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 clustersPTSD hyper-arousal symptoms include externalizing behaviors, such as irritability or outbursts of angerBoth dissociative symptoms and externalizing symptoms are commonly seen in traumatized individualsWhy This Matters . . . Trauma-Informed TherapyClient Needs: Mirroring, Idealization, Twinship (Heinz Kohut), manifested in the following ways:Relational: Therapeutic efficacy is based on the quality of the relationshipIntersubjectivity: There is not simply a client and therapist, there is also the shared internal space created through relationshipUnconditional Acceptance: The clients feelings are validated and mirrored by the therapistAppropriate Boundaries: Acceptance of feelings ends with aggression, violence, manipulation, or intoxicationRepairing 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?Recommended reading:

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma Bessel van der Kolk Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and Capacity for Relationship - Laurence Heller and Aline LaPierre Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists - Suzette Boon, Kathy Steele, and Onno van der hart * The Inner World of Trauma: Archetypal Defenses of the Personal Spirit - Donald Kalsched Trauma and the Soul: A psycho-spiritual approach to human development and its interruption - Donald Kalsched Waking the Tiger Peter Levine, and In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness - Peter Levine and Gabor Mate The Trauma Spectrum: Hidden Wounds and Human Resiliency - Robert Scaer