Trauma

What is trauma?

In the context of the American Psychiatry Association diagnostic manual, trauma is defined as: exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1) Directly experiencing the traumatic event(s), 2) Witnessing, in person, the event(s) as it occurred to others, 3) Learning that the traumatic event(s) occurred to a close family member or close friend or 4) Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)1.  In other words, trauma is an event or experience, rather than an illness. Some examples of traumatic experiences include natural disasters, war (among veterans and refugees), shootings, rape, assault, robbery, accidents, and torture.

What happens in the brain and body during trauma?

When the brain encounters stress, it is programmed to send out signals to help the body protect itself.  This is an adaptive response in moments of serious, actual danger.  When a person encounters something traumatic, the body initiates a “fight or flight” response mediated especially by two important substances: a hormone called cortisol and a neurotransmitter called norepinephrine.  Among its other functions, cortisol mobilizes glucose (sugar) for the body to use as fuel, which is helpful if someone is getting ready to fight or run away.2  Norepinephrine has effects on the brain that promote alertness and vigilance.3  A heightened physiological (body-based) response to stress can develop with subsequent stressors in a traumatized individual, especially if the trauma happened at a young age.3  Individuals can go on to develop heightened stress responses to environmental cues that are in fact not dangerous at all and this is where it becomes problematic and distressing. The areas of the brain that are most involved during and after a traumatic experience include the amygdala (fear center), hippocampus (memory center) and prefrontal cortex (executive function and cognitive control center).3  In summary, when exposed to acute danger including trauma, a fear response in the brain/body initiates the “fight or flight” mode, preparing the person to protect themselves and increasing their chance of survival.

How common is trauma?

When a national US sample of 2,953 adults filled out an online self-administered survey, 89.7% of respondents reported exposure to at least one traumatic event as defined using the criteria above.4  This statistic is in line with what has been found around the world: most people have experienced traumatic events in their lives.5  The CDC reports that 1 in 4 girls and 1 in 13 boys experience sexual abuse in childhood.6  Similarly, 1 in 3 women and 1 in 4 men have experienced sexual violence in their lifetime.7  1 in 7 children has experienced abuse or neglect in the last year.8  About 1 in 4 women and 1 in 10 men have been impacted by sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime.7   
     
What are the consequences of trauma?

Most people who endure traumatic experiences are able to recover and do not sustain longstanding impact. An individual’s response to trauma is based on many different factors including their biology, the proximity to and severity of the trauma, the context in which the trauma occurred and the personal meaning of the experience. Different people exposed to even the same trauma might have different emotional reactions. Individuals who have experienced trauma may develop treatable psychiatric conditions or symptoms in the aftermath.  While it is important to understand the role of the trauma in the development of symptoms, it is also important to consider the context in which the traumatic event occurred (for example, life events that happened before the traumatic event or pre-existing conditions.) In general trauma caused by other people (e.g. rape or torture) have a higher chance of leading to more severe impact. 

Posttraumatic Stress Disorder (PTSD)

Individuals who suffer from PTSD will have experienced a trauma and experience a constellation of symptoms which may include: intrusive distressing memories, nightmares, flashbacks, distress related to reminders of the trauma, avoidance of reminders of the trauma, inability to remember an important aspect of the trauma, persistent/exaggerated negative beliefs about oneself/others or the world, self-blame for the trauma, persistent negative emotions, decreased interest in activities, feelings of estrangement from others, inability to experience positive emotions, irritability, anger outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration and difficulty sleeping.  These symptoms would be present for over 1 month and cause significant distress or dysfunction (social, academic, occupational)1.  The projected lifetime risk for PTSD in the US is 8.7%, and the 12 month prevalence is 3.5%1.  It is more prevalent across the lifespan in females than in males.1  PTSD might have delayed onset and start even years after the trauma occurred.

Acute stress disorder

Acute stress disorder includes the symptoms listed above for PTSD, but the duration is less than 1 month after the trauma.  Acute stress disorder is diagnosed in less than 20% of people who have experienced a traumatic event, but when the traumatic event involves interpersonal trauma it may increase to 50%.1 It is more prevalent among females than males. Half of individuals who eventually develop PTSD initially present with acute stress disorder.1     

Adjustment disorder

Adjustment disorder involves the development of emotional or behavioral symptoms in response to an identifiable stressor, including trauma.1  The level of distress experienced is usually out of proportion to the stressor and there is impairment in function. The symptoms may last for up to 6 months. 

Trauma/Stressor related disorder

Individuals who are affected by trauma might not experience all of the PTSD criteria. However, that does not mean they are not distressed or experience functional impairment. Those who do not meet all of the criteria for PTSD or Acute stress disorder may still have symptoms that are related to the trauma.  We will outline a few here below: 

Insomnia

Insomnia in an individual who has experienced trauma may be caused by a number of different factors.  If an individual has developed frightening nightmares, they may attempt to avoid sleep for as long as possible to avoid the nightmares. If they are preoccupied with worries about their safety and feel the need to constantly check to make sure they are protected, this may also have an impact on sleep.  Intricate routines to ensure the home is locked and secure before bedtime may develop.  If an individual is using any type of illicit substance, this will also surely have an impact on sleep. Co-morbid diagnosis of depression or anxiety may also play a role in an individual’s insomnia.  It is important to address sleep disturbances so that the person feels their best in their waking hours. 

Hyperarousal

Individuals who have experienced trauma may feel like they are constantly on high-alert. They may feel like they always have to watch over their shoulder, and they may prefer to have their back against a wall to ensure nothing will take them by surprise from behind. They may go through extensive rituals to ensure their safety or the safety of others, especially as they prepare for sleep. For this reason, many people experience difficulty sleeping because it requires them to take their guard down.     

Dissociative symptoms

Individuals may experience depersonalization which is described as a feeling of detachment from one’s body. They may feel like they are seeing themselves from a different vantage point.1  They may also experience derealization which is described as a feeling of detachment from one’s surroundings. They may feel like things are happening in slow motion or they may not be fully aware of events happening around them.1  These symptoms can be quite unsettling, especially at their onset. Dissociative states may last from a few seconds to several hours or even days. During the dissociation, the individual may re-experience aspects from the trauma.    

Depression

Individuals who suffer from depression may experience at least two weeks of low or irritable mood most of the day nearly every day, lack of positive emotions, alterations in appetite, alterations in sleep, decreased energy, excessive guilt, difficulty concentrating and recurrent thoughts of death or suicidal ideation.1  

Individuals who have experienced trauma may internalize the event and have subsequent negative thoughts about themselves or they may generalize the event and have negative thoughts about the world.  The persistence of these negative thoughts can impact their emotional experience.  Depression is also highly cooccurring with PTSD.

Anxiety

Individuals who have experienced trauma may experience anxiety in a variety of forms from an increase in generalized worries to panic attacks.  Individuals may also experience avoidance of social situations that may be more related to trauma symptoms than a fear of embarrassment.  Anxiety and avoidance are connected in individuals with PTSD.  One of the pillars of treatment in PTSD is to break the cycle of avoidance. Avoidance is naturally reinforcing because individuals who avoid anxiety-provoking situations or thoughts experience a decrease in anxiety.  This cycle of avoidance can become particularly impairing if left un-treated.

Substance Use/Abuse

There are a number of factors which may draw a person who has experienced trauma to the use of substances.  Substance use disorders develop when an individual continues using substances despite negative consequences from their use of that substance.  Uniformly, substances make the trauma symptoms worse and will complicate the treatment of any other co-morbid psychiatric illnesses.  A nationally representative study of US adults showed that for individuals who met full criteria for PTSD, 46.4% also met criteria for a substance use disorder. 

What are the risk factors for development of PTSD after exposure to trauma?

As noted above, some people who are exposed to trauma go on to develop trauma related symptoms, or even PTSD, while others do not. Researchers have identified some risk factors for development of PTSD5

Pre-trauma factors:

  • Female
  • Low IQ
  • Prior trauma exposure
  • Prior mental health condition
  • Personality factors
  • Genetics

Trauma factors:

  • Perceived fear of death
  • Interpersonal trauma
  • Severity of trauma
  • Physical injury

 

Post-trauma factors

  • High heart rate or sympathetic response
  • Low social support
  • Financial stress
  • Pain severity
  • Intensive care unit stay
  • Traumatic brain injury
  • Peritraumatic dissociation
  • Disability

What therapies are available for trauma-related conditions?

There are evidence-based treatments for trauma related disorders.  It is important for people to know that trauma related disorders are treatable, and they can experience relief from their symptoms. On the other hand, delay in treatment may lead to detrimental impact on mental and physical health (including cardiovascular disease, obesity, pain).

A cornerstone of treatment in a traumatized individual is therapy. There are various types of therapy that are commonly used as treatment modalities for trauma. The most commonly used treatments include exposure therapy, trauma focused-cognitive behavioral therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR).  

  •     Exposure Therapy

Exposure therapy often involves working with a therapist to first create a hierarchy of feared situations and then progress up the ladder towards the most feared situation. For some individuals, this may involve writing a trauma narrative.  The idea is to write and read the narrative so many times that it will no more trigger the highly disturbing fear response every time it is recalled.  For example, a person who experienced an armed robbery at a grocery store may start by working with the therapist on the trauma narrative and then progress to eventual return to the grocery store where the event happened. An important element of exposure therapy is gradually reintroducing the person to safe situations and activities they are avoiding due to the trauma (e.g. being among the public or near areas that remind them of the trauma).

  •     TF-CBT

Trauma focused CBT is useful for anyone, but it is a particularly good choice for children and adolescents10.  TF-CBT usually starts with education about trauma in general and progresses towards relaxation strategies, identifying emotion states, challenging unhelpful or false thoughts, creation of a trauma narrative and exposure in real life. For instance, traumatized people might blame themselves for what happened to them. CBT will challenge such false belief and as a result remove its negative impact on the person’s feelings. Sessions with caregivers often focus on parenting strategies.  The caregiver is encouraged to provide supportive responses to the child in which the caregiver remains calm and in control.  Joint caregiver/child sessions help to facilitate healthy communication between the caregiver and child.  They will also work to enhance the child’s safety in the future to prevent re-traumatization of the child/adolescent.  A beginning session of this type of therapy might look like the therapist and child playing an emotion naming game or emotion charades to first obtain a foundation in identifying emotion states.  

  •     EMDR 

Eye movement desensitization and reprocessing therapy can also be helpful for individuals who have experienced trauma.  In this form of therapy, the assumption is that PTSD results from inadequate processing of the trauma.11  The individual is asked to recount the traumatic memory while moving their eyes from side to side.  In the beginning, this action is paired with an individual’s distorted belief (for example “I am bad”) and later it is coupled with a coping thought (for example “I can handle this.”)11  It is unclear the exact mechanism through which EMDR exerts its effects, however this type of therapy does consistently outperform no treatment in clinical studies.11  

Medications

Patients with PTSD, depression and anxiety are commonly treated with selective serotonin reuptake inhibitors (SSRI’s). These medications help reduce the high level of anxiety and arousal and allow the person to control negative emotions more easily. Individuals who may not respond to SSRI’s may also consider trying serotonin norepinephrine reuptake inhibitors (SNRI’s).  An individual experiencing nightmares may benefit from taking Prazosin at bedtime. 

What about trauma in childhood?

Childhood trauma is very common; two thirds of children report at least one traumatic event by age 16.12  Of those who experience trauma, about 13% go on to develop trauma related symptoms.12  As with adults, there are many factors which may predict a child’s development of symptoms after a trauma including previous traumas and prior psychiatric conditions.  A child could experience trauma through a multitude of events including physical/emotional/sexual abuse, community/school violence, witnessing domestic violence, natural disasters, terrorism, sexual exploitation/human trafficking, refugee or war experiences, neglect, accidents or life-threatening illness13.  When a child has experienced trauma, it is important to understand how it has affected them and what symptoms they may be having.  The child may exhibit repetitive play with themes of the traumatic event and nightmares.1 The nightmares may not necessarily be about the trauma itself.1  

Children may also have alterations in mood with increases in irritability and at times, aggression.  Children are largely helpless when it comes to their own safety so when they have experienced trauma, they may try to make themselves appear big and strong in ways that adults may conceptualize as “bad behavior.”  Children and adolescents often experience a great deal of self-blame about the trauma already, so it is important for caregivers, teachers and other adults who interact with the child to conceptualize their behavior as a result of trauma, not because they are “bad.” Traumatized children and adolescents may have difficulty concentrating and sleeping.  Adolescents who have experienced trauma may exhibit increasingly reckless or self-destructive behavior.  

We have learned over time that childhood trauma and what are now labeled as “adverse childhood experiences” (ACEs) actually have long term effects on a multitude of health outcomes. The ACEs studies14 collected data about the following adverse childhood experiences: psychological abuse, physical abuse, sexual abuse, substance abuse in the household, mental illness in the household, domestic violence in the household, and criminal behavior in the household.  The most prevalent ACE was substance abuse in the household and the least prevalent was criminal behavior in the household.14  More than half of the people in the study experienced one or more ACE and 6.2% reported 4 or more ACEs.14  The prevalence and risk for smoking, severe obesity, lower levels of physical activity, depressed mood, substance use and suicide attempts increased as the number of ACEs increased.14  The number of ACEs an individual had experienced also correlated with the presence of ischemic heart disease, cancer, chronic bronchitis/emphysema, history of hepatitis, skeletal fractures, and poor self-rated health.14  This group of studies prompted screening efforts in pediatric offices in an attempt to uncover these ACEs as we know they are risk factors for negative downstream health outcomes.  

How should I help my child who has experienced trauma?

Recognizing that your child is struggling and needs help is the first and most difficult step. It may be difficult to acknowledge that a trauma has taken place, because it may evoke guilt in a caregiver whose role it is to protect the child. Caregivers must keep in mind that occurrence of trauma does not necessarily mean they have failed in their caregiving responsibilities. It is important for caregivers to recognize how symptoms that are commonly conceptualized as behavior problems, or other psychiatric illness may actually be better attributed to effects from trauma. Caregivers may experience their own feelings of guilt when it comes to their child going through a traumatic experience, which is understandable, but should not impede the child from receiving the needed care. Unfortunately, denial might be a caregiver’s response to a child’s trauma, especially when perpetrated by someone known to the caregiver. Such denial can have devastating lifelong impact on mental and physical health, and prosperity of the child even as an adult. Childhood trauma and trauma in general are incredibly common and trauma related conditions and symptoms are treatable.   

The next step is to connect with your child’s pediatrician for referrals for a mental health professional.

Here are some helpful resources for parents with children who have experienced trauma:

•   https://zerotothrive.org/about/strategic-plan/
•   https://trailstowellness.org/materials/cbt-and-mindfulness-groups/resources/psychoeducation-trauma
•   https://www.nctsn.org/what-is-child-trauma/about-child-trauma

What about continuous trauma?

There are some individuals who may never reach the “post” period of a trauma, and they may experience continuous trauma.  Examples include victims of abusive relationships, racism, child abuse or human trafficking, first responders, and refugees.15  For instance, first responders are often exposed to scenes of horrific murders, deaths, terrorist attacks, and severe illness on a regular basis as part of their job. It is very important to be aware of continuous trauma, and the effects it may have on an individual’s mental health.  Treatment of continuous trauma may need to be more flexible than treatment of a singular traumatic event and will highlight: safety to address current and ongoing dangers, education about continuous traumatic stress, identity development and stimulating the will to survive.16

What are the long-term effects of PTSD if untreated?

Traumatic stress can actually play a role in influencing the size and function of certain brain areas (amygdala, hippocampus and prefrontal cortex). Individuals with PTSD are also more likely to have imbalances in the levels of Cortisol and Norepinephrine compared to individuals without the disorder.3,17  These all increase long term chances heart disease, diabetes, obesity, chronic pain, depression, and substance use. 14,18

References:

1.     American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596
2.     Thau L, Gandhi J, Sharma S. Physiology, Cortisol. In: StatPearls. StatPearls Publishing; 2021. Accessed May 13, 2021. http://www.ncbi.nlm.nih.gov/books/NBK538239/
3.     Bremner JD. Traumatic stress: effects on the brain. Dialogues Clin Neurosci. 2006;8(4):445-461. doi:10.31887/DCNS.2006.8.4/jbremner
4.     Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and DSM-5 Criteria: DSM-5 PTSD Prevalence. J Trauma Stress. 2013;26(5):537-547. doi:10.1002/jts.21848
5.     Sareen J. Posttraumatic Stress Disorder in Adults: Impact, Comorbidity, Risk Factors, and Treatment. Can J Psychiatry. 2014;59(9):460-467. doi:10.1177/070674371405900902
6.     Pereda N, Guilera G, Forns M, Gómez-Benito J. The prevalence of child sexual abuse in community and student samples: A meta-analysis. Clin Psychol Rev. 2009;29(4):328-338. doi:10.1016/j.cpr.2009.02.007
7.     Smith, S.G., Zhang, X., Basile, K.C., Merrick, M.T., Wang, J., Kresnow, M., Chen, J. (2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief – Updated Release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
8.     Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results From the National Survey of Children’s Exposure to Violence. JAMA Pediatr. 2015;169(8):746. doi:10.1001/jamapediatrics.2015.0676
9.     Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord. 2011;25(3):456-465. doi:10.1016/j.janxdis.2010.11.010
10.     Cohen JA, Mannarino AP. Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families. Child Adolesc Psychiatr Clin N Am. 2015;24(3):557-570. doi:10.1016/j.chc.2015.02.005
11.     Lancaster C, Teeters J, Gros D, Back S. Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment. J Clin Med. 2016;5(11):105. doi:10.3390/jcm5110105
12.     Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic Events and Posttraumatic Stress in Childhood. Arch Gen Psychiatry. 2007;64(5):577. doi:10.1001/archpsyc.64.5.577
13.     “Understanding Child Trauma.” SAMHSA, www.samhsa.gov/child-trauma/understanding-child-trauma. Presented at the:
14.     Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. Am J Prev Med. 1998;14(4):245-258. doi:10.1016/S0749-3797(98)00017-8
15.     Kira IA, Ashby JS, Lewandowski L, Alawneh AWN, Mohanesh J, Odenat L. Advances in Continuous Traumatic Stress Theory: Traumatogenic Dynamics and Consequences of Intergroup Conflict: The Palestinian Adolescents Case. Psychology. 2013;04(04):396-409. doi:10.4236/psych.2013.44057
16.     Ibrahim Aref Kira, “Interventions with Continuous Traumatic Stress of Discrimination in Youth” (May 30, 2013). International Symposium on Arab Youth. Paper 3. http://scholar.uwindsor.ca/arabyouthsymp/conference_presentations/presentations2/3. Presented at the:
17.     Pan X, Kaminga AC, Wen SW, Liu A. Catecholamines in Post-traumatic Stress Disorder: A Systematic Review and Meta-Analysis. Front Mol Neurosci. 2018;11:450. doi:10.3389/fnmol.2018.00450
18.     Harrop-Griffiths J, Katon W, Walker E, Holm L, Russo J, Hickok L. The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse. Obstet Gynecol. 1988;71(4):589-594.


The content of this page (created in June, 2021) was provided by  ADAA members Jane Harness, DO, Child and Adolescent Psychiatry Fellow, University of Michigan and Arash Javankbakht, MD, Associate Professor, Director of Stress, Trauma, and Anxiety Research Clinic (STARC) www.starclab.org, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine.

 

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