What is trauma?
While entire books are written on this, Bessel Van der Kolk says, “It is inside of you – it is what happens inside, after the event has passed.” And “If the person felt immobilized, they couldn’t do anything about the trauma, if they felt trapped, they were traumatized.” You can simply define trauma as any event or condition that an individual cannot manage with their own resources, and that leaves a mark – that affects the way they feel, act, and think, and function at home, at work, and in relationships.
Around 90% of the clients in my practice, perhaps more, live with a trauma history.
Most have experienced early life trauma – moving, bullying, parents who yelled or were emotionally unavailable, parents who were depressed or anxious, not seeing love in the home, school failure or humiliation, conditions that disrupted secure attachment or caused a constant sense of fear, hypervigilance. Others had what most people think of as trauma: frank emotional, sexual, or physical abuse, usually by someone they knew, or an accident threatening bodily integrity, or serious illness. There is complex trauma, where more than one event has happened, usually across time, in different conditions, and not on a predictable schedule, such that the individual lives in constant expectation, primed, or numb.
Some traumatized individuals never feel safe. They spend lots of energy staying under control, not blowing up, not collapsing. The brain has changed and the person is no longer able to be present, “An illness of not being fully alive in the present.” Disengagement and fear lead to lack of interest and willingness to engage, and reluctance. One may lose the instinct of purpose. Life loses charm, meaning, purpose when traumatized.
What symptoms might someone with trauma experience?
The diagnosis of posttraumatic stress disorder (PTSD; see the the DSM-5 Diagnostic Criteria for PTSD for the full detail informing this below abbreviated description) is made when an individual experiences trauma in a particular way and usually within 6 months (and for a duration of more than one month) begins to experience some of the following, which affects functioning in major areas of life.
Recurrent, intrusive traumatic memories that feel inserted into their thoughts
Nightmares with traumatic content
Flashbacks, where the person feels the events are recurring
Intense or prolonged emotional distress or physiologic reactions when exposed to internal or presented cues that remind the person of their trauma
Efforts to avoid memories, thoughts, feelings, places conversations, reminders, media, anything that arouses distressing feelings or sensations
Inability to remember important aspects of trauma, due to dissociative amnesia
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," “I will never feel better again,” “my life will be foreshortened”)
Persistent, distorted cognitions of self-blame
Persistent negative states such as strong anger, fear, guilt, or shame
Markedly diminished interest or participation in significant activities – as though the person is frozen
Feelings of detachment or estrangement from self or others
Persistent inability to experience positive emotions, such as satisfaction or love
Marked alterations in arousal and reactivity, such as hypervigilance, exaggerated startle, angry outbursts or irritability, aggression, reckless or self-destructive behavior, difficulty concentrating, and insomnia or restless sleep
People living with PTSD may experience dissociation, either depersonalization or derealization
An interview for civilians with PTSD is available, as is one for dissociation.
What might trauma look like, if the person does not meet criteria for PTSD?
I have clients who constantly overwork, or numb themselves with substances or television or video games, to stay away from their centers – so they don’t have to feel, or because their sense of self is fragile, and they can’t make sense of their thoughts, feelings, or context in the world. They have constant hypervigilance, perhaps only that one symptom. They always expect that the other shoe will drop, they are walking on eggshells, something could spike behind them or drop out from under them, their nervous system expects harm will occur. Because their primary caregiver was unavailable in an important way, to raise them in the world, they did not develop a strong sense of self, and they are constantly pinging the world, asking questions, feeling uncertain. Van der Kolk tells the story of a client who had pictures and photographs, all framed, but in 5 years not hung on the walls of her apartment. Some people feel frozen, unable to act outside their routine.
Trauma may take an endless number of presentations,
but hypervigilance is a kingpin for almost all: if that is lifted, sleep, anxiety in all forms, and cognition improve, and people gain freedom of movement. I have four clients who were so impacted by trauma they were house-bound, and lifting hypervigilance allowed them to venture out and make friends and become employed.
Why do some people develop lasting trauma reactions, and others do not?
Trauma is biopsychosocial
Trauma can have a genetic component, for instance; those with the s/s allele on the gene SLC6A4 are more likely to develop PTSD than are those with the s/l and l/l variants. Neuropeptide Y and COMT genes are also associated
Plasma levels of the neurotransmitter GABA are associated with PTSD’s resolving at one year, or not
Trauma that is recurrent, unpredictable, and/or caused by someone the individual knows is more likely to cause sequelae
The individual may have buffering strengths, such as consistent, supportive adults in childhood, certain life habits, secure attachment style, loving relationships, a history of successes, a strong sense of self, and a lack of comorbid depression or other expressions of anxiety
Those with early life trauma are more likely to develop symptoms if trauma occurs later in life. Here are just a few explanations:
We make most of our neural networks before the age of 8, then prune what we aren’t utilizing at that time. It’s during this period of high glutamate activity that our sense of self is cemented, and much of the patterns that will inform our lives are made.
Early life trauma causes structural changes in the brain, including inefficiency in the tracts (swaths of white matter that connect brain regions and structures) connecting the prefrontal cortex (where executive function happens) and the limbic system. The limbic system is important in perception, emotional valence, categorization, memory of relevance, and the relation between organism and surrounds. If these tracts are not efficient, the person cannot self-sooth, and experiences hypervigilance.
Opiate receptors in the anterior cingulate gyrus receive kindness – if a person is not shown nurturing as a child, this brain region’s development is impacted.
The orbitofrontal cortex, which inhibits inappropriate action and reward seeking, is damaged by early abuse or neglect.
If trauma is largely what one sees, the visual system is altered. If one is yelled at a lot, acoustic system is altered.
The vagus nerve allows the brain and body to speak with each other, and informs the gastrointestinal system, cardiovascular system, and our responses to stimuli. Chronic trauma leads to hypoarrousal, dissociation/numbing, parasympathetic shut-down.
Three excellent articles on childhood adversity and neurobiology are
Bessel Van der Kolk, Author, therapist, researcher, on brain, mind, and trauma
MDMA – makes people become deeply compassionate for themselves. Changes perception of self.
Psilocybin – people have spiritual experiences that allow them to accept death and dying. A person can experience a much larger reality than they usually do.
You’ll notice that the symptoms and conditions in trauma that can be treated with medicine are a select few – where medicine can provide a tremendous relief, and psychotherapists tell me that clients make more progress after medicine is established, the goal of medicines is to lessen the burden of pain and allow the client to manage better on their own and to make better use of psychotherapy, which is highly encouraged.
How is trauma treated with psychotherapy?
Somatic therapies hold that the body bears the burden of trauma. Peter Levine explains that while animals will shake off a traumatic event and then run, human beings store trauma in the body and nervous system.
Many of my adults living with trauma have developed gastrointestinal distress such as irritable bowel syndrome, fibromyalgia, other pain syndromes, they are more likely to develop cardiovascular disease, and more. Immune function is altered. CD45 cells (memory cells) in the immune system become hyperactive to danger. Inflammation, an immune system that is on alert, leads to disease.
Some somatic therapies include Levine’s Somatic Experiencing, Pat Ogden’s Sensorimotor therapy, trauma sensitive yoga which trains heart rate variability and the body’s responses, and Tension, Stress, and Trauma Release (TRE).
Enhanced functional connectivity in neural networks, with placebo (a) vs psillocybin (b) Petri et al, 2014
How is trauma treated with medicines?
I have always found it curious that clinical trials for medicines impacting trauma are usually targeting “PTSD”, though not always. Many very good interventions impact a single symptom.
Along with topiramate and cyproheptadine (rarely used), a number of blood pressure medicines, most notably prazosin, treat nightmares
Lamotrigine treats hypervigilance; although it is not well-studied for such, I have a 90% response rate. Buspirone and topiramate have utility also
SSRI antidepressants treat many symptoms of PTSD, in part by dampening the smoke detector in one’s amygdalae, and they have been studied thoroughly for it. They do not treat hypervigilance. They have commonly-occurring side effects and difficult withdrawal syndromes, amongst other potential drawbacks. These drugs where are considered the “standard of care” are rarely used in my practice; you may download an educational sheet if you like.
Peter Levine, designer of Somatic Experiencing, on how the body releases trauma
Dr. Pat Ogden: Reflection on Foundational Principles of Sensorimotor Psychotherapy
Other therapies calm the limbic system, and help you to rewrite memories or your reactions to them. Francine Shapiro’s Eye Movement Desensitization and Reprocessing (EMDR) helps with desensitization of traumatic memories, and installation of positive beliefs. Tapping (also called Emotional Freedom Technique) is a self-guided treatment for calming the nervous system, and lessening responses to triggers. It brings people out of parasympathetic shutdown and numbing, gets frozen individuals to move. Helps them to orient to their bodies, and feelings. Here’s Nick Ortner’s second site.
An interview with Francine Shapiro, designer of EMDR
Nick Ortner Talks About How to Rewire the Brain with EFT - The Tapping Solution
Mindfulness meditation helps to strengthen healthy neurotransmission between the prefrontal cortex and the limbic system, lessening depression, stress, and anxiety. It also gives clients “room” between their feelings and reactions. Another technique that gives some room, while teaching distress tolerance powerfully, is Marsha Linehan’s Dialectical Behavior Therapy. Designed for those living with borderline personality disorder, it is effective and helpful for anyone who has distressing emotions.
There additionally are many other techniques focusing on limbic system retraining, feel free to download some ideas. Limbic system retraining, or brain retraining, is useful for trauma and burnout, chronic pain, POTS and MCAS, and many other applications.
There are techniques used at the Veteran’s Administration, Cognitive Processing Therapy and Prolonged Exposure, which have many good studies attesting to their effects. These are used by therapists outside the VA also. Those of us treating clients in the community who follow Van der Kolk, Levine, Ogden, and Stephen Porges tend to recommend the therapies I’ve previously listed. I have personally met clients who believed that prolonged exposure was retraumatizing, and cognitive processing therapy is a form of cognitive behavioral therapy. Trauma doesn’t live in the prefrontal cortex. And language does not heal: the center of who we are in the brain is nowhere near the language centers. You can know why you feel badly, but it doesn’t help you feel better. While CPT may cause extinction of memories, EMDR can give reconsolidation. CBT is very effective – but it does not release trauma. Still, I would be incomplete and remiss not to mention these, and you may consider reading widely, interviewing therapists, and deciding which treatments fit your body and mind’s best wisdom.
Lifestyle matters – the Big 5
Just as with any other condition involving mood and anxiety symptoms, clients are encouraged to treat their bodies well, doing as many of the following as suits them. According to the CDC, only 6% of Americans have a healthy body mass index (BMI), sleep adequately, drink alcohol moderately or not at all, exercise adequately, and are never smoking. And only 12% of American adults are metabolically healthy! Here are some possible goals:
1 Anti-inflammatory diet, for instance paleolithic or Mediterranean diets, including plentiful fruits and vegetables, and avoiding gluten, sugar, and dairy, as well as any food allergens.
I offer laboratory testing, to check inflammatory markers and micronutrient status.
Listen to Emily Deans and Chris Kresser discuss ancestral diet and psychiatry here.
2 Limit alcohol use. The National Institute on Alcohol Abuse & Alcoholism (NIAAA) defines moderate drinking as up to four alcoholic drinks for men and three for women in any single day and a maximum of 14 drinks for men and seven drinks for women per week – a cardiologist or oncologist would have very different recommendations.
3 Exercise – aiming for half hour five times weekly. If regular walking is what suits you, this is largely what our ancestors did.
5 I would round this out with a meditation practice. There are many types (not just mindfulness), and each may change your brain differently. I practice Vedic meditation, 20 minutes twice daily. There are many teachers, including the Transcendental Meditation corporation, and Emily Fletcher in New York, my teacher. When I started, my sleep improved, and feelings of pressure/“anxiety” vanished, within 5 days.
Favorite Books on Trauma
By Bessel Van der Kolk – a researcher and author who synthesizes the current thinking on trauma and therapeutic work in a very useful way
By Peter Levine, designer of Somatic Experiencing therapy. Waking the Tiger is his first book, which really explains the theoretical underpinnings of how the body holds trauma
By Pete Walker
By Robert Scaer, another writer on trauma, dissociation, and somatics
Stephen Porges’ books on Polyvagal Theory
Gabor Mate writes about the link between stress and disease, about trauma and addiction, about trauma being misdiagnosed as ADHD
Helpful Websites – see also those listed above under psychotherapies
Van der Kolk is a widely-published expert on the treatment of trauma, and an excellent lecturer
A collection of educational materials on complex trauma
Bruce Perry’s organization, developing innovative treatment programs for traumatized children, disseminating innovation, and developing programs for the protection of high-risk children
International Society for Traumatic Stress Studies – assessment, treatment, education, and research
An organization for survivors of trauma and victimization
Traumatic stress education, advocacy, resources
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