Trauma
Trauma is not defined by what happens to you, but by what happens inside you as a result. It is the enduring emotional, somatic, and psychological response to an overwhelming experience that exceeds your capacity to cope, process, or make meaning of it — leaving behind a sense of fragmentation, disconnection, or threat that persists even after the event has passed.
“Trauma is not what happens to you. Trauma is what happens inside you as a result of what happened to you.”
Signs and Symptoms of Trauma.
“Classic” Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) Symptoms:
T: Traumatic event (single, multiple, developmental, transgenerational) leads to…
R: Re-experiencing the event through nightmares, flashbacks, or intrusive thoughts
A: Avoidance of re-traumatization by triggers (includes detachment and dissociation)
U: Unable to function in the context of the trauma response at work, in school, or in relationships
M: More than 1 month of the aforementioned symptoms (for PTSD) or less than 1 month (for ASD)
A: Arousal increased such that the individual is in a persistent state of hyperarousal or hypervigilance, at times escalating to a sense of paranoia and profoundly impaired trust
Unaccounted for by the DSM-5, but emergent in trauma literature are the experiences of emotional regulation difficulties, disturbed ipseity (selfhood, self-concept, self-organization), and interpersonal difficulties consequent to traumatic experiences that can be seen in Complex PTSD (cPTSD).
Screening and Evaluation.
PTSD Checklist for DSM-5 (PCL-5). The gold standard screening tool to evaluate for the presence and severity of trauma symptoms. This tool is also helpful in monitoring PTSD symptoms throughout treatment. Outside of just a “checklist,” this tool provides a useful gauge of the intensity of trauma symptoms.
Adverse Childhood Experiences (ACE). This tool evaluates childhood and developmental trauma. The tool captures traumatic events that occurred in childhood that may be contributing to current symptoms. An ACE score of >4 is associated with a 4x increased risk of alcohol use disorder, a 3x increased risk of chronic depression, a 2-3x increased risk of financial and occupational problems, and a 2x increased risk of heart attack and stroke.
Beyond the ACE Score. At the core of trauma is disconnection. The ACE score captures traumatic events that “did” happen. What it does not account for is what “didn’t” happen that would normally support growth and development. This includes experiences of being validated, seen, heard, held, and contained. Early in our development, we develop the capacity to internalize these crucial skills - provided the environmental conditions support it. Much of this occurs before we are even able to create narrative (explicit) memories. Depth-oriented work allows a skilled traumatologist to explore these non-verbal (implicit) memories and facilitate deep healing.
Transgenerational Trauma. Can an individual experience trauma symptoms without being exposed to a classifiable traumatic event? Yes. Transgenerational trauma is an experience of trauma transfer from caregiver to child. This occurs in a two-fold fashion: (1) the caregiver reacts to the child in the context of their own traumatic experiences, thereby transferring the trauma response to the child, and (2) the caregiver transfers a genetic alteration in cortisol (stress hormone) response and management that predisposes the child to trauma syndrome.
Relationship to Other Conditions. Trauma is commonly discovered to be at the core of several other conditions (e.g., addiction, ADHD, depression, anxiety, etc.). Some traumatologists argue that there’s only one condition, trauma, and everything else represents various permutations of trauma.
“Until you make the unconscious conscious, you will call it fate and it will rule you.”
Impact of Trauma.
Trauma impacts the whole individual, not just the mind. Consider the impact on a psychological/neurological, biological, lifestyle, and spiritual level.
Psychological/Neurological. In the event of external trauma, there is a consequent state of increased energy (fight or flight response). When the individual is unable to act on fight or flight, this increase in energy (which can be metabolically measured) escalates to the point of overwhelm, and consciousness goes offline (“the thousand-yard stare,” technically referred to as peritraumatic dissociation or PTD). This event is essentially the equivalent of a traumatic brain injury (TBI) and significantly disrupts neural connectivity. This is the point at which an individual is disconnected from their sense of self and other. At this point, narrative (explicit) memory (responsible for the ongoing narrative of experience, the “story” of our life) goes offline. In contrast, implicit memory (reconstitutes with sensorial experience here and now) and the amygdala (related to the fear response) remain online. This results in fear-charged sensorial fragments in the here and now without associated narrative content. This fragments are attached to narrative content, creating a fragmented cluster of perceptions, behaviors, and emotions. This accounts for some of the nature of trauma triggers (response to perceived threat) and subsequent actions in response to the triggers.
Biological. Trauma impacts several body systems, leading to ancillary problems as a result.
Hypothalamic-Pituitary-Adrenal Axis. Perpetual reactivation, overstimulation, and overwhelm associated with triggering activate the stress response, which usually functions to sustain energy in the context of a threat. However, in the context of trauma, the stress response is sustained, which significantly damages memory, attentional networks, and amygdala regulation. What’s more, cortisol directly influences the immune system, producing a pro-inflammatory environment.
Immune-Brain Axis. Outside of the influence of cortisol described above, traumatic stress reduces immune system integrity, making you more susceptible to infection and autoimmune disease. Immune dysregulation also influences how the brain manufactures dopamine, serotonin, and norepinephrine and reduces the effectiveness of some psychiatric medications.
Lifestyle. Trauma influences several domains of an individual’s lifestyle.
Relationships. Trauma influences relationships in several ways. Because our bodies become wired to remain vigilant for cues of threat, it becomes difficult to establish a connection with others without experiencing threat and reactivity.
Leisure. Trauma makes it challenging to relax in the context of a hypervigilant or disconnected state.
Labor. As mentioned above, those with high ACE scores experience difficulty in the occupational setting.
Nutrition. A change in energy supply and demand drives dietary orientation to a degree in the context of trauma, making it difficult to sustain a healthy and balanced diet.
Sleep. Sleep quantity and quality may be disrupted through an experience of nightmares, hypervigilance (difficulty relaxing), and cortisol abnormalities (disrupting circadian rhythm).
Substance Use and Addiction. Addiction is a solution to a deeper underlying problem, trauma. It’s important to note that addiction does not necessarily only include substances but can also include behavioral addictions and habit patterns that have developed in the context of trauma.
Spiritual. Trauma makes it challenging to establish and maintain a sense of connection, meaning, and purpose in the context of the various degrees of disconnection experienced by the individual.
“Where there is a trigger, there is an implicit memory at play. The trigger would otherwise be neutral if it were not attached to a loaded gun.”
Integrative Psychiatry Approach to Trauma.
There are several options for the treatment of trauma. Often a multimodal approach is best:
Medications.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): front-line treatments for trauma syndrome. One of the most notable SSRIs for the treatment of trauma is sertraline (Zoloft), which has FDA approval for the treatment of PTSD. These medications help to desensitize the overactivity of the amygdala as well as improve upon consequent depression symptoms.
Prazosin: A gold-standard trauma medication used to block some of the overactivity of the sympathetic nervous system (responsible for fight and flight). Prazosin has been useful for the reduction of nightmares, flashbacks, daytime hyperarousal and hypervigilance, and anxiety experienced in PTSD.
Propranolol: This medication similarly calms some of the overactivity of the sympathetic nervous system and can be helpful as an as-needed medication for trauma-associated anxiety, hyperarousal, and hypervigilance.
Second-generation Antipsychotics: Sometimes used for complex trauma syndromes with refractory intrusive thoughts and the emergence of psychosis (e.g., paranoia and hallucinations).
Trazodone/Mirtazapine: These sedating antidepressants are sometimes used for a combination of sleep difficulties, depression, and nightmares for those experiencing trauma syndrome.
Benzodiazepines: Should be avoided in trauma. These medications tend to temporarily suppress overactivation, making them very effective in the short term. In the long term, these medications perpetuate avoidance strategies and strengthen the embodiment of trauma such that it is inadequately processed.
Nutraceuticals.
Several adaptogenic herbs such as Ashwagandha and Rhodiola may be effective at diminishing the overactivity of the hypothalamic-pituitary-adrenal axis, resulting in improved cortisol management (reduced stress).
Sometimes, Adrenal Support preparations are helpful depending on an evaluation of adrenal functionality and hypothalamic-pituitary-adrenal axis activity.
Adequate supplementation with key vitamins and minerals and methylation support can promote appropriate neurotransmitter (brain chemical) functioning, synthesis, and storage.
Other nutraceutical considerations depend on an appropriate bodily-based working.
The Body.
The brain does not exist on an island. Instead, there’s a dynamic interaction between the brain and the body. Because of this, it’s crucial to explore the influence trauma has on the body and vice versa. An Integrative Psychiatry specialist will help you explore the following areas using advanced diagnostic and laboratory testing: adrenal (e.g., stress hormone), gonadal (e.g., sex hormones), gut, thyroid, metabolism, immune, micronutrients, and epigenetics. This exploration helps to personalize treatment based on your unique needs.
Psychotherapy.
There are two united steps in trauma treatment: (1) Desensitization and (2) Integration (conversion of the trauma into a narrative where meaning-making can occur and the individual experiences a “life worth living”). While there are two primary steps, this is much easier said than done. As mentioned, trauma is in the response, not the event. Therefore, accessing implicit (non-verbal) memories is crucial.
“You can’t treat the implicit using explicit (verbal) means. This is why ‘talk’ therapy does not fully resolve trauma. You can be fine talking about your trauma, yet still be held hostage by the implicit effects.”
Trauma-oriented therapies aim to achieve this, including Somatic Experiencing (SE), Modified Psychoanalysis, Eye Movement Desensitization and Reprocessing (EMDR), Internal Family Systems (IFS), and Compassionate Inquiry (CI). An approach developed by Dr. Hatcher at Catharsis Health is Experiential Transformation Therapy which combines techniques from the modalities above. What’s more important, however, is the ability of the therapist to remain a compassionate presence while working with you, safely holding space for the work of processing.
Lifestyle.
Sleep: Often impaired in trauma secondary to stress, intrusive thoughts, and nightmares. Establishing a sleep routine and reducing blue light exposure and stimulating activities prior to bed may be helpful. The introduction of relaxing activities to calm the nervous system such as a warm bath, scented candles, or meditative practices may also be effective.
Exercise: The goal of exercise is moderate-intensity aerobic exercise for 30 minutes five times per week. The incorporation of a mind-body modality with a breathing component helps significantly with desensitization (reducing the overactivation induced by trauma) and increases parasympathetic nervous system (rest, digest, relate) activity. Aim for familiarity in exercise techniques over novelty, and notice shifts in nervous system states during exercise. Avoid frequent high-intensity exercise as this may add to inflammation and physiologic stress.
Nutrition: A reasonable general goal is to aim for a Mediterranean diet. Reducing added sugars to <10% in individual food/drink products will help reduce unnecessary stress on the body.
Relationships: Trauma has a profound impact on relationships. The capacity to trust is shattered by traumatic experiences. Building upon interpersonal skills such as assertiveness, relationship building, connection, and boundary establishment can be effective.
Additional Options.
Psychedelic-assisted therapy (PAT) has emerged as a treatment option for those struggling with trauma syndrome. Currently, MDMA-assisted psychotherapy (MAT) is in stage 3 clinical trials for the treatment of PTSD. So far there are impressive results with nearly 70% of individuals undergoing treatment are exiting the trials no longer meeting criteria for PTSD! These promising results may ultimately translate to the availability of MDMA-assisted psychotherapy as a treatment option pending FDA clearance over the next few years. Other psychedelic-assisted treatments have been explored, but not as extensively as MDMA.
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