Trauma.

More About Trauma.

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 a 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. At this point, narrative memory (responsible for the ongoing narrative of experience, the “story” of our life) goes offline, whereas implicit memory (reconstitutes with sensorial experience here and now) and the amygdalae (related to the fear response) remain online. This results in fear-charged sensorial fragments in the here and now without associated narrative content. This accounts for some of the nature of trauma triggers and avoidance behaviors. Perpetual reactivation, overstimulation, and overwhelm maintains activation of the stress response (related to the hypothalamic-pituitary-adrenal axis), which significantly damages memory, attentional networks, and amygdalae regulation.

In the absence of an external trauma, the response is transferred via learning as well as biologically. There is a genetic transfer of abnormal cortisol (stress hormone) receptor responsiveness and other impaired mechanisms related to cortisol management. This consequently lends itself to a trauma syndrome that occurs in the absence of a “traumatic event”.

Types of Trauma.

Single-Incident Trauma: This form of trauma occurs in response to a single traumatic event, such as experiencing or witnessing violence or abuse.

Multiple-Incident or Complex Trauma: An experience of repeated or prolonged exposure to traumatic experiences.

Developmental Trauma: An experience of traumatic experiences that tend to be pre-verbal such as perinatal trauma, disruption in early attachment to caregivers, and inadequate caregiver-child fit.

Transgenerational Trauma: An experience of trauma transfer from caregiver to child. This occurs in a two-fold fashion: (1) the caregiver responds 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.

Signs and Symptoms.

“Classic” Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) Symptoms:

• T: Traumatic event 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.

Also unaccounted for is the impact of transgenerational trauma on an individual’s ongoing experience of life in several domains including work, school, leisure, and relationships.

Diagnosis.

The Diagnostic and Statistical Manual for Mental Disorders (DSM) diagnosis of trauma syndrome focuses on the constellation of symptoms captured by the TRAUMA acronym described above. If these symptoms are present for < 1 month following the trauma, the individual is identified with Acute Stress Disorder. If these symptoms are present > 1 month following the trauma, the individual is identified with Post-Traumatic Stress Disorder. A specialist in Integrative Psychiatry expands these diagnostic categories to incorporate the impact of transgenerational, developmental, attachment, and complex trauma syndromes to help you identify the most appropriate approach to treatment. Because of the transcendent nature of trauma in our culture, trauma can almost invariably be assumed unless proven otherwise.

Screening.

The PTSD Checklist for DSM-5 (PCL-5) is the gold standard screening tool to evaluate for the presence of DSM-5 PTSD symptoms. This tool is also helpful in monitoring PTSD symptoms over the course of treatment. The Adverse Childhood Experiences (ACE) scale helps to evaluate for experiences that may account for childhood and developmental trauma. 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 these tools, a careful and ongoing evaluation of a person’s experiences and links to past events may reveal trauma etiology. There are several developmental traumatic experiences beyond the ACEs captured in the ACE scale.

Treatment.

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, and 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/Mirtazepine: These sedating antidepressants are sometimes used for a combination of sleep difficulties, depression and nighmares for those experiencing trauma syndrome.

Benzodiazepines: Should be avoided in trauma. These medications have a tendency 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 a mix of 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, a 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 navigate an exploration of 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.

Several forms of psychotherapy for the treatment of trauma that aim to achieve these goals include: Cognitive processing therapy (CPT), Prolonged exposure (PE) therapy, somatic experiencing (SE), Dialectical behavioral therapy (DBT), psychodynamic psychotherapy (PDT), Eye movement desensitization and reprocessing (EMDR), and Internal Family Systems (IFS).

Catharsis Health provides a specialized form of therapy that combines the most effective strategies from several of these evidence-based and well-grounded therapy modalities. Treatment is typically well-tolerated and rapid compared with traditional strategies. For more information click here (coming soon).

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.