What is Trauma?
The word “trauma” is derived from the Greek word meaning “wound”, and can apply to physical as well as psychological injury.
It is estimated that 75% of all people will be exposed to trauma of one kind or another during their life-times – in some ways it can be seen as a natural part of human life. Police, fire brigade or ambulance workers are more likely to have such experiences – they often have to deal with horrifying scenes. Soldiers may be shot and see friends killed or injured.
A traumatic event is an emotional shock. It is not easy to take in what has happened and to come to terms with it. After a trauma, it is quite normal to experience all kinds of unpleasant feelings, emotions, and body sensations. These may take some time to die down. In the meantime, memories and images of the trauma, and thoughts about it, come into your mind even if you try to shut them out. These experiences may be confusing and even frightening.
However, you will discover from this handout that the thoughts, feelings and sensations you are experiencing are a normal reaction to stress, and show that your body and your mind are working to come to terms with the traumatic event.
Traumatic events can be things like:
Air, Rail or Road Accidents
Combat exposure, War
Rape, Sexual Abuse, Physical Assault
Child Sexual or Physical Abuse
Emotional Abuse or Neglect
Major Injuries or Illness
Death of a loved one, especially if unexpected or due to an accident or suicide
“Psychological trauma is the experience and psychological impact of events that are life threatening or include a danger of injury so severe that the person is horrified, feels helpless, and experiences a physiological alarm response during and shortly following the experience” (Schauer, Neuner & Elbert, 2005)
Trauma can be caused by anything that is perceived as life threatening and overwhelming to our ability to handle it. Each person reacts to trauma in his or her own unique way. Trauma does not have to be caused by a catastrophe. It only has to be a perceived serious threat by the individual. Nonetheless, there are common reactions which many people share. This handout describes some of these common reactions.
Practitioners distinguish between different types of trauma:
A simple trauma (Trauma I) is a one-time event such as a car accident or a physical assault. A person can have multiple simple traumas.
A complex trauma (Trauma II) is repeated traumatic events over a period of time, such as severe neglect or abuse as a child, severe repeated violence or abuse as an adult such as domestic violence. 'Complex trauma' will be described in more detail later on in this leaflet.
In order for the experience of an event to be traumatic it does not have to directly affect a person - witnessing or even hearing about an event can be considered to be exposure to a traumatic event. It is often the meaning or perception of the event that is more significant than the actual severity of incident.
Common Stress reactions affecting our emotions:
Anxiety and Fear :
We might feel jumpy, hyper -vigilant, tense, fearful, easily startled at a sudden or loud noise
Irritability or Anger -
We might fly into a rage more quickly, lose patience, be irritated at people we usually care about
Depression and Low mood
We might feel tired all the time, or numb, have bouts of crying, lose interest or enjoyment, deep sadness or grief particularly if we’ve lost someone
Guilt and Shame
Sometimes we might experience survivor guilt – guilt at the fact that we survived and others may not; we may blame ourselves, or feel we did not do enough to prevent the event, or feel shame for acting in ways we would not normally behave
Stress Reactions after a trauma often include effects on our thoughts, emotions and behaviour
Often people cope in very different ways, some coping strategies or coping behaviours may be more effective than others…. In other words, trauma is defined by the experience of the survivor. Two people could undergo the same harmful event and one person might be traumatized while the other person remained relatively unscathed.
Most people who are exposed to trauma will experience a stress reaction – this is entirely normal as our bodies through years of evolution developed the fight-flight or freeze response.
Being exposed to trauma can result in increased anxiety and depressive symptoms, feelings of guilt and shame, and increased anger, resentments or a sense of betrayal. The world may no longer appear to be a safe place and the worldview may be shattered.
Usually these symptoms naturally ease off after a while, and there seems to be evidence to suggest that various factors such as a supportive family and friends may increase resilience.
Anxiety is a common and natural response to a dangerous situation. For many it lasts long after the trauma ended. This happens when views of the world and a sense of safety have changed. You may become anxious when you remember the trauma, or sometimes anxiety may come out of the blue. Triggers or cues that can cause anxiety may include places, times of day, certain smells or noises, or any situation that reminds you of the trauma. As you begin to pay more attention to the times you feel afraid you can discover your anxiety is really triggered by things that remind you of your trauma.
If you are not used to feeling angry these feelings may feel foreign to you, and you may not know how to deal with them. In therapy, you will be able to explore your anger and what you are angry about in a safe environment with your therapist who will understand and support you. You will learn that the anger is often triggered by subtle reminders of the trauma, and by your thoughts about the unfairness of the trauma, and you will learn ways of dealing with these memories and thoughts.
Another common reaction to trauma is sadness, or feeling down or depressed. You may also feel that life is no longer worth living and that plans you had made for the future no longer seem important or meaningful. With therapy, as you work through the memory of your traumatic event and start reclaiming your life again, you will find that your mood will also improve.
Trauma often leads to feelings of guilt or shame. These may be related to something you did, or did not do, in order to survive or cope with the situation. It is common for people to go over and over what happened in their minds. You may find yourself going over steps you might have taken to prevent the trauma from occurring, or different ways you might have reacted. You may also blame yourself for not having been able to put the trauma behind you and get back to normal, rather than understanding your symptoms as a normal, human reaction to intolerable stress. Equally, others may not understand the nature of post-traumatic stress, and give you the message that you should be pulling yourself together and getting on with life. Self-blaming thoughts are a real problem, because they can lead to feeling helpless, depressed and bad about yourself. In therapy, you will discuss these thoughts with your therapist, and learn to be less hard on yourself. You will discover that you had good reasons for the way you behaved at the time.
What is PTSD?
Whereas most people recover from trauma after a period of time, a small minority go on to develop Post Traumatic Stress Disorder or PTSD.
It is estimated that roughly between 10 and 20% of people exposed to a traumatic event will subsequently develop PTSD. Researchers are busy trying to elicit what pre-disposing factors may influence its development. Some things that increase the likelihood of developing PTSD are:
Freezing in response to trauma – those who become immobile in the face of severe threat as an instinctive survival technique
Previous history of trauma
Greater distress at the time of trauma and immediately thereafter
Pre-existing psychological disorder
Poor coping skills
Age – younger or older people are at greater risk
PTSD is treatable. There are a number of interventions available that have been shown to markedly reduce or even eliminate the symptoms of PTSD. This is not a condition you need to live with forever. Although we cannot change history, we can change the way your history affects your life now. You can recover from your traumatic experience(s).
Imagine you are taking a walk in the woods, it’s a lovely spring day, the sun is
shining, you have no care in the world, and your body is relaxed. Suddenly out
of nowhere a big black dog comes charging out of the undergrowth...
You may experience your heart beating faster to get more blood to your muscles ready for action, your mouth may go dry, your vision may be sharper, hands may go cold, you may be sweating. These happen through the processes in the Sympathetic Nervous system, releasing adrenalin into the blood stream…..
DSM V Criteria for PTSD
Exposure to an event that involved or held the threat of death, violence or serious injury.
Intrusion or re-experiencing the event
Avoiding reminders of the event
Negative changes in thoughts and mood
Increased Arousal Symptoms
The duration of symptoms is more than 1 month
The disturbance causes clinically significant distress or impairment in functioning
The disturbance is not attributable to the physiological effects of a substance or other medical condition
Symptoms of PTSD
These symptoms occur because our bodies and brains have been affected by trauma. Some symptoms occur soon after the trauma and some develop over time. The major categories are:
You find yourself re-living the event, again and again. This can happen both as a 'flashback' in the day and as ‘nightmares’ when you are asleep. These can be so realistic that it feels as though you are living through the experience all over again. You see it in your mind, but may also feel the emotions and physical sensations of what happened - fear, sweating, smells, sounds, pain.
Ordinary things can trigger off flashbacks. For instance, if you had a car crash in the rain, a rainy day might start a flashback.
Numbing and Avoidance
It can be just too upsetting to re-live your experience over and over again. So you distract yourself. You keep your mind busy by losing yourself in a hobby or working very hard. You avoid places and people that remind you of the trauma, and try not to talk about it.
You may deal with the pain of your feelings by trying to feel nothing at all – by becoming emotionally numb. You communicate less with other people who then find it hard to live or work with you.
This is the sense of being hyper-alert. These symptoms can be felt physically with a racing heart, shallow breathing, sweats, tingling, tense muscles and churning stomach. They can also be experienced mentally with racing thoughts, worry, rising sense of panic and repetitive thoughts. Typical symptoms are:
Anxiety and Panic attacks
Hypervigilance – always being on guard
Sensitivity to light and sound – startle response
Abrupt mood swings – sudden rage, crying
Is part of our survival instinct when we cannot fight or escape any other way. It is a mechanism that allows us to temporarily escape distressing experiences, emotions, sensations and thoughts. This can happen without conscious awareness. Examples of dissociation are:
Amnesia: Can’t remember incidents or experiences that happened at a particular time, or can’t remember important personal information.
Depersonalisation: A feeling that your body is unreal, changing or dissolving. Out of body experiences such as seeing yourself watching a replay.
Derealisation: World seems unreal. May see objects changing in shape, size or colour.
Identity Confusion: Uncertain about who you are or struggling to define self.
“I wasn’t there for anyone anymore — it was like I had checked out, emotionally. I went through the motions every day, but didn’t really feel anything or want to be around anyone. I couldn’t focus. Hours would pass with nothing done. And I know my family saw it, I know they felt the void. I think this hurt everyone around me, which made me feel even worse. I knew something was very, very wrong with me, I just didn’t know what. And I didn’t know what to do about” it.”
If dissociation is not treated it can become a way of dealing with minor stresses and problems. The continued use of dissociation as a way of coping with stress interferes with the capacity to fully attend to life's ongoing challenges and can lead to:
Constriction: Our awareness of events is blunted, as well as our emotions. A person will have a hard time focussing or concentrating, will see and hear less clearly, and be easily distracted.
Withdrawal and Avoidance: A person will withdraw more, perhaps becoming socially isolated, and put a lot of energy into avoiding reminders of the trauma.
Detachment: Time seems distorted and people are not aware of their boundaries so they can be clumsier and be injured easily.
Rigidity: Sometimes in order to cope, people will gravitate to the other extreme of being super-organized and seem over-controlling of one self and/or others.
Does everyone get PTSD?
No. But nearly everyone will have the symptoms of post-traumatic stress for the first month or so. This is because they can help to keep you going, and help you to understand the experience you have been through. This is an 'acute stress reaction'. Over a few weeks, most people slowly come to terms with what has happened, and their stress symptoms start to disappear.
PTSD occurs when the body’s and brain’s abilities to process the trauma is overwhelmed. It is primarily a physiologic (to do with bodily functions) process with psychological symptoms. To understand this, we need to look at how the brain and body respond to severe trauma.
Brain and Body Responses to Trauma
When a severe threat occurs our brain perceives this and sends signals to different parts of the brain and body to react.
The Human Brain can be divided into three main sections or parts:
The reptilian brain (brain stem)
The mammalian brain (limbic system which includes the amygdala and hippocampus)
The human brain (Cortex)
Research has shown that during trauma the only parts of the brain which are activated are the brain stem and some parts of the limbic system.
The cortex, which is the part of our brain that allows us to think, plan and make decisions is largely shut down
Two brain structures within the limbic system that play an important role in PTSD are the amygdala and the hippocampus.
In response to stress the amygdala activates the body's alarm system causing the body to fight, flee or freeze. This occurs instinctively and before we can consciously respond to a threat.
This is important to know because sometimes our bodies respond to a threat which feels shameful such as freezing or running away. However, this is not something we’ve thought out, it happens instinctively to protect us and we have no conscious control.
During trauma the parts of your brain that creates memory, with a beginning and an end, are shut down so memories of trauma stay with you all the time and you continue to feel as if you are in constant danger. This is not a conscious process and you cannot think your way out of this.
When the danger is over, the alarm system is supposed to shut down, allowing the body to relax and return to normal. However, traumatic events can impair the functioning of the alarm system so that you cannot tell when the danger is over. You continue to feel as if the danger is ever present, which promotes a state of chronic hyperarousal. Any trigger associated with the trauma can cause anxiety and panic. Sometimes it’s difficult to know why something has triggered anxiety because the association with the trauma has been forgotten.
“Once you’ve been bitten by a snake you are afraid of even a piece of rope”
This form of trauma usually starts in childhood and is characterized by harmful and persistent emotional, physical and/or sexual abuse. This can include neglect. Although complex Trauma can also occur after any prolonged exposure to trauma.
In a secure and loving household children neurologically develop a “learning brain,” while those who have grown up in abusive households develop a “survival brain.”
Whilst the symptoms of Post Traumatic Stress Disorder (PTSD) are well defined and respond well to psychological treatment, the role of complex trauma, particularly that occurring in childhood, is becoming associated with an increasing range of psychopathology and can perhaps best be understood as a spectrum of conditions rather than a single disorder.
Our early experiences of care can often affect how we feel about ourselves and impact on the relationships we form with other people. People who experience abuse in what is meant to be a caring relationship can often feel that it is their fault and think badly about themselves. They may also believe that all relationships will be similar and accept this or believe that it is better to be alone. Some people report that experiencing one traumatic event after another can make them feel powerless and helpless and there is no point trying to get help because there is nothing they can do.
Complex Trauma often produces feelings of fear, guilt, shame, sadness and despair that can often be difficult to manage and control.
Often these feelings start suddenly and become overwhelming. Sometimes people report that the only way they can cope or find any relief is through drugs and alcohol or other forms of self-harm.
A complicated association between love and violence can develop in someone who was sexually or physically abused. It is difficult to understand the connection between current behaviour and past trauma.
Through specialized assessment, many personality disorders, particularly Emotionally Unstable/Borderline Personality Disorder, can be understood and therefore treated in the framework of complex trauma.
Usually the person has no idea why they keep behaving a certain way. With trauma our memories are affected and much of the detail has been “forgotten”. Therapy is helpful in making the link between the past and present.
Lack of trust in other people – and the world in general – is central to complex PTSD. Treatment often needs to be longer to allow you to develop a secure relationship with a therapist – to experience that it is possible to trust someone in this world without being hurt or abused.
Later Symptoms – These symptoms tend to develop either months or years later. These can occur without PTSD but they commonly are the result of complex trauma:
Attraction to dangerous situations
Addictive Behaviour (eating disorders, alcohol or drug dependency, sex addiction)
Exaggerated or diminished sexual activity
Excessive shyness, lack of self confidence
Inability to commit
Chronic fatigue, low energy
Many physical ailments such as migraines, immune deficiencies, chronic pain, skin problems, Irritable Bowel Syndrome, severe premenstrual syndrome, asthma, back pain and chronic fatigue.
Processing Trauma – The Factory Metaphor
The factory metaphor can often help when we’re trying to understand how we can best process difficult traumatic memories. So the mind can be thought of as being a bit like a factory. One of its jobs is to process life events so that they become memories. Most life events are of a size and type that the “mind factory” can quite easily cope with:
However, sometimes events occur which are too difficult to process in the normal way. This is likely to be because the event itself is too traumatic, and the difficulty may also be contributed too because the person experiencing it is too young to understand adequately what is happening.
Because the event isn’t properly processed, it is prevented from becoming a normal memory – hence the symptoms of re-experiencing & arousal that may occur, while avoidance is because the “mind factory” doesn’t want to keep running into the problems that arise each time an attempt is made to process the trauma. This is why working with these difficult traumatic experiences so often needs to be done carefully and methodically, breaking them down into smaller pieces that can be adequately processed and turned into the kinds of memories that are not nearly so overwhelming.
In the UK only psychiatrists or Clinical Psychologists can provide a diagnosis of PTSD, however assessment of PTSD symptoms can be carried out by professionals working in the mental health field such as psychotherapists, counsellors or other practitioners.
Assessments are of prime importance in order to determine what type of Trauma is being dealt with which will inform a treatment plan.
Treatments for PTSD include psychological therapies and medication, sometimes they may be combined.
There is good evidence for the effectiveness of either, although research seems to suggest that psychological therapies are more effective than medication.
“While each approach involves trade-offs, the most appropriate treatment choices depend on history, capabilities & goals of each patient, as well as the nature of the traumatic events”
Psychological Therapies for PTSD include:
Emotional Regulation and Stabilisation
Trauma Focused Cognitive Behavioural Therapy
Eye Movement Desensitization and Reprocessing (EMDR)
Emotional Regulation and Stabilisation
This is the first step in trauma therapy. During this stage you will learn how to manage your overwhelming emotions such as anger, shame, fear, anxiety and panic. You will also learn various techniques to cope with your body’s hyperarousal. These will include relaxation methods, visualisation, grounding techniques, mindfulness techniques, work with body awareness and ways of finding internal and external safety.
It is important that you are able to master this stage before you move onto processing the trauma in the therapies below. Sometimes this stage alone is enough to help with your trauma symptoms and no further therapy is necessary.
The course of treatment and its duration can vary quite dramatically and a variety of different treatment strategies might be used across the stages of treatment.
Some clients stay in therapy for years (especially those with the most extensive trauma histories and those with insecure attachment styles) may never move beyond the first stage, while others move through the stages in much less time, and still others only engage in treatment episodically as needed.
Cognitive Behavioural Therapy (CBT)
In cognitive therapy, your therapist helps you understand and change how you think about your trauma and its aftermath. Your goal is to understand how certain thoughts about your trauma cause you stress and make your symptoms worse.
You will learn to identify thoughts about the world and yourself that are making you feel afraid or upset. With the help of your therapist, you will learn to replace these thoughts with more accurate and less distressing thoughts. You will also learn ways to cope with feelings such as anger, guilt, and fear.
By using protocols you will be exposed to your trauma(s) repeatedly, with a therapist, in a specific, safe way. You'll learn to get control of your thoughts and feelings about the trauma. You'll learn that you do not have to be afraid of your memories. This may be hard at first but over time, you'll feel less overwhelmed.
With the help of your therapist, you can change how you react to the stressful memories. Talking in a place where you feel secure makes this easier.
Eye movement desensitization and reprocessing (EMDR) uses rapid eye movement similar to what we see in REM sleep in which your brain processes events that have happened to you. This results in dreams in sleep and in changes of perceptions while awake. EMDR helps you process the trauma by making connections between the part of the brain involved with trauma and the part which can make sense of the trauma. EMDR is effective for one off traumas and more prolonged complex trauma. It is also use for other conditions such as anxiety, phobias and depression.
In the UK currently there are only 2 types of medication licensed for the use of PTSD – these being paroxetine and sertraline, both in the class of SSRI’s (selective Serotonin Reuptake Inhibitors).
SSRI’s are a type of antidepressant medicine. These can help you feel less sad and worried. They appear to be helpful, and for some people they are very effective. SSRIs include citalopram, fluoxetine (Prozac), paroxetine, and sertraline.
Chemicals in your brain affect the way you feel. Talk to your doctor about which medications are right for you.
Components in Therapy:
Grounding and Relaxation Techniques – These are used for dissociation and hyperarousal symptoms. Identifying these symptoms and when they occur is the first step. Progressive relaxation and mindfulness meditation are both useful here.
Emotional Regulation – Identifying strong emotions and understanding where they come from. Techniques to regulate these will be talked about.
Trigger Identification – We will be identifying what things in your environment and within you cause you to have PTSD symptoms and work out ways to handle them so they don’t affect you so much. Also looking at what things/triggers you avoid. Some of these may be sensible but others may be stopping you from having a full life such as avoiding leaving the house.
Work on your thoughts – Looking at how you see the world and what thoughts you automatically think in certain situations. You may see the world as dangerous and full of predators. There are techniques that can help see the world in a different, more balanced and healthy light. Developing a coherent story about the trauma is helpful.
Work on Emotions Associated with Trauma – This will involve working with the emotions that come up thinking about the trauma. This will be done in a controlled way so you do not become overwhelmed.
What to expect when you see a trauma specialist:
Before starting a Trauma Process there will be a thorough assessment of criteria and symptoms through diagnostic tools, a detailed client history and a structured Interview assessing Trauma History.
When you begin therapy, you and your therapist should decide together what goals you hope to reach in therapy. Not every person with PTSD will have the same treatment goals.
For instance, you might focus on:
Reducing your PTSD symptoms
Learning the best way to live with your symptoms
Learning how to cope with other problems associated with PTSD, like feeling less guilt or sadness, improving relationships at work, or communicating with friends and family, or changing unhelpful habits (alcohol or drug addiction)
PTSD: Stages of treatment:
Crisis stabilisation and engagement
Education about PTSD and related conditions
Strategies to manage symptoms
Trauma focused therapy (confronting the painful memories and feared situations)
Cognitive Restructuring (Learning to think more realistically about what happened)
Relapse prevention and on-going support)
It is important to know that you do not need to fully remember the trauma in order to treat it. Dredging up exact memories could cause more damage than good. Instead we will be working with existing memories, symptoms of the trauma and building up your resources and resilience to the effects of trauma.
The symptoms you have due to trauma are your body’s way of telling you there is something wrong. You can learn to listen to these messages, make sense of them and become more aware of what your body is telling you. In this way these PTSD symptoms can be considered helpful in guiding treatment to help you feel better.
It can be difficult to talk about painful situations in your life, or about traumatic experiences you've had. Feelings that emerge during therapy can be scary and challenging. Talking with your therapist about the process of therapy, and about your hopes and fears in regards to therapy, will help make therapy successful.
You should feel comfortable with your therapist and feel you are working as a team to tackle your problems. You should also agree on what you will do if it does not seem to be working. If you have any questions about the treatment, your therapist should be able to answer them.