Looking back at the Bucket

Notice, in the picture of the bucket, that the 2 valve isn’t at the bottom of the bucket.  There is an area at the bottom that never gets drained by the 2 valve.  And the heavier stressors settle down there and sit.  Note too, in our bucket picture, that there is a dot at the bottom.  This is a drain plug to get rid of the old, accumulated stressors and traumas that normal coping skills don’t touch.  Metaphorically, the drain plug symbolizes Trauma therapy, clearing out the old, unresolved traumas.

  The Psychobiology of Trauma

In this next section I want to explore trauma and how the psychological community thinks about trauma and its impact.  This piece may get a little technical, or dry, so feel free to skip ahead to the next section.  (You won’t hurt my feelings.)

How to define trauma?

If we go to the dictionary we find “A disordered psychic or behavioral state resulting from mental or emotional stress or physical injury.” 
          (Webster’s Ninth New Collegiate Dictionary) 

That seems vague to me.  How about:

“Trauma occurs when an actual or perceived threat of danger or loss overwhelms a person’s usual coping ability.”  
     (From Beverly James, 1994) 

This approaches my understanding.  Overwhelm.  That, to me, best summarizes the concept of trauma.  

Overwhelm, or traumatic experiences, can vary greatly in terms of their intensity, duration, frequency, meaning and other factors.  But even for a particular stressor, there is no clear and simple cause-and-effect relationship between a traumatic experience and subsequent psychological symptoms.  Two people can have the same traumatic experience yet show very different responses. The measure of trauma isn’t really about the degree of overwhelm, rather it is how one is able to return to a stable state afterwards.

For example, there was an article in the newspaper some years ago, where two sisters, twins, had been kidnapped and held hostage for over a week.  The story was reporting how the sisters, now some years older, are dealing with that traumatic experience.  One had taken her experience as a lesson that she needed to live each moment as though it were her last.  She was happily married, and felt successful and complete.

Her sister, on the other hand, had been in and out of mental health facilities and was diagnosed with severe PTSD.  

Traumatic experiences become problematic when an overwhelming experience to the emotional and or psychological nervous system cannot be processed nor does the person have the resilience to integrate the experience.

The key factor in this definition is the word resilience.  Each individual has a threshold for experiences, a level which, when crossed, causes the experience of being overwhelmed.  There is no way to determine this level ahead of time, nor even predict it with much accuracy.  It is the individual who must determine if the experience was “traumatic” or not.  

Some people can experience what we might consider an insignificant event and find it traumatic.  Like beauty, trauma is in the eye of the beholder.

There is debate in the psychological community about trauma.  This is because trauma has degrees of complexity.  There are several diagnostic categories, including Acute, Severe, PTSD (Posttraumatic Stress Disorder) and, more recently Complex trauma. ***According to the National Center for PTSD, complex PTSD was not included as a separate diagnosis in the DSM-5 because 92% of those with C-PTSD also met the criteria for PTSD.  A review of the literature by Resick in 2012 found insufficient evidence to support complex PTSD as a distinct diagnosis from PTSD as defined in the DSM-5.  This is in spite of a significant body of research literature supporting complex PTSD as a separate diagnosis.  For example, a study by Powers et al. of African women found “clear, clinically-relevant differences” between the two conditions.  C-PTSD was associated with lower likelihood of having secure attachment, greater comorbidity with other mental illnesses, increased emotional dysregulation and dissociation.  *** National Center for PTSD. (2014). Literature on DSM-5 and ICD-11. PTSD Research Quarterly, 25(2).

In the DSM IV,  Posttraumatic Stress Disorder – is described as            “Exposure to stressors; experienced, saw or learned of event(s) that involved actual or threatened death, serious injury or violation of the body of self or others

Person’s response involved intense fear, helplessness, or horror (in children, the response may involved disorganized or agitated behavior).

The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor.

That stressor may involve a direct personal experience of:

• actual or threatened death
• serious injury
• other threat to one’s physical integrity
• witnessing an event that involves death, injury or a threat to another person
• learning about unexpected or violent death, serious harm, or threat of death
• injury experienced by a family member or other close associate.  

The symptoms of Posttraumatic Stress Disorder can be summarized as:

• having the event re-experienced  
• Avoidance of similar situations
• Hyper arousal, or watchfulness
• Must have a duration of more than one month
• And the experience leaves life disrupted

Many individuals who experience traumatic events develop a distinct set of physical signs and symptoms. These symptoms tend to fall into three clusters; 

1) persistent re-experiencing of the event, i.e. recurring intrusive recollection of the traumatic event such as dreams and ‘flashbacks’ 

2) persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness and 

3) persistent symptoms of increased arousal characterized by hypervigilence, increased startle response, sleep difficulties, irritability, anxiety and physiological hyper-activity. These symptoms are exacerbated by exposure to stimuli associated with the original event. 

In addition these symptoms:

1. must be present for more than one month and 
2. must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition)

PTSD in the DSM-5. The definition of trauma exposure has changed: it no longer requires someone to respond with fear, helplessness or horror to the event. The exposure to actual or threatened death, serious injury or sexual violation will be central to the definition, with media exposure being explicitly excluded unless it is work-related.

Post-Traumatic Stress Disorder (PTSD) is when, 6 months after the event, we are continuing to have symptoms of distress.  For example:

Emotional symptoms

• Shock, denial, or disbelief 
• Confusion, difficulty concentrating
• Anger, irritability, mood swings
• Anxiety and fear
• Guilt, shame, self-blame
• Withdrawing from others
• Feeling sad or hopeless
• Feeling disconnected or numb

Physical symptoms:

• Insomnia or nightmares
• Fatigue
• Being startled easily
• Difficulty concentrating
• Racing heartbeat
• Edginess and agitation
• Aches and pains
• Muscle tension

Trauma Theories

From Pavlov – the traumatic event acts as a conditioned response, which means that victims will respond automatically to events or things associated with the trauma, even if they are non-threatening in nature

In 1889, Pierre Janet postulated that intense emotional reactions make events traumatic by interfering with the integration of the experience into existing memory schemes. Intense emotions, Janet thought, cause memories of particular events to be dissociated from consciousness, and to be stored, instead, as visceral sensations (anxiety and panic), or as visual images (nightmares and flashbacks). Janet also observed that traumatized patients seemed to react to reminders of the trauma with emergency responses that had been relevant to the original threat, but that had no bearing on current experience. He noted that victims had trouble learning from experience: unable to put the trauma behind them, their energies were absorbed by keeping their emotions under control at the expense of paying attention to current exigencies. They became fixated upon the past, in some cases by being obsessed with the trauma, but more often by behaving and feeling like they were traumatized over and over again without being able to locate the origins of these feelings.)

What Makes Us More Vulnerable to PTSD-(Schiraldi)

• The event is sudden & unpredictable
  • The event lasts a long time 
  • It recurs or is thought likely to recur
  • Can contain real or threatened violence
  • Can involve multiple forms
  • May occur in early years before the personality is fully integrated

Pre-Trauma Vulnerabilities –

• Underdeveloped life skills – protective, problem-solving, self-esteem, resilience, creativity, humor, discipline, ability to express emotion, ability to tolerate stress.  PTSD can stimulate us to develop these symptoms:
• Lack of a support system – the feeling of isolation, that one is alone and that no one understands.
• Personality and habitually negative thought patterns – this often includes a belief that the person somehow deserved the trauma or feelings of unworthiness of being happy.
• Biology. Some people appear to have overreactive nervous systems. Heredity and a history of drug abuse appear to influence this factor.  Also there is research that trauma is often causal in substance abuse in the future.
• History of Prior Trauma

Responding to a Real or Perceived Threat or a Trigger

When a living being is triggered by a real or perceived threat the Hypothalamus-Pituitary-Adrenal Axis (HPA) is activated.  This involves the Sympathetic Nervous System and we see symptoms of:

• Fight, Flight or Freeze
• Heart rate
• Sweat response
• Energy increase

Our Body’s Chemical Response

The human system is a wonderful chemical machine.  We have a variety of substances that manage our life experience.  Sometimes, however, these same systems can be problematic. 

Catecholamines: Epinephrine and norepinephrine are part of our fight or flight response.  There is research showing that trauma survivors often continue to have these chemicals operating long after the traumatic event has concluded and create a state of “hyperstress”.

Another part of our chemical response to trauma are Corticosteriods: Glucocorticoids and cortisol are involved in:

• Regulation of the catecholamines
• Increase of energy
• Increase of immune functioning

A third chemical response are Endogenous Opiods.  They serve a wonderful purpose in a traumatic experience by preventing experiencing the pain so we can act.  We have heard stories of mother’s having lifted tremendous weights to help their children, things that seem like superpowers.  On the downside, these chemicals can prevent memory consolidation, making recollection difficult or impossible.

With “normal” amounts of stress, these chemicals facilitate a process that allows people to function with greater endurance, strength, immunity, and clarity. In extreme amounts of stress, however (rape, domestic violence, and other forms of victimization), these chemicals may often be released in amounts that are damaging to the brain and inhibit memory functions.

Inverted “U” Response

At optimum levels, the biochemical changes allow us to function at a higher capacity during stressful events. However, if the stress continues too long or is too overwhelming, functioning becomes impaired rather than enhanced.

Stress chemicals during the trauma and subsequent triggered periods often result in biochemical changes during and after the traumatic event and a change in memory functions during and after the event

Serotonin. While the role of serotonin in PTSD has not been systematically investigated, both the fact that inescapably shocked animals develop decreased CNS serotonin levels, and that serotonin re-uptake blockers are effective pharmacological agents in the treatment of PTSD, justify a brief consideration of the potential role of this neurotransmitter in PTSD. Decreased serotonin in humans has repeatedly been correlated with impulsively and aggression. Low serotonin in animals is also related to an inability to modulate arousal, as exemplified by an exaggerated startle and increased arousal in response to novel stimuli and the handling of pain. 

The behavioral effects of serotonin depletion on animals is characterized by hyperirritability, hyperexitability, and hypersensitivity, and an exaggerated emotional arousal and/or aggressive display, to relatively mild stimuli . These behaviors bear a striking resemblance to the phenomenology of PTSD in humans. Furthermore, serotonin re-uptake inhibitors have been found to be the most effective pharmacological treatment of both obsessive thinking in people with OCD, and of involuntary preoccupation with traumatic memories in people with PTSD. It is likely that serotonin plays a role in the capacity to monitor the environment flexibly and to respond with behaviors that are situation-appropriate, rather than reacting to internal stimuli that are irrelevant to current demands. 

So, what do these chemical components create in the way of biochemical changes during and after the traumatic event?

• Catecholamines – levels are chronically increased resulting in constant hyperstress and inability to distinguish danger signals
• Corticosteriods- Chronically low levels – results in reduced immune functioning, impaired regulation of the catecholamines, and damage to brain passages in the brain responsible for memory
• Biochemical changes during and after the traumatic event
• Catecholamines – levels are chronically increased resulting in constant hyperstress and inability to distinguish danger signals
• Corticosteriods- Chronically low levels – results in reduced immune functioning, impaired regulation of the catecholamines, and damage to brain passages in the brain responsible for memory
• Biochemical changes during and after the traumatic event 2
• Damage of the neuroreceptors that control the stress response  
• Increase of receptors for cortisol, with the result that it is easier to be triggered
• Viscous cycle – less able to switch off the stress, which produces more of the stress hormones that damage the neuroreceptors that control the stress response….
• Biochemical changes during and after the traumatic event 3
• Increased endogenous opioid levels during traumatic memory triggers
• Acoustic startle response (when you jump at loud, unexpected noises)
• Vasopressin – stress headaches?
• Oxytocin – Damage to traumatic memory recall.  Bonding to a perpetrator
• Reduction of the hippocampus

Catecholamines. Neuroendocrine studies of Vietnam veterans with PTSD have found good evidence for chronically increased sympathetic nervous system activity in PTSD. One study  found elevated 24h excretions of urinary NE and epinephrine in PTSD combat veterans compared with patients with other psychiatric diagnoses. 

Corticosteroids. Two studies have shown that veterans with PTSD have low urinary cortisol excretion, even when they have comorbid major depressive disorder. In a series of studies, Yehuda et al  found increased numbers of lymphocyte glucocorticoid receptors in Vietnam veterans with PTSD. Interestingly, the number of glucocorticoid receptors was proportional to the severity of PTSD symptoms. Yehuda  also has reported the results of an unpublished study by Heidi Resnick, in which acute cortisol response to trauma was studied from blood samples from 20 acute rape victims. Three months later, a prior trauma history was taken, and the subjects were evaluated for the presence of PTSD. Victims with a prior history of sexual abuse were significantly more likely to have developed PTSD three months following the rape than rape victims who did not develop PTSD. Cortisol levels shortly after the rape were correlated with histories of prior assaults. These findings can be interpreted to mean either that prior exposure to traumatic events result in a blunted cortisol response to subsequent trauma, or in a quicker return of cortisol to baseline following stress. The fact that Yehuda also found subjects with PTSD to be hyperresponsive to low doses of dexamethasone argues for an enhanced sensitivity of the HPA feedback in traumatized patients.

Trauma and Memory – how the Amygdala & Hippocampus are impacted by trauma.

            The Amygdala, an almond sized organ in the brain, is responsible for Implicit Memory, that is, memory not available to conscious awareness, including storage of senses and emotions.

            The Hippocampus, located next to the Amygdala, is responsible for Explicit Memory, or conscious memory, such as remembering facts, recording events, logical thinking, reasoning capabilities.

Research on trauma’s impact on memory shows a clear loss of volume of the hippocampus.  Autopsies of PTSD victims have shown the hippocampus shriveled “like a raisin.” The lack of memory consolidation between the amygdala and hippocampus results in a sensory memory with no anchor in time or fact, indicative of the client’s report that “the trauma didn’t happen in the past; it’s happening now!”

“the trauma didn’t happen in the past; it’s happening now!”

This often accompanied by a consistent “acoustic startle response” where sounds trigger a strong reactive emotional response, similar to the initial trauma.

These auditory cues which trigger the original trauma result in a partial or complete shut down of the hippocampus and activation of the amygdala; i.e. flight or fight.

Traumatic memory can be come locked in an emotional/sensory state, so that this activated emotional state becomes the norm.  The traumatic state can become a “new normal.”

Research indicates that there can be some gender differences in the trauma response.  Most findings of gender differences in PTSD found that females are reported to be diagnosed with PTSD after a trauma twice as often as males and developed stronger symptoms than males.  The lifetime prevalence of PTSD in females is reported as higher (10.4%) than in males (5.0%).  These findings also show that women experience a longer duration of symptoms (4 years for females compared to 1 year for males) and display more re-experiencing  avoidance and hyperarousal.^[2]

Research has shown that, under ordinary conditions, many traumatized people, including rape victims, battered women and abused children have a fairly good psychosocial adjustment. However, they do not respond to stress the way other people do. Under pressure, they may feel, or act as if they were traumatized all over again. 

Thus, high states of arousal seem to selectively promote retrieval of traumatic memories, sensory information, or behaviors associated with prior traumatic experiences. The tendency of traumatized organisms to revert to irrelevant emergency behaviors in response to minor stress has been well documented in animals, as well. Studies at the Wisconsin primate laboratory have shown that rhesus monkeys with histories of severe early maternal deprivation display marked withdrawal or aggression in response to emotional or physical stimuli (such as exposure to loud noises, or the administration of amphetamines), even after a long period of good social adjustment. In experiments with mice, they found that the relative degree of arousal interacts with prior exposure to high stress to determine how an animal will react to novel stimuli. In a state of low arousal, animals tend to be curious and seek novelty. During high arousal, they are frightened, avoid novelty, and perseverate in familiar behavior, regardless of the outcome. 

Under ordinary circumstances, an animal will choose the most pleasant of two alternatives. When hyperaroused, it will seek whatever is familiar, regardless of the intrinsic rewards. Thus, animals who have been locked in a box in which they were exposed to electric shocks and then released return to those boxes when they are subsequently stressed. This also might explain domestic violence victims who return to their abusers.  Perhaps the known problem is easier, safer or less frightening than the unknown.

            PTSD is contagious – children catch it from their caregivers

Some thoughts for professionals dealing with trauma survivors.  Initial memories can be fragmented, disjointed and confusing.  Your client may offer “excited utterances” versus telling the story in a linear fashion.  As helpers we can just listen and provide support.  In addition, we can normalize the experience by educating about normal responses to abnormal events.  It can be helpful to keep track of the client’s story by writing down events and reminding them of the chronological order, as time memory is often distorted.

Trauma First Aid

• Moderate to heavy exercise within 48 hours of the trauma
  • Drink lots of water
  • Verbalize what happened only in a safe setting
  • Journal writing

The big message is that “It is possible to extinguish trauma!” 

I believe that effective treatment would:

• help a person form a declarative memory of a traumatic event
• bleed-off the sensory/emotive aspects
• enable a person to remember the event without being physiologically triggered.

Charles Figley writes that a trauma victim becomes a survivor when they can:

• Tell the story 
• Recall the timeline
• Revisit the location
• Talk about their reactions and
• Talk about what they might do differently 

All without being emotionally retriggered.

Main references:

Bessel van der Kolk, Bruce Perry, Glenn R. Schiraldi, S. Wang, Emily Spence-Diehl, Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society and The Psychobiology of Trauma, The PTSD Sourcebook

Descilio, Teresa, MSW, CTS (Executive Director, Victim Services Center), Understanding Victim Behavior.  A presentation for TIRA, International

Recent research estimates PTSD affects roughly eight million people each year^[3] in the United States. According to the Diagnostic and Statistical Manual [DSM V^[4], the current criteria for PTSD include the following:

• Exposure to actual or threatened death, serious injury or sexual violence.
• Symptoms following the event such as intrusive memories, recurring dreams, flashbacks or other bodily reactions to cues related to the event.
• Avoidance of things associated with the event (for example: similar or actual location, people or related feelings or thoughts).
• A generally negative change in thoughts or mood following the event(s).
• hanges in level of reactivity or heightened arousal beginning or worsening after the event(s) (for example: being startled very easily, feeling “on edge,” or having difficulty sleeping).

For those who do not meet these criteria, they may be experiencing post-traumatic stress that does not meet the clinical definition of PTSD. In both instances, therapeutic support can be life-changing. Like someone with diagnosable PTSD, a person who has experienced or witnessed a traumatic event may work with a licensed mental health provider to moderate the impact of the event, cope better, and return to a higher level of functioning.

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^[2] Gender Differences in PTSD: Susceptibility and Resilience
By Jingchu Hu, Biao Feng, Yonghui Zhu, Wenqing Wang, Jiawei Xie and Xifu Zheng
Submitted: May 5th 2016Reviewed: August 19th 2016Published: February 1st 2017

https://www.intechopen.com/books/gender-differences-in-different-contexts/gender-differences-in-ptsd-susceptibility-and-resilience

^[3] https://www.ptsd.va.gov/understand/common/common_adults.asp

^[4]) The diagnostic classification is the official list of mental disorders recognized in DSM. Each diagnosis includes a diagnostic code, which is typically used by individual providers, institutions, and agencies for data collection and billing purposes. These diagnostic codes are derived from the coding system used by all U.S. health-care professionals, known as the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM).