Trauma Therapy

Trauma Therapy

TRAUMA

Traumatization is part of the human experience, whether it is caused by acts of nature or acts of man. The result can be a state of psychological overwhelm; in fact, trauma has been defined as "more than the mind can bear". At the time of the actual event, there is an intense experience of helplessness, terror and loss of control as the person is faced with the fear of annihilation.

Traumatization can also result from the witnessing of such a terrifying event – one need not be involved directly to be traumatized. This is termed vicarious trauma.

Trauma reactions can also develop as a result of the adaptation to a life of perpetual fear, such as witnessed in the histories of those who have experienced chronic maltreatment in childhood or domestic violence.

SYMPTOMS OF TRAUMA

The onset of symptoms of traumatization may occur immediately after the event or may occur weeks or even years later. The defining symptoms of post-traumatic stress are bipolar in nature, consisting of elements of intrusion, re-experiencing and avoidance. There may be vivid nightmares and flashbacks, intrusive thoughts about the event or what could have happened, anxiety, panic, sleep disturbances, irritability, feelings of uncontrollable rage and a sense of hypervigilance. Conversely, there may also be emotional numbing, depression, fatigue, a sense of detachment both from oneself and others and loss of motivation, joy and interest in one's life.

Who develops post-traumatic symptoms?

It is important to note that not everyone who faces a traumatic event develops persistent post-traumatic symptoms. Most people may experience some symptoms for a few weeks or months and then the symptoms disappear. This resilience is enhanced by a safe and supportive environment that allows the person to make sense of the events.

For that person, the trauma becomes a point in time – a part of their history, rather than remaining a part of their present as is the case for those suffering with post-traumatic stress disorder (PTSD).

For these people, the chronic and debilitating symptoms of their PTSD often force them to develop adaptive strategies in attempts to avoid the disturbing, distressing and disorienting effects of their symptoms. These strategies may include self-harm (in an effort to numb the pain or conversely to feel more alive), self-medication with substances and alcohol, suicidality and high risk behaviours (to counter the sense of detachment/deadness).

Symptoms of post-traumatic stress disorder (PTSD)

PTSD may be classified as acute (duration of symptoms is less than three months), chronic (duration is three months or more) or delayed onset (onset of symptoms is at least six months after the stressor). For some people, symptoms may not emerge until years later when another trauma or distressing event triggers the original trauma, causing it to return in its full intensity.

Perhaps the most painful aspects of trauma are the losses it causes: loss of a world view that the world is a safe and predictable place to be, the personal loss of a sense of control and efficacy, a shattered sense of identity, loss of meaning in life and a loss of self.

BRAIN STRUCTURES AND PHYSIOLOGICAL RESPONSES TO TRAUMA

PTSD reactions are physiologically as well as psychologically based. During a traumatic event, a person's brain and physiology are profoundly affected. Lower brain centres responsible for the emergency strategies of fight/flight and freeze are immediately called into play, resulting in a dramatic biochemical cascade which readies the body for survival.

The amygdala - our early warning system

At the heart of our survival responses is a midbrain structure called the amygdala, considered to be part of the brain's emotional processing system (the limbic system). It is like an early warning system – a "smoke detector" in our brains. It can appraise sensory input within a fraction of a second and is responsible for alerting us to possible danger, assigning an event its emotional valence (good/bad, safe/dangerous).

The amygdala is an organ of memory as well as appraisal, registering experience in the form of presymbolic (nonverbal) emotional memories which are not conscious. Thus, our appraisals of the present may be affected by traces of the past that lie outside of our awareness.

What does the amygdala do?

When activated, the amygdala triggers an immediate, body-wide response to threat by signaling the brainstem to activate the sympathetic branch of the autonomic nervous system. The result is a release of potent neurochemicals, including epinephrine (adrenaline), norepinephrine and cortisol. There is an instant alertness and blood is shunted to where it is needed most to carry out the neuromuscular activity of fight / flight.

However, the body does not move into a full-blown fight or flight response unless the meaning assigned by yet another limbic structure – the hippocampus - is that the situation is indeed dangerous. This structure modulates the amygdala's bias toward hair-trigger reactions.

How the hippocampus modulates the amygdala's reaction

The hippocampus organizes information according to sequence and context. It places an event in time and essentially is the brake that engages the parasympathetic branch of the autonomic nervous system to deactivate the state of arousal that was initiated by the amygdala.

The body returns to a state of relaxation once the emergency is over and either fight or flight was successful or the event was evaluated to be a false alarm.

How Trauma can "short-circuit" the return to relaxation

However, in cases of overwhelming trauma, the extreme cascade of neurochemicals is thought to bypass the engagement of the hippocampus as well as the language centres of the brain (hence, the experience of "speechless terror"). In this case, the amygdala remains in a reactive state, priming the body for fight or flight. This may be experienced subjectively as emotional reactivity, with periods of either unremitting anxiety or a propensity towards aggression and rage. It also explains the symptoms of intrusion that exist in PTSD.

In childhood, secure relationships have the effect of allowing the child's developing hippocampus to balance the reactivity of the amygdala. However, experiences of abuse, neglect and acute trauma can temporarily shut down the hippocampus or inhibit its development, leaving the reactive amygdala unmodulated. This has widespread implications for the child's development.

Dissociation and the freeze response to danger

The third biologically driven response to danger is the freeze or immobility response. The freeze state is activated when fight or flight are pointless. While in this state, the body releases additional doses of pain-killing endorphins. It is here that we must turn our attention to dissociation. Dissociation is thought to be the human correlate of the immobility response in animals.

While in a freeze state, people dissociate – that is, they become detached and disconnected from the event. The alert mind becomes numb, perhaps owing to effect of increased circulating opioids, and memory access and storage are impaired, resulting in some amnesia for the events that occur while in this state.

Bear in mind that success in biological terms is based on survival – that is, what matters is whether we survived, not how we survived. This is important to note in countering the self-recrimination of someone who blames themselves for not running or fighting back when actually their autonomic nervous system made that decision for them by moving into a freeze response.

There is a paradoxical quality to the immobility response. Recall that huge amounts of energy have been mobilized for the fight/flight responses - this undischarged energy then remains a part of the automatic vegetative or freeze state. This has implications for treatment and will be addressed in a later section describing the body-oriented work of Somatic Experiencing®.

Relational or Developmental Trauma

Relational or developmental trauma refers to experiences of childhood abuse or neglect. This type of trauma can have a lifelong impact on how one perceives oneself and engages the world and others. People who have suffered this type of trauma often find themselves experiencing symptoms of Chronic or Complex PTSD or Dissociative Disorders.

Adult Onset Trauma

Adult onset trauma may consist of a single episode trauma, for example, an automobile accident, fall, near drowning or assault, or it may be chronic, as in domestic violence. The result may be chronic anxiety, depression or PTSD.

Medical Trauma

Medical trauma refers to experiences that were perceived as traumatic, either by their very nature (for example, a medical emergency or surgery, which even when it is elective, may be read by the body as an inescapable attack) or because they were experienced by a child who did not have the capacity to make sense of the events and may have been frightened and alone.

KINDLING

Kindling refers to what is thought to be a pattern of cycling between parasympathetic overactivation (freeze) and sympathetic overactivation (fight/flight) that becomes a self-sustaining neurological feedback circuit in PTSD. In this case, the undischarged freeze response results in a sustained state of alarm, producing excitability in the neuronal networks in the affected part of the brain – primarily the sensitive amygdala, which is responsible for processing emotion and sensation. In other words, there becomes a marked cyclical instability, or dysregulation in the autonomic nervous system.

Why traumatic flashbacks persist and intensify

Information related to survival is deeply imprinted and so after a traumatic event, spontaneous memories, flashbacks or nightmares will cause the amygdala to again become activated. It may also become activated from external cues that are vaguely connected.

So whether from internal or external cues, the amygdala triggers the alarm state, causing the same neurochemical cascade which is then followed by the parasympathetic attempts to modulate the reaction with dissociation, endorphin release and an attempt to dampen the sympathetic reaction.

The result of this is that trauma memories may become exaggerated and more intrusive while the activity of the hippocampus continues to be impaired, along with conscious memory, language and reflective thought. The cycle takes on a life of its own, with the person oscillating between hyperarousal and numbing. Over time, the heightened levels of cortisol and related stress hormones combined with the constant activation of the alarm state take a toll on the body, and can create chronic pain conditions. What began as hypervigilance may eventually become a state of chronic numbing and dissociation.

It is evident then, that in order to work with the massive physiological impact of trauma, one must employ a model of treatment that addresses the body as well as the mind, such as Somatic Experiencing or EMDR. Find out more about the body-mind connection in My Approach to Therapy or please contact me.