Introduction to PTSD and Trauma

William Harryman, MSC, NCC, MS

What Is Trauma?
Psychological trauma is the unique individual
experience of an event or enduring conditions in
which: The individuals ability to integrate
his/her emotional experience is overwhelmed
or the individual experiences (subjectively) a
threat to life, bodily integrity, or sanity.
(Pearlman & Saakvitne, 1995, p. 60)
Saakvitne, K. W. et al., Risking Connection: A Training
Curriculum for Working with Survivors of Childhood Abuse, to be
published by Sidran Press in January, 2000.

A Phenomenological Definition of Trauma

We say, Ill see you later, or a parent says to a child at bedtime,
Ill see you in the morning
These absolutisms (a kind of nave realism and optimism) allow us to
function in a world experienced as stable and predictable
Emotional trauma shatters all absolutisms
Trauma is a catastrophic loss of innocence that permanently alters
ones sense of Being-in-the-world (Heidegger)
Existence is revealed as random and unpredictable and there is no
real safety or continuity of being
After trauma, the world is fundamentally incommensurable, there is
a deep chasm between the traumatized and others in which an
anguished sense of estrangement and solitude takes form
(Robert Stolorow, Trauma and human existence: Autobiographical
psychoanalytic, and philosophical reflections, p. 16)

What Kind of Trauma?

Big T Traumas
Childhood abuse (sexual, physical, emotional)
Childhood neglect (physical, emotional)
Prolonged combat experience
Refugee camps
Natural disasters
Severe accidents

Little t traumas
Broken bones
Humiliation and ridicule
Empathic failures in infancy
Prolonged bullying
Feeling left out
Feeling not cared for

Symptoms as Adaptations
All trauma symptoms are adaptations to survive the
trauma
Traumatic events end, the person's reaction persists
The intrusion of the past into the present: re-experiencing
Intrusion may present as distressing intrusive memories, flashbacks,
nightmares, or overwhelming emotional states
Hypervigilance, dissociation, avoidance, and numbing are examples of
coping strategies that likely were effective when the trauma was
happening (or in the immediate aftermath) but now interfere with the
person's ability to live the life s/he wants.

Symptoms represent the client's attempt to cope

the best way they can with overwhelming feelings

Developmental Disruptions
Severe trauma can disrupt basic developmental
tasks
Developmental tasks underway when the
trauma happens can help determine what the
impact will be
Disruptions can include:
lack of self-soothing
the world is an unsafe place
hard to trusting others
poor executive function
more easily exploited

Developmental Disruptions
as Symptoms
Disruption of developmental tasks results in adaptive
behaviors (as we noted above)
The mental health system views these adaptations as
"symptoms," for example:
disrupted self-soothing is labeled as agitation
the disrupted ability to see the world as a safe place looks
like paranoia
distrust of others is interpreted as paranoia (even when valid)
disruptions in executive function for decision-making can look
like psychosis
avoiding/preempting exploitation is called self-sabotage

A Brief Explanation of the

Neuroscience of Trauma

Trauma: Neurological Effects

During traumatic
experiences, some regions
of the brain show increased
levels of stress hormones
A couple of those stress
hormones are cortisol and
adrenaline
Stress hormones shrinks
the hippocampus
Stress hormones enlarge
the amygdala

Trauma Rewires the Brain

Images are stored in the right
side of the limbic system
When trauma is recalled:
Brocas area is disengaged (no
verbal translation of inner
experience)
Right visual cortex is
highlighted (experience is
relived as though it is
happening NOW)
When images are emotionally
intense, they are more powerfully
encoded
Trauma memories can influence
behavior even if the person has no
visual memory of the trauma

How the Brain Processes Trauma

A Metaphor: The Cook, the Smoke Detector, and the Watch
Tower
~ Courtesy of Bessel van der Kolk
The cook is the Thalamus: It stirs all of the input from our
perceptions into a fully blended autobiographical soup, an
integrated, coherent experience of this is what is happening to me
From the thalamus, the blended information goes to the amygdala
and to the frontal cortex
Joseph LeDoux: the pathway to the amygdala is the low road,
and the pathway to the frontal cortex is the high road it takes a
few milliseconds longer for information to take the highroad
Processing by the thalamus breaks down in trauma
Images, sounds, smells, and touch are encoded as isolated,
dissociated fragments normal processing disintegrates time
freezes, and the present danger feels like it will last forever

Amygdala The Smoke Detector

The amygdala identifies
whether incoming experience
is relevant to survival
It is assisted by the nearby
hippocampus, which relates
new input to past experience
Under threaten, the
amygdala immediately
activates the stress response
to prepare for action
Because the amygdala is
faster than the frontal
cortex, it makes a decision
before we are even aware of
the danger

Trauma increases the risk that the

amygdala will see danger where
none exists hypervigilance

The Medial Prefrontal Cortex

The Watch Tower
The medial prefrontal cortex (MPFC) is the seat of
executive function the ability to read a situation,
predict outcomes, and assess our choices
As long as we are not too triggered, the MPFC can
override the stress response system and restore equilibrium
In PTSD, the balance between the amygdala and the
medial prefrontal cortex shifts radically
We are startled easily and become jumpy
We become enraged by small frustrations
We freeze if someone touches us
We react from child-like ego states when triggered

Trauma and PTSD

Symptoms, Risk, Resilience

What Is PTSD?
PTSD is a type of anxiety disorder that occurs
post-trauma, or after being exposed to some
kind of traumatic event
Four clusters of symptoms make up a PTSD
diagnosis:

Re-experiencing
Avoidance (and Emotional Numbing)
Hyperarousal
Dissociation

PTSD is more common than you might think, and PTSD

does not discriminate based on age, sex, or
racial/ethnic background

Re-experiencing Symptoms
Frequent upsetting thoughts
or memories about a
traumatic event.
Recurrent nightmares.
Acting or feeling as though
the traumatic event were
happening again, a
"flashback."
Very strong feelings of
distress when reminded of
the traumatic event.
Strong physical responsive,
such as experiencing a surge
in your heart rate or
sweating, to reminders of the
traumatic event.

Avoidance Symptoms
Avoiding thoughts, feelings, or
conversations about the
trauma
Avoiding places or people that
remind you of the trauma
Difficulty remembering
important parts of the
traumatic event
Loss of interest in important
and once positive activities
Feeling distant from others
Difficulty with having positive
feelings, such as happiness or
love
Feeling as though your life may
be cut short

Emotional Numbing Symptoms

Emotional numbing
symptoms are those
symptoms that reflect
difficulties in
experiencing positive
emotions:
A loss of interest in
important, once positive,
activities and interests.
Feeling distant from
others.
Experiencing difficulties
having positive feelings,
such as happiness or love

Hyperarousal Symptoms
Hyperarousal refers to
experiencing high
levels of anxiety:
Having a difficult time falling
or staying asleep.
Feeling more irritable or
having outbursts of anger.
Having difficulty
concentrating.
Feeling constantly "on guard"
or like danger is lurking
around every corner.
Being "jumpy" or easily
startled.

Dissociative Symptoms
The DSM-5 (Diagnostic and Statistic Manual of Mental
Disorders) has added a dissociative sub-type for PTSD
Dissociative symptoms were present in 14.4% of
subjects interviewed by WHO (2013)
Another study (2012) found 25% of their sample could
be characterized by high derealization and
depersonalization symptoms (types of dissociation)
Individuals who qualify for the dissociative subgroup
show more comorbid Axis I disorders and more
significant history of childhood abuse and neglect

Dissociation Defined
Dissociation as a process:
Overwhelming experience is split off and fragmented (the
thalamus is unable to process it)
Emotions, sounds, images, thoughts, and physical sensations
take on a life of their own

Dissociation as an experience:
Depersonalization: A subjective sense that one is changed,
has become vague, dreamlike, less real, or lacking in significance
feeling unreal as a person
Derealization: A subjective experience of unreality of the
outside world, what one sees lacks vividness or emotional
coloring, as seen through a fog, or a veil
Depersonalization and Derealization tend to co-occur

Dissociation
The more betrayal involved in the trauma, the
more psychogenic amnesia (inability to
remember the trauma) and dissociative
symptoms occur

Degrees of Dissociation
Day dreaming/
Highway
hypnosis

Dissociative
Identity
Disorder

Link Between Trauma and PTSD

Trauma and PTSD go hand-in-hand.
A number of traumatic events are connected to PTSD,
such as combat, rape, natural disasters, and motor
vehicle accidents.
To be diagnosed with PTSD, a person must have
experienced some kind of traumatic event.
Not all events are connected with the same level of risk
for developing PTSD - the level of risk connected with a
particular event is not the same for men and women.

Risk Rates for Men

For men, rape is the traumatic event most likely to be
connected with PTSD
Approximately 65% of men who said rape was the most
upsetting traumatic event developed PTSD
Other traumatic events likely to lead to PTSD:

combat (38.8%)
childhood neglect (23.9%)
childhood physical abuse (22.3%)
being sexually molested (12.2%)

Men who experience rape and seek help tend to seek

out multiple sources of support

Risk Rates for Women

As with men, rape is the traumatic event most likely to
be associated with PTSD for women
Approximately 45.9% of women who said rape was their
most upsetting traumatic event developed PTSD
Other traumatic events that are highly connected to
the development of PTSD for women were:

being threatened with a weapon (32.6%)

sexual molestation (26.5%)
being physically attacked (21.3%)
childhood physical abuse (48.5%)
childhood neglect (19.7%)

Why Do Some People Get PTSD and

Other People Do Not?
Risk factors for PTSD
include:
Living through dangerous events
and traumas
Having a history of mental illness
Getting hurt, or fear of being hurt
Seeing people hurt or killed
Feeling horror, helplessness, or
extreme fear
Having little or no social support
after the event
Distress after the event: loss of a
loved one, pain and injury, or loss
of a job or home

Some People Do Not Experience PTSD

Only 25-35% of those exposed to trauma will develop
PTSD, and of those, only 20-35% display persistent
symptoms
Resilience factors that may reduce the risk of PTSD
include:
Seeking out support from other people, such as friends and
family
Finding a support group after a traumatic event
Feeling good about ones own actions in the face of danger
Having a coping strategy, or a way of getting through the bad
event and learning from it
Being able to act and respond effectively despite feeling fear
Possessing a secure attachment style in childhood

PTSD and Attachment

Attachment and PTSD

John Bolwby, father of Attachment Theory
Innate psychobiological system (the attachment behavioral
system)
Infants seek proximity to caregivers (attachment figures)
Evolutionary system to protect infants from threats and reduce
distress, when the attachment bond is secure

Mary Ainsworth: mother of attachment theory

A Strange Situation: defined secure, anxious, and
ambivalent attachment styles

Mary Main: Adult Attachment Inventory

Added a 4th attachment style to the original three, the
disorganized style

Attachment Styles
Child and caregiver behavior patterns before the age of 18 months
Attachment
pattern

Child

Secure
About 2/3 of
adults

Uses caregiver as a secure base for exploration.

Responds appropriately, promptly and
Protests caregiver's departure, seeks proximity, and consistently to needs.
is comforted on return, returning to exploration.

Avoidant

Little affective sharing in play. Little or no distress on Little or no response to distressed child.
departure, little or no visible response to return,
Discourages crying and encourages
ignoring or turning away with no effort to maintain
independence.
contact if picked up. Child feels that there is no
attachment; the child is "rebellious" and has a lower
self-image and self-esteem.

Ambivalent/
Resistant

Caregiver not a secure base. Distressed on

separation with ambivalence, anger, reluctance to
warm to caregiver and return to play on return.
Preoccupied with caregiver's availability, seeking
contact but resisting angrily when it is achieved. In
this relationship, the child always feels anxious
because the caregiver's availability is never
consistent.

Inconsistent between appropriate and

neglectful responses. Generally will only
respond after increased attachment
behavior from the infant.

Disorganized

Stereotypies (compulsive behaviors) on return such

as freezing or rocking. Lack of coherent attachment
strategy shown by contradictory, disoriented
behaviors such as approaching but with the back
turned.

Frightened or frightening behavior,

intrusiveness, withdrawal, negativity, role
confusion, affective communication
errors and maltreatment. Very often
associated with many forms of abuse
towards the child.

Caregiver

Disorganized Attachment
Disorganized attachment: Activation of incompatible
approachavoidance systems, creating confusion
Caregiver is both a haven of safety and a source of
fear
(Main & Hesse, 1990)

Distressed child seeks proximity and contact with the

attachment figure, but the caregiver's frightening
behavior generates fear and escape behaviors
(Cassidy & Mohr, 2001; Hesse & Main, 2006)

Caregivers of disorganized infants often have histories

of childhood trauma and unresolved loss
(Lyons-Ruth et al., 2003; Solomon & George, 1999)

PTSD & Disorganized Attachment

Longitudinal correlates of early disorganized
attachment include dissociative and externalizing
behaviors
These overlap with the two of the four symptom
clusters for diagnosing PTSD
PTSD avoidance symptoms include dissociative
behaviors, such as emotional numbing or isolating
With the addition of a dissociative subtype for PTSD, there
may be a realignment of the symptom clusters

PTSD hyper-arousal symptoms include externalizing

behaviors, such as irritability or outbursts of anger
Both dissociative symptoms and externalizing symptoms
are commonly seen in traumatized individuals

Why This Matters . . .

Trauma-Informed Therapy
Client Needs: Mirroring, Idealization, Twinship (Heinz Kohut),
manifested in the following ways:
Relational: Therapeutic efficacy is based on the quality of the
relationship
Intersubjectivity: There is not simply a client and therapist,
there is also the shared internal space created through
relationship
Unconditional Acceptance: The clients feelings are validated
and mirrored by the therapist
Appropriate Boundaries: Acceptance of feelings ends with
aggression, violence, manipulation, or intoxication
Repairing Empathic Failures: Therapists are human and make
mistakes, repairing these failures with the client models this
skill for them to learn, and assures them that the therapist will
not abandon them

Discussion and Questions?

Recommended reading:
The Body Keeps the Score: Brain, Mind, and Body in the Healing of
Trauma Bessel van der Kolk
Healing Developmental Trauma: How Early Trauma Affects SelfRegulation, Self-Image, and Capacity for Relationship - Laurence Heller
and Aline LaPierre
Coping with Trauma-Related Dissociation: Skills Training for Patients
and Therapists - Suzette Boon, Kathy Steele, and Onno van der hart *
The Inner World of Trauma: Archetypal Defenses of the Personal Spirit Donald Kalsched
Trauma and the Soul: A psycho-spiritual approach to human
development and its interruption - Donald Kalsched
Waking the Tiger Peter Levine, and In an Unspoken Voice: How the
Body Releases Trauma and Restores Goodness - Peter Levine and Gabor
Mate
The Trauma Spectrum: Hidden Wounds and Human Resiliency - Robert
Scaer