THE ROLE OF TRAUMA IN PSYCHOLOGICAL DISORDERS

In his book, Shake Hands with the Devil: The Failure of Humanity in Rwanda, Retired General and now Senator Romeo Dallaire has given us a home grown and dramatic description of Post Traumatic Stress Disorder (PTSD). Our knowledge about the effects of extreme trauma on people's emotional health has grown significantly over the past 30 years with the aftermath in the US of the Vietnam War, the Persian Gulf War and the war in Iraq and in Canada, the war in Afghanistan. However, PTSD is only one type of psychological disorder that can develop from traumatic life events. The whole area of trauma and its related disorders is extremely complex, encompassing the fields of neurophysiology, cognitive psychology, memory and psychotherapy to name a few. In this blog, I will try to give you an overview of how trauma can affect people and what can be done about it.

The flagship trauma-related diagnostic category, PTSD, involves exposure to an extreme, possibly life threatening experience that causes intense fear, helplessness or horror. In response to this experience, the person manifests a variety of symptoms including 1) re-experiencing the event through dreams or flashbacks, 2) emotional numbing, 3) avoidance of stimuli that remind the person of the event, and 4) increased arousal, such as the "startle response". PTSD manifests itself differently across different people, but it always involves some combination of these four symptom groups.

Many people understandably try to cope with these symptoms by self-medicating with alcohol or other drugs, so substance abuse problems commonly co-occur with PTSD. Given the pain that people are enduring and the withdrawal from many normal activities and relationships, people often develop some form of depression following traumatic experiences. Similarly, trauma experiences, even non-life threatening ones, can lead to the development of anxiety disorders. For example, there was the case of a woman who witnessed the drowning of a kitten as a child and subsequently developed a debilitating phobia of cats. If a person is inclined to develop behavioural rituals or rules to cope with trauma-related anxiety (to create a sense of control), they may end up with a diagnosis of Obsessive Compulsive Disorder.

Though not currently an official diagnostic category, clinicians have identified a syndrome called "Complex PTSD" (C-PTSD), which is similar to PTSD, but has some unique features. It refers to a situation where a person has been exposed to repeated and unavoidable trauma or mistreatment over an extended time period. Hostage/torture situations would be an example of this, but more commonly, domestic child abuse or spousal abuse could create the circumstances for C-PTSD to develop. Because the traumatic experiences are usually perpetrated by caregivers in these situations, a disruption of the attachment process occurs which leads to problems with trust, self-protection and emotional regulation in relationships.

The experience of trauma creates changes at a number of levels. There are physiological reactions (related to an adrenalin surge) which are remembered at a physical level and triggered by similar stimuli later. There are cognitive reactions in which there is a story created to understand the event which may include faulty assumptions ("I am a bad person", "The world is not safe", etc.). This story may change over time as new information and experiences affect the memory. There are powerful emotions (fear, shame, anger) that are experienced along with this arousal and story that give the memory of the experience a flavour and may generalize to the personís concept of themselves.

There are many different approaches to treating people with trauma-related problems. While they may differ in application quite dramatically, they all have one common purpose, to help the person have a different (and healthier) experience with the traumatic event. This new experience usually involves helping the person expose themselves to the event (usually in memory) while being able to manage the arousal effectively and altering the meaning of the incident.

Drug therapy with Serotonin Specific Reuptake Inhibitors (SSRIs) has been shown to be effective in treating PTSD and many of the depressive and anxiety disorders that can occur post-trauma. This is likely because they chemically alter the general level of arousal and emotional response, so the response to the trauma is lessened. They do not permanently change the response to the trauma however.

Various proven psychological therapies are designed to alter the person's perception of and reaction to the traumatic event. There are exposure therapies where the person is asked to remember or describe out loud their traumatic experience while in safe environment with enhanced relaxation and self-soothing skills. Exposure allows for new learning to happen regarding the trauma and helps extinguish some of the fear. Cognitive therapies are also utilized in which the belief system underlying the post trauma reaction is challenged and a new understanding of the traumatic event and the self is developed. For example, a child sexual abuse victim who has been told they are bad person during the abuse, comes to realize it wasn't their fault. The bank employee who feels like a coward because they didn't stop the bank robber, comes to realize that they protected lives by following protocol.

A therapy called Eye Movement Desensitization and Reprocessing (EMDR) combines exposure and cognitive approaches. In this form of therapy, the person relives the trauma while the therapist helps them move their eyes rapidly back and forth. The emotional reaction lessens and core beliefs related to the incident are modified. The role of the eye movements in this technique is unclear. Some suggest they may stimulate neurological changes, others theorize that the eye movements distract and allow the person to cope with the arousal levels better during exposure.

Self-Regulation Therapy (SRT), a holistic, gentle approach that is based in neurophysiological research has become very popular in some clinical circles. SRT practitioners maintain that their approach is less likely to flood someone with an overwhelming memory and re-traumatize them. Given that traumas are memory-based, new animal research which has been focused on eliminating specific memories by altering proteins at the neurochemical level is promising, but also a bit frightening. While this approach could help people forget life-altering traumas, it could also be used for less socially positive purposes!

Fortunately, there is a variety of scientifically proven psychological and pharmacological techniques available, so that no one should have to continue to suffer from post trauma symptoms. If you are looking for therapeutic help, make sure you do your research about the potential benefits and risks and ask lots of questions about the process and effectiveness of the approach the therapist will be using.

Dr. Jim Browning