“Yaar, I had such a traumatic weekend. My friends didn’t show up for the party”. “You know it’s so traumatizing not to be selected for the team.”
The word “trauma” is used frequently and at times without knowing the meaning of it.
A quote in the book “The Fault in Our Stars” resonates with me: “That’s the thing about pain. It demands to be felt.”
Every human being is different and experiences their world differently. So, the same event can be traumatic for one person and not-so-traumatic for another.
“Trauma” comes from a Greek word that means “a wound, a hurt or a defeat.” In the sense of a psychological aspect, Trauma tells us about an unpleasant experience that causes abnormal stress.
So what makes an event traumatic?
There are usually two conditions that make an event traumatic:
- Nature of the event itself –
- Involves actual or feared death or serious physical or emotional injury.
- The more severe and repeated these conditions are, the more traumatic they become.
- What the event means to the victim –
- The person’s subjective experience of the event also shapes how the event becomes traumatic.
No “right” or “wrong” reaction to any life-threatening event exists.
We may experience some events as disturbing, stressful, or traumatic. How people are affected by stressful events differs widely.
Common reactions to Trauma:
Trauma affects the person and may create changes in body, mind, emotions, and behaviour. Everyone’s reactions to traumatic events depend on the occasion, peculiarities of the event, and the person’s unique Self and history.
|Nervous energy, Jitters, and Muscle Tension
|Changes in how you think about yourself, the world, and other people.
|Fear, inability to feel safe
|Becoming withdrawn and isolated from others
|Rapid Heart Rate
|Heightened awareness of your surroundings
|Sadness, grief, depression, guilt, anger
|Lessened awareness or disconnection from yourself
|Numbness or lack of feelings
|Avoiding places or situations
|Lack of energy or fatigue
|Intrusive images, nightmares.
|Emotional distance from others
|Becoming confrontational and aggressive
|Poor attention and memory problems
|Inability to enjoy anything
|Change in eating habits
|Difficulty concentrating and making decisions
|Loss of trust and loss of self-esteem
Types of Trauma:
There are three types of trauma. How we individually experience something (how our nervous system responds) and who or what helps us through can determine how affected we are by it later in life. Trauma is anything that exceeds your ability to cope.
|It occurs when something happens suddenly.
Typically, it is a single-incident experience.
For instance, Car accidents, sexual assault, natural disasters, and events related to medical procedures.
|It occurs when exposed to continuous traumatic experiences in the environment over time.
E.g., childhood abuse or neglect, domestic violence, bullying, sexual abuse, living in poverty or extreme conditions, and war
|It occurs when exposed to several traumatic experiences or a combination of acute and chronic traumatic events.
For instance, Attachment Trauma(ruptures in connection with caregivers in earliest years of life)
Past experiences of trauma cause an effect on present behaviour and beliefs until it is healed.
Get the apt therapeutic help to address trauma
What Can Develop Trauma?
The way trauma develops and expresses itself in people is multifaceted. There are certain contributing factors to why some people are more susceptible to developing an adverse reaction to trauma.
Why do two people with similar histories have different outcomes?
Why are only some people traumatized and not others?
Let’s try to answer these questions by looking at some main factors:
1. Intensity, duration, and timing:
- If the abuse or traumatic experiences continue they are felt with more intensity. The greater its intensity, the higher chances of one developing post-traumatic difficulties.
- Children are more susceptible for post-traumatic difficulties during critical growth periods, i.e., the first three years of their life (when the nervous system is highly fragile) and adolescence (identity formation years).
- There is a greater risk for the development of post-traumatic difficulties for those children whose parent/(s) have/had anxiety disorders or post-traumatic stress disorder (PTSD).
- People living in abusive environments have more significant disruptions in care and attachment. Mothers with anxiety disorders, or PTSD, tend to be overprotective and over-reactive, resulting in children feeling intruded upon and abandoned. As children respond in fear or anger, an environmental cycle of abuse can occur.
4. In-utero experiences:
- Infants born to pregnant mothers during a traumatic event can have low birth weight and increased cortisol levels (chemicals that respond to stress). Such infants can be harder to soothe, more prone to colic, and at increased risk for PTSD.
5. Family dynamics:
- Parents develop different relationships with different children. Factors influencing this bond with a child include comfort level with a child’s gender, readiness to have a child, and events surrounding the pregnancy or birth.
- Along with this, traumatic events with family members, like incest; verbal, physical, sexual abuse, emotional abuse, early death of a parent; broken homes, etc. can also play a part in developing adverse reactions to trauma.
- Children who grow up in abusive homes tend to be exposed to multiple risk factors. Medical care may not be consistent. There may be insufficient modelling of hygiene practices or a lack of encouragement of health-promoting behaviours such as exercise on healthy eating. There may also be excessive modelling of high-risk behaviours like smoking or substance abuse.
7. Lack of resilience factors:
- Resilience factors are those protective resources that alleviate the impact of Trauma.
- Protective factors include participation in activities outside the home, positive peer relationships, a secure job, etc.
- When resilience factors are lacking, the impact of neglect or abuse can be amplified by a feeling that those around you have failed to protect you.
Theoretical models of Trauma and related disorders:
A. Physiological and biological mechanisms
1. Altered autonomic function
- So when we are experiencing visual or auditory traumatic reminders, we experience physiological arousal, like increased heart beats, increased blood pressure, muscle tension, and skin resistance. This typically leads to increased levels of noradrenaline and adrenaline.
- Dopamine and noradrenaline levels, but not adrenaline, significantly relate to symptom severity of trauma.
- Autonomic Conditioning Hypothesis
- According to this hypothesis, sympathetic hyperarousal occurs to conditioned stimuli, eliciting elements of the original ‘fight or flight response.
- To relieve these symptoms, we are more likely to misuse alcohol and drugs.
- Kolb (1987, 1993) proposed that with excessive noradrenergic activation, lower brain-stem structures, such as the medial hypothalamic nuclei and the locus coeruleus (LC), escape from cortical inhibitory control. This stimulus overload may lead to synaptic changes, reducing capacity for habituation, discriminative perception, and learning.
- Van der Kolk et al. (1985) saw the LC and its connections with the amygdala, hippocampus (HC) and temporal neocortex as a “neurophysiological analog of memory”. He suggested that long-term potentiation of the above pathways may be a biological correlate of flashbacks and vivid nightmares.
2. Neuroendocrine abnormalities
- Hypothalamic–pituitary–adrenal (HPA) axis
- Since Trauma represents a significant stress response, there are abnormalities in the HPA axis.
- The HPA axis may become underactive due to chronic and repetitive stress. This reduced adrenocortical response may reflect a heightened sensitivity in the negative feedback loop at the level of the hypothalamus (HT), hippocampus, or pituitary glucocorticoid receptors. Such an adaptive mechanism would help prevent the harmful sequelae of chronically raised glucocorticoid levels.
- Lower basal activity of the HPA-axis in PTSD as an adaptation to chronic stress.
- The cortisol response to dexamethasone
- Exaggerated suppression of cortisol and an increased lymphocyte glucocorticoid receptor number shows an abnormally sensitive negative feedback system in the HPA axis, giving rise to lower-than-normal HPA activity.
- ACTH response to CRF
- Usually, there is a rise in adrenocorticotrophin hormone (ACTH) in response to reduced corticotrophin-releasing factor (CRF).
- In some disorders like panic disorder, anorexia nervosa, and PTSD, there is a blunted ACTH response to CRF.
3. Endogenous opioids
- Encephalins and β-endorphins play a role in pain control. So when we are in intense, stressful situations, our pain sensations are reduced, which is called stress-induced analgesia (SIA). This SIA can be reversed by giving opioid antagonists through medications.
- Along with pain reduction, opiate-mediated analgesia may reduce symptoms such as numbing responsiveness by inhibiting the LC and decreasing the level of hyperarousal.
4. Sleep disturbance
- Sleep disturbance is common among those who have gone through traumatic events.
- There is increased rapid eye movement (REM) latency (the period between sleep onset and the first episode of REM sleep, usually 70–110 minutes), decreased REM sleep duration, and reduced sleep efficiency
B. Psychoanalytical models
1. Sigmund Freud:
- Freud referred to rauma as breaching a protective shield or stimulus barrier, which usually functions to prevent the overwhelming of the mind (ego) from internal and external stimuli by means of managing, or binding, the excitations.
- Many unmanageable impulses would cause a disturbance in the person’s psyche which leads to excessive use of defence mechanisms.
- Freud suggested a phenomenon called “repetition compulsion”. This occurs when a person is re-experiencing a disturbing and catastrophic event to master it. This fixation on the trauma alternated with defenses are aimed at avoiding, remembering, or repeating the Trauma. This gave rise to the “post-traumatic state,” with similar symptoms in all those experiencing an external stressor.
- This theory was again elaborated by Freud, suggesting that it was the helplessness of the ego which formed the core of the traumatic situation and that anxiety could be used as a signal of the possible danger of repeating the earlier experience, thus linking with the phenomenon of increased arousal in trauma and related disorders.
- Classical Freudian Analytic theory, with its emphasis on drives, instincts, and regression, meant that for a long time, analysts thought that it was not the stressor, in particular, that was traumatic but the recurrence of a previously repressed infantile conflict.
2. Abram Kardiner:
- He challenged and developed all of Freud’s ideas and placed much more emphasis on the actual event or stressor.
- According to his theory, ego disorganization leads to symptoms of numbing, disintegration, and intrusion.
3. Elizabeth Bret:
- She described two models for a psychodynamic view of traumatic stress.
- Derived from the work of Freud and Horowitz, describes traumatic stress as derived from re-experiencing phenomena as primary, leading to defensive functioning.
- Derived from the work of Kardiner and Krystal, which describes the reaction to the stressor as being a “massive adaptive failure,” with phenomena such as repetition compulsion being secondary.
According to Psychoanalytic theory, an individual functions partly by using defense mechanisms to defend the ego from anxiety related to internal conflicts, super-ego demands, external situations, and emotions. In response to trauma, these established defenses may be wholly or partially superseded by other defense mechanisms. Such a change may be immediately adaptive and vital for survival but maladaptive in the long term. People can be locked into their trauma and become entrenched in their view of themselves as victims. Thus in psychoanalysis, it is vital to acknowledge, recognize, explore and reintegrate the patient’s destructiveness into fact and fantasy.
According to the theory of object relations and attachment, we need to be more concerned with the meaning a person gives to a traumatic event and its aftermath. This is particularly relevant in a condition where there is often a sense of unpreparedness and helplessness.
Psychodynamic psychotherapy is concerned with the damage done by a stressor to the essential integrative functions of the mind and the necessity of giving meaning to the traumatic instance as a part of its treatment.
C. Cognitive behavioral model
According to Bowlby, a person needs to master the extraordinary information received from the event. This mastery would lead to unity between the traumatic memories and the individual’s inner working models of the mind (cognitive schemata). When we are able to do this it leads to successful integration. In people who experience traumatic events, there is a failure or inability to integrate the traumatic event successfully into the person’s cognitive schemata.
Stanley Rachman used the concept of “emotional processing” to explain the process of absorbing emotional disturbances. Successful emotional processing is associated with a return to normal functioning whereby the dynamic events no longer cause distress or disruption. He further postulated that the persistence of intrusive activities leads to unsuccessful emotional processing. He also identified factors relating to Trauma that promote or impede emotional processing.
- Affect-laden factors like intensity, uncontrollability, predictability, and dangerousness of the situation.
- State of the Individual at the time of the event, factors like high arousal, illness, fatigue, relaxation.
- The personality type of the individual factors like neuroticism, and self-efficacy.
Mardi J. Horowitz developed a model to explain the processes involved in integrating information from a traumatic event. He suggested that the information received from a traumatic event is stored in the individual’s memory and continually brought to the conscious mind or repeated in mind. During a traumatic event, the individual is faced with an overwhelming and negative experience, and this negative experience is associated with a negative emotional response. The individual has to integrate considerable changes in their schemata to achieve harmony. This is achieved by the individual working through the event so that this new information from the event is repeated several times in the conscious mind. Such repeated recollection is associated with robust negative emotional responses.
1. Behavioral models
O. Hobart Mowrer’s two-factor theory proposed that two types of learning, classical and instrumental, are present in fear acquisition and avoidance.
The first stage includes the process of classical conditioning. Via this process, a previously neutral stimulus becomes associated with an unconditioned stimulus (UCS) that innately evokes fear or discomfort. The neutral stimulus then takes on the aversive properties of the UCS, and its presence produces fear/anxiety. The neutral stimulus becomes a conditioned stimulus (CS) for fear responses. During a traumatic event, an individual is exposed to a variety of ‘neutral’ stimuli (smells, shapes, sounds, words) present at the time of the trauma. Such incentives are, in turn, associated with fear or discomfort and thus become conditioned. Their presence alone can evoke intense fear and anxiety responses. Therefore when the original CS is subsequently paired with another neutral stimulus, this stimulus may also take on the aversive properties of the CS and evoke anxiety. This process of higher-order conditioning is used to explain why many other triggers of a previously neutral nature also take on aversive properties and thus elicit anxiety responses. Similarly, stimuli similar to the original CS also gain anxiety-arousing properties in stimulus generalization.
The second stage involves the process of instrumental conditioning. In this stage, behaviors such as escape and avoidance are developed, which are selectively reinforced by their ability to reduce exposure to an aversive CS. Thus an alleviation or termination of the discomfort associated with such stimuli is experienced.
2. Cognitive models
Researchers have attempted to explain the role of cognitive factors in the development and maintenance of trauma and related disorders by drawing on theories of cognitive appraisal, expectancy theory, attributional style, and causal attributions.
Lyn Abramson et al. developed a model to explain uncontrollable events in three dimensions:
- source (internal-external);
- temporality (stable–unstable); and
- situational (global–specific).
They propose that individuals who make internal, stable, and global attributions suffer more than those who make external, unstable, and specific attributions.
3. Information-processing models
Chemtob et al. (1988) developed an information-processing model drawing on the work of other exponents of cognitive–behavioral theory. They suggested that fear structures are made up of hierarchically interconnected nodes. These nodes represent all elements (i.e., physiological, behavioral, cognitive, and affective memories) that may be required for the execution of a specific act. They postulated that the traumatized individual continues to act in the ‘survival mode’ present during the original Trauma.
Furthermore, he discussed a model that explains the development and maintenance of re-experiencing phenomena through feedback loops. This suggests that threat-related arousal may trigger threat-seeking behavior.
Which, in turn, is associated with attentional narrowing. This may lead to an increased likelihood that ambiguous information will be interpreted as threatening. Once a threat is perceived, threat-related arousal is further increased, and so on.
For instance, when we hear a noise in a dark room we don’t just go back to sleep. What we do is, try to figure out where that noise comes from. And by chance if we see a pile of clothes, we might imagine it to be a person. And then we get scared even more. Chemtob suggested that when this network is activated, we cannot activate other more adaptive networks.
Foa and Kozak proposed that fear structures in the memory contain three types of information: (a) information about the feared stimulus situation; (b) information about verbal, physiological, and overt behavioral responses; and (c) interpretative information about the meaning of the stimulus and response elements of the fear structure. Such an information structure is perceived as a program for escape or avoidance behavior.
According to them, to change a dysfunctional fear structure, we need to go through two steps:
- the fear structure has to be activated in its entirety and
- new information needs to be incorporated into the system which is incompatible with some elements already present.
4. Cognitive processing theory
Resick & Schnick (1992) suggested that when a traumatic experience conflicts with prior beliefs, the victim is less able to reconcile (process) the event and has more incredible difficulty recovering. In order to explain how the individual deals with conflicts between new information and prior schemata, they used the concepts of assimilation and accommodation. They proposed that accommodation is a goal of therapy but pointed out that over-accommodation can occur when accommodation happens without good social support or therapeutic guidance.
Hollon & Garber (1988) pointed out that when an individual is exposed to schema-discrepant information, one of two things typically happens.
- Firstly, the information can be altered to fit into the existing schemata (assimilation). For example, assimilation in a rape victim might be, “it must have been something that I did to make this happen to me, so it wasn’t rape”. Thus Resick & Schnick (1992) suggested that flashbacks and other intrusive memories may be attempts at integration when assimilation fails.
- Secondly, existing schemata may be altered to accommodate new incompatible information (accommodation). An example of this might be, “the world is an unpredictable place, and sometimes bad things happen to good people.” Hollon & Garber (1988) suggested that assimilation usually happens more readily than accommodation since it appears easier to alter one’s perception of a single event than to change one’s view of the world.
While we can never save ourselves from any trauma happening to us, we can always choose to save ourselves after the trauma has happened to us. Does not mean it is easy, but it also does not mean that we have to live with the trauma for the rest of our lives and that is what therapy is all about.