Trauma Related Disorders

What is trauma (DSM-V Definition)?

  • Known as Criterion A 

  • An event that involves actual or threatened death, serious injury or sexual violence in one of the following ways:

    • Directly experiencing the event 

    • Witnessing the event (bi-curious trauma/secondary traumatic distress, considered to be an eye witness) 

    • Learning that an event occurred to a close friend/family member 

    • Repeated exposure to details of traumatic events (police officers, first responders)

  • Changes in Criterion A 

    • DSM-III: an event outside the range of usual human experience that would cause significant symptoms of distress in almost anyone 

    • DSM-IV: Person experienced, witnessed, confronted with an event that involved actual or threatened death/serious injury or a threat to the physical integrity of others. Persons response involved intense fear, helplessness, or horror 

Who gets to Define Trauma?/ Definitions of Trauma vs. Adversity, Stressors vs. Adversity 

  • Trauma is an event that psychologically impacts people. Sudden death of a loved one, the person's response. 

  • Adversity is a really stressful life event, it's about the event itself. 

  • Stress and adversity are environmental events, stress can be something like taking a test. Adversity includes homelessness, racism, discrimination; we don’t expect these things to happen.

Post-Traumatic Stress Disorder (PTSD):

  • PTSD symptoms occur in four broad categories 

    • Must have criterion A

    • Intrusion (Criterion B): Needs  1+

      • Distressing memories of the incident 

      • Terrifying dreams, nightmares

      • Dissociative reactions in which the person feels or act as if the event is reoccurring 

      • Psychological and physiological distress at exposure to cues to the event. 

    • Avoidance (Criterion C): Needs 1+ 

      • Persistent avoidance of stimuli associated with the trauma in one or both of the following ways: 

        • Avoidance or effort to avoid distressing memories, thoughts, or feelings about or closely related with the event 

        • Avoidance or effort to avoid external reminders (people, places, situations) that arouse memories, thoughts, or feelings about or closely related with the event

    • Cognition Mood (Criterion D): Needs 2+

      • Negative alterations in cognitions and mood evidence by two or more of the following:

        • Inability to remember important aspects of the event

        • Persistent and exaggerated negative beliefs about oneself, others, or the world 

        • Persistent distorted cognitions about the cause or consequences of the events that lead the individual to blame himself/herself or others

        • Persistent negative emotional state

        • Markedly diminished interest in significant activities 

        • Feelings of detachment from others 

        • Persistent inability to experience positive emotions 

    • Arousal (Criterion E): Needs 2+

      • Changes in arousal and reactivity evidenced by two or more of the following: 

        • Irritability 

        • Reckless self-destructive behavior 

        • Hypervigilance 

        • Exaggerated startle response 

        • Problems with concentration 

        • Sleep disturbance 

PTSD Summary:

  • Core symptom: experience of trauma (Criterion A) 

  • At least the following symptoms:

    • Intrusion 

    • Avoidance 

    • Negative Alterations in Cognition/Mood 

    • Alternations in Arousal & Reactivity 

  • Significant distress and impairment 

  • Duration: more than 1 month 

Acute Stress Disorder:

  • Core symptoms: experience of trauma (Criterion A)

  • Symptoms include:

    • Intrusion 

    • Avoidance 

    • Negative Mood 

    • Alterations in Arousal & Reactivity 

    • Dissociative Symptoms 

  • 9 or more of the symptoms from any of the 5 categories 

  • Significant distress and impairment 

  • Duration: occurs between 3 days to 1 month after trauma 

Language: Potentially Traumatic Events (PTE’s): 

  • Advocating for the phrase traumatic event, because of the different outcomes of PTSD we don't want to call it a traumatic event if the person does not believe they have experienced a traumatic event. 

    • Trauma is person dependent, the event could be traumatic if the person going through it does not believe it is. 

Prevalence of PTEs and PTSD:

  • Experience of PTEs is quite common 

    • Lifetime prevalence: 40-90%

    • Higher prevalence for female-identifying, non-binary individuals, and trans individuals

  • Still PTSD is rare: 

    • Lifetime prevalence: 6.8%

    • 12-months prevalence: 3.5%

Responses to Traumatic Events:

  • 4 Typical Trajectories: 

  • Chronic- elevated distress across time, the events have a big impact throughout the course of time and it's not getting any better.

  • Delayed- as time goes on distress increases, first you might experience moderate distress although latter it turns into severe distress. 

  • Recovery- elevated distress right after the PTE, but that decreases as time goes on.

  • Resilience- most common, mild distress across time, low symptoms of distress after the event, over time you are not being impacted by the event.

Exposure to PTE does not necessarily relate to the development of only PTSD 

  • The more PTE a person experiences, the more likely they are to develop anxiety disorders, depressive disorders, conduct disorders, or substance use disorders. (all types of psychopathology)

Factors that impact responses to PTEs:

  • Pre-trauma factors- gender, age, socioeconomic status, emotional development, coping mechanisms

  • Peri-trauma factors- interpersonal trauma, car accidents, natural disasters (the event itself)

  • Post-trauma factors- social support, access to resources, ongoing stressors 

Post-Trauma Factors:

  • Latent vulnerability approach: PTEs exert influence by creating lasting change in specific vulnerabilities across multiple units of analysis (neural, cognitive, behavioral). Not directly shown at first, measured through behaviors. 

    • Threat Biases (What we deem as a threat)

      • Hypersensitivity or blunted response to PTEs

      • avoidant behaviors, stress dysregulation, target in therapeutic setting, exposure based. 

    • Reward Biases (What we believe we deserve/pleasurable) 

      • Salient within context of emotionally numb presentations of PTSD

      • poverty or neglect as PTEs

    • Social-Emotional Deficits (How we are able to regulate our emotions)

      • Emotional dysregulation 

      • difficulties identifying emotions, inappropriate responses to emotions

    • The PTE changes the domain in these three biases

Etiology:

  • Unlike many disorders, PTSD/acute stress disorder have a clear etiology, must experience a traumatic event.

  • Vulnerable communities: 

    • Children- particularly those who experience trauma or abuse related to loved ones, rather than strangers 

    • Veterans- more likely in ethnic minority veterans 

    • Low SES communities- chronic, long-term stressors 

  • Intersectionality can play a big role in determining risk

    • First conceptualized by the Combahee River Collective 

    • Term coined by Kimberle Crenshaw 

Racial Trauma:

  • An event that involves events of danger related to real or perceived racial discrimination 

    • Threats of harm or injury 

    • Humiliating or shaming events 

    • Witnessing harm to other POC due to real or perceived racism

    • Experiences of microaggressions 

 

Treatments:

  • Medication 

  • Important Components in treatment 

    • Establishing a trusting therapeutic relationship 

    • Psychoeducation for clients about the process of coping with truama 

    • Stress-management training 

    • Encouraging clients to re-experience and integrate the traumatic event into their lives and self-schemas (trauma narrative) 

  • Trauma Narrative 

    • able to think and talk about the trauma, particularly the worst moments 

    • Identify unhelpful or inaccurate cognitions and altered views of self, other or the world

    • Identify more helpful and accurate ways of thinking about traumatic events, self, others, the world, the future. 

  • Prolonged Exposure (PE) Therapy 

    • Talking about the traumatic event in first person as if it were happening in the moment 

    • Record this narrative for daily playback 

    • In vivo exposure in similar, but safe locations 

  • Cognitive Processing Therapy 

    • The focus is on cognitive restructuring of:

      • Self-blame thoughts 

      • The meaning of the event 

      • The implications of the truama on their lives 

      • Beliefs about safety, trust, power/control, esteem, and intimacy 

    • This also has an exposure element, similar to PE therapy. Requieres thinking and facing the trauma to then gradually expose the trauma to your mind. 

    • Example.. Being robbed at gunpoint late at night 

      • Thought that you are trying to address 

      • talking about Feelings you are having 

      • Evidence for why it is your fault

      • Evidence against 

      • Revised thought 

  • Eye Movement Desensitization and Reprocessing (EMDR)

    • A form of exposure with a strong cognitive component accompanied by rapid eye movements. 

      • talking while following the psychologist finger 

    • Example… 

      • Patients imagine a scene from their truama 

      • focus on the accompanying cognition and arousal 

      • track the therapists rapidly moving finger 

      • sequence is repeated multiply times 

      • Supposed to rewire your brian 

    • Theory: eye movements help with information processing

      • Not scientifically based 

    • Research shows that this therapy is effective but:

      • eye movement component is irrelevant 

      • might work because of what it has in common with other therapies (exposure and cognitive restructuring)