Study Notes on Trauma and Post-Traumatic Stress

Trauma and Post-Traumatic Stress

Clinical Description and Epidemiology

Introduction to Trauma
  • Distressing Quotes:
    • Trauma steals one’s voice, leading to feeling disconnected from oneself. As described by Nikitta Gill:
    • "People get so tired of asking you what's wrong and you’ve run out of nothings to tell them. You've tried and they’ve tried, but the words just turn to ashes every time they try to leave your mouth. They start as fire in the pit of your stomach, but come out in a puff of smoke. You are not you anymore. And you don't know how to fix this. The worst part is… you don't even know how to try."
    • Judith Herman articulates:
    • "The psychological distress symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it. This is most apparent in the way traumatized people alternate between feeling numb and reliving the event."
Defining “Trauma” in the DSM: The Criterion A Debate
  • DSM-5 Criterion A for PTSD states:
    • “Exposure to actual or threatened violent death, serious injury, or sexual violence”:
    • Can be through direct experience, witnessing, learning about trauma experienced by a close other, or experiencing repeated/extreme exposure to trauma details (e.g., first responders).
  • Debate over definition and operationalization:
    • Historical context shows DSM-IV broadened the criterion compared to DSM-III, while DSM-5 subsequently tightened it.
    • Pros/Cons of Definitions:
    • Broader definitions may capture more cases but risk overdiagnosis; narrower definitions focus on severe cases but may exclude others.
  • Current definition concerns:
    • Notably emphasized by Gradus & Galea (2022).
A Post-Traumatic Stress Spectrum
  • Common Experiences Post-Trauma:
    • Immediate aftermath may include common symptoms such as distress, nightmares, hypervigilance but do not equate to PTSD.
  • Range of outcomes from resilience to severe trauma-related health issues highlighted by Hawn et al. (2022).
PTSD in the DSM
  • Introduced in DSM-III (1980):
    • Historical reflections of similar experiences existed for centuries.
    • Previous terms capturing related experiences include:
    • “war neurosis,” “combat fatigue,” “shell shock.”
  • Earlier DSM iterations noted possible impacts of extreme stressors without a specific enduring diagnosis for trauma-induced psychological symptoms.
    • DSM-5 Revisions:
    • Includes “Trauma and Stressor-Related Disorders,” repositioning PTSD outside anxiety disorders.
    • Caution: PTSD occurs across diverse populations, not limited to military veterans.
DSM-5 Criteria for PTSD
  • Criterion A: Exposure to trauma.
  • Criterion B: One or more trauma-related intrusion symptoms (e.g., flashbacks, nightmares).
  • Criterion C: Persistent trauma-related avoidance (behavioral, cognitive, emotional).
  • Criterion D: Changes in cognition and mood.
  • Criterion E: Marked alteration in arousal and reactivity.
  • Criterion F: Duration is greater than 1 month.
Statistics on PTSD Symptoms
  • Survey Findings (Bryant et al., 2023):
    • Out of 2898 respondents, 82.5% reported intrusive memories; 67.7% reported nightmares; 57.1% reported flashbacks.
    • Pattern shows symptom fluctuation over time, affecting consistency of PTSD diagnosis (Bryant & Hadzi-Pavlovic, 2023).
Epidemiology of Trauma and PTSD
  • Most individuals experience at least one “Criterion A trauma” in their lifetime (Kilpatrick et al., 2013).
  • Lifetime Prevalence:
    • Approximately 6-9% meet PTSD criteria.
    • Higher prevalence noted in certain demographic groups, such as military veterans, due to increased trauma exposure.
  • Symptom development typically occurs within 6 months post-trauma; symptoms may persist chronically in some individuals.
Epidemiology of PTSD
  • Comorbidity: PTSD often co-occurs with other mental health conditions.
  • Gender Differences:
    • Higher rates in women (2-3x compared to men).
    • Possible connections to life circumstances and trauma exposure types.
  • Sociocultural Factors:
    • Influence rates of PTSD, symptom types, and expression.
  • Functional Impairment:
    • Significant impairment across various life domains (Jellestad et al., 2021).
    • Many individuals experience “subthreshold” symptoms that can also cause impairment (Fischer et al., 2024).
Acute Stress Disorder (ASD)
  • Symptoms resemble PTSD but do not require all symptom types for diagnosis.
  • Defined as being applicable within the first month after trauma exposure; diagnostic only immediately following trauma.
  • There are ethical discussions about overpathologizing normative trauma responses.
    • About 50% of ASD cases may develop into PTSD.
    • Interventions may help reduce the transition to PTSD for those experiencing ASD.
Complex PTSD (cPTSD)
  • Judith Herman's work in 1992 highlights a syndrome distinct from PTSD.
    • Focuses on prolonged trauma with limited escape, leading to challenges like emotion regulation and interpersonal relationships.
  • cPTSD remains a controversial diagnosis; it's recognized in ICD-11 but excluded from DSM-IV and DSM-5.
The Concept of “Normal Reaction to Abnormal Situations”
  • Frankl (1946): Body’s stress response serves a purpose.
    • Common PTSD behaviors reflect rational adaptations to dangerous/unpredictable environments (e.g., hypervigilance).
    • Importance of flexibility in responses emphasized; what helps in one context may hinder in another.
  • Clinical significance requires the presence of distress or impairment for diagnosis.
    • Quote by Colette Delawa:
    • "Just because an experience is understandable or expected does not mean it’s not disruptive, impairing, or debilitating and deserving of treatment."
Bereavement and Grieving in the DSM
  • Grieving varies highly and predicting outcomes is challenging (Nesse).
  • DSM-5 has diminished the “bereavement exclusion” regarding Major Depressive Disorder (MDD).
  • “Prolonged Grief Disorder” has been introduced in DSM-5-TR for the trauma and stress-related category:
    • Supporters argue it aids in access to care for suffering individuals.
    • Critics view it as an instance of overpathologization.
    • A study indicated 34.3% of bereaved individuals met PGD criteria, despite viewing their grief as normal (Thieleman et al., 2023).

Risk Factors and Etiological Models

Trauma Experience and Its Effects
  • Trauma experiences can influence memory, generate allostatic load, activate learning processes, and alter self-beliefs and worldviews.
Severity, Timing, and Type of Trauma
  • Trauma inflicted by humans (e.g., war, sexual violence) tends to be more impactful than natural events.
  • Some traumas may impair interpersonal relationships due to stigma.
    • Prolonged trauma correlates with more severe PTSD outcomes.
  • Proximity to a trauma event increases risk (e.g., closeness to WTC on 9/11).
  • Early life traumatic stress is particularly harmful.
Empirical Data on Trauma and PTSD
  • Based on Breslau et al. (1998):
    • Various trauma types and their associated PTSD prevalence:
    • Evidence includes rates of PTSD following experiences like rape (49%), serious car crashes (31.9%), and sudden unexpected death (14.3%).
Adverse Childhood Experiences (ACEs)
  • Foundational ACE study from 1995-1997 by Kaiser shows 60%+ of US adults report 1+ ACEs.
  • ACEs increase risks for various psychological and physical health issues, established as a dose-response relationship.
  • Difficulties persist even among resilient children (Copeland et al., 2023).
Mechanisms Linking ACEs to Health
  • ACEs can lead to alterations in gene expression, brain development related to threat and reward responses, and impacts on stress and immune systems.
  • Changes may manifest in health behaviors, with different ACEs exerting varying effects (e.g., deprivation vs. threat; McLaughlin et al., 2014).
Searching for Individual Risk Factors for PTSD
  • Differentiating between risk for trauma exposure and risk for PTSD following exposure is crucial.
  • Ethical dilemmas related to potential double victimization posed by examinations.
Overlapping Risk Factors with Anxiety
  • Conditioning, cognitive factors, personality traits, genetic predispositions, and neural circuitry all play roles in PTSD risk.
    • Not all PTSD cases exhibit predominantly fear-centric symptom profiles.
Additional Risk Factors
  • HPA axis dynamics, including cortisol levels, may impact PTSD risk with a pronounced reactivity.
  • Brain structures like the amygdala and hippocampus are critical in PTSD development and symptomatology.
  • Contextual placement of memories, self-appraisal of symptoms, and coping strategies also remain influential.
Resilience and Protective Factors
  • Key factors leading to resilience include:
    • Psychological factors (meaning, optimism), supportive environments, community connections, resources, and prior experience serving as stress inoculation.
  • Genetic resilience overlaps significantly with PTSD risk genes (Wolf et al., 2018).
Model of Causes of PTSD
  • TF Figure: Details pathways from generalized psychological and biological vulnerabilities through trauma exposure, resulting in PTSD symptoms moderated by social support and coping ability.

Treatment

Trauma-Focused Psychotherapy (TFP)
  • Considered the first-line treatment for PTSD and preventing transition from Acute Stress Disorder to PTSD:
    • Different TFP types with Prolonged Exposure and Cognitive Processing Therapy being the most widely studied.
  • Emphasizes exposure in supportive environments, effective but often results in high dropout rates (Lewis et al., 2020).
Misconceptions about TFP
  • Common misconceptions among users and providers include:
    • Unsuitability for complex traumas, perceived fragility of patients, fear of exacerbating symptoms.
    • Misunderstandings can drastically influence the care received.
Medication for PTSD
  • Only two FDA-approved SSRIs recognized for PTSD, with limited efficacy in full recovery:
    • Roughly 30% achieve full recovery; risk of relapse after treatment cessation is notable.
    • Other medications aim to manage specific symptoms like nightmares (e.g., Prazosin).
  • Benzodiazepines are frequently prescribed despite limited evidence of efficacy (Davis et al., 2021).
    • New pharmacotherapy developments (e.g., MDMA) require further research for approval.
Controversies in PTSD Treatment
  • Discusses various controversies surrounding treatment methodologies, including:
    • Critical Incident Stress Debriefing (CISD) effectiveness is debated, and the potential for harm.
    • Eye Movement Desensitization and Reprocessing (EMDR) as a controversial method.
Prevention Strategies
  • Emphasizes pre-exposure interventions for high-risk groups and post-exposure strategies to disrupt memory consolidation:
    • Examples include stress inoculation training and potential medication strategies.
  • Systematic support initiatives aim to improve assessment and care access, especially within military frameworks.
Trauma-Informed Care
  • Recognizes trauma's role in broader health contexts, shifting the focus from pathology to individual experiences.
  • Advocated for trauma-informed training across various professional fields (e.g., medicine, education).

Bonus Slides

Moral Injury
  • Term coined by Jonathan Shay; focuses on the psychological and cultural dimensions of trauma.
  • Co-occurring moral injury and PTSD correlates with heightened distress and suicide risk.
Post-Traumatic Growth
  • Some individuals report positive personal changes following trauma experiences, though causation studies yield mixed results (e.g., Bonner et al., 2025).
Summary Framework for Distress Origins
  • Replaces the diagnostic question of “What is wrong with you?” with a more comprehensive series of questions regarding personal experiences, threats, and coping mechanisms.