Defining Trauma

Psychological trauma is damage to a person's mind as a result of one or more events that cause overwhelming amounts of stress that exceed the person's ability to cope or integrate the emotions involved, eventually leading to serious, long-term negative consequences. Trauma is not the same as mental distress or suffering, both of which are universal human experiences.

Introduction

Given that subjective experiences differ between individuals, people will react to similar events differently. In other words, not all people who experience a potentially traumatic event will actually become psychologically traumatised (although they may all be distressed and experience suffering). However, some people will develop post-traumatic stress disorder (PTSD) after being exposed to a major traumatic event.

Trauma is not viewed the same as mental distress or suffering, both of which are catagorised as universal human experiences.

People who go through these types of extremely traumatic experiences often have certain symptoms and problems afterwards. The severity of these symptoms depends on the person, the type of trauma involved, and the emotional support they receive from others. The range of reactions to symptoms of trauma can be wide and varied, and differ in severity from person to person. A traumatised individual may experience one or several of them.

After a traumatic experience, a person may re-experience the trauma mentally and physically. For example, the sound of a motorcycle engine may cause intrusive thoughts or a sense of re-experiencing a traumatic experience that involved a similar sound (e.g., gunfire). Sometimes a benign stimulus (e.g., noise from a motorcycle) may get connected in the mind with the traumatic experience. This process is called traumatic coupling.

In this process, the benign stimulus becomes a trauma reminder, also called a trauma trigger. These can produce uncomfortable and even painful feelings. Re-experiencing can damage people's sense of safety, self, self-efficacy, as well as their ability to regulate emotions and navigate relationships. These triggers cause flashbacks, which are dissociative experiences where the person feels as though the events are recurring. Flashbacks can range from distraction to complete dissociation or loss of awareness of the current context.

“Re-experiencing of symptoms is a sign that the body and mind are actively struggling to cope with the traumatic experience.”.

Triggers and cues act as reminders of the trauma and can cause anxiety and other associated emotions. Often the person can be completely unaware of what these triggers are. In many cases this may lead a person suffering from traumatic disorders to engage in disruptive behaviors or self-destructive coping mechanisms, often without being fully aware of the nature or causes of their own actions. Panic attacks are an example of a psychosomatic response to such emotional triggers.

Consequently, intense feelings of anger may frequently surface, sometimes in inappropriate or unexpected situations, as danger may always seem to be present due to re-experiencing past events. Upsetting memories such as images, thoughts, or flashbacks may haunt the person, and nightmares may be frequent. Insomnia may occur as lurking fears and insecurity keep the person vigilant and on the lookout for danger, both day and night. Trauma doesn't only cause changes in one's daily functions, but could also lead to morphological changes.

“Epigenetic changes can be passed on to the next generation, thus making genetics one of the components of psychological trauma”.

The person may not remember what actually happened, while emotions experienced during the trauma may be re-experienced without the person understanding why (see Repressed Memory). This can lead to the traumatic events being constantly experienced as if they were happening in the present, preventing the subject from gaining perspective on the experience.

This can produce a pattern of prolonged periods of acute arousal punctuated by periods of physical and mental exhaustion. This can lead to mental health disorders like acute stress and anxiety disorder, traumatic grief, undifferentiated somatoform disorder, conversion disorders, brief psychotic disorder, borderline personality disorder, adjustment disorder, etc.

In time, emotional exhaustion may set in, leading to distraction, and clear thinking may be difficult or impossible. Emotional detachment, as well as dissociation or "numbing out" can frequently occur. Dissociating from the painful emotion includes numbing all emotion, and the person may seem emotionally flat, preoccupied, distant, or cold. Dissociation includes depersonalisation disorder, dissociative amnesia, dissociative fugue, dissociative identity disorder, etc. Exposure to and re-experiencing trauma can cause neurophysiological changes like slowed myelination, abnormalities in synaptic pruning, shrinking of the hippocampus, cognitive and affective impairment.

Some traumatised people may feel permanently damaged when trauma symptoms do not go away and they do not believe their situation will improve. This can lead to feelings of despair, transient paranoid ideation, loss of self-esteem, profound emptiness, suicidality, and frequently, depression. If important aspects of the person's self and world understanding have been violated, the person may call their own identity into question.

Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that can develop in response to exposure to an extremely traumatic event or series of events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. In addition to the symptoms of post-traumatic stress disorder, an individual with C-PTSD experiences emotional dysregulation, negative self-beliefs and feelings of shame, guilt or failure regarding the trauma, and interpersonal difficulties.

Six clusters of symptoms have been suggested for diagnosis of C-PTSD:

Experiences in these areas may include:

Some researchers believe that C-PTSD is distinct from, but similar to, post-traumatic stress disorder (PTSD), somatisation disorder, dissociative identity disorder, and borderline personality disorder. Its main distinctions are a distortion of the person's core identity and significant emotional dysregulation. Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatisation beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others.

Hypervigilance

Hypervigilance is when the nervous system is inaccurately filtering sensory information and the individual is in an enhanced state of sensory sensitivity. This appears to be linked to a dysregulated nervous system which can often be caused by traumatic events or PTSD. Normally, the nervous system releases stress signals in certain situations as a defense mechanism to protect people from perceived dangers. In some cases, the nervous system becomes chronically dysregulated, causing a release of stress signals that are inappropriate to the situation and create inappropriate and exaggerated responses.

In hypervigilance, there is a perpetual scanning of the environment to search for sights, sounds, people, behaviors, smells, or anything else that is reminiscent of activity, threat or trauma. The individual is placed on high alert in order to be certain danger is not near. Hypervigilance can lead to a variety of obsessive behavior patterns, as well as producing difficulties with social interaction and relationships. Hypervigilance is differentiated from dysphoric hyperarousal in that the person remains cogent and aware of their surroundings. In dysphoric hyperarousal, a person with PTSD may lose contact with reality and re-experience the traumatic event verbatim.

Where there have been multiple traumas, a person may become hypervigilant and suffer severe anxiety attacks intense enough to induce a delusional state where the effects of related traumas overlap. This can result in the thousand-yard stare (a phrase often used to describe the blank, unfocused gaze of combatants who have become emotionally detached from the horrors around them). Hypervigilance can be a symptom of post-traumatic stress disorder (PTSD) and various types of anxiety disorders. It is distinguished from paranoia. Paranoid diagnoses, such as can occur in schizophrenia, can seem superficially similar, but are characteristically different.

People suffering from hypervigilance may become preoccupied with scanning their environment for possible threats. They might 'overreact' to loud and unexpected noises or become agitated in highly crowded or noisy environments. Sustained states of hypervigilance, lasting for a decade or more, lead to higher sensitivity to disturbances in their local environment, and an inability to tolerate very small or large groups. After resolution of the situation demanding their attention, people are exhausted and are often unable to function in normal society.

Trauma trigger

A trauma trigger is a psychological stimulus that prompts involuntary recall of a previous traumatic experience. The stimulus itself need not be frightening or traumatic and may be only indirectly or superficially reminiscent of an earlier traumatic incident, such as a scent or a piece of clothing. Triggers can be subtle and difficult to anticipate. A trauma trigger may also be called a trauma stimulus, a trauma stressor or a trauma reminder. When trauma is "triggered", the involuntary response goes far beyond feeling uncomfortable and can feel overwhelming and uncontrollable, such as a panic attack or a strong impulse to flee to a safe place.

The trigger can be anything that provokes fear or distressing memories in the affected person, and which the affected person associates with a traumatic experience. Some common triggers are:

The trigger is usually personal and specific. However, it need not be closely related to the actual experience. For example, after the Gulf War, some Israelis experienced the sound of an accelerating motorbike as a trigger, which they associated with the sound of sirens they heard during the war, even though the resemblance between the two sounds is limited. The realistic portrayal of graphic violence in visual media may expose some affected people to triggers while watching movies or television.

Emotional dysregulation

Emotional dysregulation is a term used in the mental health community that refers to emotional responses that are poorly modulated and do not lie within the accepted range of emotive response. Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as reactive attachment disorder.

Emotional dysregulation may be present in people with psychiatric disorders such as attention deficit hyperactivity disorder,] autism spectrum disorders, bipolar disorder, borderline personality disorder, complex post-traumatic stress disorder, and fetal alcohol spectrum disorders.

“In such cases as borderline personality disorder and complex post-traumatic stress disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain”.

Possible manifestations of emotional dysregulation include extreme tearfulness, angry outbursts or behavioral outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. Emotional dysregulation can lead to behavioral problems and can interfere with a person's social interactions and relationships at home, in school, or at place of employment. Smoking, self-harm, eating disorders, and addiction have all been associated with emotional dysregulation.

Somatoform disorders may be caused by a decreased ability to regulate and experience emotions or an inability to express emotions in a positive way. Individuals who have difficulty regulating emotions are at risk for eating disorders and substance abuse as they use food or substances as a way to regulate their emotions. Emotional dysregulation is also found in people who have an increased risk of developing a mental disorder, in particularly an affective disorder such as depression or bipolar disorder.

While cognitive behavioral therapy is the most widely prescribed treatment for such psychiatric disorders, a commonly prescribed psychotherapeutic treatment for emotional dysregulation is dialectical behavioral therapy, a psychotherapy which promotes the use of mindfulness, a concept called dialectics, and emphasises the importance of validation and maintaining healthy behavioral habits.

Existential crisis

Existential crisis, also known as existential dread, are moments when individuals question whether their lives have meaning, purpose, or value, and are negatively impacted by the contemplation. It may be commonly, but not necessarily, tied to depression or inevitably negative speculations on purpose in life such as the futility of all effort (e.g., "if one day I will be forgotten, what is the point of all of my work?"). This issue of the meaning and purpose of human existence is a major focus of the philosophical tradition of existentialism.

An existential crisis may often be provoked by a significant event in the person's life—psychological trauma, marriage, separation, major loss, the death of a loved one, a life-threatening experience, a new love partner, psychoactive drug use, adult children leaving home, reaching a personally significant age (turning 18, turning 40, etc.), etc. Usually, it provokes the sufferer's introspection about personal mortality, thus revealing the psychological repression of said awareness. Existential crisis can be similar to anxiety and depression.

Dissociation

Dissociation is a concept that has been developed over time and which concerns a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a false perception of reality as in psychosis. Its cause is believed to be related to neurobiological mechanisms, trauma, anxiety, and psychoactive drugs. Research has further related it to suggestibility and hypnosis, and it is inversely related to mindfulness, which is a potential treatment.

French philosopher and psychologist Pierre Janet is considered to be the author of the concept of dissociation. Contrary to some conceptions of dissociation, Janet did not believe that dissociation was a psychological defense. Janet claimed that dissociation occurred only in persons who had a constitutional weakness of mental functioning that led to hysteria when they were stressed. Although it is true that many of Janet's case histories described traumatic experiences, he never considered dissociation to be a defense against those experiences. Quite the opposite: Janet insisted that dissociation was a mental or cognitive deficit. Accordingly, he considered trauma to be one of many stressors that could worsen the already-impaired "mental deficiency" of a hysteric, thereby generating a cascade of hysterical (in today's language, "dissociative") symptoms.

For most of the twentieth century, there was little interest in dissociation. Despite this, a review of 76 previously published cases from the 1790s to 1942 was published in 1944, describing clinical phenomena consistent with that seen by Janet and by therapists today. In 1971, Bowers and her colleagues presented a detailed, and still quite valid, treatment article. The authors of this article included leading thinkers of their time – John G. Watkins (who developed ego-state therapy) and Zygmunt A. Piotrowski (famed for his work on the Rorschach test). Further interest in dissociation was evoked when Ernest Hilgard (1977) published his neodissociation theory in the 1970s. During the 1970s and 1980s an increasing number of clinicians and researchers wrote about dissociation, particularly multiple personality disorder (now know as Dissociative identity disorder).

Dissociation has been described as one of a constellation of symptoms experienced by some victims of multiple forms of childhood trauma, including physical, psychological, and sexual abuse. This is supported by studies which suggest that dissociation is correlated with a history of trauma. Dissociation appears to have a high specificity and a low sensitivity to having a self-reported history of trauma, which means that dissociation is much more common among those who are traumatised, yet at the same time there are many people who have suffered from trauma but who do not show dissociative symptoms.

Symptoms of dissociation resulting from trauma may include depersonalisation, psychological numbing, disengagement, or amnesia regarding the events of the abuse. It has been hypothesised that dissociation may provide a temporarily effective defense mechanism in cases of severe trauma; however, in the long term, dissociation is associated with decreased psychological functioning and adjustment. Other symptoms sometimes found along with dissociation in victims of traumatic abuse (often referred to as "sequelae to abuse") include anxiety, PTSD, low self-esteem, somatisation, depression, chronic pain, interpersonal dysfunction, substance abuse, self-harm and suicidal ideation or actions.

Dissociative disorders

Dissociative disorders (DD) are conditions that involve significant disruptions and/or breakdowns "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." People with dissociative disorders also use dissociation as a defense mechanism involuntarily. The individual experiences these dissociations to protect themselves from traumatic stress. Some dissociative disorders are triggered by significant psychological trauma, though depersonalisation-derealisation disorder may be preceded by lesser stress, psychoactive substances, or no identifiable trigger at all.

The dissociative disorders listed in the American Psychiatric Association's DSM-5 are as follows:

Dissociative disorders most often develop as a way to cope with psychological trauma. People with dissociative disorders were commonly subjected to chronic physical, sexual, or emotional abuse as children (or, less frequently, an otherwise frightening or highly unpredictable home environment). Some categories of DD, however, can form due to trauma that occurs later in life and is unrelated to abuse, such as war or the death of a loved one. Dissociative disorders, especially dissociative identity disorder (DID), should not be treated with an extraordinary or supernatural status. DDs would be better examined and treated through the lens of any other psychological disorder.

Derealisation

Derealisation is an alteration in the perception of the external world, causing those with the condition to perceive it as unreal, distant, distorted or falsified. Other symptoms include feeling as if one's environment is lacking in spontaneity, emotional coloring, and depth. It is a dissociative symptom that may appear in moments of severe stress. Derealisation is a subjective experience pertaining to a person's perception of the outside world, while depersonalisation is a related symptom characterised by dissociation towards one's own body and mental processes. The two are commonly experienced in conjunction with one another, but are also known to occur independently.

Chronic derealisation is fairly rare, and may be caused by occipital–temporal dysfunction. Experiencing derealisation for long periods of time or having recurring episodes can be indicative of many psychological disorders, and can cause significant distress. However, temporary derealisation symptoms are commonly experienced by the general population a few times throughout their lives, with a lifetime prevalence of up to 26–74% and a prevalence of 31–66% at the time of a traumatic event. The experience of derealisation can be described as an immaterial substance that separates a person from the outside world, such as a sensory fog, pane of glass, or veil.

Individuals may report that what they see lacks vividness and emotional coloring. Emotional response to visual recognition of loved ones may be significantly reduced. Feelings of déjà vu or jamais vu are common. Familiar places may look alien, bizarre, and surreal. One may not even be sure whether what one perceives is in fact reality or not. The world as perceived by the individual may feel as if it were going through a dolly zoom effect. Such perceptual abnormalities may also extend to the senses of hearing, taste, and smell.

The degree of familiarity one has with their surroundings is among one's sensory and psychological identity, memory foundation and history when experiencing a place. When persons are in a state of derealisation, they block this identifying foundation from recall. This "blocking effect" creates a discrepancy of correlation between one's perception of one's surroundings during a derealisation episode, and what that same individual would perceive in the absence of a derealisation episode. Frequently, derealisation occurs in the context of constant worrying or "intrusive thoughts" that one finds hard to switch off.

Derealisation also has been shown to interfere with the learning process, with cognitive impairments demonstrated in immediate recall and visuospatial deficits. This can be best understood as the individual feeling as if they see the events in third person.

In such cases it can build unnoticed along with the underlying anxiety attached to these disturbing thoughts, and be recognised only in the aftermath of a realisation of crisis, often a panic attack, subsequently seeming difficult or impossible to ignore. This type of anxiety can be crippling to the affected and may lead to avoidant behavior. Those who experience this phenomenon may feel concern over the cause of their derealisation. It is often difficult to accept that such a disturbing symptom is simply a result of anxiety, and the individual may often think that the cause must be something more serious. This can, in turn, cause more anxiety and worsen the derealisation.

The instances of recurring or chronic derealisation among those who have experienced extreme trauma and/or have post-traumatic stress (PTSD) have been studied closely in many scientific studies, whose results indicate a strong link between the disorders, with a disproportionate amount of post traumatic stress patients reporting recurring feelings of derealisation and depersonalisation (up to 30% of those with the condition) in comparison to the general populace (only around 2%), especially in those who experienced the trauma in childhood. Derealisation can also be a symptom of severe sleep disorders and mental disorders like depersonalisation disorder, borderline personality disorder, bipolar disorder, schizophrenia, dissociative identity disorder, and other mental conditions.