Introduction

How is trauma defined?

It’s hard to measure rates of trauma. Some types are easier to track, such as emergency room visits for motor vehicle accidents. More endemic trauma, stemming from violence, for instance, is harder to measure, and reported estimates are typically assumed to be lower than the actual incidents.

The CDC reports that at least 1 in 7 children experience abuse and/or neglect each year. Rates of trauma in patient populations are likely much higher and often unidentified unless an evaluation is trauma-informed.1 Sixty-one percent of US adults surveyed reported at least one adverse childhood experience (ACE), and 1 in 6 reported 4 or more types of childhood maltreatment. The greater the number of ACEs, the higher the risk for future illnesses, ranging from depression to heart disease.

There are many frameworks for understanding trauma, especially given that trauma can be subjective; the same situation may be traumatizing to one person but not another, requiring clinicians to balance objective approaches with personalized care. It’s important to consider the moral dimensions of trauma, given the growing recognition that “moral injury” or “moral hazard” often takes place at the same time as trauma. Consider, for example, soldiers who engage in activities against their moral code that are required in the line of duty.

PTSD: The Trauma of the 21st Century

The prevailing theory of what causes post-traumatic stress disorder (PTSD) is that traumatic memories and fear-based reactions become over-learned (“conditioned”) and associated together. Treatment of PTSD ideally centers on exposure to traumatic memories in the absence of threat, leading to the extinction of fear conditioning. Memories can then be recontextualized to become part of a person’s narrative, rather than being overwhelming.

While there are many different accepted models discussing trauma and its consequences, for the purposes of clinically-oriented review, this primer will focus on PTSD as a unifying, evolving diagnostic framework.

PTSD Diagnosis: DSM Definitions and Frameworks

According to the DSM-5, PTSD is defined as exposure to actual or threatened serious injury, sexual violence, or death (Criterion A) and include:2

  • intrusion symptoms, such as flashbacks, nightmares, and emotional reactivity (Criterion B)
  • avoidance, such as memories and external reminders (Criterion C)
  • negative alterations in mood and cognition, including memory gaps, negative emotion, social withdrawal, and self-blame (Criterion D)
  • alterations in arousal and reactivity, such as significant changes in anger and irritability, impulsive self-destructive behaviors, hypervigilance, exaggerated startle responses (Criterion E)
  • duration (Criterion F)
  • functional significance (vG)
  • exclusion (Criterion H)

For diagnosis, Criterion A, F, G, and H must be met along with one symptom or more from B and C, and two symptoms or more from D and E.

There is a dissociative subtype of PTSD, characterized by depersonalization and derealization, as well as emotional detachment, affecting a little over 14% of those with PTSD.

According to SAMHSA’s 2014 consensus report, “Concept of Trauma and Guidance for a Trauma-Informed Approach:”3

Individual trauma results from an event, series of events, or set of circumstances that is  experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”

Editor’s Note: See also how ACEs predispose children to chronic pain as adults on our sister clinical site, Practical Pain Management.

The agency organizes trauma-informed care around four Rs:

A program, organization, or system that is trauma-informed Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and Responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively Resist re-traumatization.

These types of programs should be implemented with six principles in mind:

  1. safety
  2. trustworthiness and transparency
  3. peer support
  4. collaboration and mutuality
  5. empowerment, voice, and choice
  6. cultural, historical, and gender distinctions.

Type I and Type II Trauma

Experts in complex trauma differentiate between “Type I” and “Type II” trauma, a nuance separate from the basic PTSD diagnostic framework.4

Type I traumas are single-incident or short-duration traumas that happen without warning, including “a traumatic motor vehicle accident; a natural disaster; a terrorist bombing, an episode of abuse, assault, or rape; a sudden death or displacement; or the witnessing of violence or something overwhelming that is highly out of the ordinary.” 4

Type II traumas are chronic and/or complex, referring to “ongoing physical, sexual, and emotional abuse and neglect and other forms of maltreatment in the nuclear or extended family (or quasi-family); domestic violence; community danger and violence; cultural, gender, political, ethnic, illness and religion-based oppression; violence, and physical and geographic displacement; refugee status; terrorism; torture; war; and genocide.” 4

Type II trauma tends to be more pervasive and defining and may look like personality, affecting all areas of a person’s life and requiring extensive treatment. Complex PTSD, or C-PTSD, was not added to the DSM-5 but has been added to the ICD-11.5

Trauma-Informed Care

A Brief History

Trauma is often missed in clinical assessments, due to lack of awareness, stigma, and shame, systemic issues (including racial and/or gender discrimination), and misdiagnosis or delayed diagnosis. Historically, trauma has been under-recognized. Clinicians also must be aware that patients may have experienced trauma during prior experiences with healthcare, which may lead patients to be hesitant about new clinicians and/or healthcare settings.

In the early 1900s, Freud described “traumatic neurosis” in combat veterans; it was subsequently described in military medicine under the names “battle fatigue,” “shell shock” and “lack of moral fiber” – adding to the stigma. It was not until 1980 that PTSD was recognized in Vietnam Veterans and added to that era’s DSM, controversially. This change opened the door for the increasing inclusion of trauma, dissociation, and now, moral hazard, into clinical care.

How to Set the Environment for a Patient with Trauma History

Following SAMSHA guidelines, clinicians can engage trauma-informed care on the organizational level by creating a safe and empowering environment characterized by openness, choice, and communication. Patients should be given multiple chances to share trauma history and practices should evaluate online and in-personal patient education materials to raise awareness about trauma while being sensitive to the potential risks of triggering.3

(See also, SAMHSA’s brief on trauma-informed care implementation.)

Some patients feel more comfortable with someone (a trusted confidant) present with them in the waiting room and in the exam and/or therapy room, but clinicians must be wary that abusers may accompany patients to make sure they do not disclose abuse. Clinicians and organizations are required (check your local jurisdiction) to varying degrees to screen and notify patients about abuse; such regulatory requirements may be integrated into the trauma-informed approach.

Trauma History Intake and Assessment

Structured instruments may be used to assist in collecting information at initial visits or via patient intake forms to ensure that trauma is not missed. These include the ACES (Adverse Childhood Experiences Scale) and related instruments which are carefully worded, the Childhood Trauma Questionnaire, the Life Events Checklist for DSM-5, and the PCL-5 (PTSD Check List). Clinicians may also use structured instruments to guide interviews in order to reduce the chance of missing critical information. See Table I for more detail.

Table I: Assessing for Trauma: Sample Interview & Self-Report Questions6,7

Life Events Checklist for DSM-5 (LEC-5) Standard Version (full pdf)  ACE Scale (full questionnaire)

Introductory Text: Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening to a close family member or close friend; (d) you were exposed to it as part of your job (for example, paramedic, police, military, or another first responder); (e) you’re not sure if it fits; or (f) it doesn’t apply to you.

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events:

  1. Natural disaster (for example, flood, hurricane, tornado, earthquake)
  2. Fire or explosion
  3. Transportation accident (for example, car accident, boat accident, train wreck, plane crash)
  4. Serious accident at work, home, or during recreational activity
  5. Exposure to  a toxic substance (for example, dangerous chemicals, radiation)
  6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)
  7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)
  8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
  9. Other unwanted or uncomfortable sexual experience
  10. Combat or exposure to a war-zone (in the military or as a civilian)
  11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)
  12. Life-threatening illness or injury
  13. Severe human suffering
  14. Sudden violent death (for example, homicide, suicide)
  15. Sudden accidental death
  16. Serious injury, harm, or death you caused to someone else
  17. Any other very stressful event or experience

Suggested Prologue: I’d like to ask you some questions about events that happened during your childhood…. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions….

Now, looking back before you were 18 years of age:

  1. Did you live with anyone who was depressed, mentally ill, or suicidal?
  2. Did you live with anyone who was a problem drinker or alcoholic?
  3. Did you live with anyone who used illegal street drugs or who abused prescription medications?
  4. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or another correctional facility?
  5. Were your parents separated or divorced?
  6. How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?
  7. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say—
  8. How often did a parent or adult in your home ever swear at you, insult you, or put you down?
  9. How often did anyone at least 5 years older than you or an adult, ever touch you sexually?
  10. How often did anyone at least 5 years older than you or an adult, try to make you touch sexually?
  11. How often did anyone at least 5 years older than you or an adult, force you to have sex?

 

Clinicians can carefully weigh the value of obtaining history with the risk of triggering reactions, deferring evaluation when appropriate but not forgetting to follow-up. It’s important that providers communicate with and get consent from patients at each step, much as is done with physical examination (eg, I am going to press on your abdomen, Is that OK?)

In a therapy setting, this may sound like:

I’d like to ask you some questions about your upbringing. Some of these questions are about stressful or unwanted experiences people sometimes have.

If you feel uncomfortable at any time, want to stop, or have any other questions, please let me know.

What questions do you have now? Is it OK if we go ahead?

Because trauma can evoke strong reactions (countertransference) in healthcare personnel leading to omissions as well as difficulty conducting trauma-focused evaluations, it is important to adopt and train with a standardized, straightforward, compassionate, and flexible approach. In addition to screening for trauma and traumatic sequelae (eg, impaired self-care), it is helpful to assess strengths, resilience, and goals to highlight empowerment and set the stage for recovery.

Consider, for instance, the Connor-Davidson Resilience Scale, Brief Resilience Scale, positive goal-setting, self-care screenings, and Self-Compassion Scale and Fears of Compassion Scale to identify barriers and motivators to trauma-informed care.

Treatment Options for Trauma: A Brief Overview

A core focus of PTSD treatment is unlearning conditioned fear responses via controlled exposure to the traumatic stimulus (ie, exposure therapy).

Traditional techniques include:

  • exposure to traumatic stimuli leading to desensitization of memory from fear
  • recontextualizing traumatic memories into a coherent framework (re-consolidation)
  • modifying distorted cognitions resulting from trauma (eg, of feeling irreparably damaged, cognitive reprocessing)
  • addressing trauma sequelae including related
    • emotional dysregulation
    • self-care behaviors (eg, poor sleep routines, self-medication with substances or food)
    • body-related issues (eg, sexual problems, relationship difficulties)
    • workplace difficulties including executive function issues affecting attention, judgment, and decision-making
    • dissociative symptoms

Risks for Severe PTSD

It is not currently possible to predict who will develop clinically significant post-traumatic stress. While rates of trauma are high, 10 to 20% of people exposed to trauma will develop significant PTSD symptoms.8 Risk factors for severe PTSD following trauma include: peri-traumatic dissociative reactions, vagueness in autobiographical memory, elevated stress and difficulty with emotion regulation, and negative emotion including depressive reactions.

There is no clear evidence that early psychotherapy will prevent PTSD, and over-zealous efforts may worsen traumatic memory conditioning.9 Patients with early predictive factors, however, should be monitored more closely with basic supportive care to bolster resilience and allow for early intervention if required.

EMDR and TF-CBT

Based on comprehensive meta-reviews, eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive behavioral therapy (TF-CBT) are similarly effective.10,11 The approaches share significant overlap in terms of exposure-based and cognitive processing mechanisms. It is unclear whether bilateral stimulation (eg, eye movements) in EMDR offers specific value, and if so via what mechanism of action, although there are many hypotheses.12

TF-CBT, in addition to prolonged exposure (PE) to desensitize aberrant fear conditioning, focuses on reworking maladaptive responses to trauma with cognitive processing therapy (CPT) as well as modifying behaviors. EMDR uses bilateral eye movements and related activities which advocates speculate may improve the efficiency of memory reprocessing via the introduction of a distraction task or a vague mechanism of facilitating integration between the two brain hemispheres, though there is limited evidence to support either hypothesis.

Response rates across studies vary. Patients treated with PE no longer met diagnostic criteria for PTSD 41 to 95% of the time in different studies while patients receiving CPT did so 30 to 97%, and CBT 61 to 82.4% of the time.13

Long-Term Trauma Treatment

While treating core PTSD symptoms is critically important, especially for those with chronic or complex trauma, shorter-term therapies may not address problems arising from the impact of trauma on personal development, relationships, and worldview.

As a result, longer-term approaches are “phase-based” – usually with three phases:14

  1. establishing safety, stabilization, control of symptoms, and overall improvement in ego functioning
  2. confronting, working through, and integrating traumatic memories
  3. continued integration, rehabilitation, and personal growth.

Present-Centered Therapy (PCT), originally developed as a non-trauma-focused research condition, is effective for PTSD although not as effective as TF-CBT/EMDR, with a significantly lower dropout rate for patients who cannot tolerate trauma-focused work.15 PCT is designed to capture the “common” factors in good therapy – a positive therapeutic relationship, symptom normalization, validation, emotional support, and increasing confidence and problem-solving mastery.

Medication Options for PTSD, Trauma

Medications can be useful for managing post-traumatic stress. Only sertraline and paroxetine have FDA indications for PTSD. About 60% of patients see improvement and 30% go into remission.16 Other antidepressants are used off-label, including SSRIs and SNRIs, as are other medication classes including antipsychotics, older antidepressants, mood stabilizers, anxiolytic medications, and anti-adrenergic medications such as the blood pressure medicine prazosin,17 which may help with activation and nightmares.

Most medications are chosen to alleviate symptoms while psychotherapeutic approaches address the underlying causes – although novel psychopharmacological approaches also hold promise to directly alleviate PTSD on the neurobiological level, both alone and in combination with psychotherapeutic approaches. Emerging research suggests that the psychedelic MDMA may be effective for PTSD.18 The only drug to date which may reduce or prevent clinically-significant posttraumatic reactions if given immediately is hydrocortisone, a steroid,19 though this is not in routine use.

Caution is always required when prescribing controlled substances.

Additional Treatment Options for PTSD and Trauma

Other evidence-based therapies which help with PTSD and related conditions (eg, personality disorders) include: Dialectical Behavioral Therapy, Acceptance and Commitment Therapy, Compassion Based Therapy, “STAIRS” (Skills Training in Affective and Interpersonal Regulation), TARGET (Trauma Affect Regulation: Guide for Education and Treatment), and related group and individual modalities which focus on both trauma and co-occurring problems.

In addition, stress management, mindfulness-based stress reduction (MBSR), various meditation-based approaches, trauma-focused yoga, somatic experiencing, sensorimotor, and other body-oriented therapies may be helpful. The latter must be used with caution in people with physical and sexual abuse.

Ketamine/esketamine may be helpful for patients, with varying degrees of evidence. There are a variety of other interventional approaches in use including stellate ganglion injections, vagus nerve stimulation, and others that are important to be familiar with but not widely used.

TMS (transcranial magnetic stimulation) and neurofeedback have also been cited in the literature for trauma.

Professional Takeaways on Trauma-Informed Psychiatry

Despite an ever-expanding array of “trauma-focused” treatments, the evidence is limited and research lacks coherence. It’s important to review research carefully rather than follow anecdotal claims which are often persuasive and enthusiastic but based on limited and inconsistent evidence.

The strongest evidence for trauma therapy is for TF-CBT and EMDR. For those who cannot or prefer not to address trauma head-on, a combination approach with medication and common-factor therapies may be helpful. Patients should never be forced to engage in trauma-focused work, as this may be retraumatizing and counterproductive. In the same regard, safely identifying and gently exploring barriers to potentially effective treatments is part of ongoing trauma work (see also, how the American Rescue Plan aims to train more mental health professionals in trauma-informed care).

It is important for clinicians to partner with patients and families/confidants to help identify areas of need, review the available options, and discuss research-based alternatives when necessary. At the same time, it is key for providers to discourage inadvisable options – those without evidence – while supporting a patient’s autonomy to help develop an effective individualized treatment plan.

 

 

Treating Trauma in the 21st Century

More on PTSD, pandemic trauma, and trauma-informed care.

Trauma Series
References
Last Updated: Mar 12, 2021