The Psychiatric Implications of

Trauma: The Baltimore Experience

Kenneth M. Rogers, MD, MSPH, MMM

Chair, Department of Psychiatry

Greenville Health System and University of South Carolina-Greenville

February 6, 2015

What is Trauma?

• In medicine, trauma is damage to a biological

organism caused by physical harm from an

external source.

• In psychology, trauma is a type of damage to

the psyche that occurs as a result of a severely

distressing event.

Why Discuss Trauma?

• Childhood psychic trauma is a crucial etiological

factor in the development of a number of

serious disorders both in childhood and in

adulthood.

• Like many early childhood illnesses, psychic

trauma sets a number of different problems into

motion, any of which may lead to a definable

mental condition.

Sources of Trauma

• Familial (normalized)

• School

• Community

• Internet

• Bullying

• Personal vs Witnessed

Types of Trauma

• Experienced vs Witnessed

• Personal vs Group

• Sexual vs Non-sexual

• Physical vs Non-physical

Types of Trauma

• First described by Lenore Terr, MD in 1987

• Chowchilla, CA Kidnapping-July 1976

Kids were 8-14

26 children buried alive for 16 hours

• Type 1 Trauma: single incident

• Type 2 Trauma: sustained incident

Type 1 Trauma

• Full, detailed memories

• Personal explanations for why the trauma

occurred

• Misperceptions

Type 2 Trauma

• Denial, self-hypnosis, and intense anger

• Forget blocks of history

• Block out physical and emotional pain (self

hypnosis)

• Force themselves to think of being somewhere

else or being with someone else

• Anger is directed at themselves and others

The Biology of Trauma

• Limbic System – Emotion

– Behavior

– Memory

– Stimulus processing

• Prefrontal Cortex – Executive function

– Problem-solving,

– Planning

– Organizing

– Time management

– Attention/memory

• Brain Stem – Heart rate,

breathing, blood pressure, appetite, temperature, etc. • Integrates with emotions and thoughts to adjust internal responses • Major role in traumatic stress and brain stem. •

Baltimore in Film and Television

Prominent Gangs

• Black Guerilla Family

• 18th Street Gang

• Bloods

• Crips

• Gangster Disciples

• Latin Kings

• MS 13

• Carnell Cooper 2009

Violence Prevention Programs

• Violence Intervention Program (VIP): Evidence, hospital-based violence intervention program.

• Promoting Healthy Alternatives for Teens (PHAT): An innovative violence prevention format designed to engage youth who are at risk for either becoming victims and/or victimizing others.

• My Future-My Career (MF-MC): An after-school initiative called that concentrates on fostering healthy coping skills and professional growth in a group of youth who are at risk for failing school.

• The Bridge Project: Domestic Violence initiative to break the cycle of intimate partner violence.

Surprising Presentations

• 60% did not identify the trauma as a trauma

• 86% felt disrespected by hospital staff

Risk Factors for Becoming a

Victim of Violence

• African-American male

• Adolescence/Early Adulthood

• Unemployed

• No health insurance

• Income less than $10,000 yearly

• Current drug user

• Past or present drug dealer

• Positive test for psychoactive substances upon admission

Violence Intervention Program

• Personal and Public Safety Issues: Retaliation, domestic violence, risk taking behavior, etc.

• Attribution of Meaning to Events and Recovery: Medical, mental, social adjustment, etc.

• Reinforcement and Development of Positive Skills and Supports: Healthy coping skills, etc.

• Connection to Community-Based Services: Needed referrals for personal growth, etc.

• Stabilization: "Handling daily crises"

• Recovery & Rehabilitation: Substance abuse, criminal justice, etc.

• Community Reintegration: Education, employment, housing, medical, etc.

• Self-Reliance & Self-Referral: Personal goals

Assessing Violence

• Open ended questions are not enough

• Have you ever been injured during a fight or

confrontation with another person?

• Has anyone ever forced you to have a sex act

when you did not want to?

• Has anyone ever used a weapon in your

presence?

Study Outcomes

VIP Participants repeat hospitalization rate due to violent injury

83 % decrease (36% savings as compared to those not getting the intervention )

VIP Participants violent crime 66.7 % decrease

VIP Participants violent criminal activity

75 % reduction

VIP Participants employment at the time of follow-up

82 % rate (as compared to 20 % not getting the intervention)

Persistently Dangerous Schools

Experiencing of Trauma

• 45% of elementary school children had

witnessed a violent act

• 30% had seen a dead body in their lifetime

• 50% had been the victim of an assault

• 60% knew someone who had been killed

Intervention

• Public health intervention

• Community based intervention

• Assertiveness

• Recognition of risk

• Focus on safety and violence prevention

• Family based interventions (MST, FFS)

• Trauma Focused CBT

Recognition of Trauma

Case Study #1

14 year old male seen at the Department of

Juvenile Services after being arrested secondary

to assault and battery. Youth has been an “A”

student until this year. He has no prior history of

legal or school problems. He lives with his mother

and father.

Recognition of Trauma

Case #2

• 16 year old girl seen at a girls detention center

where she had been placed on charges of

prostitution and drug possession. She had a

history of excellent academic performance

through the 8th grade. Her grades began to

decline after she became pregnant . She

dropped out of school in the 9th grade. Her

mother has a history of substance abuse and is

not currently employed.