Trauma and Post-Traumatic Stress Disorder (PTSD)

Julie Rosen, LCSW, MPHAlbuquerque, NM, USA

Psychotherapist / Clinical Social WorkerEMDR Therapy Certified, Approved Consultant, and Trainer

Facilitator, EMDR Humanitarian Assistance Programs

What Is Trauma?

TRAUMA

• Psychological response to an experience that is deeply distressing or disturbing

• Has lasting negative effect on the person’s functioning and their mental, physical, social, emotional, and/or spiritual well-being

• Was unable to be processed and integrated

• “Big T” trauma versus “Small t” trauma

“Big T” TRAUMA

• Threatens the life or sense of physical safety of the person, or of someone very important to them (such as a parent, or sibling, spouse, child).

• Causes an overwhelming sense of terror, helplessness, and horror.

• The body reacts to this threat automatically… with an increased heart rate, shaking, dizziness or faintness, rapid breathing, release of stress hormones like adrenaline and cortisol, and sometimes loss of control of the bowel or bladder.

“Small t” TRAUMA

• Neglect, or failure to provide for a person’s basic needs

• Not having proper care, attention, and supervision

• Bullying

• Emotional abuse

• Verbal abuse

• Other “smaller” harms that cause lasting damage

Response to Trauma

Basic Somatic Trauma Processes

• Fight, Flight, Freeze

Working with Trauma: Triune Brain

Dissociation• Type of “freeze” response

• Disconnect from present surroundings and appear to withdraw internally or completely “space out”

• Normal response to abnormal circumstances

• Can be a coping strategy to escape pain

Dissociation

Recognizing Dissociation in Session

Sudden shift in affect or level of affect

Client is suddenly overwhelmed

Unable to follow instructions

Presenting in a much more child-like way

Unable to maintain dual awareness

Client becomes unresponsive, staring ahead

Suddenly develops intense headache

Window of Tolerance(Siegel, 1999, Ogden, 2006)

Hyperarousal = Overwhelm

Tolerable Arousal and Experience

Hypoarousal = Collapse

A Case

• Du is a 14 year old girl from the Black Hmong tribe, living in the Sapa region of Vietnam.

• When Du was 5 years old, her mother was trafficked by a neighbor, brought to China and sold into the sex trade and virtually imprisoned in a brothel, cut off from all contact with Du and other family members.

• Du’s father quickly turned to alcohol and was often absent from the household, leaving Du to care for her 2 younger siblings. When he was present, he often raged at everyone around him, both physically and verbally, including his kids.

Common Symptoms of Trauma

• Shock, denial, or disbelief.

• Confusion, difficulty concentrating.

• Anger, irritability, mood swings.

• Anxiety and fear.

• Guilt and shame.

• Withdrawing from others, difficulty trusting people.

• Feeling sad or hopeless.

• Feeling disconnected or numb.

• Difficulty experiencing any positive emotions.

• Negative thoughts and beliefs about self and others.

Post Traumatic Stress Disorder (PTSD)DSM 5 Criteria

• Intrusions: The trauma comes back into memory even with attempts to avoid thinking about the event(s)

•Avoidance: Avoiding reminders of the trauma

•Arousal: Hypervigilant, hyper-alert

•Reduced functioning: Problems with relationships, work, other major life areas

One’s ability to cope with trauma

Factors include:• Single vs. repeated trauma•Age when trauma occurred or

began•Agent – natural vs.

human caused•Nature of the trauma – accidental

vs. purposeful• Innate resilience

Assessing for PTSDPCL-5 PTSD Checklist

• Tool to get information on trauma symptoms that a person is experiencing

•Not diagnostic

•Validated in many countries, with different cultures and languages, including Zimbabwe, Sri Lanka, and Malaysia.

Work in Pairs

• Take the case of Du

• Roleplay, with 2 people, clinician and Du

• Clinician use the PTSD checklist, and ask about the different symptoms.

• Person playing client Du just make up likely responses

• No right or wrong with this! Just an opportunity for practice

Adverse Childhood Experiences (ACES)

ACES Study (Felitti, et al, 1998)

• Over 17,000 adults studied in

the USA (CA)

• Measured negative childhood

experiences and a range of

mental health and health

outcomes

• ACES include “little t” traumas as well as the “big T” traumas

ACES = Adverse Childhood Experiences

AbuseNeglect

Household dysfunction

emotional

physical

sexual

emotional

physical

Mother treated violently

Household substance abuse

Household mental illness

Parental separation/divorce

Incarcerated household member

Felitti et al, Am J Prev Med 1998

Small Groups

• What ACES (Adverse Childhood Experiences) has Du experienced?

• Think of one case of a client that you have worked with, and discuss with your group what ACES that person experienced.

ACES Study

ACES are common!

In ACES Study (Felitti et al, 1998)• Nearly two-thirds had at least 1 ACE (62.1%)• More than 1 in 5 reported 3 or more ACEs (22%)

Chicago Longitudinal Study (Mersky et al, 2013):• Nearly four out of five (79.5%) experienced at least

1 ACE• Over one third (34.7%) had 3 or more ACEs

ACES in Southeast Asia

VIETNAM: 2,099 medical university students throughout the country (Tran, et al, 2015):

• Three-quarters (76.2%) experienced at least 1 ACE

• Over one third (35.9%) had 3 or more ACEs

THAILAND: Study of 202 young residents of Northern Bangkok, 16 to 25 years old (Jirapramukpitak, T., et al, (2005):

• 38% reported having experience at least 1 ACE during childhood

A study on methamphetamine use among 755 vocational school students in 3 different schools in Bangkok (Htikeet al, 2017).

• 55% had at least one ACE

• 21% had 3 or more ACES

ACES StudyStrong “dose-response” relationship between ACES and a wide range of negative mental health and health outcomes throughout the life-span.

Similar graded results found in low-income and minority communities in Chicago, in the urban population of Manila in the Philippines, among medical students in Vietnam, and among vocational students in Thailand.

Impact of ACES

Cancer

Severe Obesity

Risky Sexual Behaviors

ALCOHOLISM

Illicit drug useHeart attacks

Chronic Lung Disease

Depression

Domestic violence

Hostinar, Dev Psychol, 20155

WHY?

Children with ACES

Don’t learn emotion regulation

Lack modeling typically given by parents.

Lack significant attachment figure

Need to focus on SURVIVAL

ACES Impact Substance Misuse

Each one of the ACEs was associated with an increased likelihood of illicit drug use across the lifespan.

Any 1 ACE increased early drug initiation by 2- to 4-fold

People with 5 or more ACEs were up to 10 times more likely to suffer from SUDs later in life than those with no ACEs

ACES score increased the likelihood, in a dose-response manner, of…• Ever having drug problems• Ever being addicted to drugs• Injection drug use

What about in Thailand?

Thailand

• The study of 755 vocational students found that the ACES of physical neglect and family violence were significantly associated with increased use of methamphetamines

• Among 202 young (16-25 yo) Bangkok residents, history of sexual abuse and emotional abuse during childhood (ACES) were both associated with higher levels of alcohol and drug use later in life.

Impact of PTSD/Trauma on Substance Use Disorders (SUDS)

For someone suffering from Trauma/PTSD, substances may provide:

• Escape from the pain (physical and/or emotional)

• Distraction from disturbing emotions

• Temporary respite from PTSD symptoms, a way to avoid painful memories

• Way to numb feelings that are difficult to tolerate

As the drugs wear off…..PTSD symptoms are often exacerbated.

Impact of SUDs on PTSD/Trauma

Being intoxicated may:

• interfere with decision-making abilities

• increase risk-taking behaviors• make people more vulnerable to

being victimized• increase possibilities for accidents,

other trauma

When people withdraw from substances, it can worsen PTSD symptoms and make recovery more difficult.

Links Between PTSD and Substance Use Disorders

• Both produce a profound urge to be in an altered state

• Each of the disorders increases the likelihood of presence of the other

• Each of the disorders may exacerbate the symptoms of the other

What Can We Do?Trauma Informed Treatment

According to SAMHSA, trauma-informed programs, organizations, or systems:

• Realize the widespread impact of trauma• Recognize signs and symptoms of trauma

in patients, families, staff, and other stakeholders

• Respond by fully integrating knowledge about trauma into policies, procedures, and practices

• Avoid re-traumatization

Trauma Informed Treatment

Break into small groups.

Discuss the questions….

• If someone like Du were to walk into your clinic or treatment setting, what ways might that person be re-traumatized?

•What could you do to make the environment more trauma-sensitive?

Some Evidence-Based Approachesto Treating Trauma and PTSD

• Cognitive Behavioral Therapy (CBT)

• Prolonged Exposure Therapy

• Trauma-Focused CBT

• Seeking Safety

• EMDR Therapy

Some Evidence-Based Approaches

Cognitive Behavioral Therapy (CBT)

• Focuses on the relationship between thoughts, feelings, and behaviors

• Usually short-term

• Can be provided in group or individually

• Helps to address trauma by reducing symptoms and improving functioning

Cognitive Behavioral Therapy (CBT)

Some strategies that may be used:

• Stress management, relaxation skills, mindfulness, grounding skills

• Understanding & challenging cognitive distortions• Self-Blame: Blaming myself for anything that goes

wrong, even if I had nothing to do with it

• Catastrophizing: Making a big deal out of small things

• Psycho-education about trauma, fight/flight/freeze responses, understanding triggers, patterns of avoidance

Prolonged Exposure Therapy

• (PE) helps clients to gradually approach trauma-related memories, feelings, and situations that they have avoided facing.

• Client is exposed to the trauma story, reminders of the trauma, or emotions associated with the trauma

• Exposure is done in a controlled way, and planned collaboratively

• The goal is to return a sense of control, self-confidence, and predictability, and reduce avoidance behaviors.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

• Structured, short-term (8-25 sessions)

•Used in outpatient setting such as clinic, hospital, school, or in-home setting.

• Cognitive behavioral techniques help modify distorted or unhelpful thinking and negative reactions and behaviors.

• Includes family therapy to work with family dynamics that contribute to the problem; teaches parenting, stress management, and communications skills.

Some Evidence-Based Approaches

Seeking Safety by Lisa Najavits (1997)

An evidence-based and trauma-focused therapy that is highly flexible and beneficial in treating co-occurring addiction and PTSD.

Treatment for Traumaand Co-occurring SUD

Seeking Safety

• Evidence-based therapy that effectively treats co-occurring addiction and PTSD.

• Manual with 25 topic areas addressing recovery and coping skill development

• Very flexible; can be used individually or with groups; topics are independent and can be presented in any order

Working with Trauma: Right and Left Brain

EMDR - Eye Movement Desensitization and Reprocessing (Francine Shapiro, 1987)

•Uses eye movements (or other BLS) to facilitate physiological processing of past traumatic experiences

• It works! 30+ randomized controlled trials to date

• Experiences are translated into physiologically stored memories.

• Memories are stored in associative memory networks.

• New experiences link with previously stored memories, and form basis of interpretations, feelings, and behaviors.

Adaptive Information Processing Model (AIP)

AIP & Trauma Experience

• Trauma (big T or small t) causes a disruption of normal adaptive information processing

• Traumatic experiences get stuck in memory networks

• Unprocessed and maladaptively stored memories don’t link up with adaptive networks

• These memories are the primary cause of psychopathology

Processing Memories• EMDR therapy facilitates an associative

process, connecting maladaptive memories with the adaptively stored memory networks

• Therapist facilitates, but the brain is moving through a natural process of healing, digesting past memories that continue to disturb in present time

Video about EMDR Therapy

Mechanism of Action Hypotheses

• EMDR therapy was developed based on clinical experience

• Since 1987, researchers have been exploring what specific brain activity is activated or shifted related to the BLS component.

• Remember that no form of psychotherapy can be explained on a neurobiological level.

Mechanism of Action Hypotheses

REM Brain State Similarities

Rapid Eye Movement stage of sleep

• Eye movements take place during sleep

• We process memories during REM sleep, including integrating information, and enhancing weak associations.

Mechanism of Action Hypotheses

Working Memory

Working Memory = currently “active” stored information that is used to perform cognitive operations, a limited resource

A traumatic memory is brought up in working memory and then a “second task” (the BLS/DAS) is added, disrupting the intensity of the memory.

Mechanism of Action Hypotheses

Multiple Mechanisms

Theories not mutually exclusive

Several different brain processes are likely occurring simultaneously

Theories highlight the importance of “bilateral stimulation / dual attentionstimulus” (BLS/DAS)

EMDR Therapy and SUDS

• Can use EMDR Therapy to process past trauma for people with SUDs

• Caution early in recovery

• EMDR is also being used to reduce cravings in people with SUDs who are not yet abstinent

• Efficacy studies ongoing presently

Recognition of EMDR Therapy• 2013 World Health Organization

“Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR therapy does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.”

• Professional EMDR Associations in Asia, Africa, Europe, Latin America, USA Countries: Cambodia, Pakistan, Thailand, Philippines, Singapore, Taiwan, others

• Small group of psychologists and social workers in Hanoi presently being trained in EMDR Therapy (Blue Dragon NGO)

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

Htike, Min & Thepthien, Bang-on & Chucharoen, Prapapun. (2017). A web-based survey on adverse childhood experience, anxiety, depression, sexual behavior affecting methamphetamine use among adolescents in Bangkok, Thailand. Journal of Public Health and Development. 15. 17-31.

Jirapramukpitak, T., Prince, M. & Harpham, T.(2005). The experience of abuse and mental health in the young Thai population. Soc Psychiat Epidemiol 40: 955-63.

Mersky, J. P., Topitzes, J., & Reynolds, A. J. (2013). Impacts of adverse childhood experiences on health, mental health, and substance use in early adulthood: A cohort study of an urban, minority sample in the U.S. Child Abuse & Neglect, 37(11), 917–925.

Ramiro L, Madrid B, Brown D (2010). Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child Abuse & Neglect 2010; 34: 842-855.

Tran, Quynh et al., (2015). Adverse Childhood Experiences and the Health of University Students in Eight Provinces of Vietnam. Asia-Pacific Journal of Public Health 27(8).

Assess for trauma/PTSD

Develop trauma-informed and trauma-sensitive treatment approaches

Provide recovery services that address both SUDS and trauma/PTSD

Thank you!

Julie Rosen, MPH, LCSW

JulieRosen44@gmail.com

+01-505-417-5870