Trauma
Trauma is not defined by what happens to you, but by what happens inside you as a result. It is the enduring emotional, somatic, and psychological response to an overwhelming experience that exceeds your capacity to cope, process, or make meaning of it — leaving behind a sense of fragmentation, disconnection, or threat that persists even after the event has passed.
“Trauma is not what happens to you. Trauma is what happens inside you as a result of what happened to you.”
So What Happens Inside You?
At the core of trauma is disconnection. In any event, it is registered consciously or unconsciously as a threat to survival. When this event is registered as a threat to survival, the body moves into a state of heightened energy if there’s no anchor to connection or safety. In response, the body mobilizes protective mechanisms. But if these responses can't be acted upon, the surge of energy (which we can measure metabolically) escalates to overwhelm.
At the point of overwhelm, parts of consciousness begin to shut down. The narrative centers of the brain—responsible for making meaning and storing explicit memories—go offline. This state is often described as the "thousand-yard stare," technically called peritraumatic dissociation.
But while narrative memory fades, implicit memory—the body’s sensorial and emotional imprint—remains. The amygdala stays active. This means the body stores fragments of the experience, charged with fear, but without a coherent story. These unconscious fragments often cluster together, forming subpersonalities—protective parts frozen in time. Fragmentation leads to an apparent multiplicity, where different parts of the person compete for control to ensure survival.
Frozen in the past, these fragmented aspects prioritize protection over connection. They're activated by perceived threats, external or internal, in the present moment, and become what we refer to as trauma triggers. A trigger is neutral if it’s not attached to a loaded gun. Processing and metabolizing the original experience removes the “explosive material.”
Signs and Symptoms of Trauma.
The trauma response can be captured well by the acronym TRAUMA.
T: Traumatic event. When experienced or witnessed, this leads to…
R: Re-experiencing the traumatic imprint through thought, behaviors, nightmares, and flashbacks in a repetition compulsion. These experiences represent attempts to process the trauma.
A: Avoidance of activities, persons, places, or events associated with the traumatic experience that may become triggers. A also stands for affective numbing, which includes loss of interest or anhedonia, depression, lack of motivation, detachment, and dissociation.
U: Unable to function in the context of the trauma response at work, in school, or in relationships
M: Mood reactivity with difficulty regulating emotions and maintaining balance in the context of triggers.
A: Arousal increases such that the individual is in a persistent state of hypervigilance, at times escalating to a sense of paranoia and profoundly impaired trust. This may be associated with impaired focus and irritability.
When these symptoms are present for a month or more, according to the DSM, you meet criteria for PTSD.
The Traumatic Event and Beyond.
Two people can go through the same event, like a car accident, emotional neglect, or a breakup, and have very different responses. One may process it and move on, while the other may develop symptoms of trauma. It’s not just the event itself, but how the nervous system perceives and stores that experience.
Some traumatic events may be more subtle. For instance, in children, implicit memory dominates until around age 4; at that point, we begin to have the capacity to construct explicit, or narrative, memories. Before this point, trauma may be stored in the body as an implicit memory, establishing a developmental or preverbal trauma. This can include perinatal trauma, unwanted or stressful pregnancies, domestic violence or substance use during pregnancy, maternal post-partum depression, and several events that the developing nervous system may perceive as a threat to survival. An important consideration is that the nervous system does not come online at the moment of birth, but within the first few weeks after conception. Oftentimes, developmental trauma becomes a significant source of unexplained somatic and psychological symptoms.
This coincides with attachment-related problems, where a child learns to regulate their nervous system by borrowing the parent’s nervous system. This is an essential ingredient in trauma resiliency. Internalization of a secure base and container for potential overwhelm is critical for the child’s ability to regulate and maintain a stable sense of self with a balance between proximity seeking and exploration. These activities coalesce into attachment patterns.
In a step a little deeper, transgenerational trauma describes a phenomenon where the imprint of trauma can be passed from parent to child. When trauma of one generation is not processed and resolved, it becomes a legacy for the next generation. Not only does the parent act out the trauma response, influencing the child through thoughts and behaviors… Rachel Yehuda showed that epigenetic changes in the way the body metabolizes cortisol, stress hormone, may be passed from mother to child - influencing their resiliency to stress, overwhelm, and trauma. This can become the source of distressing sensations, emotions, and physical symptoms of illness with no known cause.
Complex PTSD (cPTSD).
Complex or cPTSD is a condition arising from prolonged or repeated exposure to traumatic events, especially those that occur in interpersonal relationships and often during childhood or over an extended period of time. This prolonged exposure can come from childhood abuse or neglect, lack of attunement, domestic violence, ongoing social stress and bullying, community and political violence, and prolonged captivity, among other experiences.
In addition to the response accounted for by the TRAUMA acronym, these individuals experience:
Emotion regulation difficulties with significant oscillation between high and low arousal states with overwhelming emotional and sensorial experiences.
Disturbed ipseity or in other words an impaired sense of self and self-organization. Dissociation tends to be pronounced.
And prominent interpersonal problems where patterns learned in the context of early trauma tend to get repeated in adulthood until new and effective interpersonal strategies are developed. Withdrawal, blaming or externalizing, pushing away, and criticizing are common.
Screening and Evaluation.
The gold standard screening tool to evaluate the presence and severity of trauma symptoms is the PTSD checklist for the DSM-5 (or PCL-5). In addition to focusing more on the response than the event, this 20-item tool helps monitor PTSD symptoms throughout treatment. Outside of being just a “checklist,” this tool provides a useful gauge of the intensity of trauma symptoms. The standardized cutoff for this screening tool is 31-33 points with anything lower indicating potential “subthreshold” PTSD.
When the PCL-5 is “subthreshold” or not clear, consider the more hidden factors associated with trauma and other origins of trauma, such as developmental or transgenerational trauma. A hallmark question is “What was it like for you growing up?” This leads us into the Adverse Childhood Experiences (or ACE) questionnaire. This tool provides a means of evaluating trauma with its origins in childhood. Three categories include abuse, household challenges, and neglect.
⅔ of the population has experienced 1+ ACEs, and 1 in 6 have experienced ACE scores of 4 or higher. Individuals with 4+ ACEs are more likely to have been in prison, develop heart disease, frequently visit the doctor, develop diabetes, have committed violence in the past 12 months, and are at high risk for drinking, smoking, or other drug use. 5 out of 10 of the leading causes of death are associated with ACEs. Males with an ACE of 6 or higher are 46 times more likely to have injected illicit drugs than males with an ACE of 0. Those with an ACE of greater than 6 tend to die prematurely, typically around 20 years earlier than those with lower ACE scores.
Beyond the ACE Score. At the core of trauma is disconnection. The ACE score captures traumatic events that “did” happen. It does not account for what “didn’t” happen that would normally support growth and development. Trauma is not just the presence of something that shouldn’t have happened; it’s also the absence of something that should have happened.
This includes experiences of being validated, seen, heard, held, and contained. This captures the more subtle nuances of developmental and transgenerational trauma, the truly unspoken and nonverbal aspects of trauma, which can be accessed and processed by a skilled trauma specialist.
Impact of Trauma.
Trauma impacts the whole individual, not just the mind. Consider the impact on a psychological/neurological, biological, lifestyle, and spiritual level.
Psychological/Neurological. In the event of external trauma, there is a consequent state of increased energy (fight or flight response). When the individual is unable to act on fight or flight, this increase in energy (which can be metabolically measured) escalates to the point of overwhelm, and consciousness goes offline (“the thousand-yard stare,” technically referred to as peritraumatic dissociation or PTD). This event is essentially the equivalent of a traumatic brain injury (TBI) and significantly disrupts neural connectivity. This is the point at which an individual is disconnected from their sense of self and other. At this point, narrative (explicit) memory (responsible for the ongoing narrative of experience, the “story” of our life) goes offline. In contrast, implicit memory (reconstitutes with sensorial experience here and now) and the amygdala (related to the fear response) remain online. This results in fear-charged sensorial fragments in the here and now without associated narrative content. This fragments are attached to narrative content, creating a fragmented cluster of perceptions, behaviors, and emotions. This accounts for some of the nature of trauma triggers (response to perceived threat) and subsequent actions in response to the triggers.
Biological. Trauma impacts several body systems, leading to ancillary problems as a result.
Hypothalamic-Pituitary-Adrenal Axis. Perpetual reactivation, overstimulation, and overwhelm associated with triggering activate the stress response, which usually functions to sustain energy in the context of a threat. However, in the context of trauma, the stress response is sustained, which significantly damages memory, attentional networks, and amygdala regulation. What’s more, cortisol directly influences the immune system, producing a pro-inflammatory environment.
Immune-Brain Axis. Outside of the influence of cortisol described above, traumatic stress reduces immune system integrity, making you more susceptible to infection and autoimmune disease. Immune dysregulation also influences how the brain manufactures dopamine, serotonin, and norepinephrine and reduces the effectiveness of some psychiatric medications.
Lifestyle. Trauma influences several domains of an individual’s lifestyle.
Relationships. Trauma influences relationships in several ways. Because our bodies become wired to remain vigilant for cues of threat, it becomes difficult to establish a connection with others without experiencing threat and reactivity.
Leisure. Trauma makes it challenging to relax in the context of a hypervigilant or disconnected state.
Labor. As mentioned above, those with high ACE scores experience difficulty in the occupational setting.
Nutrition. A change in energy supply and demand drives dietary orientation to a degree in the context of trauma, making it difficult to sustain a healthy and balanced diet.
Sleep. Sleep quantity and quality may be disrupted through an experience of nightmares, hypervigilance (difficulty relaxing), and cortisol abnormalities (disrupting circadian rhythm).
Substance Use and Addiction. Addiction is a solution to a deeper underlying problem, trauma. It’s important to note that addiction does not necessarily only include substances but can also include behavioral addictions and habit patterns that have developed in the context of trauma.
Spiritual. Trauma makes it challenging to establish and maintain a sense of connection, meaning, and purpose in the context of the various degrees of disconnection experienced by the individual.
“Where there is a trigger, there is an implicit memory at play. The trigger would otherwise be neutral if it were not attached to a loaded gun.”
Integrative Psychiatry Approach to Trauma.
There are several options for the treatment of trauma. Often a multimodal approach is best:
Medications.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): front-line treatments for trauma syndrome. One of the most notable SSRIs for the treatment of trauma is sertraline (Zoloft), which has FDA approval for the treatment of PTSD. These medications help to desensitize the overactivity of the amygdala as well as improve upon consequent depression symptoms.
Prazosin: A gold-standard trauma medication used to block some of the overactivity of the sympathetic nervous system (responsible for fight and flight). Prazosin has been useful for the reduction of nightmares, flashbacks, daytime hyperarousal and hypervigilance, and anxiety experienced in PTSD.
Propranolol: This medication similarly calms some of the overactivity of the sympathetic nervous system and can be helpful as an as-needed medication for trauma-associated anxiety, hyperarousal, and hypervigilance.
Second-generation Antipsychotics: Sometimes used for complex trauma syndromes with refractory intrusive thoughts and the emergence of psychosis (e.g., paranoia and hallucinations).
Trazodone/Mirtazapine: These sedating antidepressants are sometimes used for a combination of sleep difficulties, depression, and nightmares for those experiencing trauma syndrome.
Benzodiazepines: Should be avoided in trauma. These medications tend to temporarily suppress overactivation, making them very effective in the short term. In the long term, these medications perpetuate avoidance strategies and strengthen the embodiment of trauma such that it is inadequately processed.
Nutraceuticals.
Several adaptogenic herbs such as Ashwagandha and Rhodiola may be effective at diminishing the overactivity of the hypothalamic-pituitary-adrenal axis, resulting in improved cortisol management (reduced stress).
Sometimes, Adrenal Support preparations are helpful depending on an evaluation of adrenal functionality and hypothalamic-pituitary-adrenal axis activity.
Adequate supplementation with key vitamins and minerals and methylation support can promote appropriate neurotransmitter (brain chemical) functioning, synthesis, and storage.
Other nutraceutical considerations depend on an appropriate bodily-based working.
The Body.
The brain does not exist on an island. Instead, there’s a dynamic interaction between the brain and the body. Because of this, it’s crucial to explore the influence trauma has on the body and vice versa. An Integrative Psychiatry specialist will help you explore the following areas using advanced diagnostic and laboratory testing: adrenal (e.g., stress hormone), gonadal (e.g., sex hormones), gut, thyroid, metabolism, immune, micronutrients, and epigenetics. This exploration helps to personalize treatment based on your unique needs.
Psychotherapy.
There are two united steps in trauma treatment: (1) Desensitization and (2) Integration (conversion of the trauma into a narrative where meaning-making can occur and the individual experiences a “life worth living”). While there are two primary steps, this is much easier said than done. As mentioned, trauma is in the response, not the event. Therefore, accessing implicit (non-verbal) memories is crucial.
“You can’t treat the implicit using explicit (verbal) means. This is why ‘talk’ therapy does not fully resolve trauma. You can be fine talking about your trauma, yet still be held hostage by the implicit effects.”
Trauma-oriented therapies aim to achieve this, including Somatic Experiencing (SE), Modified Psychoanalysis, Eye Movement Desensitization and Reprocessing (EMDR), Internal Family Systems (IFS), and Compassionate Inquiry (CI). An approach developed by Dr. Hatcher at Catharsis Health is Experiential Transformation Therapy which combines techniques from the modalities above. What’s more important, however, is the ability of the therapist to remain a compassionate presence while working with you, safely holding space for the work of processing.
Lifestyle.
Sleep: Often impaired in trauma secondary to stress, intrusive thoughts, and nightmares. Establishing a sleep routine and reducing blue light exposure and stimulating activities prior to bed may be helpful. The introduction of relaxing activities to calm the nervous system such as a warm bath, scented candles, or meditative practices may also be effective.
Exercise: The goal of exercise is moderate-intensity aerobic exercise for 30 minutes five times per week. The incorporation of a mind-body modality with a breathing component helps significantly with desensitization (reducing the overactivation induced by trauma) and increases parasympathetic nervous system (rest, digest, relate) activity. Aim for familiarity in exercise techniques over novelty, and notice shifts in nervous system states during exercise. Avoid frequent high-intensity exercise as this may add to inflammation and physiologic stress.
Nutrition: A reasonable general goal is to aim for a Mediterranean diet. Reducing added sugars to <10% in individual food/drink products will help reduce unnecessary stress on the body.
Relationships: Trauma has a profound impact on relationships. The capacity to trust is shattered by traumatic experiences. Building upon interpersonal skills such as assertiveness, relationship building, connection, and boundary establishment can be effective.
Additional Options.
Psychedelic-assisted therapy (PAT) has emerged as a treatment option for those struggling with trauma syndrome. Currently, MDMA-assisted psychotherapy (MAT) is in stage 3 clinical trials for the treatment of PTSD. So far there are impressive results with nearly 70% of individuals undergoing treatment are exiting the trials no longer meeting criteria for PTSD! These promising results may ultimately translate to the availability of MDMA-assisted psychotherapy as a treatment option pending FDA clearance over the next few years. Other psychedelic-assisted treatments have been explored, but not as extensively as MDMA.
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