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Psychological trauma, mental trauma or psychotrauma is an
emotional response Emotions are mental states brought on by neurophysiological changes, variously associated with thoughts, feelings, behavioral responses, and a degree of pleasure or displeasure. There is currently no scientific consensus on a definition. ...
to a distressing event or series of events, such as
accident An accident is an unintended, normally unwanted event that was not directly caused by humans. The term ''accident'' implies that nobody should be blamed, but the event may have been caused by unrecognized or unaddressed risks. Most researche ...
s,
rape Rape is a type of sexual assault usually involving sexual intercourse or other forms of sexual penetration carried out against a person without their consent. The act may be carried out by physical force, coercion, abuse of authority, or ...
, or
natural disaster A natural disaster is "the negative impact following an actual occurrence of natural hazard in the event that it significantly harms a community". A natural disaster can cause loss of life or damage property, and typically leaves some econ ...
s. Reactions such as psychological shock and psychological denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, difficulties with
interpersonal relationships The concept of interpersonal relationship involves social associations, connections, or affiliations between two or more people. Interpersonal relationships vary in their degree of intimacy or self-disclosure, but also in their duration, in t ...
and sometimes physical symptoms including
headaches Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resu ...
or
nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of th ...
. Trauma is not the same as mental distress or
suffering Suffering, or pain in a broad sense, may be an experience of unpleasantness or aversion, possibly associated with the perception of harm or threat of harm in an individual. Suffering is the basic element that makes up the negative valence of a ...
, both of which are universal human experiences. Given that
subjective experience In philosophy of mind, qualia ( or ; singular form: quale) are defined as individual instances of subjective, conscious experience. The term ''qualia'' derives from the Latin neuter plural form (''qualia'') of the Latin adjective '' quālis'' ...
s 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 traumatized (although they may be distressed and experience suffering). Some people will develop
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats o ...
(PTSD) after being exposed to a major traumatic event (or series of events). This discrepancy in risk rate can be attributed to protective factors some individuals may have that enable them to cope with difficult events, including temperamental and environmental factors (such as
resilience Resilience, resilient, resiliency, or ''variation'', may refer to: Science Ecology * Ecological resilience, the capacity of an ecosystem to recover from perturbations ** Climate resilience, the ability of systems to recover from climate change * ...
and willingness to seek help).


Signs and symptoms

People who go through extremely traumatizing experiences often have problems and difficulties afterwards. The severity of these symptoms depends on the person, the types of trauma involved, and the emotional support they receive from others. The range of reactions to trauma can be wide and varied, and differ in severity from person to person. 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 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 trauma ...
. These can produce uncomfortable and even painful feelings. Re-experiencing can damage people's sense of safety, self,
self-efficacy In psychology, self-efficacy is an individual's belief in their capacity to act in the ways necessary to reach specific goals. The concept was originally proposed by the psychologist Albert Bandura. Self-efficacy affects every area of human end ...
, as well as their ability to regulate emotions and navigate relationships. They may turn to
psychoactive substances A psychoactive drug, psychopharmaceutical, psychoactive agent or psychotropic drug is a chemical substance, that changes functions of the nervous system, and results in alterations in perception, mood, consciousness, cognition or behavior. Th ...
including
alcohol Alcohol most commonly refers to: * Alcohol (chemistry), an organic compound in which a hydroxyl group is bound to a carbon atom * Alcohol (drug), an intoxicant found in alcoholic drinks Alcohol may also refer to: Chemicals * Ethanol, one of sev ...
to try to escape or dampen the feelings. 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 Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and other associated emotions. Often the person can be completely unaware of what these triggers are. In many cases, this may lead a person with a traumatic disorder 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 attack Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, sweating, chest pain or chest discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a feeling of impending doom or of losing ...
s 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
nightmare A nightmare, also known as a bad dream, Retrieved 11 July 2016. is an unpleasant dream that can cause a strong emotional response from the mind, typically fear but also despair, anxiety or great sadness. The dream may contain situations of ...
s may be frequent.
Insomnia Insomnia, also known as sleeplessness, is a sleep disorder in which people have trouble sleeping. They may have difficulty falling asleep, or staying asleep as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, ...
may occur as lurking fears and insecurity keep the person vigilant and on the lookout for danger, both day and night. A messy personal financial scene, as well as debt, are common features in trauma-affected people. Trauma doesn't only cause changes in one's daily functions, but could also lead to morphological changes. Such epigenetic changes can be passed on to the next generation, thus making genetics one of the components of psychological trauma. However, some people are born with or later develop protective factors such as genetics that help lower their risk 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 Repressed memory is an inability to recall autobiographical information, usually of a traumatic or stressful nature. The concept originated in psychoanalytic theory where repression is defined as a protective mechanism that excludes memory of ...
). 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 Somatization disorder is a mental and behavioral disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms. It was recognized in the DSM-IV-TR classification system, but in the latest ve ...
,
conversion disorder Conversion disorder (CD), or functional neurologic symptom disorder, is a diagnostic category used in some psychiatric classification systems. It is sometimes applied to patients who present with neurological symptoms, such as numbness, blindnes ...
s,
brief psychotic disorder Brief psychotic disorder ⁠— according to the classifications of mental disorders DSM-IV-TR and DSM-5 ⁠— is a psychotic condition involving the sudden onset of at least one psychotic symptom (such as disorganized thought/speech, delusions ...
,
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
, adjustment disorder, etc. Obsessive- compulsive disorder is another mental health disorder with symptoms similar to that of psychological trauma, such as hyper-vigilance and intrusive thoughts. Research has indicated that individuals who have experienced a traumatic event have been known to use symptoms of obsessive- compulsive disorder, such as compulsive checking of safety, as a way to mitigate the symptoms associated with trauma. In time, emotional exhaustion may set in, leading to distraction, and clear thinking may be difficult or impossible.
Emotional detachment In psychology, emotional detachment, also known as emotional blunting, is a condition or state in which a person lacks emotional connectivity to others, whether due to an unwanted circumstance or as a positive means to cope with anxiety. Such a ...
, 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. This is significant in brain scan studies done regarding higher-order function assessment with children and youth who were in vulnerable environments. Some traumatized 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 Self-esteem is confidence in one's own worth or abilities. Self-esteem encompasses beliefs about oneself (for example, "I am loved", "I am worthy") as well as emotional states, such as triumph, despair, pride, and shame. Smith and Mackie (2007) d ...
, 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. Often despite their best efforts, traumatized parents may have difficulty assisting their child with emotion regulation, attribution of meaning, and containment of post-traumatic fear in the wake of the child's traumatization, leading to adverse consequences for the child. In such instances, seeking counselling in appropriate mental health services is in the best interests of both the child and the parent(s).


Causes


Situational trauma

Trauma can be caused by human-made, technological and natural disasters, including war, abuse, violence, mechanized accidents (such as vehicle accidents), or medical emergencies. An individual's response to psychological trauma can be varied based on the type of trauma, as well as socio-demographic and background factors. There are several behavioral responses commonly used towards stressors including the proactive, reactive, and passive responses. Proactive responses include attempts to address and correct a stressor before it has a noticeable effect on lifestyle. Reactive responses occur after the stress and possible trauma has occurred and is aimed more at correcting or minimizing the damage of a stressful event. A passive response is often characterized by an emotional numbness or ignorance of a stressor. Those who are able to be proactive can often overcome stressors and are more likely to be able to cope well with unexpected situations. On the other hand, those who are more reactive will often experience more noticeable effects from an unexpected stressor. In the case of those who are passive, victims of a stressful event are more likely to develop long-term traumatic effects and often enact no intentional coping actions. These observations may suggest that the level of trauma associated with a victim is related to independent coping abilities like spending excessively on alcohol, food, tobacco and shopping sprees. It may be caused by impairments in the brain from trauma. There is also a distinction between trauma induced by recent situations and long-term trauma which may have been buried in the unconscious from past situations such as
childhood abuse Child abuse (also called child endangerment or child maltreatment) is physical, sexual, and/or psychological maltreatment or neglect of a child or children, especially by a parent or a caregiver. Child abuse may include any act or failure to a ...
. Trauma is sometimes overcome through healing; in some cases this can be achieved by recreating or revisiting the origin of the trauma under more psychologically safe circumstances, such as with a
therapist Therapist is a person who offers any kinds of therapy A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis. As a rule, each therapy has indi ...
. More recently, awareness of the consequences of climate change is seen as a source of trauma as individuals contemplate future events as well as experience climate change related disasters. Emotional experiences within these contexts are increasing, and collective processing and engagement with these emotions can lead to increased resilience and post traumatic growth, as well as a greater sense of belongingness. These outcomes are protective against the devastating impacts of psychological trauma.


In psychodynamics

Psychodynamic Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...
viewpoints are controversial, but have been shown to have utility therapeutically. French neurologist,
Jean-Martin Charcot Jean-Martin Charcot (; 29 November 1825 – 16 August 1893) was a French neurologist and professor of anatomical pathology. He worked on hypnosis and hysteria, in particular with his hysteria patient Louise Augustine Gleizes. Charcot is know ...
, argued in the 1890s that psychological trauma was the origin of all instances of the mental illness known as
hysteria Hysteria is a term used colloquially to mean ungovernable emotional excess and can refer to a temporary state of mind or emotion. In the nineteenth century, hysteria was considered a diagnosable physical illness in women. It is assumed that ...
. Charcot's "traumatic hysteria" often manifested as paralysis that followed a physical trauma, typically years later after what Charcot described as a period of "incubation".
Sigmund Freud Sigmund Freud ( , ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating pathologies explained as originating in conflicts i ...
, Charcot's student and the father of
psychoanalysis PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might ...
, examined the concept of psychological trauma throughout his career.
Jean Laplanche Jean Laplanche (; 21 June 1924 – 6 May 2012) was a French author, psychoanalyst and winemaker. Laplanche is best known for his work on psychosexual development and Sigmund Freud's seduction theory, and wrote more than a dozen books on p ...
has given a general description of Freud's understanding of trauma, which varied significantly over the course of Freud's career: "An event in the subject's life, defined by its intensity, by the subject's incapacity to respond adequately to it and by the upheaval and long-lasting effects that it brings about in the psychical organization". The French psychoanalyst
Jacques Lacan Jacques Marie Émile Lacan (, , ; 13 April 1901 – 9 September 1981) was a French psychoanalyst and psychiatrist. Described as "the most controversial psycho-analyst since Freud", Lacan gave yearly seminars in Paris from 1953 to 1981, and ...
claimed that what he called "
The Real In continental philosophy, the Real refers to the remainder of reality that cannot be expressed, and which surpasses reasoning. In Lacanianism, it is an "impossible" category because of its opposition to expression and inconceivability. I ...
" had a traumatic quality external to symbolization. As an object of anxiety, Lacan maintained that The Real is "the essential object which isn't an object any longer, but this something faced with which all words cease and all categories fail, the object of anxiety ''par excellence''".Lacan, J., ''The Seminar of Jacques Lacan: Book II: The Ego in Freud's Theory and in the Technique of Psychoanalysis 1954–1955'' , p.164 (W. W. Norton & Company, 1991), Fred Alford, citing the work of
object relations Object relations theory is a school of thought in psychoanalytic theory centered around theories of stages of ego development. Its concerns include the relation of the psyche to others in childhood and the exploration of relationships between ...
theorist Donald Winnicott, uses the concept of inner other, and internal representation of the social world, with which one converses internally and which is generated through interactions with others. He posits that the inner other is damaged by trauma but can be repaired by conversations with others such as therapists. He relates the concept of the inner other to the work of
Albert Camus Albert Camus ( , ; ; 7 November 1913 – 4 January 1960) was a French philosopher, author, dramatist, and journalist. He was awarded the 1957 Nobel Prize in Literature at the age of 44, the second-youngest recipient in history. His work ...
viewing the inner other as that which removes the absurd. Alford notes how trauma damages trust in social relations due to fear of exploitation and argues that culture and social relations can help people recover from trauma.
Diana Fosha Diana Foșha is a Romanian-American psychologist, known for developing accelerated experiential dynamic psychotherapy (AEDP), and for her work on the psychotherapy of adults suffering the effects of childhood attachment trauma and abuse. Educ ...
, a pioneer of modern psychodynamic perspective, also argues that social relations can help people recover from trauma, but specifically refers to attachment theory and the attachment dynamic of the therapeutic relationship. Fosha argues that the sense of emotional safety and co-regulation that occurs in a psychodynamically oriented therapeutic relationship acts as the secure attachment that is necessary to allow a client to experience and process through their trauma safely and effectively.


Stress disorders

All psychological traumas originate from stress, a physiological response to an unpleasant stimulus. Long-term stress increases the risk of poor mental health and mental disorders, which can be attributed to secretion of glucocorticoids for a long period of time. Such prolonged exposure causes many physiological dysfunctions such as the suppression of the immune system and increase in blood pressure. Not only does it affect the body physiologically, but a morphological change in the hippocampus also takes place. Studies showed that extreme stress early in life can disrupt normal development of hippocampus and impact its functions in adulthood. Studies surely show a correlation between the size of hippocampus and one's susceptibility to stress disorders. In times of war, psychological trauma has been known as shell shock or
combat stress reaction Combat stress reaction (CSR) is acute behavioral disorganization as a direct result of the trauma of war. Also known as "combat fatigue", "battle fatigue", or "battle neurosis", it has some overlap with the diagnosis of acute stress reaction used ...
. Psychological trauma may cause an acute stress reaction which may lead to posttraumatic stress disorder (PTSD). PTSD emerged as the label for this condition after the
Vietnam War The Vietnam War (also known by #Names, other names) was a conflict in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. It was the second of the Indochina Wars and was officially fought between North Vie ...
in which many veterans returned to their respective countries demoralized, and sometimes, addicted to psychoactive substances. The symptoms of PTSD must persist for at least one month for diagnosis to be made. The main symptoms of PTSD consist of four main categories: trauma (i.e. intense fear), reliving (i.e. flashbacks), avoidance behavior (i.e. emotional numbing), and hypervigilance (i.e. continuous scanning of the environment for danger). Research shows that about 60% of the US population reported as having experienced at least one traumatic symptom in their lives, but only a small proportion actually develops PTSD. There is a correlation between the risk of PTSD and whether or not the act was inflicted deliberately by the offender. Psychological trauma is treated with therapy and, if indicated, psychotropic medications. The term ''continuous posttraumatic stress disorder'' (CTSD) was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire, and emergency services. As one of the processes of treatment, confrontation with their sources of trauma plays a crucial role. While debriefing people immediately after a critical incident has not been shown to reduce incidence of PTSD, coming alongside people experiencing trauma in a supportive way has become standard practice.


Moral injury

Moral injury A moral injury is an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression on the part of themselves or others, which produces profound feelings of guilt or shame—and in some cases a profou ...
is distress such as guilt or shame following a moral transgression. There are many other definitions some based on different models of causality. Moral injury is associated with
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats o ...
but is distinguished from it. Moral injury is associated with
guilt Guilt may refer to: *Guilt (emotion), an emotion that occurs when a person feels that they have violated a moral standard *Culpability, a legal term *Guilt (law), a legal term Music * ''Guilt'' (album), a 2009 album by Mims * "Guilt" (The Long Bl ...
and
shame Shame is an unpleasant self-conscious emotion often associated with negative self-evaluation; motivation to quit; and feelings of pain, exposure, distrust, powerlessness, and worthlessness. Definition Shame is a discrete, basic emotion, d ...
while PTSD is correlated with
fear Fear is an intensely unpleasant emotion in response to perceiving or recognizing a danger or threat. Fear causes physiological changes that may produce behavioral reactions such as mounting an aggressive response or fleeing the threat. Fear ...
and
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
.


Vicarious trauma

Vicarious trauma Vicarious trauma (VT) was a term invented by McCann and Pearlman that is used to describe how working with traumatized clients affects trauma therapists. Previously, the phenomenon was referred to as secondary traumatic stress coined by Dr. Charle ...
affects workers who witness their clients' trauma. It is more likely to occur in situations where trauma related work is the norm rather than the exception. Listening with empathy to the clients generates feeling, and seeing oneself in clients' trauma may compound the risk for developing trauma symptoms. Trauma may also result if workers witness situations that happen in the course of their work (e.g. violence in the workplace, reviewing violent video tapes.) Risk increases with exposure and with the absence of help seeking protective factors and pre-preparation of preventive strategies. Individuals who have a personal history of trauma are also at increased risk for developing vicarious trauma. Vicarious trauma can lead workers to develop more negative views of themselves, others, and the world as a whole, which can compromise their quality of life and ability to work effectively.


Diagnosis

As "trauma" adopted a more widely defined scope, traumatology as a field developed a more interdisciplinary approach. This is in part due to the field's diverse professional representation including: psychologists, medical professionals, and lawyers. As a result, findings in this field are adapted for various applications, from individual psychiatric treatments to sociological large-scale trauma management. While the field has adopted a number of diverse methodological approaches, many pose their own limitations in practical application. The experience and outcomes of psychological trauma can be assessed in a number of ways. Within the context of a clinical interview, the risk of imminent danger to the self or others is important to address but is not the focus of assessment. In most cases, it will not be necessary to involve contacting emergency services (e.g., medical, psychiatric, law enforcement) to ensure the individuals safety; members of the individual's
social support Social support is the perception and actuality that one is cared for, has assistance available from other people, and most popularly, that one is part of a supportive social network. These supportive resources can be emotional (e.g., nurturance), ...
network are much more critical. Understanding and accepting the psychological state of an individual is paramount. There are many misconceptions of what it means for a traumatized individual to be in psychological crisis. These are times when an individual is in inordinate amounts of pain and incapable of self-comfort. If treated humanely and respectfully the individual is less likely to resort to self harm. In these situations it is best to provide a supportive, caring environment and to communicate to the individual that no matter the circumstance, the individual will be taken seriously rather than being treated as delusional. It is vital for the assessor to understand that what is going on in the traumatized person's head is valid and real. If deemed appropriate, the assessing clinician may proceed by inquiring about both the traumatic event and the outcomes experienced (e.g., post-traumatic symptoms, dissociation,
substance abuse Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods which are harmful to the individual or others. It is a form of substance-related disorder. Differing definitions of drug abuse are used in public health, ...
, somatic symptoms, psychotic reactions). Such inquiry occurs within the context of established
rapport Rapport () is a close and harmonious relationship in which the people or groups concerned are "in sync" with each other, understand each other's feelings or ideas, and communicate smoothly. The word stems from the French verb which means litera ...
and is completed in an empathic, sensitive, and supportive manner. The clinician may also inquire about possible relational disturbance, such as alertness to interpersonal danger,
abandonment issues Emotional abandonment is a subjective emotional state in which people feel undesired, left behind, insecure, or discarded. People experiencing emotional abandonment may feel at a loss. They may feel like they have been cut off from a crucial so ...
, and the need for self-protection via interpersonal control. Through discussion of interpersonal relationships, the clinician is better able to assess the individual's ability to enter and sustain a clinical relationship. During assessment, individuals may exhibit activation responses in which reminders of the traumatic event trigger sudden feelings (e.g., distress, anxiety,
anger Anger, also known as wrath or rage, is an intense emotional state involving a strong uncomfortable and non-cooperative response to a perceived provocation, hurt or threat. A person experiencing anger will often experience physical effects, su ...
), memories, or thoughts relating to the event. Because individuals may not yet be capable of managing this distress, it is necessary to determine how the event can be discussed in such a way that will not "retraumatize" the individual. It is also important to take note of such responses, as these responses may aid the clinician in determining the intensity and severity of possible post traumatic stress as well as the ease with which responses are triggered. Further, it is important to note the presence of possible avoidance responses. Avoidance responses may involve the absence of expected activation or emotional reactivity as well as the use of avoidance mechanisms (e.g., substance use, effortful avoidance of cues associated with the event, dissociation). In addition to monitoring activation and avoidance responses, clinicians carefully observe the individual's strengths or difficulties with affect regulation (i.e., affect tolerance and affect modulation). Such difficulties may be evidenced by mood swings, brief yet intense depressive episodes, or
self-mutilation Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilati ...
. The information gathered through observation of affect regulation will guide the clinician's decisions regarding the individual's readiness to partake in various therapeutic activities. Though assessment of psychological trauma may be conducted in an unstructured manner, assessment may also involve the use of a structured interview. Such interviews might include the Clinician-Administered PTSD Scale, Acute Stress Disorder Interview, Structured Interview for Disorders of Extreme Stress, Structured Clinical Interview for DSM-IV Dissociative Disorders - Revised, and Brief Interview for post-traumatic Disorders. Lastly, assessment of psychological trauma might include the use of self-administered psychological tests. Individual scores on such tests are compared to normative data in order to determine how the individual's level of functioning compares to others in a sample representative of the general population. Psychological testing might include the use of generic tests (e.g.,
MMPI-2 The Minnesota Multiphasic Personality Inventory (MMPI) is a standardized psychometric test of adult personality and psychopathology. Psychologists and other mental health professionals use various versions of the MMPI to help develop treatment p ...
, MCMI-III, SCL-90-R) to assess non-trauma-specific symptoms as well as difficulties related to personality. In addition, psychological testing might include the use of trauma-specific tests to assess post-traumatic outcomes. Such tests might include the post-traumatic Stress Diagnostic Scale, Davidson Trauma Scale, Detailed Assessment of post-traumatic Stress, Trauma Symptom Inventory, Trauma Symptom Checklist for Children, Traumatic Life Events Questionnaire, and Trauma-related Guilt Inventory. Children are assessed through activities and therapeutic relationship, some of the activities are play genogram, sand worlds, coloring feelings, self and kinetic family drawing, symbol work, dramatic-puppet play, story telling, Briere's TSCC, etc.


Definition

The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5) defines trauma as the symptoms that occur following exposure to an event (i.e., traumatic event) that involves actual or threatened death, serious injury, or sexual violence. This exposure could come in the form of experiencing the event, witnessing the event, or learning that the event was experienced by a family member or close associate. Trauma symptoms may come in the form of intrusive memories, dreams, or flashbacks; avoidance of reminders of the traumatic event; negative thoughts and feelings; or increased alertness or reactivity. Memories associated with trauma are typically explicit, coherent, and difficult to forget. Due to the complexity of the interaction between traumatic event occurrence and trauma symptomatology, a person's distress response to aversive details of a traumatic event may involve intense fear or helplessness but ranges according to the context. In children, trauma symptoms can be manifested in the form of disorganized or agitative behaviors. Trauma can be caused by a wide variety of events, but there are a few common aspects. There is frequently a violation of the person's core assumptions about the world and their
human rights Human rights are moral principles or normsJames Nickel, with assistance from Thomas Pogge, M.B.E. Smith, and Leif Wenar, 13 December 2013, Stanford Encyclopedia of PhilosophyHuman Rights Retrieved 14 August 2014 for certain standards of hu ...
, putting the person in a state of extreme
confusion In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion"
and insecurity. This is seen when institutions depended upon for survival violate, humiliate,
betray Betrayal is the breaking or violation of a presumptive contract, trust, or confidence that produces moral and psychological conflict within a relationship amongst individuals, between organizations or between individuals and organizations. Oft ...
, or cause major losses or separations instead of evoking aspects like positive self worth, safe boundaries and personal freedom. Psychologically traumatic experiences often involve
physical trauma An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or ...
that threatens one's survival and sense of security. Typical causes and dangers of psychological trauma include
harassment Harassment covers a wide range of behaviors of offensive nature. It is commonly understood as behavior that demeans, humiliates or embarrasses a person, and it is characteristically identified by its unlikelihood in terms of social and moral ...
,
embarrassment Embarrassment or awkwardness is an emotional state that is associated with mild to severe levels of discomfort, and which is usually experienced when someone commits (or thinks of) a socially unacceptable or frowned-upon act that is witnessed ...
, abandonment, abusive relationships, rejection, co-dependence, physical assault,
sexual abuse Sexual abuse or sex abuse, also referred to as molestation, is abusive sexual behavior by one person upon another. It is often perpetrated using force or by taking advantage of another. Molestation often refers to an instance of sexual assa ...
, partner battery,
employment discrimination Employment discrimination is a form of illegal discrimination in the workplace based on legally protected characteristics. In the U.S., federal anti-discrimination law prohibits discrimination by employers against employees based on age, race, ...
,
police brutality Police brutality is the excessive and unwarranted use of force by law enforcement against an individual or a group. It is an extreme form of police misconduct and is a civil rights violation. Police brutality includes, but is not limited to ...
, judicial corruption and
misconduct Misconduct is wrongful, improper, or unlawful conduct motivated by premeditated or intentional purpose or by obstinate indifference to the consequences of one's acts. It is an act which is forbidden or a failure to do that which is required. Misc ...
,
bullying Bullying is the use of force, coercion, hurtful teasing or threat, to abuse, aggressively dominate or intimidate. The behavior is often repeated and habitual. One essential prerequisite is the perception (by the bully or by others) of an ...
,
paternalism Paternalism is action that limits a person's or group's liberty or autonomy and is intended to promote their own good. Paternalism can also imply that the behavior is against or regardless of the will of a person, or also that the behavior expres ...
,
domestic violence Domestic violence (also known as domestic abuse or family violence) is violence or other abuse that occurs in a domestic setting, such as in a marriage or cohabitation. ''Domestic violence'' is often used as a synonym for '' intimate partn ...
,
indoctrination Indoctrination is the process of inculcating a person with ideas, attitudes, cognitive strategies or professional methodologies (see doctrine). Humans are a social animal species inescapably shaped by cultural context, and thus some degree ...
, being the victim of an
alcoholic Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomina ...
parent, the threat or the witnessing of violence (particularly in
childhood A child (plural, : children) is a human being between the stages of childbirth, birth and puberty, or between the Development of the human body, developmental period of infancy and puberty. The legal definition of ''child'' generally refers ...
), life-threatening
medical condition A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
s, and medication-induced trauma. Catastrophic
natural disaster A natural disaster is "the negative impact following an actual occurrence of natural hazard in the event that it significantly harms a community". A natural disaster can cause loss of life or damage property, and typically leaves some econ ...
s such as
earthquake An earthquake (also known as a quake, tremor or temblor) is the shaking of the surface of the Earth resulting from a sudden release of energy in the Earth's lithosphere that creates seismic waves. Earthquakes can range in intensity, fr ...
s and
volcanic eruption Several types of volcanic eruptions—during which lava, tephra (ash, lapilli, volcanic bombs and volcanic blocks), and assorted gases are expelled from a volcanic vent or fissure—have been distinguished by volcanologists. These are oft ...
s, large scale transportation accidents, house or domestic fire, motor vehicle accident, mass interpersonal violence like
war War is an intense armed conflict between states, governments, societies, or paramilitary groups such as mercenaries, insurgents, and militias. It is generally characterized by extreme violence, destruction, and mortality, using regular o ...
,
terrorist attack Terrorism, in its broadest sense, is the use of criminal violence to provoke a state of terror or fear, mostly with the intention to achieve political or religious aims. The term is used in this regard primarily to refer to intentional violen ...
s or other mass victimization like
sex trafficking Sex trafficking is human trafficking for the purpose of sexual exploitation. It has been called a form of modern slavery because of the way victims are forced into sexual acts non-consensually, in a form of sexual slavery. Perpetrators of the ...
, being taken as a hostage or being
kidnapped Kidnapped may refer to: * subject to the crime of kidnapping Literature * ''Kidnapped'' (novel), an 1886 novel by Robert Louis Stevenson * ''Kidnapped'' (comics), a 2007 graphic novel adaptation of R. L. Stevenson's novel by Alan Grant and Cam ...
can also cause psychological trauma. Long-term exposure to situations such as extreme
poverty Poverty is the state of having few material possessions or little income. Poverty can have diverse
or other forms of
abuse Abuse is the improper usage or treatment of a thing, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, assault, violation, rape, unjust practices, crimes, or other t ...
, such as
verbal abuse Verbal abuse (also known as verbal aggression, verbal attack, verbal violence, verbal assault, psychic aggression, or psychic violence) is a type of psychological/mental abuse that involves the use of oral, gestured, and written language direct ...
, exist independently of physical trauma but still generate psychological trauma. Some theories suggest
childhood trauma Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, ...
can increase one's risk for
mental disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
s including
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats o ...
(
PTSD Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
), depression, and substance abuse. Childhood adversity is associated with
neuroticism In the study of psychology, neuroticism has been considered a fundamental personality trait. For example, in the Big Five approach to personality trait theory, individuals with high scores for neuroticism are more likely than average to be moody ...
during adulthood. Parts of the brain in a growing child are developing in a sequential and hierarchical order, from least complex to most complex. The brain's neurons change in response to the constant external signals and stimulation, receiving and storing new information. This allows the brain to continually respond to its surroundings and promote survival. The five traditional signals (sight, hearing, taste, smell, and touch) contribute to the developing brain structure and its function. Infants and children begin to create internal representations of their external environment, and in particular, key attachment relationships, shortly after birth. Violent and
victimizing Victimisation ( or victimization) is the process of being victimised or becoming a victim. The field that studies the process, rates, incidence, effects, and prevalence of victimisation is called victimology. Peer victimisation Peer victimisati ...
attachment figures impact infants' and young children's internal representations. The more frequently a specific pattern of brain neurons is activated, the more permanent the internal representation associated with the pattern becomes. This causes
sensitization Sensitization is a non-associative learning process in which repeated administration of a stimulus results in the progressive amplification of a response. Sensitization often is characterized by an enhancement of response to a whole class of sti ...
in the brain towards the specific neural network. Because of this sensitization, the neural pattern can be activated by decreasingly less external stimuli. Childhood abuse tends to have the most complications with long-term effects out of all forms of trauma because it occurs during the most sensitive and critical stages of psychological development. It could also lead to violent behavior, possibly as extreme as serial murder. For example, Hickey's Trauma-Control Model suggests that "
childhood trauma Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, ...
for serial murderers may serve as a triggering mechanism resulting in an individual's inability to cope with the stress of certain events." Often
psychodynamic Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...
aspects of trauma are overlooked even by health professionals: "If clinicians fail to look through a trauma lens and to conceptualize client problems as related possibly to current or past trauma, they may fail to see that trauma victims, young and old, organize much of their lives around repetitive patterns of reliving and warding off traumatic memories, reminders, and affects."


Treatment

A number of psychotherapy approaches have been designed with the treatment of trauma in mind— EMDR, progressive counting (PC),
somatic experiencing Somatic experiencing (SE) is a form of alternative therapy aimed at treating trauma and stressor-related disorders like PTSD. The primary goal of SE is to modify the trauma-related stress response through bottom-up processing. The Clients’ ...
,
biofeedback Biofeedback is the process of gaining greater awareness of many physiological functions of one's own body by using electronic or other instruments, and with a goal of being able to manipulate the body's systems at will. Humans conduct biofeed ...
, Internal Family Systems Therapy, and sensorimotor psychotherapy, and
Emotional Freedom Technique Emotional Freedom Techniques (EFT) is a form of counseling intervention that stimulates acupressure points by pressuring, tapping, or rubbing these points while focusing on situations that represent personal fear or traumata. EFT draws on var ...
(EFT) etc. There is a large body of empirical support for the use of
cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
for the treatment of trauma-related symptoms, including
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats o ...
.
Institute of Medicine The National Academy of Medicine (NAM), formerly called the Institute of Medicine (IoM) until 2015, is an American nonprofit, non-governmental organization. The National Academy of Medicine is a part of the National Academies of Sciences, Eng ...
guidelines identify cognitive behavioral therapies as the most effective treatments for PTSD. Two of these cognitive behavioral therapies, prolonged exposure and
cognitive processing therapy Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the ...
, are being disseminated nationally by the Department of Veterans Affairs for the treatment of PTSD. A 2010 Cochrane review found that trauma-focused cognitive behavioral therapy was effective for individuals with acute traumatic stress symptoms when compared to waiting list and supportive counseling. Seeking Safety is another type of cognitive behavioral therapy that focuses on learning safe coping skills for co-occurring PTSD and substance use problems. While some sources highlight Seeking Safety as effective with strong research support, others have suggested that it did not lead to improvements beyond usual treatment. Recent studies show that a combination of treatments involving dialectical behavior therapy (DBT), often used for borderline personality disorder, and
exposure therapy Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger (desensitization). Doing so is thou ...
is highly effective in treating psychological trauma. If, however, psychological trauma has caused
dissociative disorders Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily. The in ...
or
complex PTSD Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that is theorized to develop in response to exposure to a series of traumatic events in a context in which the individual perceive ...
, the trauma model approach (also known as phase-oriented treatment of structural dissociation) has been proven to work better than the simple cognitive approach. Studies funded by pharmaceuticals have also shown that medications such as the new anti-depressants are effective when used in combination with other psychological approaches. At present, the selective
serotonin Serotonin () or 5-hydroxytryptamine (5-HT) is a monoamine neurotransmitter. Its biological function is complex and multifaceted, modulating mood, cognition, reward, learning, memory, and numerous physiological processes such as vomiting and va ...
reuptake inhibitor (SSRI) antidepressants sertraline (Zoloft) and paroxetine (Paxil) are the only medications that have been approved by the Food and Drug Administration (FDA) in the United States to treat PTSD. Other options for pharmacotherapy include serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants and anti-psychotic medications, though none have been FDA approved. Trauma therapy allows processing trauma-related memories and allows growth towards more adaptive psychological functioning. It helps to develop positive coping instead of negative coping and allows the individual to integrate upsetting-distressing material (thoughts, feelings and memories) and to resolve these internally. It also aids in the growth of personal skills like resilience, ego regulation, empathy, etc. Processes involved in trauma therapy are: * Psychoeducation: Information dissemination and educating in vulnerabilities and adoptable coping mechanisms. * Emotional regulation: Identifying, countering discriminating, grounding thoughts and emotions from internal construction to an external representation. * Cognitive processing: Transforming negative perceptions and beliefs about self, others and environment to positive ones through cognitive reconsideration or re-framing. * Trauma processing: Systematic desensitization, response activation and counter-conditioning, titrated extinction of emotional response, deconstructing disparity (emotional vs. reality state), resolution of traumatic material (in theory, to a state in which triggers no longer produce harmful distress and the individual is able to express relief.) * Emotional processing: Reconstructing perceptions, beliefs and erroneous expectations, habituating new life contexts for auto-activated trauma-related fears, and providing crisis cards with coded emotions and appropriate cognition. (This stage is only initiated in pre-termination phase from clinical assessment and judgement of the mental health professional.) *
Experiential Experience refers to conscious events in general, more specifically to perceptions, or to the practical knowledge and familiarity that is produced by these conscious processes. Understood as a conscious event in the widest sense, experience invol ...
processing: Visualization of achieved relief state and relaxation methods. A number of complementary approaches to trauma treatment have been implicated as well, including yoga and meditation. There has been recent interest in developing
trauma-sensitive yoga Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological ...
practices, but the actual efficacy of yoga in reducing the effects of trauma needs more exploration. In health and social care settings, a trauma informed approach means that care is underpinned by understandings of trauma and its far-reaching implications. Trauma is widespread. For example, 26% of participants in the
Adverse Childhood Experiences Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood. The harms of ACEs can be long-lasting, affecting people even in their adulthood. ACEs have be ...
(ACEs) study were survivors of one ACE and 12.5% were survivors of four or more ACEs. A trauma-informed approach acknowledges the high rates of trauma and means that care providers treat every person as if they might be a survivor of trauma. Measurement of the effectiveness of a universal trauma informed approach is in early stages and is largely based in theory and epidemiology. Trauma informed teaching practice is an educative approach for migrant children from war-torn countries, who have typically experienced complex trauma, and the number of such children entering Canadian schools has led some school jurisdictions to consider new classroom approaches to assist these pupils. Along with complex trauma, these students often have experienced interrupted schooling due to the migration process, and as a consequence may have limited literacy skills in their first language. One study of a Canadian secondary school classroom, as told through journal entries of a student teacher, showed how Blaustein and Kinniburgh's ARC (attachment, regulation and competency) framework was used to support newly arrived refugee students from war zones. Tweedie et al. (2017) describe how key components of the ARC framework, such as establishing consistency in classroom routines; assisting students to identify and self-regulate emotional responses; and enabling student personal goal achievement, are practically applied in one classroom where students have experienced complex trauma. The authors encourage teachers and schools to avoid a deficit lens to view such pupils, and suggest ways schools can structure teaching and learning environments which take into account the extreme stresses these students have encountered.


Society and culture

Some people, and many self-help books, use the word ''trauma'' broadly, to refer to any unpleasant experience, even if the affected person has a psychologically healthy response to the experience. This imprecise language may promote the
medicalization Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Medicalization can be driven by new evid ...
of normal human behaviors (e.g.,
grief Grief is the response to loss, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed. Although conventionally focused on the emotional response to loss, grief also has physical, cogniti ...
after a death) and make discussions of psychological trauma more complex, but it might also encourage people to respond with
compassion Compassion motivates people to go out of their way to relieve the physical, mental or emotional pains of others and themselves. Compassion is often regarded as being sensitive to the emotional aspects of the suffering of others. When based on n ...
to the distress and suffering of others.


See also


References


Further reading

* * * * * * * * *


External links

*
The International Society for Traumatic Stress Studies (ISTSS)

Trauma-Focused Cognitive Behavioral Therapy – Medical University of South Carolina

National Child Traumatic Stress Network (NCTSN)

Trauma Information Pages
{{Authority control Psychological stress Abuse Bullying Counseling Anxiety disorders Post-traumatic stress disorder Victimology Trauma types Adverse childhood experiences