By: Raymond J. Kotwicki, MD, MPH, Charles B. West Chief Medical Officer
Research shows that trauma – particularly adverse childhood events (trauma that occurs before ages 5 or 6) – is very predictive of developing all mental illnesses.
When we talk about someone’s risk for mental illness, we refer to the stress-diathesis model. We know that some people have a genetic predisposition, or diathesis, for bipolar disorder, depression, schizophrenia, PTSD, or other mental illnesses; characteristics of their DNA put them at greater risk. But you can have a genetic diathesis for an illness and never develop symptoms. Research indicates that your experiences in your environment – stress, infections, toxins, etc. – influence the expression of those genes.
Research shows that trauma – particularly trauma that occurs before ages 5 or 6 – is very predictive of developing all mental illnesses.
Adverse childhood events and other traumas, when added to a genetic diathesis, increase a person’s risk for developing mental illness dramatically.
Even for those who did not experience trauma as a child, a traumatic event in adulthood – for example an assault, car crash, or combat situation – can exacerbate mood and anxiety disorders or lead to the development of PTSD.
Trauma and PTSD
A common misconception is that everyone who experiences trauma develops PTSD. While trauma may impact someone’s life significantly, it does not always lead to the development of mental illness.
Trauma can influence or worsen all mental illnesses, not just PTSD. A survivor of trauma may be diagnosed with mood disorders like depression or bipolar illness, anxiety disorders, thought disorders like schizophrenia, personality disorders, and others.
PTSD is a specific diagnosis with distinct symptoms and diagnostic criteria. In the Diagnostic and Statistical Manual of Mental Disorders (DSM5), PTSD is included in a new category called Trauma- and Stressor-Related Disorders. A diagnosis of PTSD requires that a person meet all the following criteria:
- has had exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence
- persistently re-experiences the traumatic event through memories, nightmares, flashbacks, etc.
- avoids similar situations or thoughts or feelings related to the trauma
- has low mood and/or inability to recall key features of the trauma
- has difficulty sleeping or concentrating, is hypervigilant, is irritable or aggressive, or engages in risky or destructive behaviors
- has the symptoms described above for at least one month and the symptoms create distress or functional impairment
The DSM5 broadened the diagnostic criteria for trauma-related disorders to include not just people who directly experience violence or injury, but also people who witness traumatic events, people with a close relative or family member who experienced trauma, and people who are repeatedly exposed to the details of traumatic events.
Language Matters: Your morning commute was not traumatizing
In pop culture, the words “trauma” and “PTSD” often are used inappropriately to describe a run-of-the-mill tough situation. “I was so traumatized by that conversation last week.” “I think I have PTSD after that family vacation.”
Equating a serious medical diagnosis with everyday occurrences common to the human experience is dangerous. Using language in this cavalier fashion, though not intended to cause harm, can contribute to a societal belief that you should just be able to “move on” or “get over” a trauma.
For people with mental illness, “moving on” requires psychiatric assessment and expert care from mental health professionals. Untreated mental illnesses have long-term consequences, including suicide. All of us can help deconstruct barriers to asking for help and seeking psychiatric treatment by choosing our words more carefully.
Finding the Right Treatment for Trauma
Determining the best psychiatric treatment options for someone who has experienced trauma can be challenging, even for mental health professionals.
A comprehensive diagnostic assessment can be very helpful. An assessment with a mental health professional can shed light on the larger constellation of symptoms and challenges a trauma survivor is experiencing, including mood, anxiety, substance use, or personality disorders. A thorough psychological assessment can also uncover opportunities to promote healing and recovery such as family therapy or strategies to improve sleep cycles or eating habits. A medical workup including labs may also be important to determine if there are biologic or physical reasons why someone might be having symptoms.
Research indicates that when trauma co-occurs with another mental illness, often the best course of treatment to is treat the trauma second, after first resolving the disability caused by the depression, anxiety or other illness with the goal of developing resiliency for the hard work of treating trauma.
Trauma-informed mental health care allows trauma survivors to build resiliency for the hard work of treating trauma.
Processing trauma can be difficult and painful. When beginning trauma treatment, clients often get worse before they get better.
Trauma work is more effective when survivors have the internal capacity and external support needed to fully engage and complete the treatment. It would be difficult to do that while mired in a depressive episode or while suffering from unrelenting panic attacks.
This is especially important if someone has attempted suicide, has thoughts of suicide, or is engaging in self harm or other high risk behaviors. Beginning trauma work while someone is at risk for suicide can be dangerous.
What is Trauma-Informed Psychiatric Care?
Trauma-informed mental health care allows trauma survivors to first address the symptoms of a diagnosed mental illness like depression, anxiety, or borderline personality disorder before processing their trauma.
The residential mental health treatment program at Skyland Trail offers trauma-informed care. Through evidence-based medication strategies and therapies such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) clients gradually feel more in control of their emotions, thoughts, and behaviors. They develop skills to learn how to get through uncomfortable or triggering situations without acting impulsively or harming themselves. They are able to build support networks of family and friends. And they discover healthy ways to reinforce their self-worth by participating in their communities through work, education, volunteerism, or the arts.
Throughout treatment, care providers acknowledge that the client has experienced trauma and validate the emotions arising from that experience. But the treatment team does not ask the client to describe or re-live the trauma in any way. Treatment strategies are focused on helping the client develop skills to handle difficult emotions and stressful situations in healthy ways.
Completing trauma-informed psychiatric treatment for a mood or anxiety disorder allows clients to develop insight, adopt skills, and build a strong foundation for healthy living. Clients who are trauma survivors are then better prepared and equipped to pursue formal trauma treatment with a specialized mental health provider.
Treating Trauma through Exposure with Response Prevention (ERP)
Research indicates that, in most cases, the best treatment for resolving trauma-related psychiatric issues is Exposure with Response Prevention (ERP). ERP involves “flooding” a person with the trauma. Flooding is a term used to describe repeating the traumatic experience over and over until the emotional valence of the trauma – the connection between the trauma and the person’s pain – becomes muted through repetition.
People with PTSD or trauma may avoid situations or relationships as a protective coping strategy. The goal of ERP is to empower trauma survivors to face those triggering situations and fully engage in their communities without experiencing debilitating fear or pain.
Flooding through ERP can be approached in a variety of ways. Through Imaginal Exposure, clients repeat their traumatic experience by repeatedly imagining themselves in the same situation while under the care and supervision of a mental health professional. Through In Vivo Exposure, clients visit the place where the trauma occurred and directly confront their fears and emotions with the support of their therapist or mental health care provider.
“Flooding”: repeating the traumatic experience until the emotional valence of the trauma becomes muted through repetition
New research indicates that ERP through virtual reality technology may also be effective. Clients can virtually re-experience a combat scenario, a traumatic car crash, or the place where an assault occurred without actually being back in that potentially dangerous environment. Virtual ERP is particularly useful to treat combat PTSD in veterans who should not return to the battlefield.
Prolonged exposure – engaging in Exposure Therapy with Response Prevention for an average of 8 to 15 sessions for about 90 minutes each session – has been shown to be very effective for people with PTSD.
Medications to Treat Trauma and PTSD
New research is uncovering the potential for medications to be a part of evidence-based treatment for trauma. Preliminary data suggest that giving victims of trauma certain medications immediately after the trauma may reduce the risk of developing PTSD. Some medications being studied include beta-blockers commonly used as blood pressure medications; they block the body’s biological reaction to trauma. Anti-fungal medications may impact the formation of memories after a trauma. While not a medication, some research suggests that sleep deprivation following a trauma may impact the formation of memories and may be a helpful strategy for preventing the development of PTSD. Some of these hypotheses seem to be helpful for some people; however, none of them is considered to yet be the standard of care.
Trauma clinics – often paired with service centers for sexual assault survivors or combat veterans – are starting to use these biological interventions to treat trauma and are expanding our base of knowledge for what may work best for different patients. Exposure with Response Prevention is really difficult work, and it can be hard to adhere to the full course of treatment needed to reduce symptoms and have a positive treatment response. Medications prescribed for anxiety may be helpful for people while they are going through trauma work to help them stay engaged and complete the treatment process. These are often antidepressant medications, but psychiatrists alter the dosing for people seeking to mitigate anxiety rather than depression.
Supporting a Friend or Family Member After a Trauma
First and foremost, if someone you know experiences trauma, help them find professional mental health care as soon as possible. Connecting with psychiatric care promptly may prevent the development of chronic psychiatric issues, self harm or even suicide. Not all trauma survivors will require follow-up or on-going mental health care, but an initial evaluation is important.
While showing your support is critical, be careful not to ask your friend or loved one to recount or describe the event. Instead, try to focus on the here and now. What are your loved one’s plans to stay healthy? What support structures can we put in place now to help you with specific challenges?
If you feel that they may be at risk for additional harm or trauma, for example as part of an abusive relationship, try to protect your loved one from further harm. Seek help from appropriate professionals so that you do not put yourself in danger.
If your loved one tells you that they are having thoughts of suicide or that they want to die, take them seriously. Call a crisis hotline for immediate help and help your loved one connect with appropriate mental health services.
Supporting someone through a crisis can take a toll on friends and family as well. Pay attention to your own health and mental well-being and consider seeking professional counseling if you feel you need support. Couples counseling or family counseling may be beneficial to help you learn how to better communicate and support one another.
Recovery After a Trauma
Each person’s experience with trauma is unique. The effects of trauma may be more far-reaching for some people than for others. For people diagnosed with PTSD or a trauma-related disorder, engaging in evidence-based mental health treatment, though incredibly challenging, can lead to a significant improvement in symptoms and a better quality of life. Trauma-informed care, through a residential mental health treatment program or day treatment program, may be the best next step for people with co-occurring diagnoses like major depression, anxiety disorders, schizophrenia, or borderline personality disorder.
Evidence-based psychiatric treatment for trauma and PTSD can help individuals fully engage in their communities and live full, meaningful lives.