Excerpts from David Baldwin's Trauma Pages http://www.trauma-pages.com/trauma.php
Traumatic experiences shake the foundations of our beliefs about safety, and shatter our assumptions of trust.
Because they are so far outside what we would expect, these events provoke reactions that feel strange and "crazy". Perhaps the most helpful thing I can say here is that even though these reactions are unusual and disturbing, they are typical and expectable. By and large, these are normal responses to abnormal events.
Trauma symptoms are probably adaptive, and originally evolved to help us recognize and avoid other dangerous situations quickly -- before it was too late. Sometimes these symptoms resolve within a few days or weeks of a disturbing experience: Not everyone who experiences a traumatic event will develop PTSD. It is when many symptoms persist for weeks or months, or when they are extreme, that professional help may be indicated. On the other hand, if symptoms persist for several months without treatment, then avoidance can become the best available method to cope with the trauma -- and this strategy interferes with seeking professional help. Postponing needed intervention for a year or more, and allowing avoidance defenses to develop, could make this work much more difficult.
We create meaning out of the context in which events occur. Consequently, there is always a strong subjective component in people's responses to traumatic events. This can be seen most clearly in disasters, where a broad cross-section of the population is exposed to objectively the same traumatic experience. Some of the individual differences in susceptibility to PTSD following trauma probably stem from temperament, others from prior history and its effect on this subjectivity.
In the "purest" sense, trauma involves exposure to a life-threatening experience. This fits with its phylogenetic roots in life-or-death issues of survival, and with the involvement of older brain structures (e.g., reptilian or limbic system) in responses to stress and terror. Yet, many individuals exposed to violations by people or institutions they must depend on or trust also show PTSD-like symptoms -- even if their abuse was not directly life-threatening. Although the mechanisms of this connection to traumatic symptoms are not well understood, it appears that betrayal by someone on whom you depend for survival (as a child on a parent) may produce consequences similar to those from more obviously life-threatening traumas. Examples include some physically or sexually abused children as well as Vietnam veterans, but monkeys also show a sense of fairness, so our sensitivity to betrayal may not be limited to humans. Experience of betrayal trauma may increase the likelihood of psychogenic amnesia, as compared to fear-based trauma. Forgetting may help maintain necessary attachments (e.g., during childhood), improving chances for survival; if so, this has far-reaching theoretical implications for psychological research. Of course, some traumas include elements of betrayal and fear; perhaps all involve feelings of helplessness.
As you might expect, risk for PTSD increases with exposure to trauma. In other words, chronic or multiple traumatic experiences are likely to be more difficult to overcome than most single instances. PTSD is also more likely if passive defenses, such as freezing or dissociation, are used -- rather than active defenses such as fight or flight. Epidemiological estimates suggest that the incidence and lifetime prevalence rates of PTSD in the general population are around 1% and 9%, respectively. But these levels increase markedly for young adults living in inner cities (23%), and for wounded combat veterans (20%). There is also evidence that early traumatic experiences (e.g., during childhood), especially if these are prolonged or repeated, may increase the risk of developing PTSD after traumatic exposure as an adult. This may result from state-dependent learning, where previous responses to a terrifying event are repeated even though more appropriate responses (i.e., active defenses) may now be possible.
Several animal studies have suggested the possibility of permanent physical damage (including shrinkage) in the hippocampus and changes in the amygdala when severe or chronic trauma -- and its symptoms -- persists (see especially work by Robert Sapolsky and by Joseph LeDoux, respectively). Unfortunately, there is no easy way to compare the relative types or degree of trauma across species. The most recent human data, including Gilbertson et al's (2002) twin study, suggest that response to trauma may be influenced by pre-existing individual differences in hippocampal volume. Perhaps both processes are involved.
There's no clear evidence that susceptibility to PTSD varies for members of different ethnic or minority groups (given a traumatic experience). But individual differences clearly play some role. For example, younger children have less ability to predict, avoid, make sense of, or to actively defend against, upsetting events, and more introverted or shy individuals may experience stronger emotional reactions to such experiences.
Post-traumatic Stress Disorder (PTSD) is the most common diagnostic category used to describe symptoms arising from emotionally traumatic experience(s). This disorder presumes that the person experienced a traumatic event involving actual or threatened death or injury to themselves or others -- and where they felt fear, helplessness or horror. Three additional symptom clusters, if they persist for more than a month after the traumatic event and cause clinically significant distress or impairment, make up the diagnostic criteria.
The three main symptom clusters in PTSD are: Intrusions, such as flashbacks or nightmares, where the traumatic event is re-experienced. Avoidance, when the person tries to reduce exposure to people or things that might bring on their intrusive symptoms. And Hyperarousal, meaning physiologic signs of increased arousal, such as hyper vigilance or increased startle response. The actual symptoms used in the United States are described in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The most current version of the DSM is the Fourth Edition, Text Revision (DSM-IV-TR), published in June 2000 by the American Psychiatric Association (DSM-IV-TR; 2000). The DSM-V is not expected to appear until 2011, or later. If a traumatic event occurred recently, then an individual might suffer from Acute Stress Disorder, which involves symptoms similar to PTSD but without the one month duration requirement. An alternative classification system, the World Health Organization's International Classification of Diseases, or ICD-10, uses a comparable but somewhat different symptom summary.
PTSD is officially classed as an anxiety disorder, but some have argued that it fits more closely with the dissociative disorders, and others feel it belongs by itself. There has also been discussion over differential diagnoses for simple vs. chronic traumatic histories (such as Complex PTSD, or the proposed DESNOS diagnosis: for Disorders of Extreme Stress, Not Otherwise Specified). Recent work suggests that DESNOS may be more frequent among individuals whose subsequent adult traumas complicate chronic or unresolved childhood traumatic experiences, and that DESNOS has important implications for treatment.
While PTSD is the "prototypical" traumatic disorder, some people -- or some stressors -- present variations on this theme. Depression, Anxiety, and Dissociation are three other disorders that may sometimes arise after traumatic experiences, but Somatoform disorders -- and even hypertension -- can be seen in some populations. The differences may result from how the particular individual deals with or expresses their stress, probably influenced by the individual's subjective interpretation of the stress as well. Individual differences affect both the severity and the type of symptoms experienced.
David Baldwin's Trauma Pages http://www.trauma-pages.com/trauma.php
One additional aspect of traumatic exposure affects primarily the workers who help trauma and disaster victims. These people include psychologists and other mental health professionals, but also the emergency workers -- EMTs, physicians, fire, police, search & rescue, etc. -- exposed to an overdose of victim suffering. These professions are at-risk for secondary traumatization. Known by various names -- compassion fatigue, secondary or vicarious traumatization, and "burn out", the symptoms here are usually less severe than PTSD-like symptoms experienced by direct victims in a disaster. But they can affect the livelihoods and careers of those with considerable training and experience working with disaster and trauma survivors. Secondary trauma might also be seen in jurors, for example, or in other individuals exposed to traumatic material (e.g., journalists; news photographers). Risk for secondary trauma is not limited to professions where such exposures are commonplace. As you might expect, the risk increases when traumatic exposures are unexpected, or among those without adequate preparation.
Expect this, if you work with or are exposed to the stories of many disaster/trauma victims, and take steps to protect yourself at the first sign of trouble. Basically, there are three risk factors for secondary traumatization: 1) exposure to the stories (or images) of multiple disaster victims, 2) your empathic sensitivity to their suffering, and 3) any unresolved emotional issues that relate (affectively or symbolically) to the suffering seen.
Aside from using whatever stress reduction or stress management measures work best for you, there's little an emergency or disaster worker can do about the first two risk factors, but it does help reduce the risk for vicarious traumatization if you know your own personal vulnerabilities and unresolved upsetting issues. Those are the cases best referred to your colleagues, when possible
For many exposed individuals, especially those in the at-risk professions, participation in well-run CISD (Critical Incident Stress Debriefing) groups may also help resolve upsetting experiences more quickly, as long as participation is voluntary (not mandatory). Group debriefings may be adequate for most, but brief individual sessions might be needed for 10 - 20% of those suffering the most severe exposures. In fact, one value of debriefing groups is to help identify those workers needing additional attention.
Co-Occurring Disorders (COD)
Source: California Department of Drug & Alchohol Programs
COD refers to co-occurring substance use (abuse or dependence) and mental disorders. Clients with COD have one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental disorders. A diagnosis of COD occurs when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder.
Many may think of the typical person with COD as having a severe mental disorder combined with a severe substance use disorder, such as schizophrenia combined with alcohol dependence. However, counselors working in addiction agencies are more likely to see persons with severe addiction combined with mild- to moderate-severity mental disorders; an example would be a person with alcohol dependence combined with a depressive disorder or an anxiety disorder. Efforts to provide treatment that will meet the unique needs of people with COD have gained momentum over the past two decades in both substance abuse treatment and mental health services settings.
DSM-IV Substance Abuse Criteria
Substance dependence is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; or neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous (such as driving an automobile or operating a machine when impaired by substance use)
3. Recurrent substance-related legal problems (such as arrests for substance related disorderly conduct)
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (for example, arguments with spouse about consequences of intoxication and physical fights).
Alternatively, the symptoms have never met the criteria for substance dependence for this class of substance.
DSM-IV Substance Dependence Criteria
Addiction (termed substance dependence by the American Psychiatric Association) is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect
(b) Markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for the substance
(b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than intended.
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
DSM-IV criteria for substance dependence include several specifiers, one of which outlines whether substance dependence is with physiologic dependence (evidence of tolerance or withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3) sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment.
Ritual abuse is commonly repetitive abuse, which can be multi-generational and associated with ritual beliefs and practices (Lynette Danylchuk, Ph.D.).
Ritual abuse is a brutal form of abuse of children, adolescents, and adults, consisting of physical, sexual, psychological and spiritual abuse, and the use of rituals. The physical abuse is severe, sometimes including torture. The sexual abuse is often painful, sadistic, and humiliating, intended as a means of gaining control over the victim. The psychological abuse is devastating and involves the use of rites, which may include mind-control techniques, mind-altering drugs, and intimidation which conveys to the victim a profound terror of the abusers. The spiritual abuse can destroy the concept of a loving God, produce estrangement from or an aversion to God, and induce feelings of worthlessness and hatred of oneself and others in power. During and after the abuse, most victims live in a constant state of terror, mental confusion, and dissociation.