In Articles, Focus on Emotions

by Dr. Sarah Thompson, Clinical Psychologist

Last article we talked about emotion coaching – how to help others manage their big feels. This time, we’ll begin to focus on what happens after an individual experiences trauma – where we see some of the biggest feels, as well as the near absence of feels.

Everyone needs to be aware of trauma and its implications. Why?

Trauma is very common

In the past, it was commonly believed that trauma was a rare occurrence. We now know that this is simply not the case. Estimated rates of exposure to trauma range from 39% (in a sample of well-educated relatively young individuals as reported by Breslau, Davis, Andreski, & Peterson, 1991) to 84% (percentage of undergraduates reporting a single episode of trauma at a major Midwestern U.S. university; with 33% reporting that they had experienced four or more traumatic events; Vrana and Lauterbach, 1994). In a Canadian sample, MacMillan et al. (1997), identified rates of sexual abuse perpetrated by adults at 13% of females and 4% of males, and rates of physical abuse at 21% of females and 31% of males. Statistics Canada 2014 data reveals that Indigenous individuals experience significantly higher rates of violence than non-Indigenous counterparts. When considering emotional abuse experienced in a sample of Ontario university students specifically, rates at 25% of females and 35% of males were found (Turner & Paivio, 2002).

Data taken from the Canadian reference group for the 2016 American College Health Association’s National College Health Assessment II is a stark reminder that many young adults continue to experience abuse through their university years. Within the 12 months prior to the 2016 survey, members of the Canadian reference group reported rates of abuse outlined in the chart below.

What this means is that you work, study, or socialize with someone who has experienced at least one traumatic incident.

Trauma is a significant predictor of physical and mental health challenges

The Adverse Childhood Experiences (ACE) Study was a groundbreaking study with data collected in the mid- to late-90s from thousands of individuals attending a San Diego health clinic for physical exams. Respondents completed confidential surveys answering questions about childhood experiences and their current health status and behaviours. The ACE pyramid below demonstrates the links between the experience of adverse events in childhood and the developmental pathways to increased risk for physical and mental health problems. What researchers found was that increased exposure to adverse events in childhood was strongly associated with increased risk for physical and mental health challenges in adulthood.

Pyramid titled: Mechanism by Which Adverse Childhood Experiences Influence Health and Well-being Throughout the life span. Bottom to top order from Conception to Death: Adverse Childhood Experiences | Disrupted Neurodevelopment | Social, Emotional, and Cognitive Impairment | Adoption of Health-risk Behaviours | Disease, Disability, and Social Problems | Early Death

Image from the CDC-Kaiser Adverse Childhood Experiences Study

 

In the original CDC-Kaiser Adverse Childhood Experiences Study, researchers found that exposure to “household dysfunction” and “childhood abuse” was a significant risk factor for a wide range of mental and physical health problems in adulthood. Specifically, they reported that exposure to four or more categories of childhood abuse or household dysfunction was associated with a:

  1. 4- to 12-fold increase in alcoholism, drug abuse, depression, and suicide attempt;
  2. 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners, and sexually transmitted disease;
  3. 1.4- to 1.6-fold increase in physical inactivity and severe obesity.
The more categories of adverse childhood exposures a person experienced, the greater the likelihood of adult disease including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

But What is a Traumatic Event?

Commonly, when people think of the word trauma, they imagine ‘big T’ traumatic events such as single violent attacks, natural disasters, accidents involving vehicles or machinery, sexual assault, domestic violence, or violence experienced through large scale conflicts such as combat, or living through war or genocide. These ‘big T’ traumas involve, by definition, incidents in which an individual fears that they or someone they love is at immediate risk of death or grievous physical harm. Such experiences commonly and understandably have very significant impacts on survivors – from acute stress responses immediately following events, to the development of full blown post traumatic stress disorder. When a traumatic event has occurred that involves a single episode, some will refer to this as a ‘Type 1’ or single episode trauma.

Equally important to attend to are the ‘small t’ traumas that often underlie a variety of mental health and physical health symptoms including anxiety, depression, and what many in the trauma treatment field refer to as Complex PTSD. “Small t” traumas stem from a much broader range of experiences, typically including some kind of prolonged relational or attachment trauma – being repeatedly hurt by a parent or caregiver, for example, or by an institution responsible for one’s care such as a residential school, inpatient treatment facility, or even a government. Small ‘t’ traumas can include exposure to exploitation, to physical or emotional neglect or abandonment in childhood, or to the impacts of systemic oppression related to factors including, but not limited to the intersections of poverty, racism, ableism, sexism, homophobia, transphobia, and religious persecution. When someone has experienced ongoing trauma within close interpersonal or care-taking relationships, this is sometimes referred to as ‘Type II’ trauma.

For the purposes of the ACE Study, adverse experiences were defined in the following (Note that the final category of “Neglect” was “reverse scored”. This means that high scores on this item indicated that neglect was not present, while low scores are indicative of neglect.):

Abuse

  • Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.
  • Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.
  • Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.

Household Challenges

  • Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
  • Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.
  • Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.
  • Parental separation or divorce: Your parents were ever separated or divorced.
  • Criminal household member: A household member went to prison.

Neglect1

  • Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.2
  • Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it2, you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

1Collected during Wave 2 only.
2 Items were reverse-scored to reflect the framing of the question.

– from: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, or ACE Study

Common symptoms following trauma

I’d like to pause here to acknowledge that, while many people do not identify with the idea that they may have experienced “trauma” (or “Trauma”), many people reading this may identify as having experienced some of the circumstances described above. If you experience trauma, it does not mean that you will be suffering enduring impacts from traumatic stress. Let’s take a look at common reactions and pathways following trauma.

Traumatic Stress is Normal

Stress responses after any traumatic stressor or serious loss are normal and are a part of how our bodies are wired to cope with a physical or emotional shock. Common reactions to traumatic events include, but are not limited to:

  • Physical symptoms (e.g. fatigue, nausea, chills, dizziness, changes in heart rate, breathing, and sweating),
  • Cognitive symptoms (e.g. confusion, nightmares, intrusive images, changes in concentration and memory, and reduced sense of safety in the world),
  • Behavioural symptoms (e.g. crying, social withdrawal, agitation, using substances or taking dangerous risks to cope with pain) and,
  • Emotional symptoms (e.g. feeling frequently afraid, guilty, sad, anxious, angry, overwhelmed, or depressed).

It is always important to take care of the basics when experiencing traumatic stress. This can include spending time with loved ones, eating healthy foods, sleeping and exercising in healthy ways, and sharing your emotional reactions with others – through writing, through talking to others, or through art, music, or movement. It’s important to make connections between events you experienced or witnessed and what was happening in your body at the time.

Inner Critic: (A voice barely perceived in the distance) Trauma is a pretty big topic. I’m not sure you can meaningfully sum it up in one piece in a way that will provide the reader with a useful learning experience.
Self: Hey critic, there you are. Hmm. I do hear you. I think I’ll narrow my scope on this one and try to identify a few key take-aways I want to clearly convey. I see that you’re feeling a little anxious today. I have compassion for you – I know that you can get scared easily.
Inner Critic: I do feel a bit vulnerable today – old memories are stirring a bit. Maybe I do need some support today, thanks.
Self: Ok. We’re good?
Inner Critic: Yeah, we’re good. Thanks for narrowing the scope. I think that will be helpful.
Self: I agree. Thanks, and see you later.

Post-traumatic Stress Disorder

Not everyone who experiences traumatic stress will go on to develop PTSD. For those who do, prolonged stress responses continue, or become stuck, leading to symptoms such as: re-experiencing aspects of the trauma through flashbacks or nightmares; avoidance of thoughts, feelings, and reminders of the trauma; increased physiological arousal including hypervigilance and startle responses, and negative thought patterns. In PTSD, these symptoms last longer than one month, and, by definition, result in some form of impairment in the person’s life. For a diagnosis of PTSD to be assigned, the individual must have been exposed to threatened death, death of another, actual or threatened serious injury, or actual or threatened sexual violence.

Surprisingly, Canada has one of the highest rates of PTSD. According to a 2017 CBC report, approximately 9.2% of the population will experience PTSD in their lifetimes. Think for a moment about the enrollment and staffing complement at your university. What is 10% of your campus community? At Ryerson, that’s approximately 4000 individuals (drawing only from our current student enrollment) who are likely to experience PTSD in their lifetimes.

Complex Post-Traumatic Stress Disorder

While Complex PTSD is not an officially recognized diagnosis in the DSM-V (otherwise known as the ‘bible’ of psychiatric diagnoses), it is a concept that is widely used and valued amongst professionals with expertise in trauma treatment. In contrast to diagnoses often conveyed to those with impactful trauma histories, including combinations of PTSD, bipolar disorder, borderline personality disorder, generalized anxiety disorder, depression, OCD, and ADHD to name a few, Complex PTSD speaks directly to the developmental causes and the necessary treatment focus to assist individuals in their recovery. While individuals may certainly live with patterns of symptoms in their lives that are consistent with more than one label or diagnosis, the Diagnostic and Statistical Manual is, at its core, a listing of symptom clusters and characteristics in the general population. While symptom patterns inform mental health treatment, they are only part of the puzzle. Much as a topical cream is important for soothing the itch associated with a rash, knowing and stopping the cause of a persistent rash is the ultimate goal. Ideally, this will be true for persistent mental health conditions as well. In my opinion, an additional benefit of the diagnosis of Complex PTSD is that this diagnosis is less likely to result in implicit pathologization of those living with mental health challenges following trauma, or in undesired misperceptions by clients themselves that they are fundamentally genetically flawed or broken as is too often the case for individuals receiving non-trauma focused diagnoses when trauma has been a central feature in the development of persistent symptom patterns.

When to get help?

If you believe that you may be experiencing enduring symptoms of traumatic stress, including symptoms of PTSD or Complex PTSD, I strongly encourage you to reach out for support. If safe, talk to friends or family, and if you believe that traumatic stress may be underlying pervasive symptoms of depression, anxiety, self-harm, substance use, or interpersonal challenges, reach out to a therapist who practices from a trauma-informed perspective. You can find psychologists, social workers, or psychotherapists online through their provincial associations or through your local family physician or employee assistance program. If your struggles are intense, consider contacting your local distress line for immediate support.

Join me in the next installment where we will go into more depth about what happens to the nervous system and our emotions when trauma occurs, and why approximately 20% of individuals tend to be at highest risk for developing post traumatic stress symptoms following trauma.

References

Breslau, N., Davis, G., Andreski, P., Federman, B., & Anthony, J. C. (1998). Epidemiological findings on post traumatic stress disorder and co-morbid disorders in the general population. In B. P. Dohrenwend (Eds.), Adversity, stress, and psychopathology (pp. 319-330). New York. Oxford University Press.

MacMillan, H. L., Fleming, J.E., Trocme, N., Boyle, M.H., Wong, M., Racine, Y.A., et al. (1997). Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. JAMA, 278, 131-135.

Turner, A., & Paivio, S.C. (2002, August). Alexithymia as a transmission mechanism between childhood trauma, social anxiety, and limited social support. Poster presented at the 100th Annual Convention of the American Psychological Association, Chicago, IL.

Vrana, S.,& Lauterback, D. (1994). Prevalence of traumatic events and post-traumatic psychological symptoms in a nonclinical sample of college students. Journal of Traumatic Stress, 7, 289-302.

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