Understanding Trauma, PTSD and Effective Treatments
Let’s start with a hypothetical situation: Two different people experience the same disturbing event. Perhaps they are each mugged on their way home from work. They are held at gunpoint and forced to turn over their wallets, and then the mugger runs away. Neither person is harmed physically, but they each feel helpless, powerless to defend against or avoid the threat. In each of them, the sympathetic nervous system, also known as the “fight-or-flight” response, is activated. Adrenaline floods the body. The kidneys stimulate epinephrine and norepinephrine release, sending “speed up” messages throughout the body and causing the heart to beat faster, blood vessels to constrict, and blood pressure to increase. Breathing becomes fast and shallow, pumping extra oxygen through dilated bronchial tubes in the lungs and onward to the muscles. The pupils dilate to allow for collection of more visual information. The liver stimulates release of extra glucose, providing quick access to energy for fighting or fleeing. Non-essential systems, such as the digestive system, shut down.
In addition to these physical changes, each of these people will experience functional changes in their brain. Two primary brain structures are affected:
Brain and Trauma
- Midbrain Structures
- Neocortex Brain Structures
- Prefrontal Cortex
Medial Prefrontal Cortex (mPFC)
Dorsolateral Prefrontal Cortex
Amygdala: The amygdala are two almond-shaped areas in the brain which are in charge of emotional perception and processing. The right amygdala specializes in perceiving and processing threat and associated emotions. For each of the people in our example, the amygdala (particularly the right amygdala) become hyper-activated, heightening their sense of danger and a fearful, angry reaction to what is going on.
Hippocampus: The hippocampus sits next to amygdala and is intimately connected with it. It is responsible for turning experiences into new neuronal pathways that are stored for future reference. In other words, the hippocampus helps with the consolidation of information from short-term memory to long-term memory. In our hypothetical mugging, the hippocampus in the brains of the two people will leap into action, accessing their memory banks to determine if the situation looks familiar. Have they experienced a similar situation before? How did it turn out? Is this a real threat, or does prior experience tell them everything is going to be OK?
Thalamus: The thalamus is responsible for the processing, filtering and transfer of most of our sensory information (sight, sound, touch, body sensation), and it makes decisions of whether to send information on to our awareness for conscious consideration. The thalamus also integrates different sensations and pieces into a complete autobiographical memory. During trauma, the thalamus shuts down, which results in less filtering and more information being sent onward to our conscious awareness. This reaction is designed to provide us with heightened senses and improved motor reflexes. Unfortunately, as a side-effect, our two people will remember the mugging as isolated sensory imprints, like “snapshots” rather than a coherent story with a beginning, middle and end.
Neocortex Brain Structures
From an evolutionary perspective, the amygdala, hippocampus and thalamus provide a very fast reaction to perceived threat. Fast reaction is what you need; the faster you can notice threats and either run away from them or fight back, the more likely you are to survive. This system worked really well for the caveman ancestors of the two people in our example. But their lives today are a lot more complicated than that of their ancestors. Some situations are not really as dangerous as they seem at first, and in this situation, it might be better to stay calm rather than fight or run away. This means there’s an advantage to being able to hold off the reflexive fight-or-flight response while the brain works out a more sophisticated analysis of the situation and the options for handling it, and that is the job of the Neocortex.
The Neocortex is responsible for the qualities that make humans unique within the animal kingdom, including language, abstract thought, planning, imagination, empathy, making choices and deductions. Unfortunately, it’s also much slower. And when we experience a threatening situation it can completely shut down, leaving us vulnerable to panic.
This is a fundamental breakdown in the way our brains react to trauma. Our initial response is primitive, intuitive action. Then, later, we actually start analyzing the problem. The “thinking” part comes second, and it’s hard for the neocortex to contradict the amygdala. This is made even more difficult by trauma’s effect on the Prefrontal Cortex.
Prefrontal Cortex: This is the front area of the neocortex, covering the frontal lobes of the brain. Two important parts of the Prefrontal Cortex are affected by traumatic experiences:
- Medial Prefrontal Cortex: Located directly above the eyes, the Medial Prefrontal Cortex is the watchtower of our reactions, involved in self-insight and self-awareness and cognitive processing of emotions. It also plays a role in extinction of fear conditioning and maintenance of extinction; it is well-connected to amygdala. This is also where we have a high concentration of mirror neurons, which provide for empathy, compassion, and guilt, fostering healthy relationships with others. During a traumatic event, this part of the brain slows way down.
- Dorsolateral Prefrontal Cortex: This area is known as the “timekeeper” of the brain. It puts our experiences on a timeline, lets us know when the experience is over, and that it is time-limited. Functioning in this area of the brain is also impaired during a traumatic event.
After the Danger is Over
Returning to our two-hypothetical people who each got mugged on their way home from work, and felt helpless, powerless to defend against or avoid the threat:
Once the danger passes, one of these people will calm down fairly quickly. The parasympathetic nervous system will engage, telling the heart to slow its beating, the lungs to expand and contract more deeply and slowly. Blood vessels will dilate, lowering the blood pressure. Pupils will return to normal dilation, digestion will begin again, sleeping will return to normal. Functioning in their brain will return to normal as well. The amygdala will calm down, no longer sending messages of fear and anger. The thalamus will again filter out unnecessary sensory input, a coherent sense of time will reassert itself, and in general the world will again seem like a safe place to live.
But let’s say that the second person is unable to return to normal functioning. His or her entire system remains at “alert status,” unable to fully appreciate that the threat has passed. This heightened, ongoing activation of the sympathetic nervous system is known as Posttraumatic Stress Disorder, or PTSD. Why do some people fail to recover? There are many hypotheses, and many factors to consider:
- Certain types of trauma, like combat or sexual assault, have a higher prevalence of PTSD.
- Pre-trauma risk factors, such as childhood adversity, family history of psychopathology, avoidant personality style, or poor social support make a person more susceptible to developing PTSD.
- Neuroendocrine predisposition: lower cortisol levels pre-trauma seems to also increase the chances of developing PTSD. We see this in children of Holocaust survivors, or of parents with PTSD and anxiety – their children are more likely to develop PTSD following trauma.
Whatever the reason, for the person who is experiencing PTSD, their environment, interpersonal functioning, and physical and mental well-being are dramatically affected. Insomnia, nightmares, intrusive memories, difficulty forming new memories, and extreme sensitivity to light and sound, along with a multitude of physical symptoms, become daily experiences. It is increasingly difficult for him or her to regulate emotions and reactions to the environment, with all three parts of the brain impacted in different ways.
Tri-une Brain: From evolutionary oldest to youngest, this is a practical way to view the brain’s functioning:
- Reptilian Brain (brainstem and cerebellum): This part of the brain controls basic physical functions, such as breathing, eating, sleep/wake cycle, and elimination. It is the most basic part of the brain negatively affected by PTSD.
- Limbic Brain (amygdala, hippocampus, thalamus): The next part of our brain to evolve, these areas are responsible for emotional responses to environment, including judgement of danger and pleasure. For the person with PTSD, the limbic brain responds to all stimuli as threat.
- Neocortex (frontal lobes take up most of this space): These areas are responsible for planning, anticipation, sense of time and context, inhibition of inappropriate actions, and making choices. This part of the brain is the “new kid on the block,” evolutionarily speaking, and is also inhibited by PTSD.
Top-Down and Bottom-Up Regulation
When strong emotion begins to impact functioning, humans can regulate their emotions in two major and opposite ways:
- Top-down regulation: This process relies on the frontal lobes for understanding the situation, based on the accumulated knowledge, and explaining emotions in that context.
- Bottom-up regulation: This relies on the activity of the brainstem and limbic system; here, if our limbic brain perceives muscle tension and fear, it means the situation is dangerous; most of our emotions and body sensations are processed in the bottom-up fashion (much faster).
In normal day-to-day functioning, top-down regulation works well; we are able to use reason, logic and restraint. With PTSD, top-down regulation is impaired due to changes in brain functioning. So, traditional talk therapy and Cognitive Behavioral Therapy (CBT) have limited effect on the survivor of trauma. Therefore, bottom-up regulation approaches have to be used in order to help these clients learn how to self-regulate in the present moment.
Typically, a trauma therapist will first teach the client self-calming techniques, using breathing and mindful movement to activate the parasympathetic nervous system, calming the body and the brain’s fight-or-flight response. Expressive therapies also help to reintegrate the brain, allowing traumatic memories to be more fully processed. When the client is ready to integrate bottom-up and top-down regulation, EMDR provides a unique combination of these two types of regulation and processing of disturbing memories.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR counseling is a type of therapy that can help people resolve whatever trauma is causing them difficulties, so they can become more present and enjoy life. A basic tenet of this approach is the belief that each client already has within him or herself the ability to heal. It is the job of the therapist to assist the client in “unlocking” doors blocking the way to this healing, and to reintegrate parts of the brain that are not communicating very well with one another due to the functional effects of trauma. Like other psychotherapies, the therapist and client do talk about what is happening in the client’s life and explore practical solutions, but they will also go one step further. By using EMDR processing to work directly with the client’s Limbic brain, the way emotional information is stored is changed. Because new neural-networks are getting linked-up during EMDR processing, the mind becomes more open in its ability to find creative solutions to what may seem like unsolvable problems.
With EMDR counseling, the client will revisit unpleasant experiences, and will awaken thoughts, images, body sensations and negative beliefs. At that point, the therapist will administer “bilateral stimulation” (“bilateral” means side-to-side; typically, this consists of sets of eye-movements or tapping) that allows the client’s mind to find its own way to resolution of painful emotions, negative thoughts and uncomfortable bod sensations.
In just a few EMDR therapy sessions (which are done after an intake and history gathering) the client can begin to find freedom from panic and anxiety attacks, worry and excessive thinking. They will likely sleep better and have improved cognitive functioning (reasoning, problem-solving ability, and memory). Clients may also notice a reduction in chronic pain and faster healing from surgeries or physical injuries.
Although EMDR does normally produce these results more rapidly than previous forms of therapy, speed is not the goal; complete healing is the goal. It is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust to be able to implement bottom-up relaxation techniques, while another may proceed quickly through the first phases of treatment only to reveal, then, something even more important that needs to be processed.
Also, treatment is not complete until EMDR therapy has focused on the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future.
When to Seek Treatment for Trauma
There are many definitions of trauma. The Diagnostic and Statistical Manual defines trauma as any event or series of events that left you feeling overwhelmed, helpless, fearful for your own life or safety, or for the life/safety of someone important to you.
Trauma is a subjective experience; it is not defined by the magnitude of the event itself, but by a person’s individual reaction to the event, in which
- The individual’s ability to integrate his/her emotional experience is overwhelmed, or
- The individual experiences (subjectively) are a threat to life, bodily integrity, or sanity.
There are many different types of trauma that can lead to the development of PTSD, and different patterns of experience which can have a cumulative effect resulting in PTSD symptoms.
Single vs. Repeated vs. Extended Trauma
- Single: Single trauma describes one event (such as rape, one criminal act, or natural disaster).
- Repeated: Repeated trauma consists of several traumatic events over the course of the lifetime (for example, a person might survive an earthquake and then several years later be robbed).
- Extended: Extended trauma is chronic, lasting for several months/years (such as child abuse, or domestic violence).
- This type of trauma happens before 18 years of age: “Children who develop in the context of ongoing danger, maltreatment, and disrupted caregiving systems … consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas.” (van der Kolk, 2014)
- This type of trauma complicates and delays development.
- Developmental trauma is often associated with long-term and more extensive damage to the brain, body, emotional and social functioning.
- This refers to a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts (for example, child abuse by primary caregivers, domestic violence, but also impact of war violence, prostitution, or trafficking).
- The term came into being over the past 1 -2 decades as researchers found that some forms of trauma were much more pervasive and complicated than others.
- Attachment trauma: This is a type of Complex trauma which occurs in the context of significant relationships/cultural contexts that presume safety and protection, often over extended period of time.
If you have experienced any of the above, no matter how agitated, anxious, or out of control you feel, it’s important to know that there are things you can do on your own to calm your sympathetic nervous system down.
- Mindfulness: This is a deceptively simple approach to self-regulation that is actually quite powerful. All you have to do is practice being more “present.” This can include listening to guided mindfulness meditation (there are multiple phone apps available for this), focusing your attention on your breath, or moving in an intentional and focused way. There is a story about an old woman who came to the Buddha and asked him how to meditate. He replied, “The next time you draw water from the well, pay attention to every movement of your hands.” Making a conscious effort to be fully present in the moment has a calming effect on the nervous system.
- Connection: Is there someone with whom you feel completely safe? Spending time with a trusted friend or loved one can help soothe your agitated nervous system. If there isn’t a person you feel safe with, petting an animal can be just as effective in restoring a sense of calm. Listening to music/lyrics you relate to is another way to feel connected and be reminded you are not alone.
- Acceptance: Rather than trying to escape from or deny what you feel, practice noticing and acknowledging your feelings about the trauma as they arise, and accepting them without judgement.
- Self-care: Trauma takes a toll on your mind and your body, so focus on implementing a regular sleep schedule, getting plenty of exercise, eating a well-balanced diet, and avoiding alcohol and drugs.
Recovering from trauma takes time, and everyone heals at their own pace. If you have been doing all you can to adapt and take care of yourself and are still experiencing symptoms, or if your symptoms have lasted longer than one month, you may need professional help from a trauma expert.
It is possible to fully recover from the effects of trauma, and you are worthy of recovery!
Sara Black LPC-S, LCDC