Psychological trauma is the intense emotional impact produced by an extremely threatening, unpredictable and uncontrollable external event, which causes cognitive, affective and somatic disruption with often disabling effects and involves life change and significant impairment in daily functioning.
Post-traumatic stress is the pathology developed by exposure to trauma, the main traumatic events being:
- Natural disasters
- Traffic, domestic or professional accidents
- Combat or war zone exposure
- Physical violence
- Sexual violence
- Bullying or psychological abuse both at school and at work
- Terrorist acts
- Torture, imprisonment and deprivation of liberty
- Accidental or violent death of a close person
- Serious illness of oneself or a loved one
- Intimate partner violence
- Witnessing critical situations such as death, serious deterioration, lack of means, etc. as a professional.
Depending on personal circumstances and the ability to cope with stressful events, major ruptures in daily life such as divorce, betrayal, financial ruin or loss of economic and social status can cause trauma.
Post-traumatic stress will develop depending on the severity of the traumatic exposure, whether it is a single episode (rape), repeated episodes that cease (war situation) or repeated episodes that continue (harassment or abuse).
What are the symptoms of post-traumatic stress?
The symptoms of post-traumatic stress are grouped into:
- Intrusions: intrusive memories, nightmares, flashbacks or re-experiencing.
- Avoidance: of distressing memories, thoughts and feelings, or of people, places or stimuli reminiscent of the trauma.
- Cognitive and mood disturbances: amnesia, negative beliefs about self, others and the world, distorted perception of cause or consequences generating guilt, negative emotional state with fear, terror, shame, anger, decreased interest in meaningful activities, detachment or alienation, inability to experience positive emotions.
- Altered alertness and reactivity: irritability and lack of anger control, reckless behavior, exaggerated startle response, concentration problems and sleep disturbance.
How does trauma manifest itself?
Trauma involves a disruption of what we thought was safe and controllable and manifests as:
- Neurobiological impact: increased sensitivity to the stress response; attentional bias to threat; episodic memory deficits with spatiotemporal fragmentation and decontextualization; deficits in attentional and emotional regulation.
- Cognitive impact: change in the interpretation of reality; the world is dangerous; no one can be trusted; I do not deserve anyone’s interest or love; I feel guilty for what happened; no one understands me.
- Affective impact: sensitization of the stress response system that can lead to anxiety, dissociative disorders, mood disorders, personality disorders and addictions, among others.
- Somatic impact: cardiovascular symptoms, gastrointestinal symptoms, fibromyalgia, chronic widespread pain, sexual symptoms with pain and recurrent infections.
Traumatic memories are fragmentary, disorganized, decontextualized, intrusive and disruptive. They creep into the present generating discomfort and can range from repetitive and obsessive imagery to complete re-experiencing of the experience in the present as it occurred. The trauma persists into the present and the future.
These memories can be uncontrollably triggered by sensory stimuli of any kind, tactile, olfactory, tastes, noises, physical appearance, lighting. This is why hypervigilance or permanent alertness and cognitive, behavioral or emotional avoidance is so significant in trauma.
Memories are often stored in an unstructured way. On the one hand, contextual, verbally encoded memories may be incomplete, whereas sensory and emotional memories are encoded more completely.
If these contextual memories correspond to sensory memories, fear can be inhibited, because both reach consciousness equally, but if the contextual memories are reduced and the sensory memories are more powerful, fear is activated, as cortical inhibition is not effective.
For this reason, controlled exposure to trauma makes it possible to fill gaps in the contextual or narrative system and make it correspond to the sensory system, consolidating the memories verbally in the memory, which activates the prefrontal cortex and inhibits the amygdala and therefore fear.
If the memories are unmanageable, dissociative disorders may arise, more common if the trauma is before the age of 12 years or there have been more traumatic events.
The main dissociative disorders
- Depersonalization/derealization disorder: Depersonalization involves experiences of unreality, being an outside observer with respect to thoughts, feelings, sensations, body or behavior. Derealization involves experiences of detachment and unreality from the environment.
- Dissociative amnesia: inability to remember certain autobiographical information. It is an impairment of the explicit, declarative memory, while the implicit, semantic memory remains complete. It is very common in repeated childhood traumas.
- Dissociative identity disorder: it is the most extreme of the dissociative disorders and is linked to a childhood full of adversities and recurrent traumas. It has a protective function to alleviate the impact of trauma. The person enters into dissociative states of consciousness that upon repetition become independent cognitive-affective identities. The personality is fragmented into different identities, each with different memories.
- Conversion disorder: alterations in voluntary motor or sensory function. Weakness, tremor, paralysis, swallowing problems, aphonia, sensory disturbances, anesthesia, produced by the high physiological activation in the face of a danger from which it is not possible to escape, appearing the response of paralysis or shutdown.
Psychological treatments for trauma
All are based directly or indirectly on exposure to traumatic events in order to eliminate the avoidance of these, cognitive, emotional, sensory or behavioral, which in turn solves the high physiological activation, intrusions in all their modalities and dissociative symptoms.
Regardless of the fact that exposure is critical, most of the best therapies treat each symptom on its own until eliminated and incorporate techniques, if the person needs them, to learn communication skills, anger management, guilt restructuring, sex therapy, emotional regulation and occupational rehabilitation.
Those that have demonstrated the most efficacy are the classic therapies of imaginal and live exposure to memories and avoided stimuli.
- Narrative exposure therapy
Integrates fragmented memories into a coherent narrative that allows reorganization of autobiographical and emotional memory.
- Prolonged exposure
Imaginal and live exposure to situations considered dangerous by the person, but which are not. Situations reminiscent of the traumatic event. Situations avoided by a low state of mind and finally imaginal exposure to the trauma with specific characteristics such as speaking loudly, in the first person and in the present tense. Discussion of dysfunctional thoughts is included.
- Cognitive processing therapy
This involves writing and then reading about the trauma in consultation. Blocking points and dysfunctional beliefs of security, trust, power, esteem and intimacy are identified and restructured so that they are no longer disabling.
- Cognitive therapy
It is based on eliminating negative appraisals of the trauma, reducing re-experiencing by reworking memories and discriminating triggers, and eliminating dysfunctional cognitive and behavioral strategies.
- Desensitization and reprocessing by means of eye movements.
It is based on exposure to scenes of the trauma and associated cognitions and sensations and concentrating on following with the eyes the movements of the therapist’s hand or a luminous device.
The theory of the technique is that it allows processing the memories and integrating them into the autobiographical memory in a conscious way.
Scenes, thoughts and sensations change spontaneously and can be commented on or simply let go. When what is called a specific sensory or thematic channel has been processed and discomfort is no longer experienced, a positive or capacity cognition is installed in the initial traumatic situation by means of new batches of eye movements.
It can be more complex when diverse reactions arise during the process, which will have to be managed with relaxation and cognitive restructuring.
- Integrative Psychotherapy
Detection of problem patterns. Work with emotions, thoughts and behaviors. Treatment of symptoms of intrusion, avoidance and irritability. The narration of the traumatic experience is at the patient’s choice, it is only done if he/she is ready and willing. Problems in the biographical history. Work with the belief system, guilt and grief. Post-traumatic growth. Detecting own resources. Detecting signs of positive change. Promoting optimism. Promote positive life changes and resilience to adversity.
- Clinical Hypnosis
Hypnosis is a method of facilitating strategies in the course of therapy and enhances the effectiveness of the treatment used. It has a wide variety of techniques conveyed by hypnotic suggestions to treat both symptoms and to enable post-traumatic growth.
It is especially useful in teaching the person to eliminate the most bothersome symptoms of hyperalertness, avoidance and emotional disturbance. Dissociative symptoms, especially resistant to any treatment, are most easily addressed with hypnosis.
The phases of the process are usually done in parallel and are: controlled recovery of memories and elaboration and integration of the traumatic experience; stabilization and elimination of alarm, intrusion and avoidance symptoms; addressing dissociative symptoms; reintegration and rehabilitation of the personality.
- Imaginal Reprocessing Therapy
Created for victims of sexual abuse. Exposure to the traumatic memory and experiencing emotions, thoughts and sensations. Scenes are relived and the frightened child is reassured and sustained and empowered to do something different where he/she is no longer paralyzed and helpless.
Subsequently, assumed beliefs and schemas are refuted and modified by more objective ones, such as the attribution of blame and shame to the perpetrator, fostering a more positive view of oneself.
This list does not include all effective treatments and the description is too brief to fit the space available.
Trauma is solvable and psychology demonstrates this through ongoing research and clinical practice.