PTSD

Not All Wounds are Visible: Post-Traumatic Stress Disorder 101

Post Traumatic Stress Disorder 101

Written By: Marialaina Bucci, LCPC, NCC, CDVP, CCTP

Brene Brown, a research professor, and storyteller has centered her research on topics of shame, courage, empathy, and vulnerability. Why is this important you ask? Hold tight.

June is PTSD Awareness Month. PTSD is the acronym for Post-Traumatic Stress Disorder. Why is this also important you ask? Keep reading. 

These two points are important and interrelated for a few reasons. Post-Traumatic Stress Disorder, or PTSD, can occur after experiencing a traumatic event or events. The symptoms of trauma can be distressing, even greatly debilitating, and can cause significant challenges in the lives of those survivors. Trauma is not something you ‘just get over’. 

The difficult part about trauma is that it feeds feelings of shame. Shame is the concept of, ‘I am bad’, ‘I am unworthy’, ‘I am undeserving’. And yet, when we are able to dig deep within ourselves, allow ourselves to be vulnerable, and tap into our courage while being met with empathy and compassion, we are able to extinguish those feelings of shame and begin to heal. 

By further breaking the silence on trauma and how it impacts so many of us, we can continue to push towards greater healing through a connection that is derived from empathy, compassion, and holding space for one another to own our stories and our bodies. 

“Shame cannot survive being spoken. It cannot survive empathy.” -Brene Brown 

What Is Trauma? (1)

According to the American Psychological Association, trauma is defined as an emotional and physiological response to any event(s) that is deemed stressful, threatening, or harmful. Events such as combat and sexual assault are oftentimes linked to the word ‘trauma’. However, it should be noted that the presence of physical danger or threat does not necessarily need to be present in order to be coined as ‘traumatic’. Situations in which an individual may deem as emotionally threatening or harmful can also be classified as trauma. 

At the heart of this issue is not specifying which exact situations or examples are labeled as traumatic but rather the way the mind and body receive and respond to the threat within the environment. In other words, trauma can be any situation that occurs too much, too fast, and ultimately floods the body and mind’s ability to cope with the situation (also known as the ‘Window of Tolerance’) and results in feelings of terror, fear, and helplessness.

What Is Trauma?

‘Big T’ and ‘Little t’ Trauma (2 & 3)

There are several categories used to more clearly understand the nature of traumatic experiences and their implications on behavioral, emotional, psychological, and physiological functioning. There are 4 different categories: 

  1. Acute Trauma- used to describe one-time events that cause immediate and intense distress following the traumatic event, such as a car crash, unexpected death of a loved one, or sexual assault.
  2. Chronic Trauma- used to describe ongoing and repeated harmful/threatening/painful events, such as domestic violence or bullying. 
  3. Complex Trauma- is similar to chronic trauma in that there is repeated and/or prolonged exposure to traumatic incidents, except there is an additional feature of being inescapable leading to increased hyperarousal and hypervigilance with significant changes in worldview. This can include ongoing childhood abuse (sexual/physical/emotional), human trafficking, racial trauma, and community violence. 
  4. Secondary/Vicarious Trauma- arises from prolonged and repeated exposure to the trauma/suffering of others; this can be either in someone’s personal life (such as a child, parent, roommate, or family member living with someone who experiences intense trauma symptoms) or a professional, such as law enforcement, doctors/healthcare providers, firefighters, and helping/social services professionals.

Additionally, there are adverse childhood experiences (ACEs) that occur and lead to negative changes in coping, functioning, and ultimately physical health. Those experiences can be classified as either chronic or complex trauma. Please see here for more information on Kaiser Permanente’s study on ACEs.

In terms of further categorizing types of traumatic events/trauma for the sake of better understanding, this concept and its implications is the idea of ‘little t’ and ‘Big T’ trauma. This is more of an informal categorization of traumatic events rather than something formally diagnosable. 

‘Little t’ trauma refers to painful experiences that ‘exceed our ability to cope leading to disruptions in emotional functioning’ and subsequent behavioral responses. It is important to note that these events are not inherently life-threatening or ‘bodily-integrity threatening’ but are distressing nonetheless leading to feelings of helplessness and emotional dysregulation. Examples include: ‘infidelity, interpersonal conflict, divorce, legal troubles, financial issues, or abrupt and/or extended relocation’. 

These situations are seen as ‘common’ but still include an emotional intensity that can overwhelm an individual’s ability to cope if chronic and/or acute for substantial periods of time. This is because ‘little t’ traumatic events add up over time and can exceed our window of tolerance leading to a breakdown in coping abilities and dysregulation. 

Types of Trauma

Conversely, ‘Big T’ traumas are larger, more acute situations such as combat, sexual assault, or school shooting. Furthermore, these types of incidents include greater feelings of fear, powerlessness, and helplessness exacerbating the severity of trauma symptoms. ‘Big T’ traumas include acuity that goes beyond the ‘little t’ traumatic experiences and is oftentimes more easily recognizable as ‘trauma’ to the individual.

It should be emphasized that both ‘little t’ and ‘Big T’ events qualify as distressing, traumatic, and valid. Your experience is not ‘less than’ simply because you have experienced ‘little t’ traumatic experiences. 

Types of Trauma: (4, 5, & 6)

There are many forms of trauma that occur on a micro (individual), meso (community), and macro (systemic/institutional) level. Below you will find a preliminary listing of various examples of trauma. Please know that this list is not exhaustive. 

Equally important to remember is that not everyone responds to these situations in the same way. One person may experience significant distress and trauma symptoms while another person may not. Neither is right or wrong. 

Remember, we are all different and have our own unique experiences that factor into our ability to cope with distressing situations. Your reactions to abnormal circumstances/situations are normal and valid nonetheless. 

  • Bullying
  • Kidnapping
  • Physical Assault
  • Neglect (physical and/or emotional)
  • Loss of Parent due to Death, Divorce, or Incarceration (also known as traumatic grief)
  • Separation From Parents in Childhood
  • Unstable Living Conditions/Environment
  • Household Member Addicted to Drugs/Alcohol
  • Community Violence
  • Historical and Racial Trauma Related to Specific Cultural, Racial, or Ethnic Groups
  • Systemic Trauma
  • Natural Disasters and Fires
  • War/Combat
  • Experiencing/Witnessing Domestic Violence
  • Medical Trauma
  • Unexpected Death/Witnessing the Death of Another Individual
  • Physical Abuse
  • Emotional Abuse
  • Sexual Abuse
  • Refugee Trauma
  • Human Trafficking (labor and/or sexual)
  • Terrorism
  • Catastrophic Accidents
  • Repeated Exposure to Death/Significant Injuries as a First Responder, Medical, or Other Helping Professions (also known as secondary/vicarious trauma) 

Effects of Trauma (7)

Effects of Trauma

In regards to the succession of PTSD and its corresponding symptoms after experiencing a traumatic event, there are several phases that typically occur.

  1. Impact Phase- occurs immediately after the event and includes feelings of ‘shock, fear, and guilt’
  2. Rescue Phase- includes the individual coming to terms with the traumatic event that occurred and experiencing a multitude of feelings such as: ‘denial, confusion, flashbacks, anxiety, nightmares, numbness, anger, hopelessness, or despair’.
  3. Intermediate Recovery Phase- includes adjustment and return to ‘normal’ life again; this phase can still include symptoms/emotions from the rescue phase while the individual is attempting to resettle and meet their needs in the wake of adversity and high levels of distress.
  4. Long-Term Reconstruction Phase- the period of recovery in which a person attempts to rebuild, assign meaning to the traumatic event, and tend to the needs/challenges that arise after experiencing trauma; the individual is often concerned about their future in this phase of recovery which can sometimes evoke feelings of depression, despair, or fear.

“Traumatized people chronically feel unsafe in their bodies. The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing what is played out inside. They learn to hide from themselves.” -Bessel van der Kolk

PTSD Description from DSM-5 (4 clusters): (8 & 9)

The Diagnostic and Statistical Manual of Mental Disorders 5, or the DSM-5, reports there are 4 clusters of symptoms experienced with PTSD.

  1. Intrusive Memories/Re-Experiencing– distressing/unwanted memories related to the event(s), flashbacks, distressing dreams/nightmares, severe emotional/physical reactions to reminders of the event(s).
  2. Avoidance– attempts to avoid thinking about, talking about, people/places/things/activities related to the traumatic event(s).
  3. Negative Changes in Thinking and Mood– hopelessness, negative thoughts about yourself/people/the world, memory issues (difficulty remembering details/sequence of events), difficulty maintaining relationships, feeling detached from others, feeling numb, loss of interest/enjoyment pleasurable activities/things, difficulty experiencing ‘positive’ emotions.
  4. Changes in Physical and Emotional Reactions– easily startled/frightened, being on guard for danger, self-destructive behaviors (i.e. drinking, drug use, reckless driving, etc.), difficulty concentrating, irritability, angry outbursts, aggressive behaviors, overwhelming feelings of guilt or shame.

Emotional & Psychological symptoms:

  • Shock, denial, or disbelief
  • Confusion, difficulty concentrating
  • Anger, irritability, mood swings
  • Anxiety and fear
  • Guilt, shame, self-blame
  • Withdrawing from others
  • Feeling sad or hopeless
  • Feeling disconnected or numb

Physical symptoms:

  • Insomnia or nightmares
  • Fatigue
  • Being startled easily
  • Difficulty concentrating
  • Racing heartbeat
  • Edginess and agitation
  • Aches and pains
  • Muscle tension

Steps to Take to Heal from Trauma & PTSD

Heal from Trauma & PTSD

Healing from trauma is possible, thanks to this concept of brain plasticity, also known as neuroplasticity, and the resilience of the human psyche. Brain plasticity loosely means that our brain’s wiring can change over time based upon consistent and repeated behavioral responses. 

Neuroplasticity is technically defined as the brain’s ability to create new neural connections over time in order to ‘adapt, master new skills, store memories, and information’, and incorporate new methods of coping in response to positive changes (10). In other words, in the same way, that we learn to adapt and survive our trauma, we can learn new ways of ‘being’ in order to ‘re-wire’ or ‘unlearn’ the effects of trauma.

In order to elicit healthy changes in behavior, emotional regulation, and cognition it is important to receive the proper care and support from professionals that are well-versed and experienced in working with trauma. If you find yourself struggling with the lingering and distressing symptoms of PTSD, please seek help. There is no shame in admitting to and healing from our past painful experiences. Below, please find a list of therapy modalities that are proven successful in the treatment of trauma and PTSD.   

Note that if you choose to begin psychotherapy with a professional that, first and foremost, you must feel a connection with them. It is important to feel safe, heard, and seen in therapy especially when working through trauma. Therapeutic relationships are just like any other- they take time to build trust through showing up, putting in the work, being transparent, and having open communication. 

Furthermore, you are well within your rights to ask what types of interventions they use in order to get a better understanding of how they approach trauma treatment. Ask questions if you do not understand something!

Finally, know that it is important to remember that this process of unlearning and ‘re-wiring’ takes time and consistent effort. Trauma recovery does not happen overnight. Be patient with yourself!

Evidence-Based Treatments for PTSD: (11)

  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
  • Psychological First Aid (PFA)
  • Cognitive Restructuring and Cognitive Processing Therapy (CPT)
  • Exposure-Based Therapy (PE)
  • Dialectical Behavior Therapy (DBT)
  • Acceptance and Commitment Therapy (ACT)
  • Somatic Experiencing (SE) and Other Body-Based Interventions
  • Attachment, Self-Regulation, and Competence (ARC)- useful for children and families touched by trauma
  • Eye Movement Desensitization and Reprocessing Therapy (EMDR)
  • Coping Skills Therapy (CST)
  • Psychoeducation
  • Mindfulness-Based Stress Reduction (MBSR)
  • Medications/Psychiatry

“Trauma is a fact of life. It does not, however, have to be a life sentence.” – Peter Levine

“Loving ourselves through the process of owning our story is the bravest thing we will ever do.” -Brene Brown

Resources for Trauma Survivors

Resources for Trauma Survivors

Applications:

  • PTSD Coach- a user-friendly app created by the VA for Apple/Android devices to track and manage PTSD symptoms
  • InsightTimer- a user-friendly app for meditation and mindfulness work (free; year-long membership available as well for additional access to courses)

Online Resources:

Books:

  • “It Didn’t Start With You”, Mark Wolynn
  • “What Happened to You?”, Oprah Winfrey
  • “My Grandmother’s Hands: Racialized Trauma and the Pathway to Mending Our Hearts and Bodies”, Resmaa Menakem
  • “Trauma and Recovery”, Judith Herman
  • “The Body Keeps Score” Bessel van der Kolk
  • “Waking the Tiger”, Peter Levine
  • “The Boy Who Was Raised as a Dog”, Bruce Perry and Maia Szalavitz

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References: 

  1. https://www.apa.org/topics/trauma#:~:text=Trauma%20is%20an%20emotional%20response,symptoms%20like%20headaches%20or%20nausea
  2. https://www.psychologytoday.com/us/basics/trauma
  3. https://www.psychologytoday.com/us/blog/trauma-and-hope/201703/different-types-trauma-small-t-versus-large-t
  4.  https://www.nctsn.org/what-is-child-trauma/trauma-types
  5. https://canpweb.org/resources/connections-newsletter/2020-editions/connections-march-2020/aces-aware/
  6. https://www.psychologytoday.com/us/basics/trauma
  7. https://thriveworks.com/blog/four-phases-ptsd-impact-rescue-intermediate-recovery-long-term-reconstruction/#:~:text=PTSD%20can%20be%20divided%20into,terms%20with%20what%20has%20happened
  8. https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967#:~:text=PTSD%20symptoms%20are%20generally%20grouped,vary%20from%20person%20to%20person
  9. https://www.helpguide.org/articles/ptsd-trauma/coping-with-emotional-and-psychological-trauma.htm 
  10. https://www.emotiv.com/glossary/neuroplasticity/
  11. https://www.apa.org/ptsd-guideline/treatments 

Clarity Clinic

At Clarity Clinic, we have highly trained staff who specialize in psychotherapy and psychiatry services for those experiencing symptoms of PTSD. To learn more about how we can support your mental health, call Clarity Clinic on (312) 815-9660 or schedule an appointment today.

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