understanding traumatic stress

Those suffering from trauma continue to experience events, often unconsciously, as if it were occurring in the here and now. The chronically aroused Autonomic Nervous System (ANS) does not know that the traumatic event is over. The trauma sufferer is in a vicious cycle; the reality within the nervous system is not of a historic event but of a currently happening event.  

It is what Bessel Van der Kolk (1996) describes as ‘a tyranny of the past that interferes with the ability to pay attention to both new and familiar situations’. With the passage of time the person has been unable to integrate the awful experiences and instead develops patterns of avoidance and lives in a chronic state of hyper-arousal. 

In non-traumatic stress the sympathetic nervous system (SNS) becomes more active whilst the parasympathetic nervous system (PNS) lowers.  Picture the process as a set of scales, two systems working together and complimenting each other. In non-traumatic stress once the threat is over the scales re-balance - arousal in the SNS will lower and the PNS will rise and with it balance is restored. 

Traumatic stress is different, both sides of the ANS are activated together. The SNS constantly prepares the body for a threat that does not exist whilst the PNS is also activated leading to tonic immobility (freeze). 

When the ANS is hyper-activated a person may experience some or all of the following internal affects without an external cause - rapid heart rate, cold sweating, rapid breath, heart palpitations, tendency to startle, hyper vigilant, difficulties concentrating, visual/auditory or somatic intrusions such as flashbacks. They may have difficulty sleeping, nightmares, loss of appetite and sexual dysfunction. In a chronic state the ANS gradually closes down into deadness, numbness and depression. The numbness might bring a sense of balance but the illusion is one that for most cannot be sustained and if it is comes with a high price tag. 

The role of Dissociation 

One of the symptoms always present in traumatic stress is some degree of dissociation. Dissociation is a basic defence against mental pain and an attempt to cut off contact with others who might generate further (unpleasant) sympathetic nervous system arousal. Van der kolk (1996) defines dissociation as a way of compartmentalising experience so that its constituent parts are not integrated. Its function is to lessen the impact of an event that was too overwhelming for the system to integrate. 

People respond to trauma in a number of ways. Some use dissociation to bury the fragments of their experience to such an extent that it does not really interfere with their overall functioning.  There are a significant number of people who do not experience the full debilitation of PTSD but who do suffer with some of the symptoms of trauma to the extent that their life is limited and restricted in some way. Others organise their whole personality around dealing with the aftermath of traumatic experiences.  This is particularly the case for those diagnosed with Borderline Personality Disorder. 

For some, dissociated fragments manifest only in circumstances reminiscent of the original event, ie, state dependent conditions. This is what is meant by flashback, which may be a visual, auditory, emotional, behavioural or somatic or combined experience. Rothschild (2000) points out that the state-dependent conditions can be triggered by introceptive and extroceptive cues. Introceptive cues are elicited from sensations within the body (heart pounding, sweating, tensing) and extroceptive from stimuli outside the body. 

In many cases disassociation is held in the body tissue and re-experienced as physical pain (somatic flashbacks). An example of this is a client who came to me with a pain in his left shoulder and lower back which began at the same time as a violent attack.  Another client connected breathing difficulties commencing when witnessing an event in which his daughter was seriously injured.  In both cases as the wounded body was given space and the emotional energy digested and integrated these somatic symptoms were no longer required.

What is traumatic?

Just because something is traumatic, shocking or overwhelming does not mean that we will go on to ‘suffer’ long-term consequences in the form of post-traumatic stress or post-traumatic stress disorder. 

Traumatisation tends to occur only when internal and external resources are inadequate to cope with the external threat. Factors that may determine whether trauma, shock, stress has a long lasting impact are:

• The duration and intensity of the event or events (external threat)
• Whether the event is perceived as natural and without malice or results 
• from malicious intent (external threat)
• The recovery environment – social support, community, societal attitudes 
• (external resource)
• The person’s life history, coping mechanisms, and resourcefulness, all of 
• which will be age specific (internal resources). Therefore you would expect a child to have fewer internal coping mechanisms and therefore less resourcefulness than a teenager and an adult to have more that a teenager. 

Life threatening experience does not need to be actual it just has to be perceived as such. The threat of something can be as traumatising as it actually happening. At times of high arousal the ability to differentiate between actual and perceived becomes blurred and can lead to our imagined fears feeling like reality. 

Trauma involves interpersonal failure i.e., experiences of abandonment, isolation, shame and invisibility – all of which are relational. What’s more it is often not the traumatic event that leads to ongoing symptoms of trauma but what happens, ie, whether those around are perceived as supportive, caring, empathic, re-assuring and/or giving assistance.  

Different types of Trauma 

There are the Big ‘T’ traumas associated with life and death situations and the small ‘t’ developmental traumas that occur during development in responses to our environment. 

Small ’t' developmental trauma results from repetitive interactions that modify behaviour. The child creates a defence against the pain, anxiety and frustration of their basic needs not being met. In contrast, big ’T’ shock trauma does not develop over time but is a reflexive process regulated by the limbic system and outside an individuals control. These reflexes are the fight, flight, freeze responses previously mentioned and operate in response to extreme threat (see Rothschild, 2000)

David Wallin (2007) in his book Attachment in Psychotherapy writes about the significance of small ‘t’ traumas, which result from a child’s repeated experiences of fear, helplessness, humiliation, shame and/or abandonment in relation to attachment figures who provided no repair. These small ‘t’ traumas can result in ‘primitive mechanisms of self protection such as dissociation and projective identification’. What is significant for these people is that they experience the therapeutic relationship itself as intolerable in a way that leads  to further fragmentation, disintegration and dissociation. 

From a biodynamic psychology* perspective trauma persists because we have been unable to restore our internal equilibrium and retained within the autonomic nervous system is a residue of the disturbance. For example a baby who has had a hard struggle through the birth canal recovers unscathed as a result of being able to fully rest and recuperate on the mother’s body. Given an atmosphere of security and trust we recover even from severe trauma but without this emotional cycles cannot complete. 

In biodynamic psychology the reason disturbance patterns accumulate is due to interruptions to the startle reflex pattern. The startle reflex is a whole body contraction in response to any sudden shock reaction whether physical, emotional or psychic stress (Boyesen M, 1978). The actual startle reflex is essentially healthy as it prepares the organism for action – fight or flight. Disturbance occurs as a result of what happens after the shock reaction. Once the event has passed the body should return to equilibrium with harmony between muscular response and respiratory rhythm (Boyesen M, 1978). This only happens if emotional expression has occurred.

In my next paper I focus on how restoring organismic regulation to support a return to equilibrium.

Note: * Biodynamic psychology is the branch of psychology developed by Clinical Psychologist Gerda Boyesen (1922-2005).

References

Boyesen, M (1978) The startle reflex pattern & organic equilibrium. Energy & Character, Vol. 9, No.2 
Rothschild, B. (2000) The body remembers; the psychotherapy of trauma and trauma treatment: New York & London, Norton 
Van der Kolk, B.A., McFarlane, A.C., Weisaeth, L. Editors (1996) Traumatic Stress, The effects of overwhelming experience on mind, body and society: New York & London, Guilford Press 
Wallin D.J. (2007) Attachment in Psychotherapy, Guilford, New York