**Trauma -- the "Common Denominator"**

*Prepared with Assistance from CMHS's National Center for
Trauma-Informed Care*

**What is Trauma?**

The American Psychiatric Association's *Diagnostic and Statistical
Manual* (DSM-IV) defines a "traumatic event" as one in which a person
experiences, witnesses, or is confronted with actual or threatened death
or serious injury, or threat to the physical integrity of oneself or
others. A person's response to trauma often includes intense fear,
helplessness, or horror.[^1] Trauma can result from experiences that are
"private" (e.g. sexual assault, domestic violence, child abuse/neglect,
witnessing interpersonal violence) or more "public" (e.g. war,
terrorism, natural disasters).

Trauma is becoming increasingly recognized as a significant factor in a
wide range of health, behavioral health, and social problems.[^2] [^3]
Trauma resulting from prolonged or repeated exposures to violent events
can be the most severe.[^4]

Trauma is a central mental health concern and the one "common
denominator" of all violence and disaster victims. Clearly, different
individuals react to trauma in their own way, depending on the nature of
and circumstances surrounding their traumatic experiences. For example,
trauma associated with repeated childhood physical or sexual abuse can
become a central defining characteristic to a survivor's identity,
impacting nearly every aspect of his or her life. However, whether the
cause of the trauma is a hurricane, loss of a loved one, sexual assault,
child abuse, or domestic violence, or other incident(s), the trauma
experience is one thing that all victims share.

**Human and Social Impacts**

Trauma, especially when untreated, can have severe negative impacts on a
person's physical and emotional well-being. Trauma has been linked to
hallucinations and delusions, depression, suicidal tendencies, chronic
anxiety, hostility, interpersonal sensitivity (i.e. poor "social
skills"), somatization (i.e. "chronic fatigue syndrome"), eating
disorders, and dissociation.[^5]

Trauma victims are at a much higher risk for co-occurring mental health
and substance abuse disorders, violence victimization and perpetration,
self-injury, and a host of other coping mechanisms which themselves have
devastating human, social, and economic costs. Trauma has been linked to
social, emotional, and cognitive impairments, disease, disability,
serious social problems, and premature death.[^6]

In fact, between 51 percent and 98 percent of public mental health
clients diagnosed with severe mental illness have trauma histories,[^7]
and prevalence rates within substance abuse treatment programs and other
social services are similar.[^8] In children, trauma may be incorrectly
diagnosed as depression, attention deficit hyperactivity disorder
(ADHD), oppositional defiant disorder (ODD), conduct disorder,
generalized anxiety disorder, separation anxiety disorder, and reactive
attachment disorder.[^9] [^10]

The Adverse Childhood Effects (ACE) study, which examined the health and
social effects of traumatic childhood experiences over the lifespan of
18,000 participants, has demonstrated that ***trauma is far more
prevalent than previously recognized***, that the impacts of trauma are
cumulative, and that unaddressed trauma underlies a wide range of health
problems (e.g. heart disease, cancer, chronic lung disease, liver
disease, skeletal fractures, HIV-AIDS) and social problems (e.g.
homelessness, prostitution, delinquency and criminal behavior, inability
to hold a job). [^11] [^12] [^13]

**Financial Costs**

The financial burden to society of undiagnosed and untreated trauma is
staggering. Untreated trauma significantly increases the use of and
further strains the financial resources of health care and behavioral
health services, decreases productivity in the workplace, increases
reliance on public welfare, and increases incarceration rates. The
economic costs of untreated trauma-related alcohol and drug abuse alone
were estimated at \$160.7 billion in 2000.[^14] The estimated cost to
society of child abuse and neglect is \$94 billion per year, or \$258
million per day.[^15] For child abuse survivors, long-term psychiatric
and medical health care costs are estimated at \$100 billion per
year.[^16]

**Disaster-related Trauma**

Research on the consequences of recent public disasters, including the
1995 Oklahoma City bombing, the 2002 Challenger disaster, and the
September 11, 2001 terrorist attacks illustrates that disasters can
induce severe and long-term trauma, particularly in those with prior
histories of mental health problems, addiction, or trauma.[^17] [^18]
[^19] All disaster victims are likely to experience some form of trauma.
While many disaster survivors "recover" from grief and shock after a few
months, 25 percent to 30 percent of those directly affected may develop
full-blown Post-traumatic Stress Disorder (PTSD).[^20] [^21]

People with severe mental illness, addictions, and previous histories of
trauma are particularly vulnerable to the psychological impact of
disasters.[^22] [^23] People with prior exposure to domestic violence
(including physical or sexual abuse) in childhood or adulthood have
significantly heightened susceptibility to severe and chronic PTSD
following exposure to any type of traumatic event.[^24] [^25] [^26]
Similarly, refugees who had been previously traumatized in their native
countries and who had been diagnosed with PTSD are at risk.[^27]

For those with previous trauma histories, PTSD symptoms, and/or
substance abuse problems, trauma symptoms can actually *increase* with
time following a disaster. Often they are able to maintain stability
during the initial crisis, but after the immediate crisis passes, they
may re-experience thoughts, emotions, symptoms, and anxiety levels like
those associated with their previous traumas, causing a kind of
"relapse," increased demand on mental health services, and increased
suicide rates.[^28] [^29]

In addition, research has shown that domestic violence incidents can
increase 30 percent to 50 percent within three to six months following a
disaster in those communities affected.[^30]

**The Science of Trauma**

Especially when experienced in childhood, trauma produces
neurobiological impacts on the brain, causing dysfunction in the
hippocampus, amygdala, medial prefrontal cortex, and other limbic
structures.[^31] [^32] When confronted with danger, the brain moves from
a normal "information-processing" state to a survival-oriented, reactive
"alarm state." Trauma causes the body's nervous system to experience: an
extreme adrenaline rush; intense fear; information processing problems;
and a severe reduction or shutdown of cognitive capacities, leading to
confusion and a sense of defeat.

If there are insufficient biological or social resources to assist in
coping, the "alarm state" may persist even when the immediate danger has
passed, and this can lead to PTSD. Excessive and repeated stress causes
the release of chemicals that disrupt brain architecture by impairing
cell growth and interfering with the formation of healthy neural
circuits. When trauma occurs repeatedly, permanent changes in the brain
can occur, compromising core mental, emotional, and social functioning
-- and resulting in a brain that is focused on surviving trauma.[^33]

Developments in neuroscience show a multi-directional interconnection
between the body, brain, and mind. Post-traumatic stress is not a
permanent neuropsychological condition, but a functional and largely
reversible distortion in the multi-dimensional somatic and autonomic
pathways that meld the mind and body. These discoveries, together with a
range of new therapy approaches, are opening new perspectives on
healing,[^34] and new treatments are being explored within this context.
For example, cognitive behavioral therapy is thought to bolster cortical
function, especially that of the prefrontal cortex. The healing journey
is now seen to include biological as well as psychological
transformation.[^35]

Hurricane Katrina has provided a new sense of urgency for the
long-standing need for trauma education and awareness-building. A
greater understanding of the nature and impact of trauma is necessary to
promote the health and well-being of survivors and their families and to
set the stage for mental health professionals, service providers, law
enforcement and criminal justice officials, emergency responders, and
others to effectively and seamlessly integrate trauma understanding into
their programs and procedures. The positive consequences of an education
and awareness campaign will stretch far beyond the immediate context of
Katrina, reaching survivors of many different types of trauma and
facilitating healing for generations to come.

[^1]: American Psychiatric Association. (2000). *Diagnostic and
    statistical manual of mental disorders (DSM IV-TR), fourth edition*.
    Washington, DC: APA.

[^2]: Felitti, V. J. (2003). The Relationship of Adverse Childhood
    Experiences to Adult Health Status. Presented September 2003 at the
    \"Snowbird Conference\" of the Child Trauma Treatment Network of the
    Intermountain West. DVD published by The National Child Traumatic
    Stress Network.

[^3]: Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A.,
    Edwards, V., Koss, M., Marks, J. (1998). Relationship of childhood
    abuse and household dysfunction to many of the leading causes of
    death in adults: The adverse childhood experiences (ACE) study.
    *American Journal of Preventive Medicine,* 14(4), 245-258.

[^4]: National Child Traumatic Stress Network Complex Trauma Task Force
    (2003). *Complex trauma in children and adolescents: white
    paper.*Eds. Cook A., Blaustein, M., Spinazzola, J., vanderKolk, B.

[^5]: Mueser, KI., Rosenberg, S., Goodman, L., & Trumbetta, S. (2002).
    Trauma, PTSD, and the course of severe mental illness: an
    interactive model. *Schizophrenia Research*, 53, 123-143

[^6]: Anda, R., Felitti, V., Walker, J., Whitfield, C., Bremner, J.,
    Perry, B., Dube, S., Giles, W. The enduring effects of abuse and
    related adverse experiences in childhood: A convergence of evidence
    from neurobiology and epidemiology. (Submitted for publication) (ACE
    Study).

[^7]: Mueser, K., Goodman, L.A., Trumbetta, S.L., Rosenberg, S.D.,
    Osher, F.C., Vidaver, R., Auciello, P., & Foy, E.W. (1998). Trauma
    and post-traumatic stress disorder in severe mental illness.
    *Journal of Consulting and Clinical Psychology, 66*, 493-499.

[^8]: Center for Substance Abuse Treatment. (2000). *Substance abuse
    treatment for persons with child abuse and neglect issues Treatment
    Improvement Protocol (TIP) series.* (DHHS Publication No. SMA
    00-3357, Number 36. Washington, DC: U.S. Government Printing Office.

[^9]: *The Science of Early Childhood Development: Closing the Gap
    Between What We Know and What We Do.* Jack P. Shonkoff, Dean of the
    Heller School for Social Policy and Management, and Chair of the
    National Scientific Council on the Developing Child. Presentation to
    the 15^th^ National Conference on Child Abuse and neglect, Boston,
    MA April 19, 2005. Powerpoint: National Scientific Council on the
    Developing Child.

[^10]: ^?^ Cook, A., Blaustein, M., Spinazzola, J., and van der Kolk, B.
    (2003). Complex trauma in children and adolescents: White Paper from
    the *National Child Traumatic Stress Network: Complex Trauma Task
    Force.*

[^11]: Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A.,
    Edwards, V., Koss, M., Marks, J. (1998). Relationship of childhood
    abuse and household dysfunction to many of the leading causes of
    death in adults: The adverse childhood experiences (ACE) study.
    *American Journal of Preventive Medicine,* 14(4), 245-258.

[^12]: Felitti, V. J. (2003). *The Relationship of Adverse Childhood
    Experiences to Adult Health Status*. Presented September 2003 at the
    \"Snowbird Conference\" of the Child Trauma Treatment Network of the
    Intermountain West. DVD published by The National Child Traumatic
    Stress Network.

[^13]: See [www.ACEstudy.org](http://www.ACEstudy.org/)

[^14]: The Economic Costs of Drug Abuse in the United States 1992-1998.
    Report prepared by The Lewin Group.

[^15]: Prevent Child Abuse America. (2001). *Total estimated cost of
    child abuse and neglect in the United States: Statistical evidence*.
    Report funded by the Edna McConnell Clark Foundation.

[^16]: The Ross Institute ([www.rossinst.com](http://www.rossinst.com/))

[^17]: Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M.,
    Gold, J., & Vlahov, D. (March 28, 2002). Psychological sequelae of
    the September 11 terrorist attacks in New York City. *New England
    Journal of Medicine*, Vol. 346, No. 13, pp. 982-987

[^18]: Terr, L. C., Bloch, D. A., Michel, B. A., Shi, H., Reinhardt, J.
    A., & Metayer, S. (1999). Children\'s symptoms in the wake of
    Challenger: a field study of distant-traumatic effects and an
    outline of related conditions. *American Journal of Psychiatry*,
    156, 1536-1544.

[^19]: Breslau, N., Chilcoat, H. D., Kessler, R. C., Davis, G. C.
    (1999). Previous exposure to trauma and PTSD effects of subsequent
    trauma: Results from the Detroit Area Survey of Trauma. *American
    Journal of Psychiatry,* 156:902-907.

[^20]: North, C.S. (2001). The course of post-traumatic stress disorder
    after the Oklahoma City bombing. *Mil Med*, 166 (12 Suppl): 51-2

[^21]: Abenhaim, L., Dab, W., & Salmi, L. R. (February 1992). Study of
    civilian victims of terrorist attacks (France 1982-1987). *Journal
    of Clinical Epidemiol*, 45(2);103-9.

[^22]: North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J.,
    Spitzanagel, E., & Smith, E. (1999). Psychiatric disorders among
    survivors of the Oklahoma City bombing. *Journal of the American
    Medical Association*, 282, 755-762.

[^23]: Mueser, K. T., Trumbetta, S. L., Rosenberg, S. D., Vidaver, R.
    M., Goodman, L. B., Osher, F. C., Auciello, P., Foy, D. W. (1998).
    Trauma and Posttraumatic Stress Disorder in severe mental illness.
    *Journal of Consulting and Clinical Psychology*, 66(3), 493-499.

[^24]: North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J.,
    Spitzanagel, E., & Smith, E. (1999). Psychiatric disorders among
    survivors of the Oklahoma City bombing. *Journal of the American
    Medical Association,* 282, 755-762.

[^25]: King et al. (1999). Stretch, Knudson, & Durand (1998). Bremner,
    Southwick, Brett, & Fontant (1992). Breslau et al. (1998). Green et
    al. (2000). Nishith, Mechanic, & Resnick (2000). In B. Litz, M.
    Gray, R. Bryant, & A. Adler. *Early intervention for trauma: Current
    status and future directions*. A National Center for PTSD Fact
    Sheet. See www.ncptsd.org/facts/disasters/fs_earlyint_disaster.html

[^26]: Breslau, N., Chilcoat, H. D., Kessler, R. C., Davis, G. C.
    (1999). Previous exposure to trauma and PTSD effects of subsequent
    trauma: Results from the Detroit Area Survey of Trauma. *American
    Journal of Psychiatry*, 156:902-907.

[^27]: Kinzie, J. D., Boehnlein, J. K., Riley, C., Sparr, L. (July
    2002). The effects of September 11 on traumatized refugees:
    Reactivation of Post Traumatic Stress Disorder*. J Nerv Ment Dis*,
    190(7):437-41

[^28]: Nader, K. (1998). Violence: Effects of a parents' previous trauma
    on currently traumatized children. In Y. Danieli (Ed.), *An
    international handbook of multigenerational legacies of trauma* (pp.
    571-583), New York, NY: Plenum Press.

[^29]: Brewin, C. R., Andrews, B., Valentine, J. D. (2000).
    Meta-analysis of risk factors for Posttraumatic Stress Disorder in
    trauma-exposed adults. *J of Consulting and Clinical Psychology*,
    68:748-766.

[^30]: Norris, F. H. *Prevalence and impact of domestic violence in the
    wake of disasters*. A National Center for PTSD Fact Sheet. (See
    www.ncptsd.org/facts/disasters/fs_domestic.html)

[^31]: Hull, A. (2002). Neuroimaging findings in post-traumatic stress
    disorder. *British Journal of Psychiatry, 181,* 102-110.

[^32]: Van der Kolk, B., Pelcovitz, D., Roth, S., Mandel, F., McFarlene,
    A., Herman, J. *Dissociation, affect dysregulation and somatization:
    The complex nature of adaptation to trauma.* May 2005

[^33]: Anda, R., Felitti, V., Walker, J., Whitfield, C., Bremner, J.,
    Perry, B., Dube, S., Giles, W. *The enduring effects of abuse and
    related adverse experiences in childhood: A convergence of evidence
    from neurobiology and epidemiology.* (Submitted for publication)
    (ACE Study).

[^34]: Bessel van der Kolk.  (2002)  *In Terror's Grip: Healing the
    Ravages of Trauma*. Cerebrum, 4, 34-50. NY: The Dana Foundation.

[^35]: Peter A. Levine, Ph.D. (1997)*Waking the Tiger: Healing Trauma:
    The Innate  Capacity To Transform Overwhelming Experiences.* 
    Berkeley: North Atlantic Books.