# Motivation and emotion/Book/2022/Psychological trauma

* Multimedia presentation (3 min)

## Overview

Have you ever been through an event or experience that caused a threat to your life or someone else’s? Do you ever try to avoid anything that reminds you of what happened so it does not distress you? Throughout the[awkward expression?] history of humankind, not only does the essence of culture, science, and arts were the story[grammar?], but also the traumatic events of nature and human origin have left a significant impact on the lives of individuals. Psychological trauma is psychological damage resulting from an uncontrollable, terrifying event experienced by an individual physically or emotionally, which adversely affects the normal functioning of their lives (Kolk, 2003). Unlike other commonplace misfortune, traumatic events leave an extremity[awkward expression?] of helplessness and terror threats to our life and bodily integrity (Herman, 2015). Fundamentally, psychological trauma aims to address the causes, signs, symptoms, and treatment of trauma[say what?][Rewrite to improve clarity].
* Focus questions:
* What is psychological trauma?
* How does psychological trauma affect people's lives[grammar?]?
* What integrated approaches is best for psychological trauma[grammar?]?

## What is Psychological Trauma?

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### Definition

Psychological trauma is an emotional response to a highly negative and distressing situation, event, or series of events such as abuse, betrayal, helplessness, natural disaster, rape, or constant deprivation (American Psychological Association, 2022; Starcevic, 2019). Individuals may directly experience or witness the trauma happening to someone that can cause overwhelming pain and distress beyond the individual's capacity to cope, leaving them feeling helpless (Ruglass & Kendall-Tackett, 2014) (e.g., see Figure 1). The traumatic event can be single or repeated over time. Given the subjective experience, the various factors impact the traumatic events; thus, not all individuals will be traumatised, although they may undergo distress (Storr et al., 2007).
* Case Study:
* Kate is 14 years old teenager, she is currently in year ten and living in foster care. She has PTSD related to childhood sexual abuse and a violent environment. At nine, Kate was sent to foster care and witnessed her stepfather's violent behaviour from age five. Her stepfather sexually abused her on many occasions. Since then, she has moved around three different adoptive parents, all of whom have physically abused her, making her return to foster care. She neither has close friends nor socialises at school and most often avoids male friends during group activities and male teachers at her school. She gets defensive, and her behaviour escalates whenever a male teacher and friends approach her to help with schoolwork.
* After thoroughly assessing her PTSD and comorbid symptoms, Prolonged Exposure (PE) Therapy treatment for Kate's disorder involved 15 sessions. The evidenced-based PE focuses on breathing retaining, psycho-education, and imaginal exposure. Kate showed improvement in her social life and the quality of her life through the treatment.

### Historical Background

The word "trauma" originated from the Greek meaning "to damage, to harm (Perrotta, 2019)." The study of traumatic emotional distress started during the late 19th century (Kolk, 2000). Kolk (2000) also explained that the French neurologist Jean-Marti Charcot proposed that the symptoms of all mental illnesses, called "hysteria," had origins in trauma histories. Pierre Janet, Charcot's student, identified that the traumatic events people experience could alter the individual's psychic system, threatening mental cohesion (Janet, 1925). Sigmund Freud, the father of psychoanalysis, also examined the concept of psychological trauma and Kolk (2005) explained that in his Beyond the Pleasure Principle (1920), Freud described how patients' sufferings from the traumatic experiences "often lack the conscious preoccupation with the memories of their accident" (p.12).

## Theories of Trauma

Trauma theories are an interdisciplinary field of study developed to examine how traumatic event occurs, and the kinds of literature and historical texts demonstrated and exposed.

#### A psychoanalytic theory of trauma

The concept of trauma to Sigmund Freud, initially the formulation of hysteria, was associated with something disorganising and overwhelming that either had already taken place or was taking place (Levine, 2014). Freud thought all the hysterical symptoms caused childhood sexual abuse leaving unconscious memories. Later, when exposed to a similar situation, those memories were reactivated upon reminiscing the original trauma (Zepf & Zepf, 2007). In the modern restatement of Freud's ideas, he described trauma as a break in the protective shield[say what?] against the stimuli creating a profound state of disorganisation and causing the mind intense anxiety (Marziller, 2014). This stimulus triggers internal anxiety, leaving the individual feeling unsafe and not regular, which once was safe and normal, rupturing the distinction between the past a present. It leads to a loss of trust and unconsciously replaces the trauma with flashbacks and nightmares. Although it is a temporary state and most people eventually recover the equilibrium, in some, it is not the same, leading to severe traumatic disorders. Thus, the essence of the psychoanalytic model explains the external trauma triggering internal anxiety (about oneself and the world), creating doubt, anxiety, and confusion (Marziller, 2014).

#### Ehlers and Clarks's cognitive model

The cognitive model proposed by Ehlers and Clark (2000) has been highly influential concerning post-traumatic stress disorder (PTSD). This model suggests that the sense of severe current threat, regardless of the onset of trauma (current or even from the past), is the core experience of PTSD (Murray & Ehlers, 2021). The sense of current threat is a consequence of "individual differences in the appraisal of the trauma and its sequelae, and individual differences like the memory for the event and its link to other autobiographical memories" (Ehlers & Clark, 2000, p. 320). They explained that upon activation, the current perceived threat is accompanied by the intrusion and other re-experiencing symptoms, leading to a severe behavioural and cognitive response intended to reduce the perceived threat and distress in a short period (Ehlers & Clark, 2000; Murray & Ehlers, 2021). Therefore, the model describes why some people develop PTSD after significant trauma, and others do not (Marziller, 2014).

#### Biological Theory

Biological theories explain how trauma can modify the expression of genes and how it can impact the brain related to the fear conditioning model associated with the traumatic stressor (Alisic et al., 2011). The biological framework focuses on the brain's interpretation and storage of external information in response to stimuli. Lee (2006) explained that the frontal cortex of children continues to develop slowly through adolescence, thus making it more malleable to external cues. The brain is the centre of emotional, behavioural, and cognitive functioning. Any traumatic experience can disrupt the neurochemical signal, such as the continuous release of stress hormone (Cortisol), leading to a disorder such as PTSD (Perry, 2008). Therefore, the biological model provides an important clue regarding the biological mechanism for trauma.

#### Developmental psychopathology model

Developmental psychopathology is the most integrated model used to guide studies on the development of PTSD in children after traumatic events, also referred to as general risk models (Alisic et al., 2011). In their [who?] findings, they explained that the characteristics of the stressor and the child's environment influence children's post-trauma adjustment. Therefore, the developmental psychopathology model suggests different avenues, such as childhood traumatic experience and PTSD, which can intesect with other anxiety disorders and result in increased impairment over the lifespan (Pynoos, Steinberg & Piacentini, 1999).

#### Trauma Model of Mental Disorder

The psychiatrist Colin Ross coined the trauma model of mental disorder. Ross posits the effects of psychological trauma as the critical factor for developing other psychiatric disorders such as depression, anxiety, and psychosis (Read et al., 2005). They have concluded that there are several psychological and biological mechanisms that increase the risk of developing psychosis, specifically for hallucinations , as a result of childhood trauma[Rewrite to improve clarity].

## What are the causes of psychological trauma?

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#### Situational Trauma

Overwhelming adverse events, such as natural disasters, child abuse, domestic violence, warfare, and many more situational traumas can cause long-lasting effects on the victim's mental health and emotional stability. Although individuals' responses to trauma can vary based on the types of traumatic events, it leaves an intense trademark on the lives of those victims. Numerous pieces of literature explain the causes of trauma, including Beaglehole et al. (2018), explaining how a natural disaster, a potentially traumatic event, can have an acute onset. They also explained the increased rate of psychological distress following a natural disaster. The [missing something?] is a difference between the trauma caused by the current situation and the long-term repressed memories underlying trauma, which may have been from past traumatic experiences such as childhood abuse (sexual/physical) (McCarthy & Cook, 2019) and domestic violence (Mezey et al., 2005). Johnson and Thompson (2007) provided a comprehensive and critical summary of the development and maintenance of PTSD following civilian war trauma and torture.

#### Medical Condition

There has been research on how existing medical conditions can cause psychological trauma. Carlson (2013) explained that all psychological traumas emerge from stress in response to an unpleasant and distressing stimulus. Exposure to long-term stress can result in the re-regulation of the sympathetic nervous system and the amygdala's (fight or flight) response from a continuous supply of stress hormones (Perry, 2008). Studies have found that existing health issues like cancer and HIV/AIDS can also result in the development of trauma. Costa-Requena and Gil (2010) conceptualised that the complex and protracted nature of cancer and its treatment is potentially a traumatic event leading to psychological trauma. Additionally, in terms of HIV/AIDS, patients were diagnosed with PTSD, which was a direct result of HIV/AIDS due to a history of sexual violation (sexual abuse) for the female gender, resulting in unprotected sex and prostitution (Olley et al., 2005).

#### Vicarious Trauma

The [which?] studies have examined the effect of vicarious trauma work on those who work with traumatised clients. According to Cohen and Collins (2013), "the impact of trauma work can potentially increase short- and long-term levels of distress" (p. 570). There is a potential risk for many people, including health care, law professionals, lawyers, and journalists, which can result in second-hand exposure to trauma that may predispose an individual to vicarious trauma (Ravi et al., 2021). Psychological trauma can also be caused by witnessing other people's traumatic situations.

#### Moral Injury

A growing body of literature recognises moral injury as emotional distress and suffering following moral transgression (Zasiekina et al., 2022). Moral injury has gained increased conceptual and empirical attention among military personnel and veterans, and the transgression-self was significantly associated with hopelessness, betrayal, and pessimism resulting in the development of PTSD (Bryan et al., 2016). Zasiekina et al. (2022) analysed moral injury to assess the attributes, consequences, and empirical referents of moral injury in Ukrainian National Guard service members during the 2022 full-scale invasion of Ukraine by Russian troops. The guards also indicated moral injury and the development of PTSD with depression and anxiety.

### Types of Traumas

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#### Characteristics of Trauma

The objective characteristics are types of traumas are those elements of traumatic events that influence the effects of traumatic stress.
Table 1
Three main types of traumas and their objective characteristics
| Types of Traumas | Objective Characteristics |
| Acute Trauma | Refers to trauma that has occurred due to single events which was overwhelming to trigger a trauma (McNally, 2002) |
| Chronic Trauma | Series of incidents for repeated and pro-longed (Overstreet & Mathews, 2011) |
| Complex Trauma | Multiple traumatic events overlapping or in succession (Cook et al., 2005) |

#### Examples of trauma

Although the classification of traumas can be natural or caused by human beings, how people react to them will mobilise in the aftermath. The following table reviews various types of traumas with examples referenced from chapter 2, Trauma Awareness of Trauma-informed care in behavioural health services (SAMHSA, 2014)
Table 2
The Trauma Examples referenced from Centre of Substance Abuse Treatment, 2014
| Naturally Caused | Caused by People | Caused by People |
| Flood Tornado Wildfire Earthquake Landslide Typhoo | Accidents, Technologies | Intentional Acts |
| Flood Tornado Wildfire Earthquake Landslide Typhoo | Aircraft Crash Car accident due to malfunction Gas explosion Sport-related death | Terrorism Sexual assault Domestic Violence/ Physical abuse Genocide Warfare Human trafficking |

## What are the signs and symptoms?

Although the link between overall trauma and psychological distress and physical health issues (Goldsmith et al., 2012), the severity of these symptoms depends on the individuals' type of trauma, the response towards that traumatic event and the support received from others to overcome it. However, the expected common symptoms may occur after the traumatic events. The symptoms include the everyday experience of intrusive thoughts and memories of the event, including the unintentional re-experiencing and recall of the trauma narrative (Ehlers et al.,, 2004). For example, a bang on the door may cause intrusive thoughts of traumatic experiences like domestic violence. Traumatic events make the individual more likely to experience hyper-vigilance and hyper-arousal. Phan and colleagues studied community violence exposed to African American male adolescents. The study found that individuals exposed to the traumatic stressor represent symptoms such as difficulty sleeping, being overly careful, irritability, and being easily startled (Phan et al., 2020).
After a traumatic experience, individuals' belief about safety and security is more likely to be altered; the feeling of threatening and anxiety-provoking is likely to occur upon exposure to the cue (Marziller, 2014). In some traumatised people, emotional exhaustion sets, causing emotional detachment or emotional numbing (Kerig et al., 2012), resulting in the individuals damping down all their emotions to dissociate the painful emotions. Meanwhile, some traumatised people engage in unhealthy coping behaviours such as using psychoactive substances, including alcohol. Despite the listed symptoms, some individuals may feel annihilated, leading to low self-esteem, depression, and suicidality (Silvern et al., 1995). Therefore, it is imperative to be aware and keep an eye on these symptoms.

## How can we diagnose?

Trauma- and stressor-related disorders exposed to traumatic or stressful events can be listed explicitly as a diagnostic criterion. These include reactive attachment disorder, disinhibited social engagement disorder, post-traumatic stress disorder (PTSD), acute stress disorder, and adjustment disorder (APA, 2013). According to the DSM-5, the definition of trauma requires "actual or threatened death, serious injury, or sexual violence" (APA, 2013, p. 271). This exposure could be in one or more of four ways: experiencing the event, witnessing the event in person occurring to others, learning that the event happened to close family or friends, and experiencing repeated exposure or extreme to the aversive details of the event (Jones & Cureton, 2014). After 14 years of revision, APA released the DSM-5 (APA, 2013) version, which significantly revised the diagnostic criteria for PTSD (Marziller, 2014). Individuals exposed to traumatic situations can exhibit the symptoms in an anxiety- or fear-based context was research-based[Rewrite to improve clarity]. According to the DSM-5 (APA, 2013), the individual's response, such as intense fear or helplessness, is no longer diagnostic. In the DSM-5, PTSD symptom clusters have extended from three to four, and the PTSD diagnosis too.
During clinical assessment, individuals may exhibit distress and anxiety upon activating the response to the traumatic experience. Treating them respectfully and providing them with a caring and supportive environment is essential. The assessor's responsibility is to understand the traumatised person's opinion and situation in an unstructured manner of psychological trauma assessment such as a support source (Dadkhah et al., 2014)[Rewrite to improve clarity]. Lastly, Mildred's (2008) review of the book on helping abused and traumatised children: integrating directive and non-directive approaches by Eliana Gil explains that children can be assessed through therapy such as art, play, and sand therapy and the use of arts and play in the clinical setting.

## What are the treatments?

Several ongoing studies and approaches have been conducted, such as trauma therapy approaches, trauma-informed teaching practice, and self-help recovery strategies designed to treat trauma.

### Trauma Therapy approaches

There have been many types of trauma therapy evidenced-based treatment which has been effective in treating trauma. The following are the types of evidence-based therapy treatment:

#### Cognitive-behavioural therapy

Cognitive-behavioural therapy (CBT) focuses on thoughts, feelings, behaviours, and relationships (Cohen & Mannarino, 2008). CBT usually takes up to 12 to 16 sessions, and the therapist helps the client understand the traumatic situation and helps them to shift from a negative toward a realistic trajectory.

#### Eye Movement Desensitisation and Reprocessing

Eye movement desensitisation and reprocessing (EMDR) is a psychotherapeutic approach to treating PTSD (Valiente-Gomex et al., 2017). It involves processing trauma memory while simultaneously experiencing bilateral stimulation (eye movement) to change the beliefs about the traumatic event by reducing the vividness of the emotions associated with the trauma memories.

#### Prolonged Exposure (PE)

Prolonged Exposure (PE) is a treatment program commonly used to reduce the pathological fear-related emotions in PTSD (Foa, 2011). The three primary treatment exposure procedures: are in vivo (real life), imaginal, and interceptive, and the "pathological characteristics" dictated the selection of the type of exposure (Foa, 2011, p. 1043) of the given disorder. The pathological anxiety intentionally confronted the fear patients were exposed to reduce or overcome the fear gradually.

### Medication

Prescribed medications, such as antidepressants and monoamine oxidase inhibitors (Bernardy &Fredman, 2015), are for patients diagnosed with PTSD. It helps reduce symptoms, such as hyper-arousal, to improve sleep, decrease trauma-triggering nightmares, and help other mental disorders, such as anxiety and depression, that occur with PTSD.

### Complementary approaches to trauma threat

Several complementary approaches to treating trauma include trauma-informed teaching practice (Koslouski, 2022), acupuncture, yoga, meditation, and mindfulness.

### Quizzes
## Conclusion

Psychological trauma is a response to highly adverse events or experiences that overwhelm an individual's or community's coping resources (Kolk, 2000). It affects every race, ethnicity, age, sexual orientation, gender, and psychosocial background. The impact of trauma can also be exemplified by the rock hitting the water surface (SAMHSA, 2014). At first, it creates an intense wave followed by a less intense ripple. Likewise, the impact of trauma can be intense at first, but when it is addressed, with the help of therapeutic treatment, the effect of traumatic events gets less intense as removed further away from the trauma. So, existing theories can effectively address the underlying issues of psychological trauma. Although it can harm one's belief, access to integrated treatments that combine therapeutic models can target presenting symptoms and disorders. Thus, one's equilibrium of belief, physical integrity, and emotional response can become fundamentally stable.