In the first module, we defined trauma as the emotional response to a distressing situation. A history of trauma increases one’s likelihood of developing obesity, diabetes, myocardial infarction, stroke, smoking, and using alcohol and other substances.
In this module, we look at the impact of trauma on mental health.
Trauma: body & brain
- Overproduction of stress hormones
- Hormones stay in the system for hours or days
- Alarm system in the brain remains “on”
- Responses are involuntary
- Traumatized people may exhibit:
- An exaggerated startle response
- Difficulty reading faces and social cues
- Misinterpretations of non-threatening behaviours
- Difficulty sleeping
- Avoidance of situations they find frightening
In the first module, we discussed how our internal alarm is activated during threatening situations. This enables us to protect ourselves.
Responses to traumatic events vary greatly. Most trauma survivors are able to use social support to develop strategies that help them cope. While 70–90% of people experience a traumatic event during their lifetime, only 6% of them develop post-traumatic stress disorder (PTSD).
If the trauma occurs early in life and lasts a long time, the body’s response lasts longer as well. The limbic system, the brain’s alarm, gets stuck on “high alert.” Everyday stresses begin to keep the alarm engaged.
People in these states startle easily, have trouble reading facial expressions of others, have difficulty sleeping, and may start avoiding situations that increase stress.
Post-traumatic stress disorder is the most serious mental health condition resulting from traumatic experiences.
The trauma continuum
Accident, or a single event
Prolonged developmental trauma
Also in the first module, we discussed the trauma continuum. The continuum visualizes the degree to which a person may be affected by trauma.
People who experience fewer traumatic events and have the resources to address their impact place low on the continuum. However, as the frequency and duration of events increases, so do the symptoms that they may experience.
The other end of the continuum describes a history of severe, long-term trauma. For those who belong to marginalized groups, factors such as limited social support, socioeconomic status, and interpersonal discrimination further contribute to stressors. This is called minority stress, and also has an impact on health and well-being.
Those who have endured prolonged trauma may struggle with chronic behaviours like self-harm, substance use, and suicidal tendencies as they attempt to cope with their experiences.
It is important to understand that the continuum does not attempt to rank trauma. Rather, it seeks to explain the profound and devastating impacts of all types of trauma.
Disorder v. injury: PTSD & PTSI
- “Post-Traumatic Stress Disorder” in the Diagnostic and Statistical Manual of Mental Disorders-TR
- People with PTSD experience difficulty:
- Caring for themselves or loved ones
- Functioning at work
- Managing social relationships
- This results in significant challenges managing life on a day-to-day basis
PTSD is a mental health illness which is diagnosable using the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders. Individuals with PTSD experience difficulty caring for themselves and their families, functioning at work, and managing social relationships. While the specific symptoms vary widely from one person to the next, PTSD causes significant difficulty managing life on a day-to-day basis.
Mental health advocates have suggested using the term post-traumatic stress injury as an umbrella term to focus attention on the person’s experience of trauma. The word “injury” acknowledges that psychological trauma is inflicted on a person, just as any physical injury is, and similar to physical injury, can range in severity and impacts.
Subtypes of PTSD
- PTSD: Symptoms are significant and impact the person’s daily functioning
- Delayed PTSD: Has the same symptoms as PTSD. May occur weeks, months, or even years after the event
- Complex/Developmental PTSD: Complex PTSD is profoundly disruptive. It has the most severe symptoms of these subtypes, and impacts all of the person’s relationships
PTSD is often severe, chronic, and disabling. It’s the most serious mental health condition that people who have experienced trauma can develop.
Subtypes of PTSD include delayed PTSD and complex or developmental PTSD.
With delayed PTSD, symptoms may appear weeks, months, or even years after the traumatic event. Their onset can be frightening and confusing, as it may be unclear why they are happening.
As the term suggests, complex or developmental PTSD is the result of trauma experienced at an early age. In most cases, the childhood trauma was prolonged and involved a close relationship with an authority figure.
Complex PTSD is profoundly disruptive, with the most severe symptoms of the subtypes. It impacts every aspect of and relationship in the individual’s life — including their encounters with healthcare providers.
PTSD: diagnostic criteria
- Traumatic event
- Re-experiencing traumatic event
- Avoidance and emotional numbing
- Unable to function
- Month or more
Khouzam H. R. (2001). A simple mnemonic for the diagnostic criteria for post-traumatic stress disorder. The Western journal of medicine, 174(6), 424. doi.org/10.1136/ewjm.174.6.424
The mnemonic TRAUMA is a useful tool for remembering the criteria that diagnose PTSD:
- “T” represents the traumatic event that caused the person to experience intense helplessness, fear, and horror
- “R” represents re-experiencing that event through intrusive thoughts, nightmares, and flashbacks. Someone with PTSD will relive the trauma in images, sounds, smells, and physical sensations. These moments are usually accompanied by extreme psychological distress such as trembling, crying, fear, rage, and paralysis
- “A” represents avoidance of reminders of the trauma, which results in emotional numbing. The person may persistently avoid activities, places, people, or events associated with the traumatic experience. Emotional numbing is associated with an inability to experience pleasure and a general withdrawal from engaging with life. Those close to the person may notice a detachment from others, lack of motivation, and an avoidance of people, activities, and places the person previously enjoyed
- “U” represents unable to function. The symptoms of PTSD are distressing and cause significant impairment in social, occupational, and interpersonal functioning
- “M” represents the duration of the symptoms. In order to be diagnosed with PTSD, a person’s symptoms must last for more than one month
- “A” represents increased arousal, as the brain is unable to switch off from the high-alert state of its “fight-flight-freeze” response. Symptoms can include exaggerated startle response, poor concentration, irritable mood, insomnia, and hypervigilance
Risk factors for developing PTSD
Pre-traumatic risk factors
- Female gender (in civilian, non-military samples)
- Low socioeconomic status
- Younger age when traumatized
- Less education
- Childhood adversity
- Race (minority status)
- Past psychiatric history
- Family psychiatric history
Peri-traumatic risk factors
- Severity of the trauma
- Perceived fear of death
- Physical Injury
- Assaultive trauma
- Peri-traumatic dissociation
Post-traumatic risk factors
- Lack of social support following the trauma
- Financial stress
- Subsequent life stressors
There are many factors that contribute to one’s likelihood of developing PTSD following a traumatic event. These risk factors can occur before (pre-traumatic), during (peri-traumatic), or after (post-traumatic) the event.
- Pre-traumatic risk factors include being female or a young age when traumatized, having low socioeconomic status and/or education, other childhood adversity, race or minority status, and past psychiatric history
- Peri-traumatic risk factors include severity of the trauma, perceived fear of death, physical injury, whether the trauma is assaultive, and if the person experiences dissociation during the event
- Post-traumatic risk factors include lack of social support following the trauma, financial stress, and subsequent life stressors
It’s important to understand that the risk factors that contribute to developing PTSD vary widely among those traumatized. This makes it difficult to determine a set of common risks.
A disconnection between a person’s thoughts, feelings, actions, or sense of who and where they are.
- Depersonalization: The person feels their body is unreal, or as if they are outside and watching their body from a distance
- Derealization: The person feels the world is unreal
Dissociation is a mental process that breaks the connection between a person’s thoughts, memories, feelings, actions, and sense of identity. Most of us have experienced dissociation at some point. Have you ever driven a frequently used route, arrived at your destination, but failed to remember the last minutes of the trip? Dissociation can happen when we engage in an automatic activity and pay no attention to our immediate environment.
Dissociation can also occur as a protective strategy during periods of severe stress or trauma. People who experience trauma may learn to separate themselves from their distress in order to survive.
However, dissociation can cause a sense of distortion in time, space, or identity. The person may have difficulty identifying that their feelings are real — or even that their body is real. They may view themselves as distanced from the world.
There are two main subtypes of dissociation:
- When a person experiences depersonalization, they may experience the feeling as though they were in a dream. They may perceive a sense of unreality, or of time moving slowly. The body feels unreal, or like it is being observed by the mind from a distance
- People experiencing derealization feel as if the world is unreal. The world around the individual is experienced as unreal, dreamlike, distant, or distorted
People with a lifetime history of PTSD have higher rates of these co-occurring disorders:
- Mood disorders (like depression)
- Substance use
- Personality disorders (like borderline personality disorder)
Health and social service settings can be a source of retraumatization because:
- Caregivers may have limited understandings of the impact of trauma
- Programs and services are not provided using a trauma-informed lens
There’s a lot of overlap between symptoms of PTSD and other mental health conditions. These conditions often coexist and include depression, anxiety, substance use, and personality disorders.
This overlap, paired with a lack of screening for patients’ trauma history, means that PTSD is often misdiagnosed. This is why it’s critical for healthcare providers in any clinical setting to learn about trauma and its effects.
People who have experienced trauma are at risk of being retraumatized in healthcare settings. When retraumatization happens, it leaves the patient feeling misunderstood, unsupported, and blamed.
Few healthcare services are provided using a trauma-informed lens. Most service providers have limited knowledge of trauma and its impacts. When paired with medicalized, single-issue programming, these knowledge gaps can become a barrier to providing effective care to those with PTSD.
- Types of trauma
- Degree of severity
- Occupational exposure
Trauma exposure simply defines the type of trauma one has experienced. Healthcare providers are frequently exposed to the trauma of their patients. For example: first responders providing on-scene care to someone who has just been a victim of abuse, assault, or violence; or having a client disclose their past trauma history.
Trauma exposure response
The impact of working directly with individuals affected by trauma.
Trauma exposure and trauma exposure response can be seen as an occupational hazard.
Occupations at high risk of trauma exposure due to the COVID-19 pandemic include healthcare providers and emergency medical services (EMS).
Trauma exposure response refers to the impact of working directly with individuals who have experienced trauma.
Both trauma exposure and trauma exposure response can be seen as occupational hazards. Occupations at high risk of trauma exposure during the COVID-19 pandemic include healthcare providers and emergency medical services (EMS).
These workers face a dual challenge as a result of their roles. They can be exposed to their own trauma while on the job, and they can experience trauma exposure response while caring for their patients.
Here are some examples of trauma that HCPs have endured during the pandemic:
- Having patients die while under their care
- Feeling unable to provide good care due to staffing and resource shortages
- Working with families who respond to visiting restrictions with anger and hostility
Additionally, HCPs have experienced trauma exposure witnessing the suffering of their patients, as well as their families’ grief at being unable to see their ill loved ones.
The dual experience of coping with their own trauma while being exposed to the trauma of others has put the mental health of healthcare providers at risk.
Impact of trauma exposure on HCPs’ mental health during COVID-19
As a result of working through the pandemic, healthcare providers have a high risk of burnout. They have experienced vicarious trauma, secondary trauma, and moral injury.
- Burnout refers to the physical, mental, and emotional exhaustion caused by high levels of stress over a prolonged period
- Vicarious trauma results from empathic engagement with trauma survivors, such as witnessing and empathizing with others’ pain and loss
- Secondary trauma is when the trauma of patients in the provider’s care triggers memories of the provider’s own trauma history
- Moral injury describes the distress that arises following the violation of the provider’s moral or ethical beliefs. Although moral injury is not a mental health disorder, it is associated with an increased risk of PTSI
The prolonged trauma exposure that healthcare providers have experienced through the pandemic has had a significant impact on their mental health. Strong workplace and social support is needed to enable them to manage the impact of their experience.
Instead of asking what is wrong with the individual, trauma-informed care asks what has happened to them.
Trauma-informed care is a powerful framework to create safety for patients and healthcare providers alike. In acknowledging the prevalence of trauma and emphasizing the need for safety for everyone, trauma-informed care invites a shift in our perspective from pathology to experience.
Instead of asking what is wrong with the individual, trauma-informed care asks what has happened to them.