Trauma

The Overwhelmed Mind

Trauma is a seismic event that fractures a person's foundation. It is mentally, physically, and spiritually damaging. It exceeds the mind's ability to process it. As far the mind is concerned, trauma is undigestible. It disempowers, dehumanizes, and disconnects. And it calls into question the goodness of the world. 

PTSD

Most people experience a traumatic event in their lifetime. About 7 percent go on to develop posttraumatic stress disorder (PTSD). 

Trauma is defined in DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence. This is a narrow definition of trauma. Everyone agrees emotional abuse and neglect are traumatic. However, these traumas would not lead to a diagnosis of PTSD in the DSM-5. Think of PTSD as a very specific reaction to a very specific type of trauma. Many people harmed by trauma do not have PTSD diagnoses. Instead, they are diagnosed with depression, anxiety, eating disorders, or personality disorders. 

PTSD results from a traumatic event and the way the mind processes it. During a traumatic event, the mind's ability to form memories is disrupted. This causes traumatic memories to be fragmented. Some fragments are disturbingly vivid, while others are hazy and dream-like.

People with PTSD teeter between avoiding their trauma and concretely reliving it. Dissociating, isolating, and abusing drugs and alcohol are examples of avoidance. Nightmares, flashbacks, and fight-or-flight reactions are examples of reliving trauma. Traumatic experiences are dissociated or compartmentalized. The mind stashes them away to be forgotten or dealt with later. Ongoing dissociation keeps memories fragmented and perpetuates the cycle of avoiding and re-experiencing trauma.

Complex PTSD

A person with a history of repeated, prolonged childhood trauma, sometimes called attachment trauma, develops a profoundly negative view of themself and others. They feel inadequate and ashamed. They are emotionally dysregulated and distrustful of others. Clinicians call this complex posttraumatic stress disorder (C-PTSD). 

Although not in the DSM-5, C-PTSD is included in the International Classification of Diseases (ICD-11). To be diagnosed with C-PTSD, one has to meet diagnostic criteria for PTSD, and to have a troubled sense of self, emotion dysregulation, and problematic interpersonal relationships. 

There is academic debate whether C-PTSD is better explained as co-occurring PTSD and BPD. 

Treatment for Trauma

There are several treatments for PTSD. Prolonged exposure (PE) therapy and cognitive processing therapy (CPT) have the most research support. Eye movement desensitization and reprocessing (EMDR) is also effective. Unfortunately, these treatments can be difficult to tolerate and have high discontinuation rates. There is little research on psychodynamic therapy for PTSD, although many people find it helpful. 

Generally, I recommend PE, CPT, or EMDR for people struggling with intrusive symptoms, like flashbacks, nightmares, or panic attacks. In contrast, I recommend psychodynamic therapy or transference-focused psychotherapy (TFP) for people with C-PTSD who have experienced early childhood or attachment trauma.

In the psychodynamic treatment of trauma, the first stage emphasizes safety, modulating emotions, and lessening any self-destructive behaviors. This is empowering. It instills a sense of agency, control, and hope. The second stage of treatment focuses on remembering. Patients reflect on their traumatic experiences bit by bit, integrating memories, emotions, and somatic experiences. This helps a person feel less alone with their trauma and makes the memories more bearable. 

Recommended Readings

Allen, J. G. (2005). Coping with Trauma: Hope Through Understanding. American Psychiatric Publishing.

Herman, J. (1992). Trauma and Recovery. Basic Books.