Trauma is a state of high arousal in which severe threat or the perception of severe threat overwhelms a person's capacity to cope. It comprises a range of events, situations and
contexts. These include natural disasters, accidents, betrayal in interpersonal relationships, and diverse forms of abuse.
There are differences between the main categories of trauma. Single incident trauma, commonly associated with Post Traumatic Stress Disorder (PTSD), relates to 'one off' events, while complex trauma is cumulative, underlying, and largely interpersonally generated (Shapiro 2010). As well as being more extensive in its effects (Courtois & Ford 2009), complex trauma is more frequent and prevalent (van der Kolk 2003), with complex trauma from childhood experiences being particularly damaging. Unresolved trauma, especially childhood (complex) trauma often has substantial impacts, on both mental and physical health (Banyard et al. 2009) into adult life.
The perception of extreme and overwhelming threat activates the physiological `survival' responses of 'fight-flight-freeze'. These innate, biologically programmed responses 'cannot be helped' as they are not thought about or reflected upon. Their trigger/s are often not clear. Recovery from trauma is not about `will power' or deciding to `move on'.
However it is important to remember that people can and do recover from even early childhood trauma, but that to do so, they need the right services and support (Siegel 2003).
Childhood Trauma And Health
Multiple systems of the body are interconnected. Trauma, particularly childhood trauma, disrupts the connections between the various systems of the body, and compromises a person's physical and psychological health as well as their daily functioning (Cozolino 2002). The greater the severity and duration of childhood trauma `the more severe are the psychological and physical health consequences' (Middleton 2012).
Overwhelming childhood experiences compromise the hormonal, endocrine immune and other body systems, but because chronic conditions evolve slowly these connections are often not recognised (Karr-Morse & Wiley 2012).
Children, like adults, develop coping strategies to protect them from being overwhelmed and help them manage the physiological and psychological effects of the dysregulated arousal, emotions and behaviour which occur with trauma. Such coping strategies are often creative and effective in the short to medium term, but risky and can damage health in the longer term.
The ground-breaking Adverse Childhood Experiences (ACE) Study (Felitti et al. 1998) established the relationship between childhood coping strategies and the development of the `symptoms' of impaired well-being and ill health later in life for unresolved underlying trauma. These findings have been repeatedly replicated in further research.
Childhood Trauma And Mental Health
Childhood (complex) trauma can seriously affect a person's ability to function, their sense of themselves, and their capacity to regulate arousal, emotions and behaviour. It impairs self-conception and cohesion, one's sense of meaning, and the capacity to relate to others (Howell & Itzkowitz 2016). Unlike PTSD, complex trauma disrupts a person's identity, severely adversely affecting a person's relationship to themselves, others and the world.
A history of childhood trauma is `[t]he single most significant predictor' of subsequent contact with the mental health system' (Middleton 2012). People who have complex trauma histories receive diverse psychiatric diagnoses because their trauma presents in many forms, with severe, wide-ranging and comorbid symptoms.
Comorbidity is the norm rather than the exception. Coexisting depression and anxiety are common, as is the diagnosis of personality disorder, particularly Borderline Personality Disorder. While not all childhood trauma leads to psychosis, and not all psychosis is trauma-related, greater insights into the vulnerability of the developing brain to stress are informing our understanding of psychopathology (Howell 2005).
Psychosis features poor reality-testing and inability to distinguish the internal from the external: `[i]t is exactly this distinction that trauma disrupts' (Howell 2005). Childhood trauma is a well-documented potential risk factor for psychosis (Aas et al. 2016; Szalavitz 2012). Presentations related to trauma, particularly around dissociation and dissociative disorders can also be confused with psychosis, including within the mental health system. (Spiegel et al. 2011).
Childhood Trauma And Physical Health
Overwhelming stress such as occurs with childhood trauma negatively impacts the hypothalamic-pituitary-adrenal (HPA) axis which controls a person's reaction to stress and trauma (Siegel 2012). Stress triggers the HPA axis, i.e. `the relationship between the hypothalamus (H), the pituitary gland (P) and the adrenal glands (A) that produces finely tuned chemical messages that connect the central nervous, endocrine and immune systems' (Karr-Morse & Wiley 2012).
Increased stress hormones lead to an elevated inflammatory/ immune response, which is associated with poor health outcomes and increasing cardiovascular, pulmonary and auto- immune disease (Shonkoff & Garner 2012). Chronically overstimulated immune responses can also cause the system to attack the organs, leading to autoimmune disease such as psoriasis and lupus. They can also `catalyse inflammation at various sites in the body', paving the way for conditions such as osteoarthritis, fibromyalgia and irritable bowel syndrome (Karr-Morse & Wiley 2012).
Other diseases linked to overproduction of cortisol include functional gastrointestinal disease, diabetes, anorexia nervosa, hyperthyroidism and Cushing's syndrome (KarrMorse & Wiley 2012). A number of publications substantiate the serious physical impairments associated with trauma in general and complex trauma in particular. For example, research shows that `[t]hose with complex childhood trauma have roughly double the rate of fibromyalgia, chronic fatigue, and disorders of musculoskeletal, digestive, circulatory, endocrine and immune systems' (Banyard et al. 2009).
Physical health issues such as cancer, diabetes, heart disease, and asthma are also highly correlated with early life stress (Karr-Morse & Wiley 2012). The Adverse Childhood Experiences Study replicates these findings, with changes in the ACE score, i.e. number of adverse childhood experience categories, establishing links between childhood experience and adult biomedical disease including liver disease, chronic obstructive pulmonary disease, coronary artery disease and autoimmune disease (Felitti & Anda 2010).
Trauma And Primary Care
Primary health care plays a critical role in health promotion, prevention, screening, early intervention and treatment. For these reasons, primary health care providers need to be able to intervene early and effectively with patients with a lived experience of trauma to promote better care and health and well-being outcomes.
Epidemiological data suggests that on a daily basis a significant proportion of patients attending general practices have trauma histories (Felitti & Anda 2010). Primary care practices work with patients who present with co-morbid mental health challenges, drug and alcohol issues, suicidality and self-harm, sexual health issues as well as cardiovascular disease, asthma, diabetes, obesity, and cancer. All of these challenges can be and often are associated with unresolved trauma in general, and childhood trauma, in particular. Yet primary health services do not routinely screen for trauma.
If people have not connected their distress and health problems to their prior trauma they can't share their concerns. Even patients who suspect their issues are trauma-related might not speak about them fearing a negative response to disclosing.
As many primary care personnel are not adequately equipped to respond effectively to patients who experience the impacts of trauma, they are unable to intervene in trauma-related problems and address the cumulative negative individual, community and systemic legacies.
The health, social and economic costs of unrecognised, untreated or inappropriately treated trauma are substantial. They not only impact the individual health and psychosocial burdens of survivors but also reverberate through families, friends, communities, and society at large. If people don't receive the right support their trauma not only undermines their psychological and physical health but also erodes their capacity for healthy relationships, educational opportunities, and ongoing work participation.
Lost productivity and direct costs also impact subs
tantially on health, welfare and criminal justice budgets. Health budgets are stretched by repeated hospitalisations, crisis intervention, frequent use of services and medication, and the burden of chronic disease, compounded morbidity and premature mortality. The financial costs of not providing adult survivors of childhood trauma in Australia with the services they need are conservatively estimated at $9.1 billion annually (Kezelman et al. 2015).
Not only does trauma literacy highlight the burden of trauma-related disease, morbidity and mortality, but it also provides opportunities for enhanced treatment outcomes when practitioners and practice personnel work from a trauma-informed frame. We owe it to those with a lived experience of trauma to safely screen for, recognise, identify and appropriately address the needs of those affected.
Aas, M, Andreassen, OA, Aminoff, SR, Faerden, A, Romm, KL, Nesvag, R, Berg, AO, Simonsen, C, Agartz, I & Melle, I 2016,`A history of childhood trauma is associated with slower improvement rates: Findings from a one-year follow-up study of patients with a first-episode psychosis' BMC Psychiatry.
Banyard, VL, Edwards, VJ, Kendall-Tackett, K (eds) 2009, Trauma and physical health: Understanding the effects of extreme stress and of psychological harm, Routledge, London.
Courtois, C & Ford, J 2009, `Defining and understanding complex trauma and complex traumatic stress disorders', in Treating complex traumatic stress disorders, The Guilford Press, New York, pp. 13–30.
Cozolino, L 2002, The Neuroscience of Psychotherapy, Norton, New York, p. 270.
Felitti, VJ & Anda, RF 2010, `The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behaviour: implications for healthcare', Ch. 8 in Ruth, R, Vermetten, E & Pain, C (eds), The impact of early life trauma on health and disease: the hidden epidemic, Cambridge University Press, UK.
Felitti, V J, Anda, RF, Nordenberg, D, Williamson, DF, Spitz, AM, Edwards, V, Koss, MP, Marks, JS 1998, `Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences Study', American Journal of Preventive Medicine, 14 (4), pp.245–258.
Howell, E 2005, The dissociative mind, Routledge, New York.
Howell, E & Itzkowitz, S 2016, (eds), The dissociative mind in psychoanalysis, Routledge, New York, p. 37.
Karr-Morse, R & Wiley, MS (collaborator) 2012, Scared Sick: The role of childhood trauma in adult disease, Basic Books, New York.
Kezelman, C, Hossack, N, Stavropoulos, P, Burley, P 2015, The cost of unresolved trauma and abuse in adults in Australia, Adults Surviving Child Abuse & Pegasus Economics, Sydney.
Middleton, W 2012, `Foreword' to Kezelman, C & Stavropoulos, P, The Last Frontier: Practice guidelines for treatment of complex trauma and trauma informed care and service delivery, Adults Surviving Child Abuse, Sydney, p. x.
Shapiro, R 2010, The Trauma Treatment Handbook: Protocols across the spectrum, Norton, New York, p.11.
Shonkoff, J P & Garner, AS 2012 `The lifelong effects of early childhood adversity and toxic stress', American Academy of Pediatrics Vol, 129, Issue 1.
Siegel, DJ 2012, Pocket guide to interpersonal neurobiology, Norton, New York, A1–37.
Siegel, DJ 2003, `An interpersonal neurobiology of psychotherapy: The developing mind and the resolution of trauma', ch. 1 in Siegel DJ & Solomon, MT (eds), Healing trauma: Attachment, mind, body and brain. Norton, New York, pp. 1–56.
Spiegel, D, Loewenstein, RJ, Lewis-Fernandez, R, Sar, V, Simeon, D, Vermetten, E, Cardena, Dell, PF 2011, `Dissociative disorders in DSM-5', Depression and Anxiety 28: 824–852.
Szalavitz, M 2012, `How child abuse primes the brain for future mental illness', Time, 15 February.
van der Kolk, B 2003, `Posttraumatic Stress Disorder and the nature of trauma', in Siegel DJ & Solomon MT (eds), Healing trauma: Attachment, mind, body and brain, Norton, New York, p. 172.