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Talking about trauma for services

Complex Trauma and Mental Health

What happened to you?

What happened to you?

Our mental health system is based on symptoms and diagnosis. This is based on the question: what is wrong with a person? This system often doesn’t consider: what happened to the person to have affected them so profoundly? How did they cope? How are they coping now?  This often ignores the context of their lives and their trauma.


Screening and assessment for trauma, abuse and violence is not standard. This is despite the numbers of people who have experience trauma attending different services. Two of three people attending emergency, inpatient or outpatient mental health services have complex trauma from childhood physical or sexual abuse (Read et al., 2005).


Trauma can cause a lot of mental distress over time. It also affects a person’s ability to seek support, feel safe, trust and stay connected to services. The way services respond is important for recovery.

Re-traumatisation

All service providers need to understand the nature, dynamics and impacts of childhood trauma. People who have experienced trauma are at significant risk of re-traumatisation. This can occur inadvertently. It occurs when services replicate the power, control and silencing around prior traumatic experiences.  Sadly coercive practices e.g. seclusion and chemical and physical restraint are used more commonly with people with trauma histories in mental health units (Wilson et al., 2017). 

Complex trauma and diagnosis

People with complex trauma can have many mental health diagnoses. These include Post Traumatic Stress Disorder (PTSD), Borderline Personality Disorder (Spatz et al., 2007), Affective Disorders, Anxiety Disorders, psychosis (Shevlin et al., 2007) including Schizophrenia and Bipolar Disorder, Dissociative Disorders (Dorahy et al., 2016) and Somatic Symptom Disorder (Spitzer et al., 2008). Trauma puts people at risk for psychosis (Schäfer and Fisher, 2011). Many survivors have been diagnosed with multiple coexisting (comorbid) conditions such as substance misuse, Eating Disorders, self-harming behaviours, and suicidality (Cutajar et al., 2010).

Any diagnosis may be reflect the diagnosis of Complex Post Traumatic Stress Disorder (C-PTSD). Others may be related to a coping mechanism (e.g. substance misuse). 

The following pages feature a number of possible diagnoses of people with complex trauma histories. It is not exhaustive. It recognises that the mental health system is based primarily on diagnosis. In acknowledging that it highlight the importance of trauma and what happened to the person to contribute to their mental health issues.

Post -Traumatic Stress Disorder (PTSD) and Complex Post-Traumatic Stress Disorder 

Post-traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a group of stress reactions. It can occur after witnessing, experiencing or being exposed to a life-threatening situation.  

Who experiences PTSD?


Who experiences PTSD?

·         People who have experienced an accident or natural disaster

·         Emergency workers exposed to repeated traumas e.g. ambulance, police, firemen

·         Combat veterans and others exposed to war, genocide or terrorist attacks

·         People witnessing or experiencing domestic and family violence, physical, sexual and emotional abuse, or the sudden unexpected death of a loved one,  as an adult or child

While PTSD has long been associated with single incident trauma, people with complex trauma can also experience PTSD. In fact they are at higher risk of PTSD (Courtois and Ford, 2009, 2013).

PTSD has three main symptoms:

Three symptoms of PTSD

Hyperarousal (sense of threat) – person is easily startled or on high alert. The person feels anxious, agitated or irritable.  It is the body’s ‘fight or flight’ response to threat.

 

Intrusions - past traumatic experiences bombard the person. It feels like they are happening ‘right here, right now’.  These are called "flashbacks".

 

Avoidance - defends against overwhelming fear and danger. This can include withdrawal from other people. It can also include avoiding reminders of the trauma, or of thoughts and feelings. It can also mean emotional numbing. 


Treatment:


People with PTSD respond to different treatments. This includes a range of psychological approaches, exercise, social supports and mindfulness. Medication can also be helpful. 


Complex Post-Traumatic Stress Disorder

Complex PTSD

Complex trauma has far more extensive and debilitating impacts than PTSD alone (Courtois & Ford, 2013; van der Kolk, 2003). While complex trauma survivors are more likely to experience PTSD, the symptoms of PTSD don’t cover the variety and breadth of the adverse impacts. ‘There is more to trauma than PTSD’ (Shapiro, 2010). ‘PTSD alone is insufficient to describe the symptoms and impairments that follow exposure to complex trauma’ (Courtois and Ford, 2009, 2013). 

 

The official recognition of Complex-PTSD in the upcoming ICD-11 from June 2018 builds on the diagnosis of PTSD to capture the additional challenges of people with complex trauma.


Who experiences complex PTSD?

People can develop complex post-traumatic stress disorder (C-PTSD) after exposure to threatening event/s which are extreme, prolonged and repetitive, and from which it is difficult or impossible to escape.   Complex PTSD can occur with repeated childhood sexual or physical abuse, prolonged domestic violence, genocide, slavery and torture.

People who have experienced childhood trauma are more likely to develop C-PTSD (Karatzias et al., 2017; Shevlin et al., 2017). The more often people were traumatised as a child (Hyland et al., 2017) and the more different types of childhood trauma they experienced (Karatizias et al., 2017), the more likely they are to develop complex post-traumatic stress disorder. 

 

People who have experienced multiple traumas in adulthood (Karatzias et al., 2017) as well as those who have experienced major single incidents (Elklit et al., 2014) are also more likely to develop complex post-traumatic stress disorder.  The upcoming ICD-11 diagnosis of complex PTSD will build on core symptoms of PTSD. This will help clarity the diagnosis and inform treatment (Shevlin et al., 2017).  

 

Complex post-traumatic stress disorder is proposed to have the following six symptoms. Three are common to PTSD:

  • Intrusions
  • Avoidance
  • Hyperarousal – sense of threat
  • Emotional dysregulation: severe ongoing problems in regulating affect (emotions) 
  • Negative self-concept: ongoing sense of being worthless and defeated, as well as extreme feelings of shame and guilt                            
  • Disturbance in relationships: ongoing difficulties in forming and sustaining relationships and connection. 

Complex PTSD can cause challenges in many areas of functioning. This can include within the person, with friendships, intimate relationships, family and workplace etc. 


Treatment: 


The differences between (single incident) PTSD and `complex’ trauma has significant treatment implications (van der Kolk, 2003; Courtois & Ford, 2013). `[S]tudies…showed that these  patients may react adversely to  current, standard PTSD treatments,  and that effective treatment needs to focus on self-regulatory deficits rather than `processing the trauma’ (van der Kolk, 2003: 173).

85% of experts consulted for the ISSTS Expert Consensus Treatment Guidelines for Complex PTSD in adults reported they would use a phase-based approach as their first line of treatment (Cloitre & Courtois, 2012).

Dissociation and Dissociative Identity Disorder 

Dissociation

What is dissociation?

What is dissociation? 

Dissociation is a mental process with disruption or lack of connection between aspects of a person’s functioning which usually work together. These include thoughts, feelings and sensations. Dissociation means separation/disconnection from present experience, and awareness.

Dissociation can be healthy e.g. daydreaming or being absorbed in an activity. It can also become problematic and challenging. People can dissociate in the face of a terrifying event or a series of traumatic event/s that threaten to overwhelm them.

What is trauma-related dissociation?

While at first protective, trauma-related dissociation can cause ongoing problems. This can happen if the trauma has not been resolved. Degrees of dissociation occur with all types of trauma, including adult-onset trauma (Howell & Itzkowitz, 2016).

Both children and adults can dissociate. The younger the child, the more likely they are to dissociate. That’s because young children are less able to manage frightening situations and escape from them. Dissociation helps block terrifying events from awareness and memory. It also helps block feelings of fear, pain and distress, and the thoughts that go with them. Dissociation is a survival mechanism of hypo-arousal or shut down.

The disconnection between different aspects of a person’s functioning can become chronic. This can have serious health impacts.  Over time, dissociation can become the `go to’ response. It can be reactivated (“triggered”) when there is no obvious current threat. When this happens, it can be viewed as `a healthy defence gone wrong’ (Steinberg & Schnall, 2003). The child or adult disconnects from their surroundings, emotions and thoughts (e.g. at home, work, social events and school). This can have major impacts on daily life and relationships.

Dissociation can be subtle. For this reason it can go undetected. It is better understood than it used to be. This includes from studies of the brain. `Neuroimaging studies provide concrete, theoretically consistent evidence that dissociation exists’, showing that `dissociation is accompanied by altered activation of brain structures… involved in regulating awareness of bodily states, arousal, and emotions’ (Brand, 2012: 395). ‘It is also the case that today the mental health field is paying more and more attention to dissociation and dissociative experiences’ (Howell, 2005: vii).

Who dissociates?

It is now recognised that `the dissociative concept of multiple self-states’ relates to all of us.  This is `enormously helpful in understanding both normal experience and pathological conditions’ (Chu, 2011:46). A pioneer of dissociative studies, Frank Putnam said that`[w]e are all multiple to some degree’, and that it is `how well we can keep it together, how harmoniously we can bridge, coordinate and…integrate the different parts of ourselves that determines how functional we are’ (Putnam, 2016: 121).

Children who experience repeated child sexual or physical abuse, severe emotional abuse and neglect, or who grow up with caregivers who are frightening or who dissociate themselves are likely to dissociate as an adaptive strategy to overwhelming trauma. Ongoing childhood trauma increases the likelihood of dissociation as an adult (International Society for Study of Trauma and Dissociation, 2002) 

Dissociative Identity Disorder (DID)

Overwhelming stress in early childhood is associated with severe dissociative divisions of personality. This can result in Dissociative Identity Disorder (DID). In this condition diverse self-states to which the person has limited conscious access, are a survival mechanism for unbearable trauma (usually before the age of 6). Dissociative Identity Disorder affects approximately 1.5% of people (DSM-5, 2013, p.294).

DSM-5 defines Dissociative Identity Disorder (DID) as ‘an identity disruption indicated by the presence of two or more distinct personality states (experienced as possession in some cultures), discontinuity in sense of self and agency, and variations in affect, behaviour, consciousness, memory, perception, cognition, or sensory-motor functioning’ (American Psychiatric Association, 2013).

DID has a basis in neurobiology. It also has a robust research base (Dorahy, Brand et al, 2014; Brand et al, 2016). Dissociative Identity Disorder has very little in common with the way it is usually portrayed in media and film. It develops when a vulnerable child’s brain is flooded with terrifying input it can’t process. The child survives at the cost of a unified self. In so doing, s/he develops a number of internal `on-call’ self-states (parts) (Bromberg, 2001:200). `[T]he dissociation must be preserved….to prevent the return of unbearably traumatic self-experience’ (Bromberg, ibid:180).

People with Dissociative Identity Disorder can experience partial or total memory loss (amnesia). They can also ‘lose time’; i.e. there are blocks of time for which they have no memory. Those affected may appear moody; they may have gaps in their knowledge they can’t explain. People with DID can shift rapidly and dramatically between self-states. This can also be subtle and can be missed. Overt shifts can occur apparently without warning. We can explain such shifts when we understand the origins of DID i.e. a person’s need to dissociate `unbearably traumatic’ early life experience: `Scepticism about numbers of self-states is a potential intellectualization and deflection of the sad reality…an intolerance of the reality of severe abuse’ (Chefetz, 2015:116).

Diagnosis:

It can take an average of 6-12 years to accurately diagnose people with DID within the mental health system. Many people with DID and other dissociative disorders (DDs) are misdiagnosed with schizophrenia. `A number of studies have shown that DDs are often misdiagnosed as a psychotic disorder and such patients may suffer iatrogenic worsening of their disorders due to years of misdiagnosis and mistreatment’ (Spiegel et al, 2011).  Because people with early life trauma also have other mental health challenges, they often have multiple diagnoses. They include PTSD, depression, anxiety, eating disorder, substance abuse, engagement in risky behaviours such as self-harm and multiple suicide attempts. Hence there is an urgent need for health professionals to understand more about DID.

Treatment:

With the right support people can reconnect the parts of the self which become disconnected in DID. Increased integration of self-states (`parts’) and `co-consciousness’ (increased internal communication between them) is possible: `That even those whose sense of self has been most brutally shattered can learn to reunite the broken parts of themselves, and thereby heal, is a lesson that gives hope and wisdom to us all’ (Steinberg & Schnall, 2010:128).

The International Society for Study of Trauma and Dissociation has developed treatment guidelines for DID (ISSTD, 2011). http://www.isst-d.org/downloads/guidelines_revised2011.pdf It has subsequently been established that evidence-based treatment for DID is beneficial to those seeking treatment, and helps them to stabilise, and to enhance their quality of life (Brand et al, 2016).

For a contemporary review of the myths and media portrayals around Dissociative Identity Disorder www.teachtrauma.com/controversial-topics-trauma/myths-media-portrayals-dissociative-identity-disorder/. 

Also see Brand et al. (2016) `Separating Fact from Fiction: An Empirical Examination of Six Myths about Dissociative Identity Disorder’ Harvard Review of Psychiatry, Vol.24, Issue 4, July-August 2016, pp. 257-270.

https://journals.lww.com/hrpjournal/Fulltext/2016/07000/Separating_Fact_from_Fiction___An_Empirical.2.aspx 

Also see  https://theconversation.com/dissociative-identity-disorder.


Childhood trauma and psychosis  

Childhood Trauma and Psychosis

“I just wish they would have said ‘What happened to you?’ ‘What happened?’ But they didn’t.” Survey of NZ users of mental health services (Lothian and Read, 2002)


People with psychosis commonly report prior trauma. Multiple researchers have suggested the possible role of trauma in the development of psychosis (Cutajar et al., 2010; Schäfer and Fisher, 2011). One review of 42 studies found that people who had experienced childhood adversity were 2.8 times more likely to develop psychosis than those who hadn’t (Varese et al., 2012).

Experiences considered ‘psychotic’ include voice hearing, visions and unusual beliefs (‘delusions’). These are strongly associated with childhood trauma i.e. child sexual, physical and/or emotional abuse (Shevlin et al., 2012). Shevlin et al. recommend that psychiatric staff should consider this knowledge. Childhood trauma is also strongly associated with hallucinations in adulthood. People reporting seven or more distressing childhood events were five times more likely to experience hallucinations as adults (Whitfield et al., 2005). Whitfield et al. recommend that mental health professionals should consider this knowledge.

The more severe the abuse, the more severe, the mental health challenges (Read et al., 2005). Janssen et al. found that people abused as children are 9 times more likely to develop ‘pathology level psychosis’; those experiencing severe abuse were 48 times more likely to develop psychosis (Janssen et al., 2004). Other research shows that people who had experienced three types of trauma were 18 times more likely to experience psychosis; people who had experienced five types of trauma were 193 times more likely to be psychotic (Shevlin et al., 2007).

The use of psychosocial approaches has been suggested. These approaches are more likely to address the impacts of adverse childhood events; they have also been found to be effective for people who also have psychosis (Read et al., 2013).

Bipolar 


What is bipolar? 


Bipolar disorder is a group of mental health disorders with extremes of mood. People experiencing bipolar disorder can alternate between depression (listlessness and hopelessness) and mania (agitated, impulsive and overly optimistic). Some people with bipolar 1 can experience delusions and hallucinations during their manic periods. Not all people with bipolar experience psychosis. Some do. Bipolar disorder generally starts in a person’s twenties. It can sometimes start in adolescence. 


What is relationship between childhood trauma and bipolar?


Childhood trauma is known to put people at risk for bipolar disorder. This has been confirmed in a lot of studies (Etain et al., 2010; Daruy-Filho et al., 2011; Janiri et al., 2015). Childhood trauma is also associated with severe bipolar. It’s also associated with earlier onset of bipolar, more rapid mood cycles, suicide attempts and substance misuse (Etain et al., 2013 and Daruy-Filho et al, 2011). 

People who have experienced childhood trauma often struggle with regulating their emotions and with controlling their impulses. In people diagnosed with bipolar disorder, Aas et al., 2014 found people cycled through extremes of emotion. Bucker et al., 2015 also identified that people diagnosed with bipolar disorder also have greater challenges maintaining attention, and with memory. 


Treatment


Treatment for bipolar disease can include medication, psychological therapies, lifestyle changes and support. It tends to be effective. Maintenance treatment can greatly reduce or even prevent further episodes.

It is important to assess people presenting with bipolar disorder for a history of childhood trauma particularly for people who have early onset or challenges in managing it. Treatment approaches should focus on the underlying trauma as well as the challenges in emotional regulation, mood cycles and cognition (Etain et al., 2013). Strategies to manage and reduce everyday stress can also help to reduce the risk of relapse.


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