Trauma Type, Onset Age, Sex Effects On Transdiagnostic Traits

Trauma affects individuals in various ways. For many, it can alter their mental health perception, causing them to become increasingly anxious or depressed. Some people become more sensitive or reactive to stressors at work, school, or in their homes as a result of their violent, abusive, or neglectful experiences. As a result, individuals can exhibit signs of distress such as insomnia, nightmares, and feelings of shame, guilt, anger, or helplessness. These changes in behavior and feelings can affect every aspect of their lives. Yet, most people are unaware of the connection between their symptoms and a prior traumatic experience. They seek treatment for their anxiety, depression, or chronic pain without realizing that their symptoms may stem from traumatic circumstances. Instead of creating a cycle of crises by merely treating symptoms, clinicians can create a path to healing by identifying the transdiagnostic traits that underlie those symptoms. People who have experienced trauma often present with a set of typical typical traits such as a heightened sense of threat, emotional dysregulation, and avoidance behaviors. In addition, they may exhibit feelings of disconnection from others and themselves, shame, guilt, and low levels of trust in others. These core transdiagnostic traits are present in multiple disorders, including the mood disorders, the anxiety disorders, and in individuals diagnosed with post-traumatic stress disorder (PTSD). In addition to these psychological effects of significant trauma, it is also known to affect a person’s physical health in various ways. For example, sleep disturbances, increased pain sensitivity, and increased levels of inflammatory chemicals have all been linked to experiencing a traumatic event. Personality characteristics that emerge most prominently in individuals with a history of trauma include difficulty trusting others, low self-worth, shame, and self-blame. In contrast, individuals who experience non-interpersonal trauma (e.g. car accidents, natural disasters) tend to develop a fear-based avoidant profile, causing them to miss out on numerous life experiences. In my practice, I often see clients experience relationship crises (and relationship crises after relationship crises), intense emotions (fear, anger, sadness), withdrawal from relationships and activities that look and feel similar to depression or social anxiety. It is important for clinicians to have an understanding of how trauma can affect a person’s life and to develop a treatment plan that addresses these qualities. By helping the patient recognize and change distorted beliefs, behaviors, and thoughts that affect their life, clinicians can support their patients in finding healthier ways to cope with stress and painful emotions. Patients who have been traumatisized also need to learn how to rebuild trust in themselves and others and reclaim a sense of identity and wellness. In addition to these therapeutic approaches, the plan with the clinician and patient must also include a plan for self-care and stress management. Healthcare professionals can recommend patients who experience stress and anxiety participate in activities to help them relax such as: exercise/yoga/meditation and learn healthy ways to cope with stress such as: journaling, drawing (and other creative activities) and talking with friends and family members. A holistic approach to working with people who have experienced trauma is to help them heal from the trauma they have experienced, as well as, work to create social change to address the socio-economic and environmental factors that can cause trauma, such as: poverty, discrimination and lack of access to physical and emotional safety, adequate healthcare, quality education, and nutritious food. Working to create a more just society can help to prevent trauma from ever occurring in the first place. How do we, as mental health clinicians, address the deep suffering that can become the hallmark of a person’s life because of trauma? In addition to advocating for trauma informed mental health care and policy change in areas of mental health care, education and social services, we can advocate for safe, supportive communities and help to build a culture that fosters healing and growth. Trauma affects almost every aspect of a person’s life: their mental health and wellbeing, physical health, relationships, ability to form healthy attachments, education and vocational goals. With awareness of the transdiagnostic factors that contribute to distress, clinicians can develop a strong treatment plan to support individuals and families affected by trauma, and teach them ways to cope with traumatic experiences in a healthy and sustainable manner. This holistic approach to treating trauma includes exploring how social and environmental factors contribute to and perpetuate trauma, and teaching self care, stress management, and resilience. Together we can work to develop a more compassionate and effective mental health care system that acknowledges the profound impact of trauma and supports individuals and families to grow, heal, and recover from even the most painful of experiences. When working with individuals and families who have experienced trauma, it is important to have an understanding of the total impact of the person’s experiences. This can include an understanding of how a person’s body responds to stress and anxiety, and how they sleep at night. In addition to these physical and emotional symptoms, an understanding of the impact of neglect is critical. Neglect involves a lack of physical, emotional and/or sexual needs being met. As a result, individuals who have experienced neglect may have difficulty identifying, managing and regulating their emotions. They may have difficulty establishing and maintaining healthy boundaries and may appear disconnected or dissociative. They may engage in self-destructive or unsafe behaviours such as substance abuse, prostitution, eating disorders, cutting or other forms of self-mutilation. Sometimes neglect is hidden, even within families, and then it becomes the job of the clinician to ask the gentle questions to discover it. Once trauma occurs, it can happen at different times in a person’s life but the trauma experienced at different developmental stages can shape the personality traits and idiosyncrasies that a person develops and how changeable these are. Developmentally, children and adolescents who experience trauma have difficulty developing a healthy attachment relationship, emotion regulation, a sense of safety, and finding healthy ways to cope with distress. These issues can manifest in lifelong patterns of behavior and ways of responding to the world (e.g., impulsivity, irritability) as well as more immediate problems (e.g., sleep disturbance, difficulty trusting others). Trauma has a profound impact on the young person’s emerging identity and sense of self. Trauma intensifies social threats during middle childhood and adolescence and often elicits illogical and distorted perceptions of self and others. The adolescent’s struggle for increasing independence and growing autonomy may lead to risk taking behaviors, self-harm and substance use. In adulthood, responsibilities of work, school and parenting are impacted by the typical ways an individual copes with stress. While normally functioning adults, for example, may suddenly develop insomnia, panic, irritability, and concentration difficulties they may also avoid places, things, and situations that remind them of the original traumatic experience and withdraw from social contacts. Previous exposure to trauma can have widespread effects on an individual’s life. Additionally, there are special considerations for the impact of trauma when it is related to roles or identities that are very important to the individual, such as parent, worker, or caregiver to a family member. Past trauma can make an individual more sensitive to stress and vulnerable to additional traumatic experiences. These additional traumatic experiences can have particularly negative effects due to the sense of helplessness or betrayal that is associated with them. It is also important to recognize the different effects that trauma may have on individuals of different sexes and genders. Both biological and social factors affect how individuals of different sexes and genders display and are treated for trauma-related characteristics. Women are more likely to report experiencing internalizing symptoms (e.g. anxiety, depression, and/or physical complaints), while men are more likely to report experiencing externalizing behaviors (e.g. irritability, anger, risk-taking, and/or substance misuse). As previously mentioned, the same underlying causes of difficulty due to trauma (e.g. hyperarousal, shame, avoidance) can present in very different ways. While the typical “symptoms of trauma” include re-experiencing, avoidance and hypervigilance, the way a child or woman with stress and/or trauma presents can be very different from a man or adolescent. This means that it is helpful for clinicians to have an understanding of the ways in which stress and/or trauma present in order to develop a comprehensive treatment plan for each individual. Emotions, Puberty, Reproductive Life Stages, Hormones – and how we are socialized to view and express emotions, and how others interact with us. Examples of this are how men are often told not to show fear or sadness, yet process and express these emotions in negative ways, such as through alcohol and aggression. How women’s experiences of trauma are different from those of men, and how they often encounter shame, blame, denial and disbelief of their trauma. And how they face difficulties in being diagnosed and treated for their experiences. Most illness or injury is treated from the outside in, that is, from its obvious effects. A man with an addiction problem and a short fuse will be told he needs addiction treatment, not treatment for trauma. A woman with chronic pain and fatigue may be sent for all sorts of medical testing, but not realize that her hyperarousal and dissociation are signs of a trauma-related condition. It is one of the biggest problems in treating people with a history of trauma: the health system is not set up to treat this illness. Instead, our training tells us to look for signs of specific diseases and to treat those symptoms one by one. For many patients who have a history of traumatic experience, finding effective treatment for trauma symptoms can be very difficult. These patients may go from doctor to doctor seeing many different specialists and receiving many different treatments, none of which seem to take away their symptoms of insomnia, stomach pain, panic, or depression. Instead of helping patients and clinicians become more frustrated and “traumatised” by the treatment process, we could help them see how the patients’ typical ways of thinking, feeling, and behaving are a result of their having experienced danger and trauma. Some of the treatment goals for patients with a history of traumatic experiences might include (but not be limited to): increasing sleep quality, reducing avoidant behaviours, and regaining ability to experience and regulate their emotions. No diagnosis is ever 100% and with the right support and treatment, people are able to heal from Trauma. While trauma can happen at any age, the ways in which it presents itself and the vulnerabilities it creates can change significantly as the child grows up. A young child may exhibit irritability, regression, or have terrifying nightmares. A pre-teen/adolescent may act out with mood swings, dangerous or self-destructive behaviors, or withdraw from peers and family. An adult may present with chronic and debilitating anxiety or depression, or even seemingly unrelated problems at home, such as marital difficulties. Trauma has often been conceptualized and addressed by mental health professionals in limited ways. Addressing trauma in a more holistic fashion can guide practitioners working with individuals of all ages. Older adults experience trauma at various stages of the aging process. For example, individuals experiencing serious illness, bereavement, and cognitive decline can feel overwhelmed with trauma. Trauma can also manifest as sleep disturbances, anxiety, and depression. However, some individuals experience compounded or layered forms of trauma. For example, poor and homeless older adults, individuals from marginalized populations, those experiencing interpartner abuse, and those struggling with chronic illness. Traumatic stress can have a silencing effect on individuals. After repeated exposure to traumatic stressors, individuals may become reluctant to engage in typical aspects of life, become overly vigilant for danger, become suspicious of others, and become disconnected from their bodily experiences. These feelings can prevent the very help that an individual needs. However, individuals in helping professions, such as emergency services and health care, are not immune to the effects of traumatic stress. Their work can expose them to prolonged periods of traumatic stress that can lead to feelings of burnout, numbing, and sleep disturbances. In addition, Survivors of betrayal trauma and sexual trauma report experiencing a host of shame-based emotions. Trauma can be so isolating that people feel that if they disclose what has happened to them, no one will believe them or that it will only make things worse. Many people suffer from trauma for a long time before they disclose what has happened to them. Patients with a history of trauma can present with a host of health care problems. Health care providers can do a lot to help patients recover from the effects of trauma, but first they need to be aware of what to do differently. Currently, patients with a history of trauma are treated for chronic pain, insomnia, frequent headaches, stomach problems, etc. Children and adolescents with a history of trauma are diagnosed with behavior problems such as attention deficit and hyperactivity disorder, conduct disorder, and/or oppositional defiant disorder. Adults with a history of trauma are diagnosed with post traumatic stress disorder, relationship problems, and compulsive behaviors involving substances, sex, food, shopping, and spending. Many of these patients feel great shame and are in need of special understanding and support. Trauma affects the way a person thinks, feels and behaves in important ways. Thus, in order to best serve people with trauma hospitals including Emergency Departments should rethink the way that treatment is provided. Treatment for a variety of health conditions identifies and describes a patient’s critical thinking patterns and ways in which those patterns affect the patient in a negative way. Similarly, providers can serve people with trauma well by asking whether or not they have experienced trauma, and giving the individual control over how much or how little they wish to share about their experiences of trauma. Finally, typical measures of psychological functioning (e.g., symptoms of depression or anxiety, stress) can be supplemented by additional questions that focus on sleep, emotional regulation, and self-care. It is important to work with individuals who have experienced trauma in a collaborative, non-judgmental and respectful manner. 1) Screening and assessment: Use brief lifespan and trait-focused screening and assessment tools to assess core trauma-related traits and severity of functional impairment. Example questions might include those about sleep disturbance, avoidance of places, people or situations associated with the trauma, difficulty regulating emotions, dissociative symptoms, difficulty with trust and safety. Work with individuals who have a history of trauma in a respectful manner, and allow them to disclose information as they are comfortable. How can we as professionals use a trauma-informed lens when approaching our clients and patients? How can we use screening for trauma in a way that fosters trust and respect as opposed to causing harm? What strategies and resources can assist our clients and patients after we have screened for trauma? How can we, as professionals, use a trauma-informed approach when screening for trauma in order to reduce stress and overwhelm for clinicians? How can we use screening for trauma in a way that respects boundaries and decides when to push for more information? How can we use assessment and treatment planning in a way that honours the experience and perspective of the client or patient? How can the timing of the event and what is currently triggering symptoms be taken into account when assessing for trauma? Previous blogs have touched on the concept of early and late trauma. Early trauma (child abuse) can result in difficulties with attachment as well as chronic shame whereas late trauma (assault) may be characterised by memories, intrusive images and avoidance of reminders. Importantly, most people experience more than one type of trauma, and as a result their symptoms will change depending on context. Clinicians need to ask their patients how their symptoms are affected by being in a relationship, waking up at night, arguing with a partner or child etc. in order to have a solid enough formulation of the patient’s difficulties and to set realistic treatment goals. Furthermore, treatment and recovery pathways need to be integrated and delivered in a trauma informed way from primary care and pediatrics through to schools and the emergency services. Although treatments for trauma have typically been seen as complex, lengthy and specialized, work with individuals with significant trauma histories who report suicidal ideation should begin with basic support of sleep, safety planning, and reduction, and treatment of the use of substances to regulate negative emotions. Following this, basic skills building with the individual and their family members to improve emotional regulation (e.g., grounding, tolerating intense physical experiences of discomfort, managing extremely aversive emotional experiences) can be beneficial for many. Then, an entry-level, structured trauma treatment approach may be indicated.

A developmental pathway to address suicidal ideation and attempts that includes early stabilization in primary care is critical. The Collaborative Care model facilitates the connection between the PCP and the behavioral health consultants. Many individuals and families benefit from a trauma-informed care “whole-systems” approach to address trauma and suicidal ideation. A trauma-informed care “whole-systems” approach is not just a type of treatment but rather a way of organizing practice on a systems level. This approach to practice includes respectful communication, consistent procedures and processes throughout services, an emphasis on privacy and safety, and strategies to minimize re-traumatization. How might the patient’s nonadherence be related to avoiding, dissociating from, or being fearful of aspects of their treatment? Addressing shame about avoiding aspects of their treatment may also be important. What are the patient’s dominant personality traits and how best to engage them in treatment? For patients with emotional dysregulation, structured, skills-based therapies (DBT, or other dialectical thinking-based treatments) can teach patients to emotion label, tolerate distressful states, and control their impulses before they do harm to themselves or others. For patients with avoidance and fear conditioning, encouraging gradual exposure to the situation(s) that they fear, with some coping skills for managing their immediate reaction to the exposure, can be very helpful. For some patients with dissociation, some level of treatment-based stabilization, grounding, and paced processing may be necessary before they are ready to engage in typical, trauma-focused work. For individuals who have experienced interpersonal trauma, engagement in treatment for an engaging sex-related pattern would ideally focus on issues of trust, shame and healthy boundaries in relationships. stereotype of what sex goals look like for men and women can often hinder treatment engagement. In contrast, each individual would greatly benefit from having some unique strategies and techniques to develop a sex-related goal. This may include early gains in sleep, work performance, control of anger and other areas of life that the man feels he cannot control. For women, feeling safe and valid in their safety concerns and a decrease in shame related to their sexual behavior would be a large factor in treatment engagement. Treatment for adult victims of interpersonal trauma should be individualized and culturally sensitive. Training the workforce to address trauma is crucial and must be practical, effective and brief. An initial brief course could teach workers about safe and sensitive trauma screening, how to respond to disclosures of trauma, and teach workers and patients about recovery from trauma. Those who require more advanced training could learn about the impact of trauma based on the age of the patient at the time of the trauma, and the impact and differences of the effects of trauma on men and women. In addition, providers and payers need to understand how reimbursement systems can support the care of patients who have experienced trauma. Traditional reimbursement structures are set up to pay for treatment of specific disorders. A transdiagnostic trauma informed approach requires a shift away from a disorder focus and toward a more skills based approach that emphasizes the clinical relationship. What payment models will support longer duration of service when needed; team-based delivery; and follow-up visits focused on physical safety and optimal functioning? Until we address these care pathway design elements, even the best intentional pathways will not be enough. Incorporating prevention strategies that reduce community trauma and build resilience in our communities is also key. Timing is everything and the greatest long-term impact will come from intervening early in development. A community-based approach to reducing violence, strengthening families, securing stable housing, and education in early childhood are strategies that can reduce severe trauma in the community over time. Schools can play an important role in supporting healthy regulation and safe symptom reporting for students with RD, and in promoting schools and communities where mental health literacy and the value of mental health are supported. Framing messages about traumatic experiences for public health use can be particularly challenging. Avoiding words or language that feels inescapable or permanent, and emphasizing support, healing, and growth are important when considering how to craft messages that promote recovery. When aiming to expand screening for traumatic experiences or to add trauma-informed care into one’s work with RD, it is also important to consider potential risks and trade-offs. Screenings and care should avoid forced trauma disclosure, pathologizing typical, adaptive human behaviors, and conflation of a person’s identity with their experiences of trauma. On both an individual and system-wide level, I urge providers to focus on supporting present day functioning and to explore goals for treatment with each client. In less resourced settings, a stepped-care approach can help channel the most intensive skills building and evidence-based treatment to those most in need, while still offering a brief education about skills and some self management strategies to other clients. Such a thoughtful and balanced system can well support individuals with a trauma history.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC10906118/ https://onlinelibrary.wiley.com/doi/10.1002/jts.23023 https://pubmed.ncbi.nlm.nih.gov/36208317/ https://www.cambridge.org/core/journals/european-psychiatry/article/how-is-trauma-a-transdiagnostic-risk-factor-a-biopsychosocial-model-of-risk-and-protective-mechanisms-following-childhood-trauma/FD2E344A95E3D6E66F5177ECBECCE30F