Supporting adults who have experienced trauma or abuse in childhood
This month we discuss complex post-traumatic stress disorder (PTSD) with Priory Hospital North London Consultant Psychiatrist, Dr Liam Parsonage. We explore the links that this condition has to childhood trauma or abuse, and the importance of supporting adults who have developed mental health challenges due to these experiences.
Research has shown that children who experience early childhood trauma, abuse or neglect are more likely to go on to develop profound and long-lasting mental health problems in adulthood, such as ‘complex PTSD’. This differs from ‘PTSD’ which is more typically associated with a single traumatic incident or set of traumatic events.
The risk of developing complex PTSD is greater if trauma or abuse is repetitive and prolonged, involves harm or abandonment by care givers and if it occurs at a developmentally vulnerable age such as early childhood or adolescence, which are critical periods of brain development.
Why does this happen?
We spoke to Dr Parsonage about the ‘fight, flight or freeze response’:
- The amygdala, part of the limbic system, is the brain’s ‘smoke detector’ and emotional memory centre. The amygdala is triggered if it senses any kind of threat or danger and causes the brain stem to react instinctively and activate the fight, flight or freeze response. This causes an increase in heart rate, breathing rate and muscle tension
- The ‘thinking part of the brain’ (the neocortex), becomes less active and shuts down. At times of danger, we become overwhelmed by feelings and impulses and we don’t think about or contextualise our experiences – we simply react to the danger rather than thinking about it
- This evolutionary response to danger takes the fast route via the amygdala, rather than the longer thinking route via the cortex, which has aided our survival
- After the danger has passed, the normal response is for the thinking brain to then react, regulate responses, plan, problem solve, and allow arousal levels to return to baseline
- The amygdala is over-sensitive and the capacity of the thinking brain is reduced in individuals who have been exposed to trauma in childhood and develop complex PTSD
- Memories have not been processed and fully integrated into autobiographical memory and they remain stuck in implicit (feeling) memory
- Flashbacks and re-living of the trauma occur because the amygdala has kicked in and the hippocampus has gone ‘offline’ and is unable to contextualise the memory in the moment. Traumatic memories are therefore ‘re-experienced’ rather than ‘remembered’
The neurological systems that process emotions are significantly compromised in individuals who have experienced chronic childhood trauma:
- Chronic stress reduces the size and functioning in the area of the brain that processes memory
- The amygdala is overstimulated and is in constant overdrive
- High levels of cortisol make it harder to learn and block memories forming
- The brains of people with complex PTSD show an enhanced sensitivity to threat and are usually in a chronic state of ‘red alert’
What are the symptoms of complex PTSD to look out for?
Trauma survivors can present with a wide range of problems and symptoms ranging from physical, psychological and maladaptive coping strategies and may report any of the following:
- Re-experiencing or re-living unwanted memories as flashbacks or nightmares
- Hyper-arousal: problems with sleep, irritability, anger, anxiety, hyper-alertness, exaggerated startle response
- Hypo-arousal: feeling numb or cut off, feeling detached from others, dissociating, feeling flat or empty
- Emotional dysregulation
- Negative self-concept
- Relationship difficulties
- Avoiding thinking or talking about trauma related topics
- Abuse of alcohol or abuse of substances to avoid and numb their feelings
- Engaging in self-harm or having suicidal thoughts
When to consider the diagnosis of complex PTSD
People who have complex PTSD often present with co-morbid psychiatric conditions and patients will often not disclose that they have experienced a trauma in their childhood and therefore present with another mental health or physical health problem, relationship or behavioural problems.
It is also worthwhile considering complex PTSD when a patient presents with symptoms that don’t fit the usual pattern of depression or anxiety or don’t respond to the usual treatments.
Other conditions patients with complex PTSD might present with include:
- Major depression
- Anxiety disorders
- Substance abuse disorders
- Eating disorders
- Dissociative disorders
- Borderline personality disorder (BPD)
- Chronic pain and other health problems
How can a GP help?
- Build a trusting therapeutic relationship
- Don’t push to talk about the details of trauma as this can re-traumatise the patient and leave the patient feeling vulnerable and destabilised
- Don’t over-estimate the patient’s capacity to tolerate emotions and encourage them to engage in treatment to develop skills to manage their intense emotions
- Psycho-education regarding the effects of childhood trauma on the brain can help the patient understand why they feel such intense emotions
- Normalise and give hope
Provide them with practical techniques to build emotional stability. These can include:
- Grounding techniques
- Breathing strategies
- Trigger awareness
- Sleep hygiene
- Understanding anger
Educate the patient on the neurobiology of trauma
It can be helpful to explain the neurobiology of trauma to patients to help them understand why they have such intense reactions to everyday experiences which don’t affect others in the same way.
Tell them about the three complex sections of the brain
- The brainstem – involved with instinctive responses, controlling bodily functions such as heart rate, and breathing
- The limbic system – involved in non-verbal emotional experience, feelings and ‘gut’ memories, and traumatic memory
- The neocortex – involved with reasoning, problem-solving, verbal expression, and memory for events and facts
Refer them to a specialist for further treatment
Most people who have complex PTSD will need specialist intervention to confirm the diagnosis, manage risk, formulate an appropriate treatment plan and gain access to talking therapies.
What are the best treatments for those with complex PTSD?
Trauma-focused cognitive behavioural therapy (CBT)
Trauma-focused CBT is an evidenced-based, NICE recommended talking therapy which has been developed from CBT to specifically help people who have experienced trauma. The recommendation is 8 to 12 individual weekly sessions for an hour with the same therapist each week.
Eye movement desensitisation and re-processing (EMDR)
EMDR is another NICE recommended treatment for people who have experienced trauma and often re-live the events as nightmares and flashbacks.
EMDR involves recalling the traumatic event whilst making rhythmic eye movements similar to the eye movements we make whilst we sleep and are processing memories. This helps the brain to process the traumatic experiences and reduce the emotional content so that rather than re-living the experience, the experience becomes a memory, so that distressing symptoms associated with the traumatic event are reduced.
Five-day trauma programme
The five-day trauma programme is offered at Priory locations in the UK and is based on Pia Mellody’s Post Induction Therapy (PIT) – a method that is widely used in the USA. The PIT approach utilises an eclectic mix of therapy and treatment models, bringing together elements of psychoanalysis, gestalt therapy (gestalt helps people to focus on their immediate thoughts, feelings and behaviours and to better understand the way they relate to others), family systems therapy, transactional analysis therapy and rational emotive therapy.
By using educational and experiential processes, the programme helps patients to identify and address their childhood trauma and family-of-origin issues. Once these issues are identified, patients are able to explore ways to deal with the emotions that accompany their past traumatic events, and how to resolve the resulting grief and distress.
Medications are not the key to treatment of complex PTSD but should be used to target specific symptoms, for example antidepressants for low mood, or mood stabilisers for mood instability.