Note: This article is primarily intended to be a resource for mental health professionals who are treating individuals impacted by a history of trauma and who are seeking additional evidence-based tools to support their work. If you are not a mental health professional, you may also find this article helpful in learning more about the topic of trauma.
Experiencing and healing from trauma can be overwhelming. Understanding what has occurred and the effect it has on a person is just one step in what can feel like a never-ending journey. This is because whether an individual is struggling following a single event or complex trauma, the effects on the mind and body can significantly impair one’s sense of self and safety in the world. In this three-part series, I will walk through how to apply Dialectical Behavior Therapy in a stage-based treatment approach. Through evidence-based practice and a structure that parallels the process of stabilization, exposure and integration of trauma treatment, DBT provides a foundation from which to build to move through despair and into repair.
What is Trauma?
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) helps us define Post-Traumatic Stress Disorder (PTSD), though it is important to acknowledge that the definition of both trauma and PTSD have evolved dramatically over the years as our understanding expands. Until the 5th edition of the manual (2013), PTSD was thought of as an anxiety disorder. In the most recent edition, it has since been re-conceptualized as a trauma and stressor-related disorder; an important distinction that frames the cluster of symptoms in the context of the event rather than on the pathology of the individual. For symptoms to warrant a diagnosis of PTSD, the duration of disturbance and impairment must last more than one month and cause significant impairment in social, work and other contexts with symptoms from each of these six categories: exposure to trauma, re-experiencing symptoms, persistent avoidance, increased arousal and reactivity, negative cognitions and mood, distress and impairment. Additionally, they might experience symptoms that qualify them for a dissociative subtype of either depersonalization or derealization.
Re-Experiencing Symptoms of Trauma
Re-experiencing symptoms include intrusive thoughts, traumatic nightmares, flashbacks, intense or prolonged distress following exposure to traumatic reminders and marked physiological reactivity after exposure to the trauma related stimuli. These symptoms are incredibly distressing to the person living with them and they are often at the forefront of the clinical work. These will commonly be the first symptoms to show up in therapy and can be incredibly useful in guiding the direction of the work.
Persistent avoidance includes increased arousal and reactivity which ultimately makes life smaller and smaller and people begin to feel more and more irritable. One might notice avoidance of both external reminders of the traumatic event or events and/or avoidance of feelings, such as anxiety or depression, that serve as reminders. Imagine living life avoiding people, places and things that you once loved. Imagine living life avoiding ever feeling anxious or depressed. It is easy to understand how one might make their existence so small that they never leave the “safety” of their own home.
Increased arousal can look like aggression, hypervigilance, exaggerated startle response or sleep disturbance. The overlap with other mental health concerns is especially apparent in this symptom profile. How many other diagnoses come to mind when reading through that list? That helps us understand one of the several reasons PTSD is so often missed and goes untreated for so long. Negative cognitions and mood highlight the ways in which we can internalize traumatic events and develop beliefs about ourselves and the world around us that are pervasively negative and deeply flawed.
When we review these effects on a person’s mind, body and relationships, we certainly understand that this would correlate with marked distress and impairment, including difficulty working, focusing, maintaining healthy relationships, practicing self-care and so on. The dissociative subtypes are another new feature seen in the DSM-5 and apply to those who, in addition to meeting criteria for a diagnosis of PTSD, experience high levels of either depersonalization or derealization in reaction to trauma related stimuli. Depersonalization is the experience of being an outside observer or detached from oneself, feeling as if one were in a dream. Derealization is the experience of “unreality,” distance or distortion.
Why It’s Hard to Recognize Trauma
Oftentimes, individuals who have experienced a traumatic event or events do not recognize trauma as the source of their distress for years after experiencing the event/s. Whether someone qualifies for a diagnosis of PTSD or a sub-clinical presentation, post-traumatic stress can be assessed with various measures, including the PCL-5 and the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) . It is also most effectively done within a strong, working relationship with a therapist or psychiatrist. There are challenges in proper diagnosis for both the client and the clinician. It is no small task to begin approaching the pain of PTSD, although we know that the pain of living with it is much, much greater.
What It’s Like Living with Trauma
Let’s take a moment to consider what living with trauma symptoms means beyond just the diagnostic set of criteria. If you feel able, give yourself a moment to imagine what your body feels like when you are in crisis. For the sake of the thought experiment, I encourage you not to think of your most activating memory. Perhaps you’re calling to mind a time when you were in a near car accident, or when you flew through turbulent skies or your phone rang in the middle of the night and you were uncertain what news waited on the other end. Now think about how your body reacted in those moments. When I recall a moment like this, I think about how my heart raced, my palms sweat, my muscles clenched, and I could not really feel my feet. I got tunnel vision and became hyper focused on the threat. Then, as soon as I knew I was safe, my emotions came flooding back leading to tears, shaking and trouble breathing until I was able to re-regulate. This is your nervous system reacting in exactly the way it is designed to do.
The Body’s Response to Trauma
The two branches of autonomic nervous system, the parasympathetic (PNS) and the sympathetic (SNS), work in harmony when we are regulated. The parasympathetic branch acts as our brake, commonly known as “rest and digest” and the sympathetic branch acts as our gas pedal. So, in moments of threat when we do not have time to respond, our body does what it needs to do to survive. There are four widely known instinctive reactions in the face of trauma: fight, flight, freeze and submit. Briefly described, the responses are:
- FIGHT: High arousal response from SNS. Heart races, muscular activation, tunnel vision. We go toward the threat and try to repel it. Emotional response includes anger and rage.
- FLIGHT: High arousal response from SNS. Heart Races, Muscular Activation, Tunnel Vision. Bodies activate to get us away from danger. Emotional Response includes anxiety and fear.
- FREEZE: Possibly activates both SNS and PNS. Bodies highly activate and the mind is aware of surroundings while bodies become immobile, directing all energy toward information intake about the threatening situation; incapable of action. Emotional response includes helplessness and fear.
- SUBMIT: The PNS is activated, and the body shuts down. This is a dissociative response; think of animals “playing dead.” Heart rate slows, blood pressure lowers, body produces endogenous opioids that alter perception of time and reality. This helps us disconnect from the experience of pain associated with an attack.
(Emerson and Hopper, 2011, pgs 18-20)
These responses in and of themselves are not problematic. In fact, this is exactly how the body is meant to react. What becomes problematic is when we begin to operate in these states on a chronic or ongoing basis. When we live with fight, flight, freeze or submit stored in the body, we respond to everyday events as though they are matters of life and death.
The Window of Tolerance
Dr. Daniel Siegel coined the term Window of Tolerance (WOT) to describe how we operate when we are regulated versus when our sympathetic branch is in overdrive (pedal to the metal) or our parasympathetic branch is stuck on (brakes). After an individual experiences a traumatic event or series of events, their Window of Tolerance closes some amount, making their nervous system susceptible to experiences of hyper- or hypo-arousal. After the initial experience, it is easier to get triggered in or out of the WOT and much harder to get back in. Subsequently, that person might begin to engage in behaviors in an effort to re-regulate, or get back in the window, that actually make it smaller, such as substance use, avoidance, self-injurious behaviors, etc. It makes complete sense one might turn anywhere they can for comfort, and it also makes sense that over time they will recognize that this backfires by increasing suffering.
Prevalence Rates of Trauma
Before we discuss what to do with this information, it is useful to know how many people are impacted by trauma. Based on diagnostic interview data from National Comorbidity Survey Replication (NCS-R): An estimated 3.6% of U.S. adults (18 or over) had PTSD, the prevalence of PTSD among adults was higher for females (5.2%) than for males (1.8%), and the lifetime prevalence of PTSD was 6.8%. These statistics, while significant, still only speak to those who are actually diagnosed with PTSD. The number of people who are exposed to trauma and suffer due to that exposure is far greater. In fact, it is said that approximately 80% of individuals who seek mental health treatment identify with some type of trauma history.
Whether you are a professional in the mental health field, concerned for a loved one managing trauma related symptoms or experiencing the pain of this yourself, the pressing question we must address is: now what? It is overwhelming to be living with trauma related symptoms; it does not have to be overwhelming to treat them. In Part II of my article on this topic, I will outline how Dialectical Behavioral Therapy, an evidenced practice, provides structure in trauma treatment and how the skills we learn in DBT help us get in, stay in and expand our windows of tolerance. Stay tuned!
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
PTSD: National Center for PTSD . (2020, August 10). PTSD Checklist for DSM-5 (PCL-5). Https://Www.Ptsd.va.Gov. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
PTSD: National Center for PTSD. (2020, August 10). Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Https://Www.Ptsd.va.Gov/. https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp#obtain
Emerson, David, and Elizabeth Hopper. Overcoming trauma through yoga: reclaiming your body. Berkley, Calif.: North Atlantic Books, 2011. Print.