THE IMPACT OF TRAUMA

OUTLINE

• Trauma and psychopathology
• Case history
• Discussion
• Risk of violence

Untitled Slide

Some ways trauma effects the brain

• Changes to HPA & cortisol, Epigenetics & Autoimmune (IL6 & CRP only raised in depressed with abuse Hx)
• Threat-perception system enhanced, filtering system faulty, self
• Structural changes: reduced myelination of corpus callosum (neglect boys; sexual abuse girls) EUPDsplitting. hippocampus shrinks in prolonged stress

WHAT IS TRAUMA

• Threat to survival: Defence system activated (adrenaline fight flight)
• Beneficial to survival
• Fright without solution: Helplessness, overwhelmed, terror (cant move->freeze)
• Uneccesary functions shut down
• 2 responses: hyperarousal & dissociation
• Impact of stress reduced if can act/ move

TRAUMA & INTEGRATION PROBLEMS

• Amygdala crucial for learning about danger- emotional /fear memories Autobiographical memories then coded in hippocampus (time,space, in the past)
• In extreme stress, hippocampus disabled. In first few years of life, hippocampus not "online"
• Early & traumatic memories: out of context (dissociated)

THE IMPACT OF "SINGLE BLOW" TRAUMA - PTSD

• Intrusive re-experiencing: Flashbacks, nightmares (dissociative memories)
• In chronic PTSD - 2 subtypes of responses to triggers

THE IMPACT OF "SINGLE BLOW" TRAUMA - PTSD

• Avoidance (keeps memories away)
• Anger & Violence
• Chronic increase in cortisol & adrenaline
• Alcohol / Substance / Eating disorder
• +ve psychotic symptoms (hall, paranoia)
• Numbing (dissociative)

REPEATED TRAUMA IE CSA

• Disorganised attachment explained by conflict between 2 bodysystems (defence/attachment): caregiver is at same time source of and solution for infants fear-> fright without solution.
• Relational problems, attention, emotional instability
• Defence system overactive, so reduces child's pleasure-seeking & explorative actions (play, sex, sociability)
• Intense feeling that are not understood

REpeated traumas ie CSA - complex PTSD

• Assoc with most psych disorders esp certain features - suicidality and voices
• Repression, dissociation, agression, rage, self-anaesthesia, self-hypnosis, self-depreciation.
• Struggle to connect, lack curiosity & lose sense of pleasure
• DSH & suicidality high as a result
• Chronicity, severity, protective others

DISSOCIATIVE EXPERIENCES SCALE (Normal 5)

• Amnesia, depersonalisation, derealisation, identity confusion - high scores in scz/did and emotional/physical abuse
• Anxiety & Mood disorders 7-9
• Schizophrenia 15
• Borderline personality disorder 19
• Post traumatic stress disorder 31
• Dissociative identity disorder (MPD) 48

Psychosis & DISSOCIATION

• Complex relationship between psychosis & dissociation "dissociative hallucinosis"
• +ve symptoms & high affect dissociative in nature stemming from disorganised attachments & trauma
• Rx: safety, SSRI group/family therapy, trauma-CBT/EMDR, psychotherapy, ?trial low dose antipsychotics

JOHN

• Commands to kill
• Suicidal
• Admission

JOHN

• Overwhelmed at home
• Poor sleep
• Commands

JOHN

• Anxiety
• Depression
• PTSD
• Pain
• Suicide
• Alcohol
• Medication and trauma therapy

JOHN

• Agitated
• Whisper- commands- you've done it before you can do it again
• Low, flashbacks, nightmares, poor appetite, Guilty & suicidal
• No thought disorder or paranoia
• Insight

JOHN

• Voluntary work
• Children
• Sexual abuse
• Combat trauma

JOHN

• Dialogue, exploration
• Safety - obs
• Nightmares
• Intensity and power decreasing
• Accommodation issues
• Agitation, foetal position
• Disclosed abuse to brother

JOHN

• Any questions
• Differentials
• Risk

HETEROGENEITY OF VIOLENCE IN INPATIENTS

• Male 42%
• History of violence 40%
• Alcohol abuse 35%
• Detained 27%
• Schizophrenia 21%
• Personality disorder 14%

VIOLENCE predictors iN PSYCH DISORDERS

• SCZ - Paranoid delusions, delusions of control, thought insertion
• PTSD- severity & hyperarousal
• Veterans- history of violence, PTSD plus anger, financial instability, combat history, alcohol misuse
• Dissociation predicts violence & severity
• Childhood maltreatment - DV

CLINICAL IMPLICATIONS

• Ask about trauma history and dissociative experiences esp if voices
• Dissociative experiences / altered states - rapid changes in presentation doesn't mean they're "faking it"
• "Treatment resistance" might indicate underlying unprocessed trauma - try a different approach