Presented by The Royal's Dr. Fotini Zachariades at our annual Women in Mind Conference. She is a Clinical, Health, and Rehabilitation Psychologist currently at the Women’s Mental Health Program at The Royal

1. Trauma and
Health
Fotini Zachariades, Ph.D., C.Psych.
Psychologist, Women’s Mental Health Program
ROMHC
November 15, 2013

2. Overview
•
Definition & sources of trauma
•
Trauma & women- epidemiology
•
Physical health & the biology of trauma
•
Trauma & mental health comorbidity
•
Developmental considerations and attachment
•
Further psychological and social aspects of trauma

3. Definition of Trauma
• Occurs when threat overwhelms an individual’s adaptive
internal and external coping resources
(Fallot & Harris,
2009)
• Experience of ‘acts of omission’ and/or ‘acts of
commission’ (childhood)
(Briere, 2002)
• Broader conceptualization of trauma

4. Sources of Trauma
•
•
•
•
•
•
•
•
•
•
Emotional, physical, or sexual abuse, abandonment/neglect
(children)
Sexual assault, domestic violence, experiencing or witnessing violent
crime
Institutional abuse
Cultural dislocation/immigration
Terrorism, war, violence against a specific group (e.g., genocide)
Natural disasters
Grief/loss
Chronic stressors such as racism, poverty
Accidents, medical procedures, severe injuries/illnesses
Any situation where one person misuses power over another
(Ackley & Covington, 2008)

5. Trauma & Women –
Some Epidemiological Data I
• Estimated that around 872 979 Canadians currently
have PTSD
• 76.1% report some form of trauma exposure in their
lifetime
• Women twice as likely as men to develop PTSD

6. Trauma & Women –
Some Epidemiological Data II
• PTSD more prevalent in women across the lifespan, in
the general population women experience PTSD for
longer duration than men
• Lifetime prevalence rates: women 9.7%, men 3.6%
• 12-month prevalence:
women 5.2%, men 1.8%
• 6-month prevalence among adolescents:
girls 6.3%, 3.7% for boys

7. Impact of Adverse Childhood
Events (ACE) Study
(n)=17,000
• High ACE scores= more likely to develop mental health
problems, abuse substances, have chronic physical
illnesses, die early
• Women significantly more likely to have high ACE
score:
> 50% more likely than men to have an ACE score
of 5 or more
(Felitti et al., 2010)

8. ACE StudyFindings related to women
• Women with an ACE score of 4 or more:
> almost 9 times more likely to become victims of rape
> 5 times more likely to become victims of domestic
violence
• 54% of depression in women related to childhood abuse
• 2/3 of suicide attempts associated with ACEs:
> women are 3 times more likely to attempt suicide than
men across the lifespan
(Felitti et al., 2010)

9. ACE Study
http://www.cdc.gov/ace/pyramid.htm

10. http://www.samhsa.gov/children/social_media_apr2011.asp

11. Trauma & Women –
Some Epidemiological Data III
• Women have greater chance of exposure to interpersonal
trauma:
> 14–20% of women will be raped at least once in
their lifetime
> 25–28% will experience intimate partner violence
> 8–24% will be stalked by someone
> 25-35% will have experienced sexual abuse in
childhood

12. Process of Trauma
TRAUMATIC EVENT
Overwhelms the Physical & Psychological Systems
Intense Fear, Helplessness or Horror
RESPONSE TO TRAUMA
Fight or Flight, Freeze, Altered State of
Consciousness, Body Sensations, Numbing, Hypervigilance, Hyper-arousal
SENSITIZED NERVOUS SYSTEM CHANGES IN
BRAIN
CURRENT STRESS
Reminders of Trauma, Life Events, Lifestyle
Painful emotional state
RETREAT
SELF-DESTRUCTIVE ACTION
DESTRUCTIVE ACTION
Isolation
Dissociation
Depression
Anxiety
Substance Abuse
Eating Disorder
Deliberate Self-Harm
Suicidal Actions
Aggression
Violence
Rages
(Ackley & Covington, 2008)

13. Trauma & Physical Health I
• Physical reactions are automatic and are not controlled
by us
• Brain reactions are also automatic
• Body stores reactions:
> the body then reacts as though it is back re-living
traumatic events of the past

14. Trauma & Physical Health II
•
Trauma has negative effects on physical health
•
May promote poor health through complex interaction between
biological and psychological mechanisms
•
Likely that relationship exists between the experience of trauma
and an increase in utilization of medical services for physical health
problems
•
Higher health care costs among women reporting childhood
abuse/neglect histories

15. Trauma & Physical Health III
• Reports of childhood abuse/neglect related to increase in
physician diagnosed medical conditions
• History of childhood abuse increases risk of cardiovascular
disease:
> Link especially strong for women with nine-fold
increase

16. Trauma & Physical Health IV
• Women with PTSD:
> more hospital outpatient visits
> higher rates of hospitalizations and surgical
procedures
> longer hospital admissions
> less likely to be married
> more likely to experience disability, chronic pain,
obesity, smoke, and abuse alcohol

17. Trauma & Physical Health V
• Women trauma survivors may frequently report:
> Chronic pain
> Gynecological difficulties
> Gastrointestinal problems
> Asthma
> Heart palpitations
> Headaches
> Musculoskeletal difficulties

18. Psychoneuroimmunology I
• Research in field of PNI provides useful framework for
understanding effects of trauma on health
• Illness as a consequence of severe stress
• Chronic stress results when there is:
> too frequent and intensive an activation of the
physiological system
> not enough time to rest and repair

19. Psychoneuroimmunology II
• Inability to shut off stress
response system- lack of
adequate response due to
exhaustion
• Burnout: state of physical, emotional, and mental
exhaustion resulting from intense involvement over long
periods of time in situations that are emotionally
demanding
(Pines & Aronson, 1981)

20. Psychoneuroimmunology III
• Ongoing experience of physical symptoms over longer term
• Prior trauma “primes” physiological inflammatory response
system so that it reacts more rapidly to subsequent life
stressors
• Elevated inflammation has etiologic role in many chronic
illnesses
• Changes seen as a cost of chronic stress vary depending on
coping strategies, resources, lifestyle, life stressors, interacting
with genetics and early life events

21. Allostasis I
•Allostasis refers to body’s attempt to maintain stability
through stress and change
•Introduced as modification of homeostasis:
In allostatic model adaptation achieved through change;
physiological and behavioural states change in response to
context
•Allostasis maintained through stress hormones, immune
system, and neurological responses- defensive function for
protection during acute need

22. Allostasis II
• When body is overwhelmed by
stressors, allostatic load
(body “wear and tear”) can occur
• Our systems are set up to do this
in short-term:
> over time the cost of maintaining
this is damage
• Such underlying physiological changes
have pathophysiological consequences:
> over time trauma can increase
allostatic load by chronically activating
HPA axis and SNS

23. Allostatic Load
Potential gender differences in
physiological stress reactivity:
Women may be more reactive to
social stressors (e.g., rejection)
(Stroud et al., 2002)

24. Biology of Trauma I
• Immune system responds to threat by releasing
proinflammatory cytokines
• Cytokines increase inflammation and serve adaptive
purpose of helping body heal wounds and fight infection
• Both physical and psychological stress (such as trauma)
can trigger inflammatory response

25. Biology of Trauma II
• In case of severe/overwhelming stress the normal built-in
checks and balances of the stress response fail, leading
to high levels of inflammation
• Elevated levels of these and other inflammatory markers
associated with increased risk of health problems (CHD,
MI, chronic pain syndromes, premature ageing, impaired
immune function, impaired wound healing, Alzheimer’s
disease)

26. Biology of Trauma III
• In response to threat SNS responds by releasing
catecholamines (norepinephrine, epinephrine,dopamine)
- ‘fight or flight’ response triggered
• HPA axis responds with chemical cascade:
> hypothalamus releases corticotrophin releasing
hormone (CRH)
> CRH causes pituitary to release
adrenocorticotropin hormone
> Adrenal cortex releases cortisol

27. Biology of Trauma IV
PFC: prefrontal cortex, AMY: amygdala,
lat HYP: lateral hypothalamus, SNS: sympathetic nervous system,
PNS: parasympathetic nervous system, RSA: respiratory sinus arrhythmia,
SCR: skin conductance response, vlat PAG: ventrolateral periaqueductal gray
Norrholm & Jovanovic, 2010

28. Non-PTSD
PTSD
Cortical
region
Limbic Region
Brainstem
Region
Cortical region
Limbic Region
-
-
Memories stored in amygdala
result in flashbacks,
nightmares, over time smaller
hippocampus
SNS and PNS get locked on at
equal levels, creates
dissociation.
Brainstem
Region
Increased functioning in limbic and brainstem regions and decreased functioning in
cortical regions in PTSD compared to non-PTSD subjects. (Solid colours indicate
increased functioning, lighter shaded areas indicate decreased functioning).
(Dawson, 2007)

29. Stress Response
• Traumatic stress alters and
dysregulates key systems
forming the stress response
• 3 components of stress
response:
 Catecholamines
(norepinephrine, epinephrine,
dopamine)- ‘flight or fight’ response
 Hypothalamic-pituitary-adrenal (HPA) axis
 Immune response

30. HPA Axis Dysregulation I
• Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation in response to
chronic stress
“confused” stress response
• Low serotonin leads to less inhibition of aggression, low mood
• High serotonin leads to decreased appetite, less need for sleep,
increased
agitation
• Adrenaline and noradrenaline turn on, leading to increased “hyperfocus”
and attention
• Combined these increase cardiac output and dopamine sustains the
needed energy level
• Higher levels of opiates in system subdue the pain being experienced
• Immune cells are redistributed so that they can easily reach a site of injury

31. HPA Axis Dysregulation II
SEROTONIN
ADRENALINE
DOPAMINE
OPIATES

32. HPA Axis Dysregulation III
• High levels of adrenaline, serotonin disturbance: keyed up,
agitated, irritable to aggressive, reduced sleep efficiency (sleep
disturbance may be gateway to illness), for some food, smoking,
alcohol etc., to regulate system
• Dopamine decreases: fatigue & anhedonia, for some related
to impulsivity/self-harm (we lose interest in what we used to
love and are too tired to be healthy as it takes too much work)
• Higher levels of opiates (but less effective): numbing, blunting,
depersonalization, risk of addictive behaviours (substance abuse,
gambling, shopping)

33. HPA Axis Dysregulation IV
• Behaviours we use to cope may lead to an increase in health risk
e.g., substance use
• Reduced efficiency, poor judgement (we have to work harder now
to do what we did before and we start making poorer choices,
keeping the negative spiral going)
• Oxytocin (“attachment” hormone): protective or risk factor for
women, with HPA dysregulation there is preliminary evidence
indicating decreased circulation leading to increased social
isolation/withdrawal (which further decreases resources) & for
some use of substances to stabilize system

34. Secondary Outcomes I
• Secondary outcomes of chronic
HPA axis dysregulation
(physiological inflammatory
responses)
• Can be grouped in 4 categories:
> Reduced immunity
> Vasoactive
> Procoagulant
> Inflammatory

35. •Reduction in NK cells & Tlymphocytesopportunistic infections
•Insulin conserves
metabolism during challenge,
leptin resistance, with
increased food intakeobesity
•Inhibition of digestive
processesdiverticulitis, ulcerative
colitis, digestive tract
bleeding, IBS
•Decreased bone myelinationosteoperosis
Serotonin:
•Suppresses reproductioninfertility
Serotonin:
• Vasoconstricts peripheral
blood vessels
• Increases fasting glucose
levels, impaired glucose
tolerance
• HypocoaguabilityMI and stroke

36. Trauma & Mental Health
Comorbidity
• 79% women diagnosed with
PTSD have at least one
comorbid psychiatric disorder
• PTSD may go undiagnosed
or can be misdiagnosed as
another disorder that may
mask underlying PTSD

37. Substance Use
• High co-occurrence of PTSD and substance abuse
• Rates of co-morbidity between PTSD and substance use
disorders to range anywhere from 20% to 75%
• PTSD can elicit substance abuse (e.g., for coping), which can
make client more vulnerable to further trauma
• Recovery from substance use can trigger PTSD or memories
the substance had been blunting
• ‘Self-medication’ with drugs and alcohol to reduce arousal
symptoms or to dull the sense of fear and inability to cope

38. Depression & Hostility I
• Given high rates of mental health
comorbidities in trauma/PTSD,
important to consider
psychological factors such
as depression and hostility that
can also trigger physiological
inflammatory response
• Their effects can impair health
even if the individual does not
meet criteria for PTSD

39. Depression & Hostility II
• Depression:
> risk factor for CVD, cardiovascular events, cardiacrelated mortality
> coagulation related to depression and
cardiovascular risk in perimenopausal women
(n= 3292) (Matthews et al., 2007)
• Hostility also associated with heart disease

40. Depression & Hostility III
• Combination of depression and hostility adds to negative
health effects:
> Study (Suarez, 2006) of 135 healthy patients with
no symptoms of diabetes: women with higher
levels of depression and hostility had higher levels
of fasting insulin, glucose, and insulin resistance,
independent of other risk factors for metabolic
syndrome (BMI, age, fasting triglycerides, exercise
regularity, ethnicity)

41. Sleep I
•
Sleep disorders are common among trauma survivors (e.g., in
women primary-care patients who were sexual abuse survivors)
•
Poor sleep is also associated with increased inflammation, and
could be another way that trauma impacts health
•
Sleep problems increase the risk of CHD, type-2 diabetes, and
hypertension
•
Sleep loss reduces lymphocyte count and natural killer cell activity,
making patients more vulnerable to infection

42. Sleep II
• Poor sleep quality compromises immune, metabolic, and
neuroendocrine function, chronically activates the HPA
axis, and can increase mortality risk
• Sense of security with a partner found to promote
improved sleep as this can facilitate downregulation of
vigilance and alertness- long-term sleep deprivation
could be a health risk factor for women who are not in
stable, secure relationships (trauma survivors frequently
report relationship dissatisfaction)

43. Developmental Considerations &
Attachment I
• Trauma response can be passed down
through generations :
Transgenerational effects of pregnancy:
Vasoconstriction
Reduced arterial
blood flow
Complications
of pregnancy
E.g., gestational
hypertension,
intrauterine growth
restriction
Adaptation
HPA axis
dysregulation

44. Developmental Considerations &
Attachment II
•
Infant emotional experiences mainly stored/processed in the right
hemisphere during the formative stages of brain development
•
Right hemisphere extensively connected with the emotion
processing limbic system and with the ANS which regulates the
functions of organs
•
Energy-expending sympathetic and energy-conserving
parasympathetic circuits of the ANS generate the involuntary bodily
functions representing the somatic components of emotional states

45. Developmental Considerations &
Attachment III
•
Nonverbal right brain plays primary role in regulating physiological,
endocrinological, neuroendocrine, cardiovascular, and immune
functions- its operations are essential to the coping functions
supporting survival, and therefore to the human stress response
•
Disruption of attachment bonds in infancy
leads to a regulatory failure and “impaired
autonomic homeostasis”
•
Security of attachment bond is main
protection against trauma-induced
psychopathology

46. Developmental Considerations &
Attachment IV
•
Traumatized infants miss opportunities for socio-emotional learning
during critical periods of right brain development
•
Infant's psychobiological response to trauma involves hyperarousal
and dissociation
•
Parasympathetic dominant state of conservation-withdrawal is an
important regulatory process for maintaining homeostasisinvolves metabolic shutdown and low activity levels
•
Parasympathetic mechanism mediates the detachment of
dissociation

47. Developmental Considerations &
Attachment V
•
Not just the trauma but infant's defensive response to trauma (i.e.,
dissociation) inscribed in right brain memory system
•
Mothers of such infants likely suffered trauma- in this way such
imprinting of terror and dissociation can serve as mechanism for
intergenerational transmission of trauma
•
Survival mode of conservation-withdrawal changes the
bioenergetics of the developing brain- an infant brain that is
chronically shifting into survival modes has little energy available for
growth

48. Developmental Considerations &
Attachment VI
•
Altered development of right hemisphere in individuals with poor
attachment histories- deficits in perceiving emotional states of
others, appraising internal cues of bodily states, evaluating signals
of safety and danger (re-traumatization risk)
•
Difficulties in ‘mentalization’ lead to limited ability to reflect on
emotional states
•
Disrupted early attachments, early trauma/abuse typically evident in
those diagnosed with BPD- high correlation of PTSD and BPD

49. Developmental Considerations &
Attachment VII
•
The higher regions of the right prefrontal cortex can attenuate
emotional responses at the most basic levels in the brain
•
Such modulating processes of emotional experience can occur in
psychotherapy through interpreting and labeling emotional
expressions:
- the system that underlies psychotherapeutic change is in the
nonverbal right as opposed to the verbal left hemisphere

50. Self Trauma Model (STM)
(Briere, 2002)
•
Primary impacts of childhood abuse/neglect on subsequent
psychological functioning:
(1) Negative preverbal assumptions and relational schemata
(2) Conditioned emotional responses to abuse-related stimuli
(3) Implicit/sensory memories of abuse
(4) Narrative/autobiographical memories of maltreatment
(5) Suppressed or “deep” cognitive structures involving abuse-related
material
(6) Inadequately-developed affect regulation skills

51. Trauma Themes
•
•
•
•
•
•
•
Safety- internal external
Empowerment
Connection (Aloneness)
Normal reactions (Shame)
Mind-body connection- emotional attunement
Substance abuse
Woman-centered: in the aftermath of trauma women report the
following: - “Losing control” of life
- Re-experiencing
- Self-image changes
- Depression
- Relationship problems
- Sexuality issues
(Ackley & Covington, 2008)

52. STM Therapeutic Strategies I
•
•
•
•
•
•
•
•
Therapeutic Window
Exploration & consolidation
Goal sequence: safety & support
Self-awareness & positive identity
Boundary issues
Affect modulation & affect tolerance
Disturbed relatedness
Gradual exposure to abuse-related material
(Briere,
2002)

53. STM Therapeutic Strategies II
• Activation
• Disparity
• Processing & Resolution- cognitive & affective,
developing coherent narrative
• Grounding:
- strategies to “bring back” from dissociation into current
reality and feelings, awareness of here and now, what is
experienced is in the past and not happening now
(Briere, 2002)

54. STM (Briere, 2002)
•
-
•
Notion of “self before trauma”:
interventions working through traumatic stress can overwhelm those
with insufficient internal resources
process of accessing and processing traumatic memories
necessitates basic affect tolerance and regulation skills
in absence of such resources, exposure to traumatic material can
surpass the therapeutic window- lead to increased dissociation,
tension-reduction activities, therapy drop-out
STM approach allows trauma work to occur naturally as a function
of the therapeutic relationship and the survivor's decreasing need
for avoidance, facilitating staying within the therapeutic window

55. Trauma-Informed Practices
• Consider trauma
• Avoid triggering trauma reactions or inadvertently
re-traumatizing
• Adjust staff and organizational behaviour to support
individual’s coping capacity
• Empower trauma survivors to manage symptoms so
to be enabled to access, retain, and benefit from
services
• Emphasize safety, choice, trustworthiness,
collaboration, and empowerment

56. Vulnerability/Risk &
Resilience/Protective Factors
• Factors related to vulnerability and resilience:
> Experiences of sexual assault and pre-existing
mental health issues are related to greater
susceptibility to lifetime PTSD, with prevalence
being higher in women
> External factors such political, social, economic
and environmental instability, and lack of
resources also increases susceptibility

57. Vulnerability/Risk factors
Internal characteristics
Being female
Low sense of safety
Low sense of social support
Pre-existing mental health issues
External factors
Lower educational level
Immigrant status
Previous traumatic events
Severity of exposure (severe or prolonged trauma)
(Ahmed, 2007)

58. Resilience/Protective Factors
Internal characteristics
Self-esteem
Trust
Resourcefulness, Self-sufficiency
Self-efficacy, Sense of mastery
Internal locus of control
Secure attachments
Optimism
Interpersonal abilities (social skills, problem-solving skills, impulse control)
External factors
Safety
Strong role models
Emotional support & secure attachments
(Ahmed, 2007)

59. Relationship of biological, psychological,
& social factors
(McEwan & Seeman, 1999)

60. Case Example 1
Summary:
•57-year-old, married woman diagnosed with breast cancer
•Underwent mastectomy, treated with chemotherapy and radiation therapy
•Ongoing stressors contributing to and exacerbating current symptoms and distress:
- broke shoulder recently leading to decreased physical activity
- in 2009 three siblings passed away (sister died from breast cancer,
brother suddenly died of MI, another sister also died of an MI during her
brother’s funeral)
- following these events discovered she was diagnosed with breast cancer
- initial mammogram missed tumour, ultrasound lead to her diagnosis 1
month later
- underwent mastectomy, not aware would be undergoing this until just
prior to surgery

61. Case Example 2
Symptoms of post-traumatic stress:
- distressing recollections of cancer experience (intrusive thoughts
involving radiation therapy and surgery for mastectomy,
nightmares about this surgery, and reminders of prior fears of
radiation experienced during childhood related to growing up
during cold war and being warned about radiation and practicing
bomb drills)
- avoidance of thoughts about surgery (also attempts not to look at
her scar) and radiation therapy
- somewhat restricted range of affect associated with cancer
experience (particularly in terms of surgery and mastectomy scar)
and deaths of siblings
- sleep disturbance
- some irritability

62. Case Example 3
Symptoms of depression:
- dysphoria, increased fatigue, and decreased interest, appetite, energy,
and concentration
- symptoms of depression likely exacerbated by current experience
of poor body image due to mastectomy
Symptoms of generalized anxiety:
- worries that are sometimes difficult to control, often centring on
experience of radiation therapy and fears of effects of radiation therapy
- feeling restless or on edge
- decreased concentration
- muscle tension
- sleep disturbance
- some irritability
- experience of current stressors is exacerbated by experience of past
stressors (being placed in foster home at age of 4 years, experiencing
neglect as a child as parents abused alcohol)

63. Case Example 4
• Additional medical conditions: hypertension, hypercholesterolemia,
hypothyroidism, and diabetes (relatively well-controlled)
• Lifestyle Habits: does not engage in any exercise currently due to fatigue
since completing radiation therapy, ceased smoking (approximately 6
weeks prior to intake assessment), “social drinker,” denied any substance
use
• Coping: engages in primarily distraction coping (i.e., reads, uses the
computer, watches television), shoulder injury restricted some of her usual
coping activities (painting)
• Adequate social support: through close relationships with foster mother, 4
female friends, 2 sisters, husband, and 2 of her 3 adult daughters

64. Case Example 5
Summary/Impression:
Experiencing symptoms of post-traumatic stress, generalized anxiety, and
depression. Current symptoms can be understood in context of pre-existing
vulnerability to affective distress associated with difficult childhood
experiences (early childhood neglect, fears related to radiation
exposure/bomb threats), and are exacerbated by her experience of ongoing
stressors (i.e., the death of three siblings in 2009, being inadequately
prepared for undergoing a mastectomy, body-image issues related to the
mastectomy and scar, and insufficient information regarding radiation
therapy)

65. Case Example 6
Psychotherapeutic intervention involves:
- processing salient aspects of her cancer experience, including
unexpectedly having a mastectomy (and associated body image
issues), and her experience of radiation treatment (and associated
childhood fears regarding radiation exposure)
- processing grief related to the death of her siblings, and the impact
of
this on her coping strategies and interaction with adjustment to cancer
experience
- anxiety and stress management techniques, including cognitivebehavioural approaches, and application of these to improving sleep
- specific management of traumatic stress-related symptoms: cognitive &
affective processing, grounding and affect regulation

66. Case Example 7
Team Recommendation:
- Feels she has been inadequately informed about cancer
treatments thus far, therefore concretely explaining what she
can likely expect will facilitate decreased anxiety, foster sense
of
empowerment/control
- Tendency towards intellectualizing her experiences, important
to
be aware that she may thus appear to minimize affect, hinders
adjustment process and development of adaptive coping
strategies, may change health trajectory & outcome

67. (Antoni et al., 2006)

68. Conclusion
•
Implications for assessment & treatment
•
DSM-5: Trauma and Stressor-Related Disorders:
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
- Posttraumatic Stress Disorder
- Acute Stress Disorder
- Adjustment Disorders
- Other Specified Trauma- and Stressor-Related Disorder:
Persistent Complex Bereavement Disorder
- Unspecified Trauma- and Stressor-Related Disorder
•
Trauma-informed care- gender-informed care

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76. Questions?