The nature and history of trauma

1. Nature and History of Trauma
Sinem Bulkan
Stress and Trauma
PhD in Organisational Behaviour

2. What is Traumatic Stress?
 Overwhelming experience.
 Involves a threat.
 Results in vulnerability and loss of control.
 Leaves people feeling helpless and fearful.
 Interferes with relationships and beliefs. (Herman, 1992)
Psychological trauma is a type of damage to the psyche that
occurs as a result of a severely distressing event.
When that trauma leads to posttraumatic stress disorder,
damage may involve physical changes inside the brain and to
brain chemistry, which changes the person's response to future
stress.

3. Sources of Traumatic Stress
 Loss of a loved one
 Accidents
 Homelessness
 Community/school violence
 Domestic violence
 Neglect
 Physical abuse
 Sexual abuse
 Man-made or natural
disasters
 Terrorism

4. The 19th Century view of Trauma
 Traumatic shock is due to organic damage to the nervous
system.
 The common belief of the time was that concussions to the
head , injuries to the spinal cord (omurilik) or small cerebral
haemorrhages (beyin kanaması) alter psychical functioning,
thereby causing the psychological symptoms.

5. The 19th Century view of Trauma
 Examples of some of the most common diagnoses of the time included
‘spinal concussion’, ‘railway spine’, ‘irritable heart’, ‘soldier’s heart’, and ‘shell
shock’.
 Spinal concussion: A concussion occurs when the head hits or is hit by an
object, with confusion and amnesia, and with or without a brief loss of
consciousness.
 Railway spine: a 19th century diagnosis for the post-traumatic symptoms of
passengers involved in railroad accidents.
 Irritable heart: involves a set of symptoms which include left-sided chest
pains, palpitations (çarpıntı), breathlessness, and fatigue in response to
exertion.(post-war trauma)
 Shell shock: the reaction of soldiers in World War I to the trauma of battle. It
has been described as a reaction to the intensity of the bombardment and
fighting that produced a helplessness appearing variously as panic, or flight,
an inability to reason, sleep, walk or talk.

6. The 19th Century view of Trauma
 Charcot and Janet developed a challenge to the traditional
physicist view.
 Janet had observed his traumatised patients and discovered
that they tended to react to reminders of their trauma with
responses that were more relevant to the original traumatic
threat than to their current situation.

7. The 19th Century view of Trauma
 Breuer and Freud was affected from Janet’s work.
 In Studies on Hysteria they said ‘ hysterics suffer mainly from
reminiscences, the traumatic experience is constantly forcing
itself upon the patient and this is proof of the strength of that
experience: the patient is, as one might say, fixated on his
trauma’ (Breuer and Freud, 1955).
 Freud: Importance of repressed infantile sexuality. No
investigations of the real traumatic events. Concentrated on
the Oedipal crisis.

8. The First World War
 War exposed large numbers of soldiers to trauma.
 Caused many physicians to question whether physical injures
had any impact on psychiatric disorders.
 Increased awareness of the psychological aspects of
traumatic experience.
 Soldiers could suffer a psychiatric disorder without any
physical injury (Public Records Office in Kew, London).

9. The First World War
 War psychiatrists recognised that civilian patients, who had
been the victims of accidents or disasters, had symptoms
similar to those they had seen on the battlefield (Merskey,
1991).
 Kardiner claimed that war created a single syndrome,
psychoneurosis, and that this syndrome as essentially the
same as traumatic neurosis, the syndrome of civilian life.
(Kardiner, 1941).

10. The First World War
 Kardiner 1941 - Published The Traumatic Neurosis of War
 The essential features of psychoneurosis were:
- Persistence of startle response and irritability,
- Proclivity to explosive outbursts of aggression,
- Fixation on the trauma,
- Constriction of general level of personality functioning,
- Atypical dream life

11. Recognition of Traumatic Stress
 American Psychiatric Association, 1952 – Development of
a manual to provide a codification and classification of mental
disorders.
 1st edition: ‘gross stress reaction’, an acute reaction to
extreme stress. Characteristics was similar to those for
psychoneurosis apart from an additional situational
precondition:
‘the impact of the event to be so serious that it would have
evoked overwhelming fear in any so-called normal person’.
 2nd edition: Removed gross stress reaction, 1968

12. Recognition of Traumatic Stress
 3rd edition: the syndrome re-emerged under a new name :
‘Post-traumatic stress disorder’ (PTSD), 1980
 4th edition: Diagnostic and Statistical Manual of Mental
Disorders (DSM IV) Six criteria relating to PTSD, 1994.
- First describes the traumatic situation,
- the next three the trauma symptoms,
- the last two the duration and effect of the symptoms on
the person’s personal life and work.

13. DSM IV Diagnostic Criteria for Post-
Traumatic Stress
Criterion A: stressor
The person has been exposed to a traumatic event in which both of the
following have been present:
 The person has experienced, witnessed, or been confronted with an
event or events that involve actual or threatened death or serious
injury, or a threat to the physical integrity of oneself or others.
 The person's response involved intense fear, helplessness, or
horror.

14. DSM IV Diagnostic Criteria for Post-
Traumatic Stress
Criterion B: intrusive recollection
The traumatic event is persistently re-experienced in at least one of the following
ways:
 Recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions.
 Recurrent distressing dreams of the event.
 Acting or feeling as if the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback
episodes, including those that occur upon awakening or when intoxicated).
 Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event.
 Physiologic reactivity upon exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event

15. DSM IV Diagnostic Criteria for Post-
Traumatic Stress
Criterion C: avoidant/numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by at least three of the
following:
 Efforts to avoid thoughts, feelings, or conversations associated with the trauma
 Efforts to avoid activities, places, or people that arouse recollections of the trauma
 Inability to recall an important aspect of the trauma
 Markedly diminished interest or participation in significant activities
 Feeling of detachment or estrangement from others
 Restricted range of affect (e.g., unable to have loving feelings)
 Sense of foreshortened future (e.g., does not expect to have a career, marriage,
children, or a normal life span)

16. DSM IV Diagnostic Criteria for Post-
Traumatic Stress
Criterion D: hyper-arousal
Persistent symptoms of increasing arousal (not present before the trauma),
indicated by at least two of the following:
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hyper-vigilance
 Exaggerated startle response
Criterion E: duration
 Duration of the disturbance (symptoms in B, C, and D) is more than one
month.
Criterion F: functional significance
 The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

17. 21st Century
 There are still groups pf psychiatrists do not accept the
existence of post-traumatic stress.
 An example: ‘traumatic life experiences do not cause a
psychological disorder any more than life events cause
depression’ (Wesley, 2000).
 Another issue: Criterion A is too limiting. ‘if an individual
cannot demonstrate actual exposure to a situation, post-traumatic
stress cannot be diagnosed’.
However, there is a clinical evidence that cronic exposure to
stressful conditions including organisational bullying and
extreme pressure at work can lead to symptoms which are
indistinguishable from those caused by a single traumatic event.

18. International Classification of Diseases
 In addition to DSM IV, there is another system.
 The World Health Organisation, International Classification
of Diseases, ICD 10
Describes 3 diagnoses:
- Acute stress reaction: A transient disorder that develops without any
other mental disorder.
- Symptoms appear within minutes of the traumatic exposure, waning
within hours.
- Adjustment disorder: States of subjective and emotional disturbance
that arise in the period of adaptation to a significant life change or
stressful event.
- Symptoms usually begin within one month of the occurrence of the
stressful event and rarely exceed six months.

19. International Classification of Diseases
 PTSD: Diagnostic criteria similar to those in DSM IV.
 However, the process of making a diagnosis is different.
 ** ICD 10 recognizes that other factors such as pre-existing disorder or
a vulnerable personality may play a role in the development of PTSD,
but that these factors are neither necessary nor sufficient to explain its
occurence.

20. ICD 10 Diagnostic Criteria for Post-
Traumatic Stress
This order should not generally be diagnosed unless there is evidence that it arose
within six months of a traumatic event of exceptional severity.
A ‘probable’ diagnosis might still be possible if the delay between the event and the
onset was longer than six months, provided that the clinical manifestations are typical
and no alternative identification of the disorder (e.g. Such as anxiety or obsessive-compulsive
disorder or depressive episode) is plausible.
In addition to evidence of trauma, there must be a repetitive, intrusive recollection or
re-enactment of the event in memories, daytime imagery or dreams.
Cobspicuous emotinal detachment, numbling of feelings and avoidance of stimuli that
might arouse recollection of the trauma are often present but are not essential for the
diagnosis. (major difference between ICD 10 and DSM IV)
The autonomic disturbance, mood disorder, and behavioral abnormalities all
contribute to the diagnosis but are not of prime importance.
(World Health Organisation, 1993)

21. The Psychobiology of Traumatic Stress
The Epidemiology of Traumatic Stress
 Of all the people exposed to traumatic experiences only a small
proportion go on to suffer PTSD (Shalev and Yehuda, 1998).  This
finding challenges the original conceptualization of post-traumatic
stress as a normal response to a traumatic experience.!!
 Personal risk factors  being related to neuroticism, pre- existing
anxiety or depression, a history of childhood abuse and earlier
traumatic experiences (Bromet et al. 1998)

22. The Psychobiology of Traumatic Stress
The Epidemiology of Traumatic Stress
 Study by Breslau in 1996, over 2000 adults from the ages of 18 and
45 from Detroit in the USA.
 Found that over 85% of people had been exposed to at least one
trumatic experience – the prevalence of PTSD was low, 10.2% of
males and 18.3% of females meeting the criteria for PTSD at any
stage during their life.
 Breslau found that the risk of developing PTSD varied according to
the type of trauma.
A rape (49%), sexual assault (24%), road traffic crash (2.3)

23. The Psychobiology of Traumatic Stress
The Epidemiology of Traumatic Stress
 Few epidemiological studies in the workplace. 
 2 studies
- Disastrous bush fire in Australia, 16% of volunter firefighters suffered
PTSD (McFarlane and de Girolamo 1996)
- Kuwait / Iraq war, 9% of American soldiers were found to be suffering from
PTSD (Southwick et al 1993)

24. The Psychobiology of Traumatic Stress
The Epidemiology of Traumatic Stress
 The disorder can occur to anyone exposed to a traumatic
event.
 The important questions that need to be answered are
whether some people have:
- A specific predisposition to PTSD.
- A predisposition to mental illness that can be triggered by adversity.

25. Biological Pathways to Respond Stress
 The Neural Pathway
 The Neuro-Endocrine Pathway
 Endocrine Pathway

26. Biological Pathways to Respond Stress
The Neural Pathway
Consists of the nerves of the sympathetic and parasympathetic
nervous systems which together make up the autonomic
nervous system.
Governs the activities of the cardiac and smooth muscle, the
digestive and sweat glands (ter bezi) and other endocrine
glands such as the pancreatic gland and adrenal medulla.

27. Biological Pathways to Respond Stress
The Neuro-Endocrine Pathway
Consists of the sympathetic neural chain and the adrenal
medulla.
Release of the hormone adrenaline and nor-adrenaline.
Responsible for the flight of fight response described by Cannon
(1927).
- Rapid changes in the cardiovascular function, raising the
metabolic rate and reducing gastrointestinal (sindirim sistemi) activity.

28. Biological Pathways to Respond Stress
Endocrine Pathway
 Anterior Pituitary Gland (Ön Hipofiz Bezi)
Releases thyroid stimulating hormone (TSH)
Produces thyroxin, increases body’s metabolic rate, raising the blood
sugar levels, increasing respiration (nefes) , heart rate, blood pressure
(tansiyon) and intestinal motility (Bağırsak hareketi) (Goodman and
Gilman, 1975).
 HPA Pathway (Stimulation of Hypothalamus)
Release of corticotrophin releasing factor, increases arterial blood
pressure, mobilises fats and glucose from the fatty tissues, reduces allergic
and inflammatory reactions and decreases white blood cells ( Dryden and
Yankura, 1995).

29. Pathway Interactions
 Adrenaline and cortisol (hormon) are both elevated during the
stress response.
 They have very different roles in the stress response (Yehuda
et al, 1990).
 Adrenaline to facilitate the availability of energy to the
body’s vital organs.
 Cortisol to shut down these activities following the
withdrawal of the stressful situation. (otherwise stress would
produce long term damage)

30. Traumatic Stress v. Normal Stress
PTSD
Decreased levels of cortisol
Increased cortisol receptor sensitivity
Stronger negative feedback inhibition
HPA system becomes more
sensitized (duyarlı)
Chronic
Stress/Depression
Increased levels of cortisol
Decreased cortisol receptor
responsiveness
Erosion of negative feedback
HPA system becomes more
desensitized
Differences between the actions of the HPA pathway in PTSD and
chronic stress (Yehuda, 1998)

31. Brain Structures Involved in the PTSD
Response
 Sensory information of a traumatic experience is transported
through the central nervous system or directly into the brain.
 Most of the sensory information is passed to the thalamus.
 From the thalamus, the sensory information goes via
amygdala and the hippocampus to the pre-frontal cortex.
 When it reaches the cortex, has been assigned meaning.
 It is fed back to locus ceruleus and the amygdala.
 All these connections then able to affect behavioural,
autonomic and HPA response systems which in turn initiate
and control the body’s responses (LeDoux 1992).

32. Brain Structures Involved in the PTSD
Response

33. The Effect of Trauma on Brain
Functioning
 Locus ceruleus : Access and retrieval of memories.When it is
stimulated victims experienced repetitive intrusive memories of their
traumatic event.
Can also cause feelings of intense fear, imminent death and inability
to sleep.
 Amygdala : Emotions are elicited.Fear, anxiety, pleasure, anger..
 Hippocampus: Categorising and storing incoming stimuli in the short
term memory. Processes new stimuli to decide whether the
experience is rewarding or punishing.

34. THANK YOU....