This webinar will discuss the effects of childhood trauma on health care utilization and chronic illness. Susan Lax is an Advanced Practice Nurse with a dual degree in psychiatry/mental health nursing and primary care nursing from the Institute of Health Professions at Massachusetts General Hospital. She is certified in Trauma Studies by the Trauma Center at JRI, trained by Bessel van der Kolk and his colleagues. She has completed trainings in Sensorimotor Psychotherapy, a mindfulness approach to treating trauma disorders. In all, she has completed more than 300 hours of training in the treatment of acute and developmental trauma. In 2010 Susan was awarded a leadership in nursing award for her success incorporating a trauma treatment as she worked in acute, residential, and community settings in the Greater Boston Area, including on a PACT team.

1. ADULTS AFFECTED BY
INTERPERSONAL VIOLENCE
(IPV) IN CHILDHOOD
A Public Health Problem that contributes to
High utilization, inappropriate utilization,
poor health outcomes, and high social and economic
costs
WHAT CAN A HEALTHCARE PROVIDER DO?

2. VIOLENCE
“Violence is the intentional
against oneself, against another
person or against a group or community, which either results in
or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment, or
deprivation”
-World Health Organization; 2011

3. IPV GOES BEYOND PHYSICAL
VIOLENCE
• Any attempt to dominate or control through
behaviors that engender fear and helplessness
• The behavior inflicts emotional pain with intent
• Ranges in quality from overt to more subtle forms of
aggression

4. IPV
norma-peace-stuff-page2.blogspot.com

5. THE ADVERSE CHILDHOOD EVENTS (ACE)
STUDY
(CDC & KAISER PERMENANTE 1995-1997)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Demographic Categories
Gender
Female
54%
Male
46%
Race
White
74.8%
Hispanic/Latino
11.2%
Asian/Pacific Islander 7.2%
African-American
4.6%
Other
1.9%
Age (years)
19-29
5.3%
30-39
9.8%
40-49
18.6%
50-59
19.9%
60 and over
46.4%
Education
Not High School Graduate
High School Graduate 17.6%
Some College
35.9%
College Graduate or Higher
Percent (N = 17,337)
7.2%
39.3%

6. PREVALENCE OF EXPOSURE TO IPV IN CHILDHOOD
Category
Type
Abuse
Emotional abuse
Total
(N=17,337)
13.1
7.6
10.6
27.0
29.9
28.3
Sexual
24.7
16.0
20.7
Emotional Neglect
16.7
12.4
14.8
Physical Neglect
Household Dysfunction
Men
(N=7,970)
Physical
Neglect
Women
(N=9,367)
9.2
10.7
9.9
Mother Treated Violently
13.7
11.5
12.7
Household Substance
Abuse
29.5
23.8
26.9
Household Mental Illness
23.3
14.8
19.4
Parental Separation or
Divorce
24.5
21.8
23.3
Incarcerated Household
Member
5.2
4.1
4.7
CDC, 2013

7. TRAUMA
Individual trauma results from an event, series of
events, or set of circumstances that is experienced by
an individual as physically or emotionally harmful or
threatening and that has lasting adverse effects on
the individual's functioning and
physical, social, emotional, or spiritual well-being
SAMHSA: http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx

8. LASTING ADVERSE AFFECTS
SUGGESTED IN THE ACE STUDY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Chronic obstructive pulmonary disease (COPD)
Depression
Fetal death
Health-related quality of life
Illicit drug use
Ischemic heart disease (IHD)
Liver disease
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases (STDs)
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancy
CDC, 2013

9. ACE STUDY DATA
CDC, 2013

10. PYRAMID DEPICTING MECHANISMS
SUGGESTED BY THE ACE STUDY
CDC, 2013

11. HIGH COSTS, BUT HOW HIGH IS
UNKNOWN

12. HOW EQUIPPED ARE WE TO RESPOND?

13. A LOOK AT RECOMMENDATIONS:
YIKES!
• 1. Assess patients/clients via interview, questionnaire, history taking and
health examination processes. Use reliable, valid and normed instruments
developed for the assessment of abuse, violence and its symptoms
where available. (s)
• 2. Intervene using evidence-based and evidence-informed treatments.
(s)
• 3. Prevent violence using evidence-based and evidence- informed
methods of primary, secondary and tertiary prevention. (s)
• 4. Recognize risk factors for victimization and perpetration of violence. (k)
• 5. Recognize physical and behavioral presentations and signs of abuse
and neglect, including patterns of injury across the life span. (k)
• 6. Educate patients and clients regarding limits of confidentiality and
reporting requirements.
• 7. Identify and address the problems associated with emotional, physical,
and sexual abuse and neglect. (s)
Academy on Violence and Abuse, 2011

14. AND THEY GO ON!
• 8. Offer continuity of care and appropriate referrals to community
resources. (s)
• 9. Provide thorough documentation of patient’s and client’s statements,
clinical observations, and visual documentation of injuries, using body
maps and photographs. (s)
• 10. Be aware of and comply with state reporting laws, collaborating with
the victim of violence to make reports whenever appropriate. (s)
• 11. Organize and prioritize to provide an accurate, profession- specific
assessment of the problem, and safe, efficient, effective care. (s)
• 12. Acknowledge that achieving safety is often a long-term goal that is
achieved by the patient/client, requires significant preparation, and that
many successful interventions can be applied during the course of this
process (i.e. naming the abuse, offering support, identifying resources,
safety planning, etc.). (k, a)
• 13. Utilize models of health behavior change, advocacy and
empowerment to promote harm reduction strategies as part of an
intervention. (k, s)
Academy on Violence and Abuse, 2011

15. WHAT IS MISSING
• Digestible information to help health care providers
understand the problem conceptually so that they
can problem solve
• Straight-forward, simple, realistic guidelines about
• How to engage patients and relate to them
• How to conceptualize the underlying dynamics and barriers to
change
• Interventions to facilitate better health outcomes

16. THIS PRESENTATION WILL HOPEFULLY
• Empower you through:
• An increased understanding of IPV and the complex
trauma response
• The ability to recognize the sequelae
• The ability to understand the dynamics at play
• Provide guidelines about:
•
•
•
•
When and how to screen a particular patient
How to engage a patient
How to manage the relationship dynamics
How to facilitate positive change

17. IS THIS FAMILIAR?
You greet your next patient, Sally, a 42 year-old
married white female
She is late for her appointment
She missed her last 3 appointments
.
She is obese, smokes, has diabetes type 2, HTN, chronic
insomnia and several other health problems.
Her last Hgb A1C was 11; Today her BP is 160/90
Historically, she hasn’t adhered to recommendations
She demands that you refill a pain medication
She asks you to fill out a form that she needs to apply
for disability
When you set limits, she starts crying
You feel pressured for
time, manipulated, powerless, and frustrated as you
feel your stress level go up
You’re tempted to give her a piece of your mind

18. THE CHARACTERISTICS OF A PATIENT
TRAUMATIZED BY IPV IN CHILDHOOD
Emotional
Dysregulation
Relational
Dysregulation
Physiological
Dysregulation
Behavioral
Dysregulation
Cognitive
Dysregulation

19. THE PHYSIOLOGICAL DYSREGULATION
AT THE CENTER OF IT
Courage-counseling.com

20. DSM-V CRITERIA
•
•
•
•
•
•
•
•
•
•
•
•
•
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or
threatened sexual violence, as follows: (one required)
Direct exposure.
Witnessing, in person.
Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved
actual or threatened death, it must have been violent or accidental.
Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of
professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to
details of child abuse). This does not include indirect non-professional exposure through electronic
media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (one required)
Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in
repetitive play.
Traumatic nightmares. Note: Children may have frightening dreams without content related to the
trauma(s).
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to
complete loss of consciousness. Note: Children may reenact the event in play.
Intense or prolonged distress after exposure to traumatic reminders.
Marked physiologic reactivity after exposure to trauma-related stimuli.

21. DSM-V CRITERIA
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
Trauma-related thoughts or feelings.
Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two
required)
Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head
injury, alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am
bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event:
(two required)
Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance

22. DSM-V CRITERIA
•
•
•
•
•
•
•
•
•
•
•
•
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Criterion G: functional significance
Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
Specify if: With dissociative symptoms.
In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the
following in reaction to trauma-related stimuli:
Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling
as if "this is not happening to me" or one were in a dream).
Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").
Specify if: With delayed expression.
Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may
occur immediately.
American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.).
Washington, DC: Author.

23. COGNITIVE DYSREGULATION
•
•
•
•
•
•
Intrusive negative, fear-based thoughts
Negative thoughts about self
Cognitive distortions generally
Impaired memory
Impaired concentration and attention
Impaired learning

24. EMOTIONAL DYSREGULATION
• Emotional lability, i.e. reactivity
• Difficulty modulating emotions

25. BEHAVIORAL DYSREGULATION
• Unable to mobilize behavior to meet one’s needs
• Impulsivity
• The prefrontal cortex and higher brain functions are
shut down
• Reptilian brain functions dominate

26. RELATIONAL DYSREGULATION
•
•
•
•
•
Disturbed attachment
Lack of trust
Confused interpersonal boundaries
Tendency to engage in abusive relationships
Unconsciously engages others to replay the drama :
victim, rescuer, or perpetrator

27. TRAUMA/DRAMA REPETITION
• The Karpman Drama Triangle

28. SALLY SEEN THROUGH A TRAUMAINFORMED LENS
• Sally’s physical conditions and behaviors are
consistent with exposure to IPV and unresolved
trauma
• She exhibits “dysregulation” across
physiological, cognitive, emotional, behavioral, and
relational domains
• She could be using pain medication to soothe
distress
• She probably can not identify with having an
internal locus of control
• Unconsciously, she might pull to repeat unresolved
trauma in her relationships

29. HOW TO SCREEN
Be alert to trauma’s sequelae
Suspect trauma when the sequelae is present
Ask questions to explore functioning across domains
Ask a general question about exposure to stress in
childhood
• Avoid eliciting details about specific traumas
• Contain patients who spill
•
•
•
•

30. MEANWHILE
• Establish and maintain a relationship over time that
is characterized by respect, shared power, healthy
boundaries, and safety
• Do what you can to equalize power
• Use humor and a light touch
• Facilitate optimal arousal=optimal
functioning/performance

31. HOW TO KEEP THE RELATIONSHIP ON
TRACK
• Practice non-violence
• Model healthy limits and boundaries appropriate to
your relationship

32. NON-VIOLENCE
www.advocates-oz.org

33. IDENTIFY HYPER AND HYPO AROUSAL
AND INTERVENE
• Hyper arousal: agitation, restlessness, fast
speech, muscle tension, etc.
• Hypo-arousal: numbing, dissociation, glazed over
and checked out
www.skybrary.aero

34. SEVERE DISSOCIATION
• Personality fragmentation
• Changes in ego state
• Disturbances in continuous consciousness---loss of
time
• Psychological conflicts may be held by different
parts of consciousness with apparently distinct
personalities

35. PATIENT TEACHING
• Help the patient understand his/her experience
• Your patient knows something’s wrong---demystify it
• Most patients respond to teaching about exposure
to stress, the stress response, and how this relates to
their symptoms, health conditions, problems
functioning, and interventions
• Use diagrams and pictures
• Address shame about problems functioning
• Address fear and hopelessness
• Link your recommendations to your teaching

36. USE MOTIVATIONAL
INTERVIEWING
• Identify the patient’s goals
• Plan interventions with the patient, prioritizing his/her
goals
• Be realistic: consider problems functioning, the
patient’s living circumstances, and resources
• Don’t go forward without buy-in
• Explore resistance

37. LET THE STAGES OF CHANGE GUIDE
INTERVENTIONS

38. DON’T WORK ALONE
• Keep Maslow’s Hierarchy in mind: basic needs first
(safety, food, shelter, transportation)
• Give focus to physiological stabilization: Is
medication needed to address emotional lability,
intrusive symptoms, insomnia, etc.?
• Then consider referrals for skill building: Mindfulness
training, coping skill training, stress reduction, Yoga,
Tai Chi
• Social support
• Trauma treatment

39. REFERRAL OPTIONS
•
•
•
•
•
Social Services
Psychopharmacology
Community-based mental health services
Psychotherapy (trauma-informed)
Substance Abuse Treatment (trauma-informed)

40. A NOTE ABOUT DEALING WITH
SUBSTANCE ABUSE
Discuss it with concern and caring
Fully appreciate why the patient self-medicates
Avoid asserting power and control over the patient
Simply set boundaries: what you can and cannot
do and why
• If there’s prescription drug abuse, refer to a
specialist if possible
• Never withdraw medications abruptly
• Replace a problematic medication with one that
has less potential for abuse or harm
•
•
•
•

41. WHAT WOULD YOU DO?
You greet your next patient, Sally, a 42 year-old
married white female
She is late for her appointment
She missed her last 3 appointments
.
She is obese, smokes, has diabetes type 2, HTN, chronic
insomnia and several other health problems.
Her last Hgb A1C was 11; Today her BP is 160/90
Historically, she hasn’t adhered to recommendations
She demands that you refill a pain medication
She asks you to fill out a form that she needs to apply
for disability
When you set limits, she starts crying
You feel pressured for
time, manipulated, powerless, and frustrated as you
feel your stress level go up
You’re tempted to give her a piece of your mind

42. SUMMARY
• A large number of our adult patients have been
traumatized in childhood
• If you see smoke, think fire
• Recognize the dysregulated physiology at the root of
the problem
• Keep in mind that this gives rise to dysregulated
functioning across domains
• Practice non-violence
• Be aware of the relational dynamics
• Intervene with an understanding of the problem
• Don’t work alone; consult with others
• Maintain empathy
• Raise consciousness

43. REFERENCES
Adverse Childhood Experiences (ACE) Study. Center for
Disease Control and Prevention. n.d. Web. 2 Nov. 2013.
<http://www.cdc.gov/ace/>
Adverse Childhood Experiences (ACE) Study. Center for Disease
Control and Prevention. n.d. Web. 2 Nov. 2013.
<http://www.cdc.gov/ace/findings.htm>
Ambuel, B, K Trent, P Lenahan, P Cronholm, D Downing, M Jelley, A
Lewis-O’Connor, M McGraw, A Marjavi, L Mouden, J Wherry,
M Callahan, J Humphreys, R Block, Competencies Needed
by Health Professionals for Addressing Exposure to Violence
and Abuse in Patient Care, Academy on Violence and
Abuse, Eden Prairie, MN, April 2011. Web. 1 Nov. 2013.
<http://
www.avahealth.org/resources/ava_publications/>
Definition and Typology of Violence. World Health Organization,
n.d. Web. 3 Nov. 2013. <http://
www.who.int/violenceprevention/approach/definition/en/>

44. SUSAN’S CONTACT INFORMATION
• Email: suprilax@hotmail.com
• Phone: 617-372-5784
• Practice Locations: 23 Main Street Watertown, MA
• & The North Shore