04: Trauma, Part I: What is trauma?
[This is a continuation of my first blog post 01: Why I Wander?, and the first post in a 5-part series on trauma]
When the stark image of my own suicide entered my mind, I was terrified. “Am I really capable of that?” I thought to myself. This was in November of 2018. On October 30 of 2016, I lost one of my closest cousins to suicide. Her sudden departure from this world altered my life forever, and made my own self-inflicted demise all too tangible.
I knew I needed to seek help, immediately.
Now in a job that offered insurance, I could afford therapy. I began a phase of intensive online research: Psychologist, psychiatrist, or someone else entirely? What modalities are available beyond talk therapy? Which therapists in my city are highly rated on Psychology Today?
I also started to open up about my depression, talking to anyone who cared enough to listen, gathering insight and advice.
It was in these conversations that I first learned about trauma.
What is trauma?
I had always associated the word trauma with a catastrophic event. Trauma surgeons, traumatic brain injury, Post Traumatic Stress Disorder, etc., and the acute moment of physical injury leading to these outcomes.
But there is a different kind of trauma, more insidious than any car crash or freak accident.
Emotional trauma, also known as psychological trauma, is damage that occurs in our psyches, typically during childhood and adolescence.
Dr. Bessel Van der Kolk, author of Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, is a Harvard-educated psychiatrist and pioneering PTSD researcher. He started his career just as veterans were returning home from Vietnam, before Post Traumatic Stress Disorder was even a concept.
Van der Kolk soon began to notice that symptoms and patterns common in these veterans, were present in some of his other patients too. He defines trauma as specifically, “an event that overwhelms the central nervous system, altering the way we process and recall memories…. Trauma is not the story of something that happened back then. It's the current imprint of that pain, horror, and fear living inside people.”
Dr. Gabor Mate, another renowned thought-leader in the field of trauma research, parses the event from this imprint even further:
“Terrible things are traumatic, but they are not a trauma. Trauma is not what happens to you. The trauma is what happens inside of you as a result, the loss of connection to oneself and to the present moment.”
Starting his career as a medical doctor, and later becoming an addiction counselor, Mate came to realize that virtually all of the addicts he worked with had some adverse event in their childhood, whether it was an encounter as acute as a sexual molestation, or as passive as finding a parent or caretaker passed out drunk on the floor. He is the author of four books, most notably In The Realm of Hungry Ghosts and When the Body Says No (which I highly recommend).
What is Complex-PTSD?
I’ve mentioned PTSD, which most of you are probably familiar with. PTSD is “a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it” (1).
However, a closely related condition called complex post-traumatic stress disorder (CPTSD) is becoming more widely recognized by doctors in recent years. CPTSD results from repeated trauma over months or years, rather than a single event. The symptoms of CPTSD include the classic symptom set of PTSD — reliving the trauma, avoidant behavior, hyperarousal, somatic symptoms — as well as:
Lack of emotional regulation, such as explosive anger or ongoing sadness
Changes in consciousness (e.g. dissociation)
Negative self-perception
Difficulty with relationships
Loss of systems of meaning (2)
In the following series of posts, I will begin to explore how all of these symptoms arose within me as a result of CPTSD, but first:
Why is unresolved trauma so bad for us?
Trauma occurs when our sympathetic nervous system engages (fight or flight response), but we are unable to actually escape or thwart the perceived threat:
“As in other animals, the nerves and chemicals that make up our basic brain structure have a direct connection with our body. If the fight/flight/freeze response is successful and we escape the danger, we recover our internal equilibrium and gradually “regain our senses”... Being able to move and do something to protect oneself is a critical factor in determining whether or not a horrible experience will leave long-lasting scars.”
― Bessel A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
As van der Kolk notes, when the fight or flight response doesn’t have a chance to complete, the trauma becomes trapped in our nervous system. Recent studies comparing brain scans of PTSD vs. non-PTSD subjects have illuminated remarkable differences in cerebral structure and functioning. Notably, traumatized brains have:
An enlarged amygdala, and heightened responsivity in this area, which is the “central component of the brain's fear detection and anxiety circuits.” (3)
A smaller ventromedial prefrontal cortex, and corresponding hypo-responsiveness in this area, which plays “a general role in inhibiting negative emotion and/or signaling safety from threat” (4, 5)
Diminished volumes and functional integrity of the hippocampus, an important part of the limbic system, which regulates motivation, emotion, learning, and memory. (6)
These neuro-physiological changes underscore trauma’s profound impact on us: it literally changes the anatomy of our brains. The brain structures implicated also illustrate how trauma might affect one’s mental processes and behaviors, i.e. how they show up in the world and interact with others (*). But the field of endocrinology is uncovering a resulting hormonal cascade that wreaks even more havoc on the minds and bodies of those of us with trauma.
Research has demonstrated lasting changes in hormone levels for individuals with trauma in their past. To name a few:
Oxytocin, a neurochemical critical to emotional regulation, is significantly reduced, affecting behavior and response to emotional stimuli.
Cortisol, the stress hormone, is interestingly also reduced. This is because cortisol’s role in stress is that is helps to bring down the high levels of adrenaline and norepinephrine that are released during fight or flight. “Adrenaline and norepinephrine are responsible for memory formation and arousal, so not having enough cortisol to completely bring down the sympathetic nervous system, at the time when it is very important for a person to calm down, may partially explain the formation of traumatic memory or generalized triggers.” (7)
Being triggered is one example of just how embedded trauma is in our neurobiological programming. To be “triggered” has become something of a buzzword in the pop culture lexicon, meaning an emotion-evoking event or interaction. In psychology, a trigger is any stimuli that evokes the original traumatic event (or series of events), and sets off the alarm bells in the central nervous system, precipitating a range of unpredictable responses from the organism.
So what does all of this boil down to?
Unresolved trauma runs us, on a subconscious level — like malware running in the background of our central processing unit — subtly (or not so subtly) influencing every decision we make, every reaction to stimuli, and yes, even our thoughts, beliefs, and actions.
While trauma warps our experience of reality in a negative way, for many, it completely takes over. The cerebral and hormonal changes outlined above have been linked to depression, anxiety, addiction, schizophrenia, psychosis, eating disorders, and other clinical psychological diagnoses, but also to physiological ailments like irritable bowel syndrome (IBS), Crohn’s, symptoms of chronic pain/inflammation like sciatica, rheumatoid arthritis and fibromyalgia, neurodegenerative diseases like Alzheimer’s and ALS, autoimmune disease, and even certain types of cancer. (7)
But can’t we just “get over it?”
Enter the Adverse Childhood Experience (ACE) study — groundbreaking research first conducted in 1995 by the Centers for Disease Control and Kaiser Permanente in California.
From the CDC: “Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years)… included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding.” (9)
ACEs continue to be tracked by the CDC, and today 61% of U.S. adults report that they had experienced at least one type of Adverse Childhood Experience. These experiences — or traumas — lead to something called toxic stress:
Toxic stress explains how ACEs ”get under the skin” and trigger biological reactions that lead to those outcomes. In the early 2000s, the National Scientific Council on the Developing Child coined the term “toxic stress” to describe extensive, scientific knowledge about the effects of excessive activation of stress response systems on a child’s developing brain, as well as the immune system, metabolic regulatory systems, and cardiovascular system. Experiencing ACEs triggers all of these interacting stress response systems. When a child experiences multiple ACEs over time—especially without supportive relationships with adults to provide buffering protection—the experiences will trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time. (10)
And “revving the engine,” it seems, causes the whole vehicle to breakdown: ACEs are at the root of our society’s most devastating (and stubborn) physical and mental health issues.
“The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan.
Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold (700%) increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold (3000%) increase in attempted suicide.”
The completion of the ACE study represented a landmark moment in trauma research, finally establishing an undeniable link between childhood emotional stressors and the continued deterioration of human mental and physical wellbeing. In childhood and adolescence, the trauma becomes embedded in us, on a subconscious level. We cannot control that which we cannot see, buried deep in our psyche.
What are some examples of trauma?
As the ACE study shows, most of us have trauma — either known or hidden — somewhere in our past, and in our nervous systems(**). This is due to the sheer breadth of the types of trauma that have been identified:
Birth trauma (Pre- and peri-natal)
Circumcision trauma
Pre-verbal trauma
Ancestral / Transgenerational trauma
Epigenetic trauma
Adolescent trauma
Sexual trauma
Having this information finally allowed me to see some of the skeletons hiding in my psyche. In the remaining posts of this series, I will begin to unpack some of the specific traumas in my past. My intention in doing this is three-fold:
Writing about these is proving to be immensely therapeutic for me personally
Sharing my story, I hope, will allow others to recognize trauma in their own past
I intend to share some of the modalities I’ve used for uncovering and resolving my traumas (still a long way to go), to make these remedies more widely known, and hopefully, put into practice
My Trauma: Trapped in the Closet
In Trauma Part 2: Sacrificing my Authentic Self, I will delve into the most prominent and prolonged trauma in my life: growing up as a homosexual male in the small, southern, church-going town of Davidson, NC, in the early 1990s. And then remaining closeted for the first 21 years of my life.
But first, I’d like to conclude this post with an excerpt from an article entitled “Together Alone: The Epidemic of Gay Loneliness,” by journalist Michaal Hobbes, and published by the Huffington Post:
“The trauma for gay men is the prolonged nature of it,” says William Elder, a sexual trauma researcher and psychologist. Or, as Elder puts it, being in the closet is like having someone punch you lightly on the arm, over and over. At first, it’s annoying. After a while, it’s infuriating. Eventually, it’s all you can think about.
And then the stress of dealing with it every day begins to build up in your body. Growing up gay, it seems, is bad for you in many of the same ways as growing up in extreme poverty. A 2015 study found that gay people produce less cortisol, the hormone that regulates stress. Their systems were so activated, so constantly, in adolescence that they ended up sluggish as grownups, says Katie McLaughlin, one of the study’s co-authors. In 2014, researchers compared straight and gay teenagers on cardiovascular risk. They found that the gay kids didn’t have a greater number of “stressful life events” (i.e. straight people have problems, too), but the ones they did experience inflicted more harm on their nervous systems.
Annesa Flentje, a stress researcher at the University of California, San Francisco, specializes in the effect of minority stress on gene expression. All those little punches combine with our adaptations to them, she says, and become “automatic ways of thinking that never get challenged or turned off, even 30 years later.”
Whether we recognize it or not, our bodies bring the closet with us into adulthood... the rates of depression, loneliness and substance abuse in the gay community remain stuck in the same place they’ve been for decades. Gay people are now, depending on the study, between 2 and 10 times more likely than straight people to take their own lives. We’re twice as likely to have a major depressive episode.”
[This article is about a 20-minute read, but I highly recommend it if you have time, and feel called to it.]
So, how did I bring the closet with me into adulthood? Read Trauma Part 2: Sacrificing my Authentic Self
Notes:
† The nervous system — the physiological network of organs and nerves that allow us to perceive and respond to sensory inputs, including most notably our brains — is a concept I will be exploring in depth in a later post. For now, it is important to know that trauma affects this system in a lasting and often devastating way.
*: Trauma affects everyone differently. Even with the same demonstrated shifts to neurobiology and endocrinology. As Dr. Gabor Mate notes, one such response might be: “For those habituated to high levels of internal stress since early childhood, it is the absence of stress that creates unease, evoking boredom and a sense of meaninglessness. People may become addicted to their own stress hormones, adrenaline and cortisol. To such persons stress feels desirable, while the absence of it feels like something to be avoided.”
**: Renowned somatic therapist Dr. Peter Levine believes this too: “Trauma has become so commonplace that most people don’t recognize its presence. It affects everyone. Each of us has had a traumatic experience at some time in our lives, regardless of whether it left us with an obvious case of post-traumatic stress.”
Me, age 4, sitting on the back porch of my childhood home in Davidson, NC
Sources:
The Mayo Clinic, “ Post-traumatic stress disorder (PTSD).” https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
Gary Gilles and Kelly Morrell, “Understanding Complex Post-Traumatic Stress Disorder.” Medically reviewed by Timothy J. Legg, PhD, PsyD, January 26, 2018. https://www.healthline.com/health/cptsd#causes
Michael D. De Bellis, MD, MPH and Abigail Zisk A.B. “The Biological Effects of Childhood Trauma” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3968319/#!po=4.84694
Hilary A Marusak, Kayla R Martin, Amit Etkin & Moriah E Thomason. “Childhood Trauma Exposure Disrupts the Automatic Regulation of Emotional Processing.” Neuropsychopharmacology, retrieved from The Journal Nature: https://www.nature.com/articles/npp2014311
Koenigs, Michael and Grafman, Jordan. “Post-traumatic stress disorder: The role of medial prefrontal cortex and amygdala.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771687/
Shin, Lisa & Rauch, Scott & Pitman, Roger. (2006). “Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD.” Annals of the New York Academy of Sciences. 1071. 67-79. 10.1196/annals.1364.007. https://www.researchgate.net/publication/6894635_Amygdala_Medial_Prefrontal_Cortex_and_Hippocampal_Function_in_PTSD
Dr. Rachel Yehuda. Interview, 15 Jun 2016. Shaili Jain M.D. “Cortisol and PTSD, Part 1.” https://www.psychologytoday.com/us/blog/the-aftermath-trauma/201606/cortisol-and-ptsd-part-1
Maté, Gabor. When the Body Says No: The Cost of Hidden Stress. Toronto: A.A. Knopf Canada, 2003.
Centers for Disease Control: “Preventing Adverse Childhood Experiences” | CDC. (2019, December 31). Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/aces/fastfact.html
Harvard University: What Are ACEs? And How Do They Relate to Toxic Stress? (n.d.). Retrieved from https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions
Other contextual sources:
Cisler, Josh M. “Childhood Trauma and Functional Connectivity between Amygdala and Medial Prefrontal Cortex: A Dynamic Functional Connectivity and Large-Scale Network Perspective.” Front. Syst. Neurosci., 11 May 2017
Hiser, Jared, and Koenigs, Michael. “The multifaceted role of ventromedial prefrontal cortex in emotion, decision-making, social cognition, and psychopathology.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862740/