The Normal Human Response to Trauma Alasdair Vance and Jo Winther Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children’s Hospital Outline of presentation 1. The vast range of human life experiences 2. The definition of trauma 3. Trauma types: initial versus few months later responses 4. Vulnerability-risk and Protective-resilience models 5. Biological factors 6. Psychological factors 7. Social factors 8. Cultural factors 9. Practical tips - Jo Winther 10. Clinical illustrations – Jo Winther Prof. A. Vance Person A: 36 man, bankteller, obsessive-compulsive, MVA on the way to work, major depressive episode, 8 months to get better Person B: 26 man, intelligence operative, tortured and escapes, ASD symptoms, 8 weeks to be back at work Person C: 45 man, cleaner, avoidant, told burglar in building afterwards, develops ASD symptoms, receives counselling, develops PTSD, rehabilitation program still going at 12 months Person D: 18 year old girl, released from 6 years imprisonment with a paedophile, countless episodes of rape, physical abuse and neglect, refuses counselling, being a ‘victim’, becomes a nurse and marries Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance Prof. A. Vance Prof. A. Vance Prof. A. Vance Prof. A. Vance 2. Definition of Trauma ‘throw out, alter’ - injury living tissue by an external agent - disordered behavioural and/or psychological state resulting from a severe mental, emotional stress and/or physical injury - initial effect: Acute Stress Disorder - delayed effect: Post Traumatic Stress Disorder Prof. A. Vance 2. Acute Stress Disorder - extreme traumatic, terrifying, horrifying event experienced, witnessed, learnt about family/close friend respond with intense fear, horror, helplessness, disengaged/agitated behavior (children) - within one month and symptoms resolve within one month - psychic numbing, dazed/less aware of surroundings, derealisation, depersonalisation, dissociative amnesia Prof. A. Vance 2. Acute Stress Disorder - re-experiencing phenomena: recurrent, distressing, memories, dreams, symbols of traumatic event - avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s), decreased future - hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response Prof. A. Vance 2. Acute Stress Disorder - duration: 2 days – 4 weeks - significant impairment home, family, work, educational life domains - not due to substance abuse/dependence disorder, medical disorder, brief psychotic disorder, pre-existing psychiatric disorder Prof. A. Vance 2. Post Traumatic Stress disorder - extreme traumatic, terrifying, horrifying event experienced, witnessed, learnt about family/close friend respond with intense fear, horror, helplessness, disengaged/agitated behavior (children) - lasts more than one month, chronic if more than 3 months, delayed if onset after 6 months from traumatic event(s) Prof. A. Vance 2. Post Traumatic Stress disorder - re-experiencing phenomena: recurrent, distressing, memories, dreams, symbols of traumatic event - avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s), decreased future - hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response Prof. A. Vance 2. Post Traumatic Stress disorder - significant impairment home, family, work, educational life domains - not due to substance abuse/dependence disorder, medical disorder, psychotic disorder, pre-existing psychiatric disorder-especially OCD, malingering Prof. A. Vance 3. Trauma types (National Child Traumatic Stress Network) - physical abuse - neglect - sexual abuse - psychological maltreatment - complex trauma: multiple and/or prolonged episodes - refugee and war zone trauma - terrorism - natural disasters Prof. A. Vance 3. Trauma types - medical trauma - domestic violence - community school violence - traumatic grief Prof. A. Vance Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance 4. Vulnerability-risk model - Zubin and Spring proposed model - interplay between individual and environment crucial; a true interaction effect - biological, temperamental, psychological, social, cultural vulnerability Prof. A. Vance Zubin and Spring, 1977 Prof. A. Vance Prof. A. Vance 4. Protective-resilience model - Seligman developed model as part of positive psychology - interplay between individual and environment crucial; a true interaction effect - biological, temperamental, psychological, social, cultural resilience Prof. A. Vance Prof. A. Vance Prof. A. Vance 4. - for some factors, risk and resilience are opposite ends of the same spectrum (eg empathic relationships) - for other factors, risk and resilience are two separate domains that a person can be high or low on (eg cognitive strategies) Prof. A. Vance Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance Trauma specific factors - living through trauma event(s) - being physically injured - seeing others hurt and/or killed - experiencing intense horror and/or fear - experiencing extra loss after trauma event(s) loss loved ones, pain, injury, loss job, home, etc Prof. A. Vance Prof. A. Vance Prof. A. Vance Prof. A. Vance Region of activation BA C (mm) Z Control Group greater than ADHD-CT Group Parieto-Occipital R Precuneus 19 24 -70 32 3.53 R Cuneus 19 32 -90 28 2.82 Posterior Parietal R Inf. Parietal 40 36 -40 50 2.82 Frontal/Subcortical R Caudate Nucleus, Body 18 -12 22 2.82 Vance et al, Mol Psych 2007 N=24, CBCL inattention subscale T score: 72.14 (9.43) Prof. A. Vance Prof. A. Vance 5. Biological factors: Irritability, Mood lability Euthymia Mood Time Prof. A. Vance 5. Biological factors Arousal dysregulation: impaired physiological arousal decreased habituation Mood dysregulation: increased irritability decreased emotional salience Prof. A. Vance 5. Biological factors - Executive functioning deficits Response disinhibition: motor and cognition suboptimal response speed and accuracy Working memory deficits: verbal and visuospatial decreased span and strategy Prof. A. Vance 6. Psychological factors - dissociation: helpful initially, longer duration=increased risk - helplessness - coping strategy - able to get through trauma event(s) - able to learn from it - able to respond effectively despite fear - feel good about one’s actions - good cognitive skills – attention, problem solving - temperament; adaptive, good self-regulation-impulses/emotions - positive self-perceptions Prof. A. Vance 7. Social factors - degree of social support after trauma - ability to seek, find and maintain social support - ‘warmth’of relationships: empathy, attunement - family structure, expectations and monitoring - low parental discord - prosocial, competent, supportive family/peer group - ‘collective efficacy’ school, neighbourhood environment Prof. A. Vance 8. Cultural factors - individual versus group cultural focus Prof. A. Vance Young people exposed to trauma may react in a variety of ways : • Aggressive behaviour • Staring episodes • Eating and sleep disturbances • Difficulty concentrating • Exaggerated startle response • Irritability and outbursts of anger • Hypervigilance – jumpy or fidgety or having trouble staying in their seat • Restricted range of emotions • Guilt • Clinginess and fear of separation • Crying or giggling without obvious reason Developmentally specific responses to disasters and trauma vary in children of different ages: • Younger children commonly express new fears, separation anxiety, clinginess and show ‘regressive’ behaviours • School age children describe difficulty concentrating or having fun. Learning and behavioural problems, aggressive behaviours and withdrawal • Adolescents are at particularly high risk as their reactions can include increased risk-taking behaviours including fighting, substance and alcohol abuse, heightened sexual activity and suicidal thoughts Practical tips when working with the young person • Ensure people closest to the young person provide information and support • Protect the young person from public curiosity • Provide reassurance (the world has not completely changed) • Don’t be afraid to talk about the events – using factual information • When discussing the event with the young person keep it simple and be honest • Find out what they think and feel – allow them to guide the discussion, give them time to ask questions, discuss their feelings and emotions, and correct misperceptions with accurate but age appropriate explanations Practical tips when working with the young person • Reassure the young person by verbally acknowledging and normalising their experiences. Listen to what they say and acknowledge with them the awfulness of their experience • Inform them that what they are feeling is very normal for someone who has been through a traumatic event and to give themselves time to adjust • Sometimes stories about other young people in a similar situation can help them feel more in control • Take the young person’s lead on when, what and how much to say • Accept that some young people do not want to talk (they might express themselves through writing or drawing) Practical tips when working with the young person • Assess the situation and gather information • Seek crisis intervention