E3 - AFTER TRAUMA

In our last episode, we talked about reactions that happen to our brains and bodies during trauma. Today, we’re going to talk about what happens after trauma. Not only do you feel differently, you experience and process life differently. Because of the trauma you’re brain chemistry is different and that can have a lasting impact. One of the most immediate things that happens is that we re-experiencing the trauma and this can happen in a few different ways: replaying the trauma, nightmares, and flashbacks.

Replaying the Memory

Many people find that the mind returns over and over to the upsetting memory, almost as if on a loop. It might feel like the brain is trying to make sense of the experience, or figure out if we should have responded differently. Whatever the cause, it can be extremely distressing to relive experiences repeatedly, even as we try our best to get the memory out of our heads. Something I’ve learned while practicing mindfulness and dialectic behavioral skills, is that pushing away the thoughts is not always helpful. It’s actually helpful to allow the thoughts to come and experience the emotion. The less we avoid it, the less it builds and festers. If we allow ourselves to process the feelings and sensations the reminders cause, our emotion response will decrease over time.

Nightmares

While the actual experience probably felt like a nightmare, it's common for real nightmares to haunt our dreams in the aftermath of a trauma. The nervous system has taken a major shock, and even in our sleeping hours the brain continues to process the event. Most of the time the nightmares aren't of the exact trauma experience, but have themes in common with it—for example, betrayal, danger, dread, or being chased. Not surprisingly, these nightmares can contribute to the poor sleep that's common after a trauma.

Flashbacks

A flashback occurs when the trauma memory gets cued and makes it feel as if the trauma is happening all over again. I experience flashbacks. They are upsetting because they bring back a powerful flood of emotions and vivid memories of the trauma.

It can happen when I see or hear something that reminds me of the complex trauma and then suddenly, I’m consumed by the visions of the painful events in my head. A surge of emotions and sometimes physical reactions take hold of me. Sometimes I can tolerate it and control my reactions to it and sometimes I can’t. I flashback to a lot of painful times in my life and I find that now, smaller painful events store itself in a similar way in my brain. The flashbacks cause dread that can last for hours or days. The flashbacks can instantly ruin the moment if I go down the path that the flashbacks are showing me.

Dysregulation

Reliving the trauma through replaying the memory, having nightmares, and flashbacks can cause really intense and disproportional emotional reactions. This is called Emotional dysregulation. Meaning you have difficulty regulating (ie controlling or maintaining) your emotions. Emotions such as anger, anxiety, sadness, and shame. When trauma occurrs at a young age, this emotional dysregulation stays with you as an ongoing pattern. In individuals who are older and functioning well prior to the trauma, emotional dysregulation is usually temporary and short lived.

Self-medication and substance abuse are ways that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation. Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors, gambling or overworking, and repression or denial of emotions.

However, there are many ways to create patterns of positive self-regulation such as mindfulness and finding creative, healthy, and even industrious ways to manage through physical activity or by creating art, writing, investing time into a hobby or passion.

So what’s are the dysregulated emotions typically associated by trauma? Fear, anxiety, anger, sadness, guilt and feeling numb.

Fear and Anxiety

Perhaps the most common emotional reaction to a trauma is feeling fearful and anxious. It makes perfect sense that we would be afraid after something scary happened. In fact, like so many of these reactions, it's a sign that our nervous system is functioning as it should. Nevertheless, the fear following a trauma can be as bad or worse than the emotions we felt at the time of the trauma, and almost certainly lasts longer. You may feel like the fear is subsiding when something triggers a reminder of the trauma, and the intense fear returns. Thankfully like the rest of these reactions, most people find that they do decrease over time. 

Anger

In addition to fear and anxiety, anger is a very common reaction to trauma. We might feel anger at the person or situation responsible for our trauma. We may be angry at ourselves if we blame ourselves for what happened. We might just be more irritable than usual, and have a hard time understanding why we're snapping at our partners or less patient with our kids. Like all of these reactions, it's perfectly normal to feel anger after a trauma.

Sadness

We often will feel sad and cry after a highly traumatic event. The crying can be a way for the nervous system to come down from the fight-or-flight response, since crying is associated with the parasympathetic nervous system which calms the mind and body. The sadness can also come from feeling overwhelmed by a world that feels terribly threatening. And of course sadness and grief are common when the trauma involved the loss of someone close to us. It's normal for these feelings of sadness to wax and wane.

Guilt

If the trauma involved someone close to us being injured or killed, we may blame ourselves and feel guilty that we didn't somehow prevent it. Combat veterans might feel guilty about actions they took in the course of their duties that resulted in the deaths of enemy combatants. Or we might feel responsible for being attacked or hurt, as though somehow we caused it.

Feeling Numb

Sometimes rather than feeling strong emotions, we feel shut down emotionally, as though we're made of wood. We might not have the positive emotions we know we "should" when good things happen in our lives. Part of the numbing response can come from the body and mind's self-protective efforts in the face of overwhelming emotions.

Avoidance

Sometimes we find it easier to just avoid things related to the trauma. Anything that reminds us of it. Trying Not to Think About the Event. By definition, a traumatic event is not a pleasant memory, so it makes sense that we would want to avoid thinking about it. As mentioned above, the mind tends to replay the traumatic memory, so it can be difficult to keep it out of our minds for long. With time most people find that it becomes less painful to remember the trauma. Sometimes we avoid people, places, or things related to our trauma because they trigger the painful memory. For example, we might avoid TV shows that remind us of the event. Other times we might avoid things because they feel dangerous, like a section of the city where we were assaulted. It's common to want to avoid being in crowds after a trauma, even if the traumatic event wasn't caused directly by another person (such as an earthquake).

How does it affect they way we view ourselves and the world?

Difficulty Trusting People

When we've been attacked by another person, it can be hard to know whom we can trust—especially if we were caught off guard. We might start to suspect everyone, feeling like "if that person could hurt me, why not thisperson?" Not uncommonly we may wall ourselves off from others to protect ourselves.

Believing the World Is Extremely Dangerous

Immediately after a trauma, the mind is likely to see the world as very dangerous. Whereas we might have underestimated the danger in the world before the trauma, we might overestimate danger in the aftermath of a trauma. After all, our most recent experience of the world is as a very threatening place. Over time our beliefs tend to shift toward the middle, recognizing that the world can be quite dangerous at times, and that at other times it's relatively safe.

 Blaming Yourself for the Trauma

As mentioned above, it's common to feel guilty after something terrible happens to you, as though you're to blame that it happened. The mind may cast about for ways that you could have avoided the trauma:

• "If only I'd left work a few minutes earlier."

• "I shouldn't have been out at that hour."

• "I should have seen that he was coming for me."

• "Why wasn't I more careful?"

It's easy to use the advantage of hindsight to see the "mistakes" we made. In reality we almost certainly overstate our own responsibility for the traumatic event, and as a result feel unnecessary guilt. All the same, it's a common response after a trauma.

Thinking You Should Have Handled the Trauma Differently

So many trauma survivors I've treated have talked about how they "should have" had a different response to the trauma, which was something I thought as well for both of my incidents. It's another example of "Monday morning quarterbacking"—second guessing split-second decisions made under a high degree of stress. Perhaps we can think of a better reaction when we have hours or days to mull it over, but life is lived in real time.

Seeing Yourself as Weak or Inadequate

It's not uncommon after a trauma to start to see ourselves as being "less than" in some way. Maybe we tell ourselves we're weak for "letting it happen." I remember thinking after getting mugged that if I'd been a more intimidating presence that my wife and I wouldn't have been targeted—which ignored, of course, the fact that he had a gun. As with many trauma-related beliefs, we often are more critical of ourselves than we need to be.

Criticizing Yourself for Reactions to the Trauma

In addition to beating ourselves up for having experienced the trauma, we might also be upset with ourselves for being upset. As one person said to me, "How come everyone else has gotten over it and I can't?" There's an irony in how common it is to believe after a trauma that "nobody else would have the same kinds of struggles I'm having," given how many people feel this way.

How does it affect our behaviors?

Hyperactive Nervous System

Feeling Constantly On Guard

When the nervous system has had a terrifying shock, it doesn't immediately settle down. It's going to be turned up for a while, alert for the possibility of further danger. You might keep looking over your shoulder, or be constantly scanning your surroundings for threats. You've been hurt before, and you don't want to be caught off guard. It really means your brain is doing its job to protect you, although this knowledge doesn't make it any more comfortable to feel on edge all the time.

Seeing Danger Everywhere

When your nervous system is highly attuned for danger, it's going to be set to detect any possible threat, which probably means you'll have a lot of false alarms. You might see your assailant walking toward you, and realize as your heart pounds out of your chest that it's really just your friendly neighbor. You might be startled by a movement out of the corner of your eye, and then realize it's your own reflection. I remember literally jumping at the movement of my own shadow in the streetlights one night, thinking it was someone walking up behind me.

Being Easily Startled

A nervous system temporarily stuck in the "high" setting is going to be easily startled by things like a slamming door. You may find yourself jumpier than usual, or taking longer to come back to your baseline. It's common to feel anger at the cause of the startle. 

Difficulty Sleeping

Sleep is a vulnerable state, and when the brain and body are revved up, we're likely to have a hard time sleeping. It's as though the mind is saying, "Danger! This is no time for sleeping!" The nightmares that are common can also interfere with sleep, and can make us reluctant to go to bed. 

Loss of Interest in Sex

As with sleep, the brain may be inclined to avoid sexual activity following a trauma. It's easy to understand if the trauma was a sexual assault, when sexual activity may trigger painful memories of the attack. Even if the trauma was not of a sexual nature, we may be less interested in sex as we recover from a recent trauma.

How does it affect our thoughts?

The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

Cognitive errors

Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

Excessive or inappropriate guilt

Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor’s guilt, because others who experienced the same trauma did not survive.

Trauma-induced hallucinations or delusions

Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

Intrusive thoughts and memories

Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories. It is important to develop coping strategies before, as much as possible, and during the delivery of trauma-informed and trauma-specific treatment.

Dissociation, depersonalization, and derealization

Dissociation is a mental process that severs connections among a person’s thoughts, memories, feelings, actions, and/or sense of identity. Most of us have experienced dissociation—losing the ability to recall or track a particular action (e.g., arriving at work but not remembering the last minutes of the drive). Dissociation happens because the person is engaged in an automatic activity and is not paying attention to his or her immediate environment. Dissociation can also occur during severe stress or trauma as a protective element whereby the individual incurs distortion of time, space, or identity. This is a common symptom in traumatic stress reactions.

Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive. At times, dissociation can be very pervasive and symptomatic of a mental disorder, such as dissociative identity disorder (formerly known as multiple personality disorder). According to the DSM-5, “dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior”. Dissociative disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive, human-caused, intentional trauma, such as that experienced by concentration camp survivors or victims of ongoing political imprisonment, torture, or long-term isolation. A mental health professional, preferably with significant training in working with dissociative disorders and with trauma, should be consulted when a dissociative disorder diagnosis is suspected.

The person may not remember what actually happened, while emotions experienced during the trauma may be re-experienced without the person understanding why (this is called a Repressed Memory). This can lead to the traumatic events being constantly experienced as if they were happening in the present, preventing the subject from gaining perspective on the experience. This can produce a pattern of prolonged periods of acute arousal punctuated by periods of physical and mental exhaustion.

Prompting events (triggers) and cues act as reminders of the trauma and can cause anxiety and other associated emotions. Often the person can be completely unaware of what these triggers are. In many cases this may lead a person suffering from traumatic disorders to engage in disruptive behaviors or self-destructive coping mechanisms, often without being fully aware of the nature or causes of their own actions. Panic attacks are an example of a psychosomatic response to such emotional triggers.

Brain imaging

In the 1990's gigantic multimillion machines based on advanced physics and computer technology rapidly made neuroscience into a popular area to research. The fMRI (functional magnetic resonance imaging) enabled scientist to visualize how different parts of the brain are activated when people are engaged in certain tasks or when they remember events from the past. Now we could watch the brain as it processed memories, sensations and emotions and being to map the circuits of the mind and consciousness.

I read an excert from the book The Body Keeps Score by Bessel Van Der Kolk Pages 41-45