Surviving Childhood: An Introduction to the Impact of Trauma
 

   
 
Lesson 2: The Psychology and Physiology of Trauma

How We Respond to Threat

Figure 2-1: The psychology and physiology of trauma.

The Alarm Reaction

The human body and human mind each have a set of very important and very predictable responses to threat. Threat may come from an internal source, such as pain, or an external source, such as an assailant. One common reaction to danger or threat has been labeled the "fight or flight" reaction. In the initial stages of this reaction, there is a response called the alarm reaction .

Think about what happens when you feel threatened. Your racing heart, sweaty palms, nausea, and sense of impending harm are all symptomatic of this alarm reaction.

Figure 2-2: The acute response to trauma.

When a person perceives a threat, the initial stages of a complex, total-body response will begin. The brain orchestrates, directs, and controls this response. The more threatened an individual feels, the further their brain and body will be shifted along an arousal continuum in an attempt to ensure appropriate mental and physical responses to the challenges of the threat. The cognitive (thinking), emotional, and behavioral functioning of the individual will all reflect this shift along the arousal continuum.

During the traumatic event, all aspects of the individual's functioning change, including feeling, thinking, and behaving. For instance, someone under direct assault abandons thoughts of the future or abstract plans for survival. At that exact moment, all of the victim's thinking, behaving, and feeling is being directed by more primitive parts of the brain.

A frightened child in a threatening situation doesn't focus on the words being spoken or yelled; instead, he or she is busy attending to the threat-related signals in their environment. The fearful child will key in to nonverbal signs of communication, cues such as eye contact, facial expression, and body posture, or proximity to the threat.

The internal state of the child also shifts with the level of perceived threat. With increased threat, a child moves along the arousal continuum from vigilance through to terror. (See the above graph for different possible response scenarios.)

The Arousal Continuum

The arousal continuum is characterized by many physiological changes. Under threat, sympathetic nervous system activity increases in a gradual fashion. Heart rate, blood pressure, and respiration are altered during the arousal response. Glucose stored in muscle is released to prepare the large skeletal muscles of your arms and legs for either a fight or a flight.

These changes in the central nervous system cause hypervigilance; under threat, the child tunes out all non-critical information. These actions prepare the child to do battle with or run away from the potential threat.

This total body mobilization -- the fight-or-flight response -- has been well characterized and described in great detail for adults. These responses are highly adaptive and involve many coordinated and integrated neurophysiological responses across multiple brain areas, including the brainstem nuclei responsible for autonomic nervous system regulation.

What Does Hyperarousal Really Mean?

Hyperarousal is a multi-dimensional process characterized by both mental and physical changes. These include an increase in the activity of those parts of the central and peripheral nervous system responsible for the perception and processing of potentially threatening information . This graded response also involves action.

During the hyperarousal process, many physiological systems required for survival are activated (e.g., stress response hormones such as cortisol and adrenaline). The many physiological changes during hyperarousal will influence the way a person thinks, feels, and acts.



 



Dissociation

The fight-or-flight response is a well-characterized reaction to danger, as we've already discussed. A second common reaction pattern to threat is dissociation. Dissociation is the mental mechanism by which one withdraws attention from the outside world and focuses on the inner world.

It is increasingly clear that responses to threat can vary tremendously from individual to individual. This second major adaptation response to threat involves an entirely different set of physiological and mental changes, yet does not fall under the heading of either fight or flight.

Many common and "normal" mental and emotional states such as anxiety, dissociation, or anger are experienced by most of us to some degree. When any one of these becomes pervasive and ever-present, however, it begins to interfere with the rest of one's life. This can happen with dissociation and anxiety. When it does we characterize this as a disorder.

Figure 2-3: Dissociation.

Because of their small size and limited physical capabilities, young children do not usually have the fight-or-flight option in a threatening situation. When fighting or physically fleeing is not possible, the child may use avoidant and psychological fleeing mechanisms that are categorized as dissociative.

Dissociation due to threat and/or trauma may involve a distorted sense of time or a detached feeling that you are observing something happen to you as if it is unreal -- the sense that you may be watching a movie of your life. In extreme cases, children may withdraw into an elaborate fantasy world where they may assume special powers or strengths.

Like the alarm response, this "defeat" or dissociative response is graded along a continuum. The intensity of the dissociation varies with the intensity and duration of the traumatic event. (Remember that even when we are not threatened, we use dissociative mental mechanisms, such as daydreaming, all of the time.) During a traumatic event, all children and most adults use some degree of dissociation. However, some individuals will use, or experience trauma that induces dissociation as a primary adaptive response.

For most children and adults the adaptive response to an acute trauma involves a mixture of hyperarousal and dissociation. During the actual trauma, the child feels threatened and the arousal systems will activate. With increased threat, the child moves along the arousal continuum. At some point along this continuum, the dissociative response is activated and a host of protective mental (decreased perception of anxiety and pain) and physiological responses (decreased heart rate) occur (see Figure 3-4 below).

Figure 2-4: Differential response to threat.


 


Dissociation is not always a response to threat or trauma. It is often a normal coping mechanism used for excessive boredom or for another purpose. For example, meditation, Lamaze childbirth exercises, daydreaming, and highway hypnosis are all mild forms of dissociation.


Key Characteristics of Adaptive Response to Trauma

The following points are an overview of human response to threat and trauma. Don't worry if you don't grasp all the concepts at first reading. We will be discussing these issues in greater detail as we move through our course. Consider this a preview of sorts.

  • The brain mediates threat with a set of predictable neurobiological, neuroendocrine, and neuropsychological responses.
  • These responses may include different survival strategies -- ranging from fighting or fleeing to giving up or surrendering.
  • There are multiple sets of neurobiological and mental responses to stress. These vary with the nature, intensity, and frequency of the event. Different children may have unique and individualized sets of responses to the same trauma.
  • Two primary adaptive response patterns in the face of extreme threat are the hyperarousal continuum (defense -- fight or flight) and the dissociation continuum (freeze and surrender response). Each of these response sets activates a unique combination of neural systems.
  • These response patterns are somewhat different in infants, children, and adults -- though they share many similarities. Adult males are more likely to use hyperarousal (fight or flight) response, while young children are more likely to use a dissociative pattern (freeze and surrender) response.
  • In general, the predominant adaptive style of an individual in the acute traumatic situation will determine which post-traumatic symptoms will develop: hyperarousal or dissociative.

Exercise: Catalog Your Alarm Response Patterns

Think back to the last time you felt threatened in some way and your alarm state was activated. Perhaps you were walking down a dark street one night and heard footsteps close behind you. Perhaps you were attending a football game one afternoon when some beer-swilling fans next to you began a fight with a fan of the opposing team seated in the row behind you.
Pick two or three events from your life where you felt some element of threat. For each, make two columns. In the first column, list the emotional and mental changes you remember -- for example, a sense of unreality, intense fear, or tuning out the world. In the other, list the physical symptoms such as racing heart, sweaty palms, or light-headedness. What physical symptoms do you recall emerging as your brain sent the signal to your body that a threat was near? Did you want to run? Did you feel an adrenalin surge in preparation for possible self-defense?
Visualize your body and make a mental list, from head to toe, of every physiological response to the perceived threat that occurred. This can illustrate two key points: 1) you probably had a slightly different set of adaptive changes in each event and 2) the mental (i.e., psychological) and body (i.e., physiological) changes are interrelated, interdependent, and, in fact, components of the same neurophysiological response to threat. It is not useful or accurate to think of "psychological" vs. "physical" responses.


 



How Fear Changes Thinking, Behaving, and Feeling

Different children have different styles of adaptation to threat. Some children use a primary hyperarousal response, while others adapt a primary dissociative response. Most children, however, adopt some combination of these two adaptive styles.

In the fearful child, a defiant stance is often seen. This is typically interpreted as a willful and controlling child. Rather than understanding the behavior as related to fear, adults often respond to the "oppositional" behavior by becoming angrier and even more demanding.

The child, over-reading the nonverbal cues of the frustrated and angry adult, feels more threatened and moves from alarm to fear to terror. These children may end up in a primitive "mini-psychotic" regression or in a very combative state. Their behavior of the child reflects their attempts to adapt and respond to a perceived (or misperceived) threat.

Hyperarousal
Continuum
REST VIGILANCE RESISTANCE
Crying
DEFIANCE
Tantrums
AGGRESSION
Dissociative
Continuum
REST AVOIDANCE COMPLIANCE
Robotic/detached
DISSOCIATION Fetal Rocking FAINTING
Regulating Brain Region
NEOCORTEX
Cortex
CORTEX
Limbic
LIMBIC
Midbrain
MIDBRAIN
Brainstem
BRAINSTEM
Autonomic
Cognitive Style
ABSTRACT CONCRETE EMOTIONAL REACTIVE REFLEXIVE
Internal State
CALM AROUSAL ALARM FEAR TERROR


 



Case Examples: Adaptive Styles During a Traumatic Event

Figure 2-5: Individualized adaptive response.
  1. Same Event, Different Adaptive Styles in Different Children: On a quiet Sunday morning outside of Waco Texas, the ATF raided the Branch Davidian compound. Most of us have seen the footage of this assault on the television. Thousands of bullets were fired into that building. More than 80 children were in that building on that morning.

    In the three days following the ATF assault, 21 children were released to the FBI and became temporary wards of the State of Texas, cared for by a clinical team directed by the ChildTrauma Academy. These 21 children had a variety of individualized adaptive responses to the same event; some using a primary hyperarousal response, others a primary dissociative response -- but the majority used a combination of these two primary adaptive patterns.

    Hyperarousal: T. was an 11-year-old boy. He described a sense of heightened awareness, no primary anxiety, racing heart, and increased vigilance; he was very, very focused on the location and behavior of the ATF agents. Only after the event did he say he felt afraid. He was primarily afraid that the shooting would start again.

    Dissociative: G. was an 8-year-old girl. She reported crawling under her bed and "kind of falling asleep." She could not give significant details regarding the shooting. She reported that it didn't seem real, that "it all was like a dream."

    KEY POINT: Individual adaptive responses will vary. Many factors appear to play a role in the individual response. Several important variables are age, sex, and previous history of traumatic exposure. Young children and females are more likely to use dissociative adaptations.

  2. Same Child, Different Event, and Different Adaptive Style: X. is a 10-year-old boy. Over the course of a single year, he was exposed to two different kinds of traumatic events. The first was a shooting in the community. He was with a group of children playing in a neighborhood when an altercation broke out between two older boys. The younger children watched as these boys fought and then one went to his car to get a gun.

    X. describes the increase in his heart rate and his sense of fear, vigilance, and conflict about whether he should run home. When the older boy returned with the gun, X turned and ran. He heard the gunshot and looked back to see one boy on the ground. He later returned to the site of the shooting to see the blood on the ground. This was a classic hyperarousal response that resulted in his flight.

    Two months later, X. was visiting family in another part of Texas. A severe storm and then a tornado threatened their home. He reports that he felt terrified and then immobilized. He was unable to move; his uncle took him into a closet under the stairs. In contrast to the shooting, he has little recollection of the details of the storm except that it was dark, noisy, and it seemed to last for a long time.

    After the event he remembers walking around the neighborhood looking at the damage, then says, "Or maybe I dreamed that." This was an inescapable event. And his response was primarily dissociative in nature.

    KEY POINT: The nature of an event can determine which response pattern is most adaptive. In this case, fleeing was protective in the shooting, but would have been foolish in the storm. In general, when direct physical assault (e.g., torture or the sexual assault of a child) or inescapable threat is present, dissociation will be adaptive. In events where the individual is capable of fighting (e.g., the assault is by someone smaller than you) or fleeing (i.e., you can actually run away from the threat), the hyperarousal response is most adaptive.

  3. Same Child, Different Event, Developmental Differences in Adaptive Style: T. is a 12-year-old girl. From birth until age 5 she lived in a household characterized by domestic violence. During this time, she was noted to be quiet, compliant, "tuned out," a daydreamer, and generally "a good little girl." She reports little memory of the fighting, but her mother describes finding her in her bed, rocking, with covers over her head after some of the fights in the home.

    At age 12, her mother remarried but, unfortunately, episodes of domestic violence resumed in this household. This time, however, T. was loud, combative, and angry; she would run away from the home each time these events took place. At school she was noted to have "attention problems," which turned out to be hypervigilance.

    Rather than "tuning out" and withdrawing into a dissociative shell, this child was sensitized to fighting and had dramatic and pronounced hyperarousal during conflict.

    KEY POINT: Traumatic events of the same nature can induce different adaptive responses in the same child at different times during the child's development. An infant and young child is not truly capable of fighting or fleeing, so hyperarousal is not an adaptive response. However, by age 12, fighting back and fleeing were adaptive. In this child, both adaptive styles were used at different times in life for the same kind of perceived threat.



 



Acute Post-Traumatic Period

When the Trauma Ends

As the traumatic event ends, the phase known as the acute post-traumatic period begins. During this time, the mind and body slowly move back down the arousal or dissociative continuum. The child moves from the brink of terror through fear, alarm, and, with time and support, back to calm (see Figure 2-2 above). Heart rate, blood pressure, and other physiological adaptations normalize.

If a child can move back down the arousal continuum, his or her brain will resume baseline (pre-trauma) styles of thinking, feeling, and behaving. Hypervigilance decreases and the mental mechanisms related to attention begin to normalize as well. The child that has dissociated will begin to pay attention once again to external stimuli.

Conversely, the child that has been completely focused on external cues related to threat will actually pay attention once again to internal stimuli (e.g., feelings, thoughts, sensing their pounding heart, or noticing the cut on their leg from diving under a desk during a shooting).

Making Sense of the Event

During this acute post-traumatic period, the child will now perceive the sense of fear and anxiety. This is when they will actually feel the fear associated with the trauma. The individual will begin to process and think about what has happened, attempting to make sense out of the events just experienced. Because the traumatic event is so far out of the normal range of experience, there will be a variety of mental attempts to process and "master" this event.

The traumatic event will play itself out in the mind of the child again and again. A host of intrusive images related to the trauma may swamp the child's thinking. This set of re-living and re-experiencing phenomena may include telling the story over and over again to friends. The child may act this event out in play and drawings (see below) or experience intrusions (flashbacks or nightmares). In essence, these children have created memories of the traumatic memory.

Living With Created Memories

The death of a loved one, for example, is a trauma that can influence memory. Over the six months following the loss, children (as well as adults) will often experience unusual visual, auditory, or tactile sensations. A child may think they hear the deceased person's voice, or they think they saw them in a crowd, or out of the corner of their eye they may see their reflection in a window. At bedtime or when awakening, these misperceptions are more common.

Such "memories" may be disturbing to parents, caregivers, and the child. The child needs to be reassured when these memories of the loved one occur. These "visions" are often interpreted in context of a religious belief system ("They came back to tell me it was OK" orư "They are still with me"). This can be important for the child and there is no reason to undermine these feelings. These "hysterical materializations" are common and often mislabeled as visual or auditory hallucinations.

These types of memories are complex and multi-domain. Traumatic memory involves the storage and recall of information at several levels. The brain stores not only traditional cognitive information, such as who, what, when, and where, but also emotional information: feelings such as fear, dread, and sadness.

The old adage that "the body remembers" is referring to motor-vestibular information. An example of this might consist of a memory of the body's position during the rape. Finally, the brain contains a state memory, such as vigilance or physiological hyperarousal.

A Difficult Process

The normal and predictable mental mechanisms that are used to process all experiences will, at times, fail in the attempts to master and understand a traumatic event. Because traumatic events have features that are so outside the range of normal experience, there are very few internal experiences with which to judge or make sense out of the event.

The more outside the range of the normal experience and the more life-threatening the experience, the more difficult it will be for the normal mental mechanisms to work efficiently to process and master that experience. The inability to control elements of the traumatic event, or the intrusive thoughts that follow, lead to a set of predictable mental and physiological responses.



 



   
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