About Traumatic Stress Disorders

Traumatic experiences in children can be especially damaging because they impact and arrest critical stages of their development.

Dissociation, a natural protective defense, often occurs in children who experience chronic traumatic stress, enabling their minds to confine the trauma behind mental walls.

As fragments of trauma leak and escape through cracks in the walls, children may experience puzzling emotional, physical, and behavioral symptoms which can be perplexing to understand.

Trauma in children occurs on a continuum from moderate to severe. Examples of increasing severity include:

• Severe academic stress which can gradually overwhelm a sensitive child’s psychological coping abilities.
• Ongoing traumatic stress from peers, such as social and cyberbullying or physical intimidation and abuse in a school or after school setting.
• Recurrent experiences of verbal, psychological, physical, or sexual abuse by trusted adults in mentoring or caregiving roles.

Frequent symptoms and signs of partial or complete dissociated trauma in children include the onset of:

• Brief memory lapses, often disguised as an increase in “careless errors” such as omitting obvious answers on exams, forgetting bits and pieces of homework, and “not hearing” teachers’ explicit instructions for the subject and purpose of an essay.
• Fading in and out of conversations and appearing "day-dreamy," trance-like, or disconnected.
• Increase in generalized anxiety, breathrough of anxiety attacks and appearance of new fears and phobias.
• Obsessive thoughts or compulsive behaviors such as ruminating worries about harmful events or counting or cleansing rituals.
• Fear of going to sleep, frequent night-time awakenings and nightmares.
• Headaches and stomach aches without a clear medical explanation.

When children present with the onset of these symptoms they may benefit from diagnostic evaluation. With specialized therapeutic help children are capable of healing and overcoming their psychological injuries and of growing into healthy adults.

Adults who have experienced childhood trauma may have lived many years carrying the imbedded traumatic experiences dissociated from their awareness. As a result there may be little or no conscious memory of the trauma narrative.

If the original traumatic experiences occurred from trusted mentors or caregivers the memory fragment breakthrough may begin to occur when she/he enters sustained emotionally intimate relationships, or when their children enter the age of their own trauma.

Frequent symptoms of partial or complete dissociated trauma include:

• Persistent elevated anxiety and hypervigilance.
• Sudden breakthrough of emotions, such as anger explosions, anxiety attacks, and waves of depression and despair which are more intense than present day situations warrant.
• Unexplained physical symptoms such as perplexing and wandering muscle aches and joint pains, “attacks” of gagging or difficulty swallowing, fleeting neurological symptoms such as sudden weakness and impaired mobility of an extremity, bouts of abdominal pain and nausea and episodic headaches and “migraines”.
• Interferences in sexual intimacy such as emotional detachment, inhibition of orgasm, or pain during intercourse.
• “Out-of-body” experiences such as seeing oneself at a distance when under stress or feeling like a robot or automaton, going through the motions of life as if not fully present and participating.
• Episodes of derealization, such as seeing outside events in life as if in a fog or experiencing moments of time when the world seems strange, unreal, or dream-like.
• Fragments of disturbing visual imagery flashing through the mind, often when doing neutral activities such as folding laundry or preparing for bed.
• Disturbed sleep patterns and nightmares.
• Discomfort or avoidance of people in positions of power and authority who may be reminders of the trauma.
• Fear and avoidance of situations of imagined entrapment such as elevators and rooms with closed doors.

Adults who experience a single-incident trauma may fully recover with relatively brief treatment. Chronic trauma, such as childhood verbal, psychological, physical, or sexual abuse may require specialized treatment of longer duration, often measured in months or years.

With specialized trauma therapy adults can experience healing of their psychological injuries, deepen and sustain intimacy in relationships, and enrich their lives and those of others with renewed passion and purpose.

A Clinical Guide for Mental Health Professionals
Charles H. Rousell, M.D.

Post-traumatic stress disorder occurs when an individual is exposed to a traumatic experience that is severe enough to overwhelm the usual coping mechanisms. PTSD can be divided into two types: simple acute PTSD and chronic complex PTSD. Simple acute PTSD typically follows single incident traumas such as car accidents, workplace violence, rape and sudden life threatening medical illness such as heart attack. Treatment is brief, usually spanning 4-8 sessions. Chronic complex PTSD results from ongoing recurrent trauma as in child abuse, domestic violence and war. Treatment may require months or years.

Individuals suffering from both types of PTSD can experience dissociation as a spontaneous coping mechanism. Research shows that high degrees of dissociation result in more complicated and prolonged treatment. Dissociation can be easily measured by use of one of the self-administered instruments such as the 28 item Dissociative Experiences Scale (DES), or administration of the Structured Clinical Interview for DSM-IV Dissociative Disorders (SDID-D).

Dissociation fragments traumatic experience into pieces and then puts the pieces behind mental barriers. Whenever the individual confronts triggers of the original trauma she or he will be susceptible to experiencing breakthrough of those memory fragments. Memory fragments can break through in four ways: 1) as behavioral re-enactments (eg. not wanting to go to bed, compulsive showering) 2. As affective experiences (eg, bouts of anxiety, angry explosions) 3. as body sensations (eg, episodic abdominal pain or vaginal burning) 4. as knowledge of the event, usually experienced as visual images (eg, seeing bathroom tiles flash through the mind). People experiencing memory fragment breakthrough usually do not know what is happening to them and are often afraid they are “going crazy”. If this condition is misdiagnosed by medical or mental health professionals the patient is generally started on a variety of psychotropic medications. This can lead to tranquilizer dependency. Patients may seek out other numbing agents such as recreational drugs or alcohol.

After the diagnosis has been established it is helpful to explain it to the patient. Individuals often feel immediate relief when they learn that they are experiencing memory breakthough from a previous trauma rather than having a “breakdown”. Treatment of PTSD is stage-specific. Hypnotherapy is integrated into a cognitive and dynamic psychotherapy. The three stages of treatment are: 1) stabilization, 2) memory processing and 3) cognitive restructuring. The same approach is used for both types of PTSD. If dissociation is high it may be necessary to work with internal ego states.

It is recommended that each patient sign a hypnosis consent form after appropriate discussion about hypnosis, trauma and memory has occurred. The therapy then quickly moves into the stabilization phase. This is a skill building phase in which the patient learns how to use and integrate specific hypnotic containment skills. It is essential that all patients have a firm foundation of hypnotic containment skills in place before moving into the memory processing stage. Some of the more useful hypnotic skills we use at our center are listed in the accompanying handout. It is not necessary for each patient to utilize all of these skills. Specific skills can be matched to the needs and capacities of each specific patient.

Centering and grounding techniques are important to enable each individual to stay in the present and not be swept back into the trauma. Spontaneous abreactions (complete flashbacks) are counter-therapeutic and must be prevented. Patients quickly learn the self-hypnotic skills of diaphragmatic breathing for tension reduction, safe place, lock-up, and affect dial.

Some patients find it useful to chain tension reduction skills together as a deepening experience. Diaphragmatic breathing can progress to clouds for soothing (floating and rocking on soft white clouds) to entering a hypnotically-imaged safe place. Time distortion can be used to enhance the tension-reducing power of a safe place. Unwanted traumatic images or feelings can be locked up into hypnotically-visualized inside containers (eg. lock boxes or safes). The “key” may be left in the therapist’s office, and the traumatic contents opened and examined at the right time in the presence of the therapist. Affect dial can be particularly effective in reducing unwanted and painful affects (eg, fear or anger) or body sensations (eg, headaches, abdominal pain). The patient in hypnosis visualizes the dial with numbers from 0 to 10. Colors may accompany the numbers. The dial measures the intensity of the feeling at the moment and then the patient experiences turning the dial up and down, mastering the ability to control the sensation.

In many cases of chronic complex PTSD occurring from recurrent childhood trauma there may be ego states present which hold chunks of traumatic material. The therapy then engages these parts of the patient’s mind and the containment skills are taught to the ego states.

After stabilization has been adequately achieved the therapy proceeds to the memoryprocessing stage. In simple acute PTSD it may be possible to process the traumatic event in a few sessions. In chronic complex PTSD this stage may proceed gradually over months, augmenting containment skills whenever necessary.

Memory processing can be undertaken with the patient telling the story of the trauma from beginning to end while under hypnosis. The attendant affects, body sensations and visual images are all experienced and integrated. Emotions or sensations which are anticipated to be too powerful to cope with initially can be “fractionated” out by using affect dial. For example, the fear dial is turned down as close to zero as possible while the patient narrates the memory the first time. The next time the memory is worked on the fear dial might be set at 5. In patients with chronic complex PTSD who have ego states it is necessary to process the memories contained in each ego state with the patient and the other ego states listening, absorbing and integrating the material.

Symptoms and susceptibility to triggers will have markedly diminished or disappeared at the completion of the memory processing stage. It is then possible to move into the final stage of treatment which facilitates cognitive restructuring. Working with the patient’s negative cognitions usually occurs as part of the therapy throughout the first two stages of treatment, but now the focus shifts fully in this direction. At this stage patients come to terms emotionally and cognitively with the impact of knowing what happened to them and how they have survived. The individual before the trauma is not the same as the individual after the trauma. A new identity emerges which must be integrated. Negative cognitive assumptions are explored and give way to new beliefs and self-perceptions. Hypnotic ego enhancement techniques can be useful at this stage. In simple acute PTSD this may require only one or two sessions whereas in chronic complex post traumatic stress disorder this stage may require months or years. With appropriate treatment recovery from both types of PTSD can be complete and lasting.