PTSD and Coping with Trauma Sourcebook, 1st Ed.

By Omnigraphics

Consumer health information about posttraumatic disorder, covering topics such as types of trauma, diagnosis and treatment and living with PTSD. Includes index, glossary of related terms, and other resources.

• Language: English
• Publisher: Omnigraphics
• Release date: Nov 1, 2019
• ISBN: 9780780817722

Book preview

Part One

Understanding Psychological Trauma and PTSD

Chapter 1

The Brain and Mental Health

Chapter Contents

Section 1.1—Brain Basics

Section 1.2—What Is Mental Health?

Section 1.1

Brain Basics

This section includes text excerpted from Brain Basics: Know Your Brain, National Institute of Neurological Disorders and Stroke (NINDS), August 13, 2019.

The brain is the most complex part of the human body. This three-pound organ is the seat of intelligence, interpreter of the senses, initiator of body movement, and controller of behavior. Lying in its bony shell and washed by protective fluid, the brain is the source of all the qualities that define our humanity. The brain is the crown jewel of the human body.

For centuries, scientists and philosophers have been fascinated by the brain, but viewed the brain as nearly incomprehensible. Now, however, the brain is beginning to relinquish its secrets. Scientists have learned more about the brain in the last 10 years than in all previous centuries because of the accelerating pace of research in neurological and behavioral science and the development of new research techniques. As a result, Congress named the 1990s the Decade of the Brain. At the forefront of research on the brain and other elements of the nervous system is the National Institute of Neurological Disorders and Stroke (NINDS), which conducts and supports scientific studies in the United States and around the world.

Figure 1.1. Structure of the Brain

The Architecture of the Brain

The brain is like a committee of experts. All the parts of the brain work together, but each part has its own special properties. The brain can be divided into three basic units: the forebrain, the midbrain, and the hindbrain.

The hindbrain includes the upper part of the spinal cord, the brain stem, and a wrinkled ball of tissue called the cerebellum (1). The hindbrain controls the body’s vital functions, such as respiration and heart rate. The cerebellum coordinates movement and is involved in learned rote movements. When you play the piano or hit a tennis ball you are activating the cerebellum. The uppermost part of the brainstem is the midbrain, which controls some reflex actions and is part of the circuit involved in the control of eye movements and other voluntary movements. The forebrain is the largest and most highly developed part of the human brain: it consists primarily of the cerebrum (2) and the structures hidden beneath it.

When people see pictures of the brain, it is usually the cerebrum that they notice. The cerebrum sits at the topmost part of the brain and is the source of intellectual activities. It holds your memories, allows you to plan, enables you to imagine and think. It allows you to recognize friends, read books, and play games.

The cerebrum is split into two halves (hemispheres) by a deep fissure. Despite the split, the two cerebral hemispheres communicate with each other through a thick tract of nerve fibers that lies at the base of this fissure. Although the two hemispheres seem to be mirror images of each other, they are different. For instance, the ability to form words seems to lie primarily in the left hemisphere, while the right hemisphere seems to control many abstract reasoning skills.

For some as-yet-unknown reason, nearly all of the signals from the brain to the body and vice-versa crossover on their way to and from the brain. This means that the right cerebral hemisphere primarily controls the left side of the body and the left hemisphere primarily controls the right side. When one side of the brain is damaged, the opposite side of the body is affected. For example, a stroke in the right hemisphere of the brain can leave the left arm and leg paralyzed.

Figure 1.2. Sections of the Brain

The Geography of Thought

Each cerebral hemisphere can be divided into sections, or lobes, each of which specializes in different functions. To understand each lobe and its specialty, we will take a tour of the cerebral hemispheres, starting with the two frontal lobes (3), which lie directly behind the forehead. When you plan a schedule, imagine the future, or use reasoned arguments, these two lobes do much of the work. One of the ways the frontal lobes seem to do these things is by acting as short-term storage sites, allowing one idea to be kept in mind while other ideas are considered. In the rearmost portion of each frontal lobe is a motor area (4), which helps control voluntary movement. A nearby place on the left frontal lobe called Broca’s area (5) allows thoughts to be transformed into words.

When you enjoy a good meal—the taste, aroma, and texture of the food—two sections behind the frontal lobes called the parietal lobes (6) are at work. The forward parts of these lobes, just behind the motor areas, are the primary sensory areas (7). These areas receive information about temperature, taste, touch, and movement from the rest of the body. Reading and arithmetic are also functions in the repertoire of each parietal lobe.

As you look at the content and images on these sections, two areas at the back of the brain are at work. These lobes, called the occipital lobes (8), process images from the eyes and link that information with images stored in memory. Damage to the occipital lobes can cause blindness.

The last lobes on our tour of the cerebral hemispheres are the temporal lobes (9), which lie in front of the visual areas and nest under the parietal and frontal lobes. Whether you appreciate symphonies or rock music, your brain responds through the activity of these lobes. At the top of each temporal lobe is an area responsible for receiving information from the ears. The underside of each temporal lobe plays a crucial role in forming and retrieving memories, including those associated with music. Other parts of this lobe seem to integrate memories and sensations of taste, sound, sight, and touch.

The Cerebral Cortex

Coating the surface of the cerebrum and the cerebellum is a vital layer of tissue the thickness of a stack of two or three dimes. It is called the cortex, from the Latin word for bark. Most of the actual information processing in the brain takes place in the cerebral cortex. When people talk about gray matter in the brain, they are talking about this thin rind. The cortex is gray because nerves in this area lack the insulation that makes most other parts of the brain appear to be white. The folds in the brain add to its surface area, and therefore, increase the amount of gray matter and the quantity of information that can be processed.

The Inner Brain

Deep within the brain, hidden from view, lie structures that are the gatekeepers between the spinal cord and the cerebral hemispheres. These structures not only determine our emotional state, but they also modify our perceptions and responses depending on that state and allow us to initiate movements that we make without thinking about them. Like the lobes in the cerebral hemispheres, the structures described below come in pairs: each is duplicated in the opposite half of the brain.

The hypothalamus (10), about the size of a pearl, directs a multitude of important functions. It wakes you up in the morning and gets the adrenaline flowing during a test or job interview. The hypothalamus is also an important emotional center, controlling the molecules that make you feel exhilarated, angry, or unhappy. Near the hypothalamus lies the thalamus (11), a major clearinghouse for information going to and from the spinal cord and the cerebrum.

An arching tract of nerve cells leads from the hypothalamus and the thalamus to the hippocampus (12), this tiny nub acts as a memory indexer—sending memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieving them when necessary. The basal ganglia (not shown) are clusters of nerve cells surrounding the thalamus. They are responsible for initiating and integrating movements. Parkinson disease (PD), which results in tremors, rigidity, and a stiff, shuffling walk, is a disease of nerve cells that lead into the basal ganglia.

Figure 1.3. The Inner Brain

Making Connections

The brain and the rest of the nervous system are composed of many different types of cells, but the primary functional unit is a cell called the neuron. All sensations, movements, thoughts, memories, and feelings are the result of signals that pass through neurons. Neurons consist of three parts. The cell body (13) contains the nucleus, where most of the molecules that the neuron needs to survive and function are manufactured. Dendrites (14) extend out from the cell body like the branches of a tree and receive messages from other nerve cells. Signals then pass from the dendrites through the cell body and may travel away from the cell body down an axon (15) to another neuron, a muscle cell, or cells in some other organ. The neuron is usually surrounded by many support cells. Some types of cells wrap around the axon to form an insulating sheath (16). This sheath can include a fatty molecule called myelin, which provides insulation for the axon and helps nerve signals travel faster and farther. Axons may be very short, such as those that carry signals from one cell in the cortex to another cell less than a hair’s width away. Or axons may be very long, such as those that carry messages from the brain all the way down the spinal cord.

Figure 1.4. Axons and Cell Body

Scientists have learned a great deal about neurons by studying the synapse—the place where a signal passes from the neuron to another cell. When the signal reaches the end of the axon, it stimulates the release of tiny sacs (17). These sacs release chemicals known as neurotransmitters (18) into the synapse (19). The neurotransmitters cross the synapse and attach to receptors (20) on the neighboring cell. These receptors can change the properties of the receiving cell. If the receiving cell is also a neuron, the signal can continue the transmission to the next cell.

Some Key Neurotransmitters at Work

Acetylcholine is called an excitatory neurotransmitter because it generally makes cells more excitable. It governs muscle contractions and causes glands to secrete hormones. Alzheimer disease (AD), which initially affects memory formation, is associated with a shortage of acetylcholine.

Gamma-aminobutyric acid (GABA) is called an inhibitory neurotransmitter because it tends to make cells less excitable. It helps control muscle activity and is an important part of the visual system. Drugs that increase GABA levels in the brain are used to treat epileptic seizures and tremors in patients with Huntington disease (HD).

Serotonin is a neurotransmitter that constricts blood vessels and brings on sleep. It is also involved in temperature regulation. Dopamine is an inhibitory neurotransmitter involved in mood and the control of complex movements. The loss of dopamine activity in some portions of the brain leads to the muscular rigidity of PD. Many medications used to treat behavioral disorders work by modifying the action of dopamine in the brain.

Section 1.2

What Is Mental Health?

This section includes text excerpted from What Is Mental Health? MentalHealth.gov, U.S. Department of Health and Human Services (HHS), May 4, 2019.

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

Over the course of your life, if you experience mental-health problems, your thinking, mood, and behavior could be affected. Many factors contribute to mental-health problems, including:

Biological factors, such as genes or brain chemistry

Life experiences, such as trauma or abuse

A family history of mental-health problems

Mental-health problems are common but help is available. People with mental-health problems can get better and many recover completely.

Early Warning Signs

Not sure if you or someone you know is living with mental-health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

Eating or sleeping too much or too little

Pulling away from people and usual activities

Having low or no energy

Feeling numb or like nothing matters

Having unexplained aches and pains

Feeling helpless or hopeless

Smoking, drinking, or using drugs more than usual

Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared

Yelling or fighting with family and friends

Experiencing severe mood swings that cause problems in relationships

Having persistent thoughts and memories you cannot get out of your head

Hearing voices or believing things that are not true

Thinking of harming yourself or others

Inability to perform daily tasks such as taking care of your kids or getting to work or school

Mental Health and Wellness

Positive mental health allows people to:

Realize their full potential

Cope with the stresses of life

Work productively

Make meaningful contributions to their communities

Ways to maintain positive mental health include:

Getting professional help if you need it

Connecting with others

Staying positive

Getting physically active

Helping others

Getting enough sleep

Developing coping skills

Chapter 2

What Is Stress?

Chapter Contents

Section 2.1—About Stress

Section 2.2—The Stress Circuit

Section 2.3—Stress System Malfunction Could Lead to Serious, Life-Threatening Disease

Section 2.1

About Stress

This section includes text excerpted from 5 Things You Should Know about Stress, National Institute of Mental Health (NIMH), January 11, 2012. Reviewed October 2019.

Everyone feels stressed from time to time. But, what is stress? How does it affect your health? And what can you do about it?

Stress is how the brain and body respond to any demand. Every type of demand or stressor—such as exercise, work, school, major life changes, or traumatic events—can be stressful.

Stress can affect your health. It is important to pay attention to how you deal with minor and major stress events so that you know when to seek help.

Things You Should Know about Stress

Stress Affects Everyone

Everyone feels stressed from time to time. Some people may cope with stress more effectively or recover from stressful events more quickly than others. There are different types of stress—all of which carry physical- and mental-health risks. A stressor may be a one-time or short-term occurrence, or it can be an occurrence that keeps happening over a long period of time.

Examples of stress include:

Routine stress related to the pressures of work, school, family, and other daily responsibilities

Stress brought about by a sudden negative change, such as losing a job, divorce, or illness

Traumatic stress experienced during an event such as a major accident, war, assault, or a natural disaster where people may be in danger of being seriously hurt or killed. People who experience traumatic stress often experience temporary symptoms of mental illness, but most recover naturally soon after.

Not All Stress Is Bad

Stress can motivate people to prepare or perform, such as when they need to take a test or interview for a new job. Stress can even be life-saving in some situations. In response to danger, your body prepares to face a threat or flee to safety. In these situations, your pulse quickens, you breathe faster, your muscles tense, your brain uses more oxygen and increases activity—all functions aimed at survival.

Long-Term Stress Can Harm Your Health

Health problems can occur if the stress response goes on for too long or becomes chronic, such as when the source of stress is constant, or if the response continues after the danger has subsided. With chronic stress, those same life-saving responses in your body can suppress immune, digestive, sleep, and reproductive systems, which may cause them to stop working normally.

Different people may feel stress in different ways. For example, some people experience mainly digestive symptoms, while others may have headaches, sleeplessness, sadness, and/or exhibit anger or irritability. People under chronic stress are prone to more frequent and severe viral infections, such as the flu or common cold.

Routine stress may be the hardest type of stress to notice at first. Because the source of stress tends to be more constant than in cases of acute or traumatic stress, the body gets no clear signal to return to normal functioning. Over time, continued strain on your body from routine stress may contribute to serious health problems, such as heart disease, high blood pressure, diabetes, and other illnesses, as well as mental disorders such as depression or anxiety.

There Are Ways to Manage Stress

The effects of stress tend to build up over time. Taking practical steps to manage your stress can reduce or prevent these effects. The following are some tips that may help you to cope with stress:

Recognize the signs of your body’s response to stress, such as difficulty sleeping, increased alcohol and other substance use, being easily angered, feeling depressed, and having low energy.

Talk to your doctor or healthcare provider. Get proper healthcare for existing or new health problems.

Get regular exercise. Just 30 minutes per day of walking can help boost your mood and reduce stress.

Try a relaxing activity. Explore stress coping programs, which may incorporate meditation, yoga, tai chi, or other gentle exercises. For some stress-related conditions, these approaches are used in addition to other forms of treatment. Schedule regular times for these and other healthy and relaxing activities.

Set goals and priorities. Decide what must get done and what can wait, and learn to say no to new tasks if they are putting you into overload. Note what you have accomplished at the end of the day, not what you have been unable to do.

Stay connected with people who can provide emotional and other support. To reduce stress, ask for help from friends, family, and community, or religious organizations.

Consider a clinical trial. Researchers at the National Institute of Mental Health (NIMH), National Center for Complementary and Integrative Health (NCCIH), and other research facilities across the country are studying the causes and effects of psychological stress, and stress management techniques.

If You Are Overwhelmed by Stress, Ask for Help from a Health Professional

You should seek help right away if you have suicidal thoughts, are overwhelmed, feel you cannot cope, or are using drugs or alcohol to cope. Your doctor may be able to provide a recommendation.

Section 2.2

The Stress Circuit

This section includes text excerpted from Stress System Malfunction Could Lead to Serious, Life Threatening Disease, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), September 9, 2002. Reviewed October 2019.

A threat to your life or safety triggers a primal physical response from the body, leaving you breathless, your heart pounding, and your mind racing. From deep within your brain, a chemical signal speeds stress hormones through the bloodstream, priming your body to be alert and ready to escape danger. Concentration becomes more focused, reaction time faster, and strength and agility increase. When the stressful situation ends, hormonal signals switch off the stress response and the body returns to normal.

But, in our modern society, stress does not always let up. Many of us now harbor anxiety and worry about daily events and relationships. Stress hormones continue to wash through the system in high levels, never leaving the blood and tissues. And so the stress response that once gave ancient people the speed and endurance to escape life-threatening dangers runs constantly in many modern people and never shuts down.

Research now shows that such long-term activation of the stress system can have a hazardous, even lethal, effect on the body, increasing the risk of obesity, heart disease, depression, and a variety of other illnesses.

Much of the understanding of stress and its effects has come about from the theory by George Chrousos, M.D., Chief of the Pediatric and Reproductive Endocrinology Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and Philip Gold, M.D., of the Clinical Neuroendocrinology Branch at the National Institute of Mental Health (NIMH). Their theory explains the complex interplay between the nervous system and stress hormones—the hormonal system known as the hypothalamic-pituitary-adrenal (HPA) axis. Over the past 20 years, Dr. Chrousos and his colleagues have employed the theory to understand a variety of stress-related conditions, including depression, Cushing syndrome, anorexia nervosa, and chronic fatigue syndrome (CFS).

Figure 2.1. Hypothalamic-Pituitary-Adrenal (HPA) Axis (Source: Stress and the HPA Axis: Role of Glucocorticoids in Alcohol Dependence, National Institute on Alcohol Abuse and Alcoholism (NIAAA).)

The HPA axis is a feedback loop by which signals from the brain trigger the release of hormones needed to respond to stress. Because of its function, the HPA axis is also sometimes called the stress circuit.

Briefly, in response to stress, the brain region known as the hypothalamus releases corticotropin-releasing hormone (CRH). In turn, CRH acts on the pituitary gland, just beneath the brain, triggering the release of another hormone, adrenocorticotropin into the bloodstream. Next, adrenocorticotropin signals the adrenal glands, which sit atop the kidneys, to release a number of hormonal compounds. These compounds include epinephrine, norepinephrine, and cortisol. All three hormones enable the body to respond to a threat. Epinephrine increases blood pressure and heart rate, diverts blood to the muscles, and speeds reaction time. Cortisol, also known as glucocorticoid, releases sugar (in the form of glucose) from the body reserves so that this essential fuel can be used to power the muscles and the brain.

Normally, cortisol also exerts a feedback effect to shut down the stress response after the threat has passed, acting upon the hypothalamus and causing it to stop producing CRH.

This stress circuit affects systems throughout the body. The hormones of the HPA axis exert their effect on the autonomic nervous system, which controls such vital functions as heart rate, blood pressure, and digestion.

The HPA axis also communicates with several regions of the brain, including the limbic system, which controls motivation and mood, with the amygdala, which generates fear in response to danger, and with the hippocampus, which plays an important part in memory formation as well as in mood and motivation. In addition, the HPA axis is also connected with brain regions that control body temperature, suppress appetite, and control pain.

Similarly, the HPA axis also interacts with various other glandular systems, among them those producing reproductive hormones, growth hormones, and thyroid hormones. Once activated, the stress response switches off the hormonal systems regulating growth, reproduction, metabolism, and immunity. Short term, the response is helpful, allowing us to divert biochemical resources to dealing with the threat.

Section 2.3

Stress System Malfunction Could Lead to Serious, Life-Threatening Disease

This section includes text excerpted from Stress System Malfunction Could Lead to Serious, Life-Threatening Disease, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), September 9, 2002. Reviewed October 2019.

Whether from a charging lion, or a pending deadline, the body’s response to stress can be both helpful and harmful. The stress response gives us the strength and speed to ward off or flee from an impending threat. But when it persists, stress can put us at risk for obesity, heart disease, cancer, and a variety of other illnesses.

Stress and the Reproductive system

Stress suppresses the reproductive system at various levels, says Dr. Chrousos M.D., Chief of the Pediatric and Reproductive Endocrinology Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). First, corticotropin-releasing hormone (CRH) prevents the release of gonadotropin releasing hormone (GnRH), the master hormone that signals a cascade of hormones that direct reproduction and sexual behavior. Similarly, cortisol and related glucocorticoid hormones not only inhibit the release of GnRH, but also the release of luteinizing hormone, which prompts ovulation and sperm release. Glucocorticoids also inhibit the testes and ovaries directly, hindering production of the male and female sex hormones testosterone, estrogen, and progesterone.

The hypothalamic-pituitary-adrenal (HPA) overactivity that results from chronic stress has been shown to inhibit reproductive functioning in cases of anorexia nervosa and starvation, as well as in highly trained ballet dancers and runners. For example, in one study, Chrousos found that men who ran more than 45 miles per week produced high levels of adrenocorticotropic hormone (ACTH) and cortisol in response to the stress of extreme exercise. These male runners had low luteinizing hormone (LH) and testosterone levels. Other studies have shown that women undertaking extreme exercise regimens had ceased ovulating and menstruating.

However, the interaction between the HPA axis and the reproductive system is also a two-way street. The female hormone estrogen exerts partial control of the gene that stimulates CRH production. This may explain why, on average, women have slightly elevated cortisol levels. In turn, higher cortisol levels, in combination with other, as yet unknown, factors, may be the reason why women are more vulnerable than men to depression, anorexia nervosa, panic disorder, obsessive-compulsive disorder (OCD), and autoimmune diseases such as lupus and rheumatoid arthritis (RA).

Growth and Stress

The hormones of the HPA axis also influence hormones needed for growth. Prolonged HPA activation will hinder the release of growth hormone and insulin-like growth factor 1 (IGF-1), both of which are essential for normal growth. Glucocorticoids released during prolonged stress also cause tissues to be less likely to respond to IGF-1. Children with Cushing syndrome—which results in high glucocorticoid levels—lose about 7.5 to 8.0 centimeters from their adult height.

Similarly, premature infants are at an increased risk for growth retardation. The stress of surviving in an environment for which they are not yet suited, combined with the prolonged stress of hospitalization in the intensive care unit, presumably activates the HPA axis. Growth-retarded fetuses also have higher levels of CRH, ACTH, and cortisol, probably resulting from stress in the womb or exposure to maternal stress hormones.

Research has also shown that the stress from emotional deprivation or psychological harassment may result in the short stature and delayed physical maturity of the condition known as psychosocial short stature (PSS).

Psychosocial short stature was first discovered in orphanages, in infants who failed to thrive and grow. When these children were placed in caring environments in which they received sufficient attention, their growth resumed. The children’s cortisol levels were abnormally low, a seeming contradiction, which Chrousos investigated by studying a small, nonhuman primate, the common marmoset. These monkeys live in small family groups in which infants are cared for by both parents. As in human society, the infants are sometimes well cared for, but sometimes abused. Like humans, the abused monkeys showed evidence of PSS.

The researchers determined that the stressed and abused monkeys appeared to respond normally to stress, but seemed unable to switch off the stress response by secreting appropriate cortisol levels, thereby remaining in a state of prolonged stress arousal as compared to their peers.

The Gastrointestinal Tract and Stress

Stress can also result in digestive problems. The stress circuit influences the stomach and intestines in several ways. First, CRH directly hinders the release of stomach acid and emptying of the stomach. Moreover, CRH also directly stimulates the colon, speeding up the emptying of its contents. In addition to the effects of CRH alone on the stomach, the entire HPA axis, through the autonomic nervous system, also hinders stomach acid secretion and emptying, as well as increasing the movement of the colon.

Also, continual, high levels of cortisol—as occur in some forms of depression, or during chronic psychological stress—can increase appetite and lead to weight gain. Rats given high doses of cortisol for long periods had increased appetites and had larger stores of abdominal fat. The rats also ate heavily when they would normally have been inactive. Overeating at night is also common among people who are under stress.

The Immune System and Stress

The HPA axis also interacts with the immune system, making you more vulnerable to colds and the flu, fatigue, and infections.

In response to an infection, or an inflammatory disorder such as RA, cells of the immune system produce three substances that cause inflammation: interleukin 1 (IL-1), interleukin 6 (IL-6), and tumor necrosis factor (TNF). These substances, working either singly or in combination with each other, cause the release of CRH. IL-6 also promotes the release of ACTH and cortisol. Cortisol and other compounds then suppress the release of IL-1, IL-6, and TNF, in the process of switching off the inflammatory response.

Ideally, stress hormones damp down an immune response that has run its course. When the HPA axis is continually running at a high level, however, that damping down can have a down side, leading to decreased ability to release the interleukins and fight infection.

In addition, the high cortisol levels resulting from prolonged stress could serve to make the body more susceptible to disease, by switching off disease-fighting white blood cells (WBCs). Although the necessary studies have not yet been conducted, Chrousos considers it possible that this same deactivation of WBCs might also increase the risk for certain types of cancer.

Conversely, there is evidence that a depressed HPA axis, resulting in too little corticosteroid, can lead to a hyperactive immune system and increased risk of developing autoimmune diseases—diseases in which the immune system attacks the body’s own cells. Overactivation of the antibody-producing B cells may aggravate conditions such as lupus, which result from an antibody attack on the body’s own tissues.

Stress-Related Disorders

One of the major characteristic features of an overactive HPA axis is melancholic depression. Chrousos’s research has shown that people with depression have a blunted ability to counterregulate, or adapt to, the negative feedback of increases in cortisol. The body turns on the fight or flight response, but is prevented from turning it off again. This produces constant anxiety and overreaction to stimulation, followed by the paradoxical response called learned helplessness, in which victims apparently lose all motivation.

Hallmarks of this form of depression are anxiety, loss of appetite, loss of sex drive, rapid heartbeat, high blood pressure, and high cholesterol and triglyceride levels. People with this condition tend to produce higher-than-normal levels of CRH. The high levels of CRH are probably due to a combination of environmental and hereditary causes, depending on the person affected.

However, rather than producing higher amounts of ACTH in response to CRH, depressed people produce smaller amounts of this substance, presumably because their hippocampuses have become less sensitive to the higher amounts of CRH. In an apparent attempt to switch off excess CRH production, the systems of people with melancholic depression also produce high levels of cortisol. However, by-products of cortisol, produced in response to high levels of the substance, also depress brain-cell activity. These by-products serve as sedatives, and perhaps contribute to the overall feeling of depression.

Other conditions are also associated with high levels of CRH and cortisol. These include anorexia nervosa, malnutrition, obsessive-compulsive disorder, anxiety disorder, alcoholism, alcohol and narcotic withdrawal, poorly controlled diabetes, childhood sexual abuse, and hyperthyroidism.

The excessive amount of the stress hormone cortisol produced in patients with any of these conditions is responsible for many of the observed symptoms. Most of these patients share psychological symptoms, including sleep disturbances, loss of libido, and loss of appetite, as well as physical problems such as an increased risk for accumulating abdominal fat and hardening of the arteries and other forms of cardiovascular disease. These patients may also experience suppression of thyroid hormones, and of the immune system. Because they are at higher risk for these health problems, such patients are likely to have their life spans shortened by 15 to 20 years if they remain untreated.

Although many disorders result from an overactive stress system, some result from an underactive stress system. For example, in the case of Addison disease, lack of cortisol causes an increase of pigment in the skin, making the patient appear to have a tan. Other symptoms include fatigue, loss of appetite, weight loss, weakness, loss of body hair, nausea, vomiting, and an intense craving for salt. Lack of the hormone CRH also results in the feelings of extreme tiredness common to people suffering from chronic fatigue syndrome (CFS). Lack of CRH is also central to seasonal affective disorder (SAD), the feelings of fatigue and depression that plague some patients during the winter months.

Chrousos and his team showed that sudden cessation of CRH production may also result in the depressive symptoms of postpartum depression. In response to CRH produced by the placenta, the mother’s system stops manufacturing its own CRH. When the baby is born, the sudden loss of CRH may result in feelings of sadness or even severe depression for some women.

Chrousos and his cohort uncovered evidence that frequent insomnia is more than just having difficulty falling asleep. The researchers found that, when compared to a group of people who did not have difficulty falling asleep, the insomniacs had higher ACTH and cortisol levels, both in the evening and in the first half of the night. Moreover, the insomniacs with the highest cortisol levels tended to have the greatest difficulty falling asleep.

The researchers theorized that, in many cases, persistent insomnia may be a disorder of the stress system. From their ACTH and cortisol levels, it appears that the insomniacs have nervous systems that are on overdrive, alert and ready to deal with a threat, when they should otherwise be quieting down. Rather than prescribing drugs known as hypnotics to regulate the sleep system, the researchers suggested that physicians might have more success prescribing antidepressants, to help calm an overactive stress system. Behavioral therapy, to help insomniacs relax in the evening, might also be useful.

After conducting many years of research into the functioning of the HPA axis, Chrousos concluded that chronic stress should not be taken lightly or accepted as a fact of life.

Persistent, unremitting stress leads to a variety of serious health problems, Chrousos said. Anyone who suffers from chronic stress needs to take steps to alleviate it, either by learning simple techniques to relax and calm down, or with the help of qualified therapists.

Chapter 3

What Is Trauma?

Chapter Contents

Section 3.1—Understanding What Trauma Is

Section 3.2—Common Reactions after Trauma

Section 3.3—Avoidance

Section 3.1

Understanding What Trauma Is

This section contains text excerpted from the following sources: Text in this section begins with excerpts from Trauma, SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), Substance Abuse and Mental Health Services Administration (SAMHSA), August 2018; Text under the heading Impact of Trauma on Individuals, Families, and Communities is excerpted from Trauma and Violence, Substance Abuse and Mental Health Services Administration (SAMHSA), August 2, 2019.

Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

Figure 3.1. Causes of Trauma

In the United States, 61 percent of men and 51 percent of women report exposure to at least one traumatic event in their lifetime, and 90 percent of clients in public behavioral healthcare settings have experienced trauma. If trauma goes unaddressed, people with mental illnesses and addictions will have poor physical-health outcomes and ignoring trauma can hinder recovery. To ensure the best possible health outcomes, all care—in all health settings—must address trauma in a safe and sensitive way.

Figure 3.2. Statistics on Trauma

Providing care in a trauma-informed manner promotes positive health outcomes. A trauma-informed approach is defined by Substance Abuse and Mental Health Services Administration (SAMHSA) as a program, organization, or system that realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist retraumatization.

Impact of Trauma on Individuals, Families, and Communities

Trauma is a widespread, harmful, and costly public-health concern. Trauma has no boundaries with regard to age, gender, socioeconomic status, race, ethnicity, or sexual orientation. Trauma is a common experience for adults and children in American communities, and it is especially common in the lives of people with mental and substance-use disorders (SUDs). For this reason, the need to address trauma is increasingly seen as an important part of effective behavioral healthcare and an integral part of the healing and recovery process.

The effects of traumatic events place a heavy burden on individuals, families, and communities. Although many people who experience a traumatic event will go on with their lives without lasting negative effects, others will have difficulties and experience traumatic stress reactions. How someone responds to a traumatic experience is personal. If there is a strong support system in place, little or no prior traumatic experiences, and if the individual has many resilient qualities, it may not affect her or his mental health.

Research has shown that traumatic experiences are associated with both behavioral health and chronic physical-health conditions, especially those traumatic events that occur during childhood. Substance use (e.g., smoking, excessive alcohol use, and taking drugs), mental-health conditions (e.g., depression, anxiety, or PTSD), and other risky behaviors (e.g., self-injury and risky sexual encounters) have been linked with traumatic experiences. Because these behavioral-health concerns can present challenges in relationships, careers, and other aspects of life, it is important to understand the nature and impact of trauma and explore healing.

Section 3.2

Common Reactions after Trauma

This section includes text excerpted from Common Reactions after Trauma, National Center for Posttraumatic Stress Disorder (NCPTSD), U.S. Department of Veterans Affairs (VA), December 5, 2018.

After going through a trauma, survivors often say that their first feeling is relief to be alive. This may be followed by stress, fear, and anger. Trauma survivors may also find they are unable to stop thinking about what