Missed part 3 of our “Neuro-mental health” series “Trauma: a taxonomy”? Read on here.
Story 1
Ben has just dropped out of school. Most days now, you can find him dishevelled and bottle-in-hand, passed out on a park bench. His marks began to plummet after he started experiencing nightly flashbacks from his very dysfunctional upbringing. He would wake up screaming and drenched with sweat. Once, in a daze, he accidentally pushed his girlfriend out of bed, thinking she was out to get him.This gave her the excuse to leave him at last, after a string of strange incidents that made her feel unsafe. Now, Ben seems lost, and even his old friends are puzzled by his unpredictable behaviour. They just don’t understand why such a nice guy would suddenly be acting out.
Story 2
Nina is a paramedic. It had always been her dream. She sailed through training and was class valedictorian. Thanks to her great people and organisational skills, she was quickly promoted to shift manager. Because she was so cool-headed, she was entrusted with the assignments that even her most hard-boiled colleagues would try to dodge. The worst accidents, terrorist attacks and suicide scenes: nothing seemed to faze Nina. Now, at 35, she is on sick leave. The thought of going back to work gives her panic attacks. These days, she barely leaves the house and often freezes – even during a comedy film or a seemingly trivial conversation…
****
These may only be fictional stories, but chances are you may have experienced something comparable or witnessed similar breakdowns in your family, your work environment or your circle of friends.
Ben’s story highlights how complex post-traumatic stress disorder (or C-PTSD) from childhood can suddenly catch up on an individual – disrupting careers, relationships and everyday life. In contrast, Nina’s story illustrates the plight of otherwise highly resilient individuals working in challenging environments such as first responders or soldiers. However, whether individuals suffer from PTSD or C-PTSD, they often share symptoms – not just nightmares, flashbacks, fighting (or unconsciously re-enacting past scenarios), freezing and panic attacks, but also substance-use disorders and isolation.
In contrast, a trauma response such as fawning, i.e. excessive people-pleasing to avoid conflict or feel safe(r), tends to be associated more frequently with C-PTSD. Indeed, children (or women) caught in domestic violence settings, may not be able to fight or flee. Typically, C-PTSD victims may also experience more emotional dysregulation, negative self-perception as well as trust and relationship issues.
So how do individuals get so traumatised that they can no longer function? And what characterises trauma and its varied responses?
For a trauma to be recognised as such, the first pre-requisite is exposure to a traumatic stressor. As we discovered it in our previous article, trauma comes to people in various shapes and in diverse ways, depending on their occupation, their environment, their gender, their age or their cultural and ethnic background. So, trauma can e.g., befall police officers, victims of accidents, illnesses and all manner of catastrophes, not to mention anyone exposed to various forms of active or passive violence (think neglect or abandonment…).
However, trauma affects people (very) differently. Some individuals pull through acute trauma quickly and without professional help. Others may require ad-hoc support to recover over a few weeks or months, while others still may bear the impact of trauma over decades if not a lifetime – be it with or without therapeutic support.
For a trauma to leave a deeper imprint leading to a diagnosis of PTSD (post-traumatic stress disorder) or other mental and physical conditions, there are at least four factors that shape its ultimate impact:
· The intensity, frequency and/or layering of the trauma(s)
Particularly shocking events, such as e.g. witnessing a massacre, being exposed to repeated trauma, such as e.g. physical abuse or incest, or having to cope with multifaceted trauma, such as extreme poverty, neglect and emotional abuse, will understandably leave an individual more vulnerable to (long-term) health consequences.
· Personality, identity and upbringing
How a trauma is encountered and processed, however, is significantly influenced by how a person views themselves, their personality traits and their values as well as how their interact with their inner and outside world. For instance, a person brought up in harsh conditions but whose self-esteem has been cultivated may show more resilience when faced with a challenging experience than someone who has been very sheltered.
· Personal and environmental resources
Coping with trauma, however, is not just a question of personality but also of resources. Central to overcoming trauma is a supportive socio-economic network. Heavily traumatised individuals have better chances of recovering when they can count on the love and understanding of their entourage as well as on practical help.
· Availability and affordability of specialised care
For many individuals, despite seemingly optimal recovery pre-requisites, the only way to ultimately heal will be trauma-specific support, which can come in many forms and will be discussed later. This expert help, especially if it is required over the long-term, will have to be not only accessible but also affordable.
So, life under the sign of unresolved trauma can be extremely challenging. “Unresolved” is the key word here since trauma may be traversed without lasting scars, if it receives the attention it requires, at the right time and in the right form.
However, as transpired from the fictional stories evoked above, trauma may be encountered – perhaps repeatedly, then lay dormant until some inner or outer circumstance reactivates it. A trigger may be the sheer repetition of a trauma-inducing event, or it may arise from something seemingly insignificant, like a fleeting vision, a passing statement, emotion or sensation that echoes past discomfort. It can present under the mantle of (auto-immune) disease, serious relationship problems or a work crisis. It can underlie a serious addiction or the inability to cope with one’s physical or interpersonal environment.
Once the “genie” is out of the bottle, life may fizzle on for a while –especially if individuals use avoidance or emotional numbing tactics (think addictive behaviours). Others may enter a state of dissociation, involving (partial) amnesia. Alternatively, all hell may break loose in the shape of the immediate 4F trauma responses (fight, flight, freeze, fawn) or more long-term symptoms such as hypervigilance, mood swings, chronic listlessness or cognitive challenges.
It is these intrusive signs that usually lead a person to consult a professional who may then diagnose them with PTSD and other comorbid conditions, such as depression – along with seemingly more “physical” ailments such as heart disease or ulcerative colitis.
But, as we discovered it in our previous post, until relatively recently, trauma was not always taken seriously, or it was grossly misunderstood. Even today, trauma is not systematically recognised, especially when it affects individuals in more quiet or hidden ways, as in C-PTSD. Moreover, trauma-specific care is still far from readily available and/or affordable, even in countries with better performing healthcare systems.
Most disturbing, however, is the fact that trauma specialists still disagree on some of the most fundamental tenets of trauma biology – hence also on appropriate care.
How come?
One of the most patent explanations is no doubt the complexity of the interaction between specific trauma stressors, and personal biology – echoing our previous observations on stress. Indeed, trauma can impact the body on many levels, and many of them are still being investigated. In this respect, trauma research is still relatively young.
What we do know however, is that trauma is not “just in your head”, as previously assumed. Yes, trauma does affect the central nervous system (i.e. different areas of the brain, from the brain stem to areas responsible for memory, cognition, etc. ) but also the entire nervous system as well as the endocrine system.
It thus initially mirrors the biology of stress. In a stressful situation, however, the stressor is usually less intense, and the body is able to rapidly regain its homeostatic balance in order to function normally.
For trauma to leave a lasting psychophysiological imprint, an individual’s biology has to be overwhelmed. Trauma researcher and therapist, Aimie Apigian, suggests a helpful framework to understand this overwhelm using two scenarios : “too much, too fast” and/or “too little for too long”.
“Too much, too fast” refers to the intensity of trauma exposure as in classic PTSD. If one is suddenly confronted by something too stressful, the body feels bombarded and cannot overcome the initial 4F-responses (fight, flight, freeze, fawn). The return to homeostasis is thus compromised, leading to a form of biological collapse or shutdown in order to conserve energy.
The “too little for too long” scenario tends to apply to C-PTSD since it highlights overwhelm as a lack of resources over a longer period. For instance, a child living with a mentally ill or addicted parent will be exposed to chronic uncertainty and/or violence for years, while shouldering responsibilities exceeding their capacity. Unfortunately, these scenarios may intertwine since children can experience both forms of overwhelm.
Similarly, they can also overlap in terms of biological consequences. However, they can also present very differently, requiring different specialist inputs – which explains why trauma may be so tricky to recognise and diagnose.
So, beyond the effects that trauma shares with stress, researchers have discovered that trauma can have lasting structural and functional effects on the brain. It can trigger permanently heightened cortisol levels as well as influence other hormones and neurotransmitters – leading to a host of health issues. The heightened inflammation it catalyses can also factor into the occurrence of cardiovascular and gastrointestinal conditions, cancer as well as other auto-immune diseases. Finally, trauma also leaves an imprint at the heart of our cells, i.e. in our epigenetic makeover, enabling the transmission of its impact to further generations − but more about that in the next article.
Because trauma can affect individuals through so many different pathways, it seems obvious that there can be no one-size-fits-all when it comes to treatment. Hence, the most plausible and helpful approach appears to be multi-disciplinary, tackling all the levels of embodied experience that trauma can potentially influence, from e.g. the neurological and endocrinological to the epigenetic and psychiatric,while also involving other relevant medical specialities. However, this vision is still anything but self-evident in the field of trauma care.
Because trauma was believed to affect mostly the brain, it long remained the province of psychiatry and to some extent neurology. Unfortunately, this historical development led to deep divides in trauma care about what constitutes appropriate and scientifically backed treatment.
Currently, evidence-based treatments for trauma tend to heavily rely on the psychological and psychiatric aspects of trauma. So the main (recognised) treatment modalities rely heavily on trauma-informed cognitive behavioural therapy (TI-CBT) as well as related interventions such as prolonged exposure (PE), cognitive processing therapy (CPT) or internal family systems (IFS). In the case of severely disruptive PTSD, medication will often be prescribed in parallel, such as selective serotonin reuptake inhibitors (SSRIs), so that patients are able to actually engage with therapy without shutting down.
The main criticism levelled at these types of “talk” therapies is that, depending on how they are carried out, they may be ineffective or may re-traumatise patients. But even more crucial is the reproach that these therapies often overlook the more embodied symptoms of trauma – especially its effects on the nervous and endocrine system.
As to medication, while it can initially level the playing field, it is not always effective and can cause serious side-effects.
So, in recent years, many alternative trauma theories and therapies have arisen that aim to offer more holistic or body-centred approaches but may (still) fail to meet “evidence-based” criteria due to a lack of studies, questionable study design or unconvincing outcomes.
Most notable but also contentious pioneers include Stephen Porges and his “polyvagal theory” (1994) that has inspired a number of body-based trauma interventions but is not recognised by mainstream social neuroscience. “Somatic experiencing” (1997), developed by Peter Levine, as well as “Tension & Trauma Release Exercises“ elaborated by David Berceli (late 1990s) are partially based on polyvagal theory. While increasingly popular, they still struggle with a lack of or inconclusive empirical evidence.
In his seminal book, “The Body Keeps the Score” (2014), trauma expert, Bessel van de Kolk, suggested a number of modalities that he found helpful in his quest to provide more comprehensive care for heavily traumatised patients – from Vietnam war veterans to children suffering from what he described as developmental trauma disorder (DTD; a diagnosis that can evolve into adult C-PTSD).
Among the alternative approaches he endorses are neurofeedback, yoga, theatre, psychomotor therapy and eye movement desensitisation and reprocessing (or EMDR). Until now, only EMDR, which was developed by another pioneer, psychologist Francine Shapiro, in 1987, has been subjected to relatively broad randomised controlled trials. This has lent it not just broader credibility but also a recommendation as a second line of treatment for PTSD. However, its mode of action is still poorly understood.
More recently, in his latest book “The Myth of Normal: Trauma, Illness & Healing in a Toxic Culture” (2022), medical “rock star”, Gabor Maté, not only reviews many of the above-mentioned therapies but also evokes the potential of (ancient) psychedelic approaches. Indeed, the administration of e.g., ayahuasca or MDMA in controlled contexts is rapidly gaining traction in both research and practice.
So, while therapeutic options still resemble a somewhat chaotic smorgasbord, they offer exciting perspectives for more holistic and individualised forms of trauma care, and will no doubt significantly evolve as new findings emerge over the next few years.
But before investing in trauma therapies, wouldn’t it be more rewarding to invest in trauma prevention? And if trauma cannot be fully prevented, can forms of resilience nevertheless be cultivated? Finally, what is the potential impact of trauma on (healthy) ageing and on one's offspring?
Discover some of the fascinating answers in our next instalment!
Sources and further reading
Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/
“Post-traumatic Stress Disorder (PTSD): Signs, Risk Factors, Types, and Treatment”, White Light Behavioral Health. Published August 7, 2024 & Last Updated: August 8, 2024. Online: https://whitelightbh.com/resources/mental-health/ptsd/
“The science and biology of PTSD”. PTSDUK. Online: https://www.ptsduk.org/what-is-ptsd/the-science-and-biology-of-ptsd/
Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, Milad MR, Liberzon I. "Biological studies of post-traumatic stress disorder". Nat Rev Neurosci. 2012 Nov;13(11):769-87. doi: 10.1038/nrn3339. Online: https://pmc.ncbi.nlm.nih.gov/articles/PMC4951157/
De Bellis MD, Zisk A. “The biological effects of childhood trauma”. Child Adolesc Psychiatr Clin N Am. 2014 Apr; 23(2):185-222, vii. doi:10.1016/j.chc.2014.01.002. Online: https://www.sciencedirect.com/science/article/abs/pii/S1056499314000030?via%3Dihub
Alley, Jenna, Gassen, Jeffrey, Slavich, George M. “The effects of childhood adversity on twenty-five disease biomarkers and twenty health conditions in adulthood: Differences by sex and stressor type”. Brain, Behavior, and Immunity, Volume123, 2025, Pages 164-176, doi:10.1016/j.bbi.2024.07.019. Online: https://www.sciencedirect.com/science/article/pii/S0889159124004884?via%3Dihub
Tucker P, Pfefferbaum B, North CS, et al. "Learning from Hindsight: Examining Autonomic, Inflammatory, and Endocrine Stress Biomarkers and Mental Health in Healthy Terrorism Survivors Many Years Later". Prehospital and Disaster Medicine. 2024; 39(5):335-343. doi:10.1017/S1049023X24000360. Online: https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/learning-from-hindsight-examining-autonomic-inflammatory-and-endocrine-stress-biomarkers-and-mental-health-in-healthy-terrorism-survivors-many-years-later/C5935399886A5B10F0EBD55C6C7B0F4A
Watkins LE, Sprang KR, Rothbaum BO. „Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions”. Front Behav Neurosci. 2018 Nov 2;12:258. doi: 10.3389/fnbeh.2018.00258. Online: https://pmc.ncbi.nlm.nih.gov/articles/PMC6224348/
“PTSD Treatments“. APA (American Psychological Association). 2017 (Last updated: April 2025). Online: https://www.apa.org/ptsd-guideline/treatments
Sonya Norman, PhD, Jessica Hamblen, PhD, & Paula P. Schnurr, PhD. “Overview of Psychotherapy for PTSD”. U.S. Department of Veterans Affairs. Online: https://www.ptsd.va.gov/professional/treat/txessentials/overview_therapy.asp
Herman, Judith. Trauma and Recovery: From Domestic Abuse to Political Terror. London: Pandora Press, 1994.
Levine, Peter A. Waking the Tiger: Healing Trauma. Berkeley: North Atlantic Books, 1997.
Berceli, David. Trauma Releasing Exercises (TRE). Charleston (NC): Booksurge Publishing, 2005.
“Tension and Trauma Releasing Exercises“. Wikipedia. Online [deutsch]: https://de.wikipedia.org/wiki/Tension_and_Trauma_Releasing_Exercises
Shapiro, Francine. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. New York: Guildford Press, 2001.
Van der Kolk, Bessel. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking Press, 2014.
Maté, Gabor. The Myth of Normal: Trauma, Illness & Healing in a Toxic Culture. Toronto: Vermilion (Penguin Random House Canada), 2022.
Illustrations
RDNE Stock Project / pexels & PNW Production / pexels + epiAge
Alex Green/ pexels
Mart Production / pexels
Kelly / pexels
Tima Miroshnichenko / pexels
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