1. What is Trauma?

The formal definition of Trauma as relates to the well-being of the mind defines Trauma as exposure to life-threatening events, serious injury or sexual assault; crucially, this can be actual events, perceived events, or threatened events [1][2]. Trauma can be experienced directly as the victim of a traumatic event, or secondarily, by witnessing it first-hand, or learning about Trauma experienced by close relations or repeated exposure to details of traumatic events [1]. Trauma can be acute or chronic [2]. Trauma has an impact on physical and mental health and quality of life [2]. According to the World Mental Health Survey Consortium, 70% of people will experience Trauma in their lifetime [1][2].

The trauma response refers to the biological and behavioural ways in which we respond to traumatic events. The trauma response is the famous “fight or flight (or freeze)” response. Suppose the systems in the body activated in this response do not become deactivated, or the threat causing the response appears to continue. In that case, the acute (short-term) trauma response develops into a chronic (long-term) response [2]. Since Trauma is a state of existential stress, a chronic response does not bode well.

Trauma bonding occurs when a person forms an emotional attachment with their abuser, where the emotional attachment is directly linked to survival outcomes [4].

A trigger is anything that serves as a reminder of the Trauma. Triggers can provoke emotional responses which seem disproportionate to the situation [4].

A flashback involves experiencing the present moment not as it is, but as though the traumatic event is occurring again. Intrusive thoughts and memories can trigger flashbacks. Flashbacks may or may not have a specific trigger and typically last for a few seconds [4].

2. How does Trauma Impact People

Trauma can impact physical and mental health, socialisation, and spirituality [1]. Trauma impacts how we think and relate to ourselves, the world around us and the future. A trauma survivor may feel irreparably damaged, constantly vulnerable and powerless to protect themselves from a world that is no longer safe and instead full of dangerous people who wish to harm them. The future may seem hopeless [4].

Alexithymia is characterised by difficulty identifying, describing, or communicating emotions and feelings [5]. Those who have experienced Trauma at a time when they had not yet become familiar with identifying emotions, i.e. at a young age, may have trouble identifying or engaging with their emotions [4].

The impact of childhood trauma tends to be worse than trauma experienced as an adult. Childhood trauma impacts attachment styles, personality development, stress tolerance and as it generally involves betrayal and a violation of trust, it will impact discernment and trust building in relationships. Childhood trauma is a risk factor for further trauma [2].

In Stockholm syndrome and Trauma bonding, we see people have undue compassion and loyalty to those harming them. Trauma survivors idealise the perpetrator, justifying actions that are not justifiable [4].

3. Positive Trauma responses

Traumatic stress reactions are considered healthy reactions to threatening events. Traumatic stress reactions can indicate resilience. When reactions reach a threshold, they are no longer considered healthy; this can be in terms of time or intensity [4].

Early intervention, acknowledgement and support of Trauma is essential for limiting the propensity for the development of long-term effects such as PTSD [3]. Reactions immediately following a traumatic event are influenced by the family, community or social context in which that event occurs, and how these structures offer support, if there is any focus on healing and the emotional or psychological tools and skills available to provide support. Delayed responses can present as somatisation [4]. Somatisation occurs when dysfunctions in bodily functions start to occur due to underlying trauma.

Memories form within a social framework. Therefore, the social context of a traumatic event, how the event is/ was replayed in the social collective surrounding the victim(s), has a key role in how well the Trauma is processed. When a traumatic event affects a group of people, it can impact the collective memory of the event. i.e. impacting the society. An event becomes traumatic when it exceeds the individual/group's ability to adapt [6].

Culture has an impact on the perception of what constitutes a mental illness versus what's regular. Previously, not speaking about a traumatic event was considered to indicate a maladaptive response. However, more recently, there is a distinction whereby if survivors make an active choice not to speak about it, this could be an effective coping mechanism in terms of changing the narrative of self, the world around us and the future, for example leaning into our Joy rather than pain can be healing [4].

Beyond early intervention and social support, other positive responses to Trauma include having a greater sense of purpose, meaning or stronger relationships. More positive behaviours for dealing with Trauma include being physically active or engaging in new social networks for trauma support. Wellness activities, such as yoga, meditation, and exercise, can alleviate somatisation [4].

4. Adverse effects of Trauma

Emotional dysregulation, i.e. the symptom of being unable to regulate one’s emotions due to Trauma, shows itself through unhealthy behaviours done to regulate emotionally, such as substance abuse, high-risk activities, self-injuring, eating disorders, compulsive behaviour, gambling, workaholism, repression and emotional denial [4].

Emotional numbing is the inability to attach emotions to our thoughts or memories. It can hide the severity of an experience. It can lead to feelings of disconnectedness from others and minimising one’s own experience, distress or dysfunction. It can present as flat, emotionless, or lacking in empathy for others or oneself [4].

Hyperarousal (hypervigilance) refers to the body remaining alert and on the lookout for a perceived constant and imminent threat. Signs include muscle tension, disordered sleep, and being easily startled [4].

Trauma can induce hallucinations and delusions if a situation presents something which remotely resembles a traumatic encounter or event. For example, if you were assaulted in a bar by someone, you might keep believing that the perpetrator of that assault is at any bar you try to go to or thinking that you have seen or heard them there, when they weren’t there [4].

Intrusive thoughts and memories are disturbing thoughts and memories about trauma which feel out of control, overwhelming (flooding) and make it hard to distinguish between the present moment and the space and time a person was in at the time of a traumatic event. These often have a trigger and can be triggered by talking or thinking about the traumatic event, making it difficult to heal since recovery often requires thinking or talking [4].

Dissociation involves a disconnection between thoughts, memories, feelings, actions, and/or a sense of self. Dissociation occurs when we perform an activity automatically without needing to think about it consciously; alternatively, dissociation can be a symptom of Trauma. Dissociation is a protective coping and survival tool, a demonstration of resilience, although in excess, it becomes an issue. Dissociation can leave a person feeling stuck, unable to connect their physical and emotional reactions, or feel as though they are losing their mind. Signs of dissociation include fixed or glazed-over eyes, a monotonous voice, not speaking, or responses that feel detached or strangely flat [4].

Avoidance and re-enactment exist on the same spectrum. There needs to be a good amount of exposure to fear to relieve hypersensitivity/ hypervigilance, but this does not mean exposing ourselves through generally considered risky behaviour. Avoidance comes from anxiety around trigger areas; if short-lived, this can allow for a time and space to heal. However, if avoidance continues, it will become unhealthy and escalate not just in time but also in the impact on a person's life. For example, being physically assaulted at night, on a particular street, after the event, the survivor stops going to that street, then they stop going out at night, and then they become afraid to leave their house at any time of day. The avoidance issue is that it removes the opportunity for events to occur which contradict the fear. Trauma survivors may re-enact their trauma story repeatedly. One theory for this is that it is an attempt to feel a sense of control regarding the event. Hyper-sexuality following rape is an example of a re-enactment or being involved in a string of abusive relationships [4].

5. Trauma-related Conditions

ASD and PTSD differ in that ASD typically lasts a few weeks and occurs within the first few weeks immediately following a traumatic event, whereas PTSD can appear years after the event and can last for years [2]. One theory for why traumatic events which occurred from a deliberate intent of harm rather than by pure chance could be more harmful is the presupposition that these are more likely to be repetitive or sustained for longer periods [7].

PTSD has a worldwide prevalence of 1.3% - 12.2%. 10% of people who experience a traumatic event will develop PTSD [1]. Traumatic events in which a person was deliberately and intentionally harmed have a higher risk of PTSD, for example, assault versus natural disasters or accidents [7]. PTSD is observed in animals as well as humans. PTSD in animals can be identified by particular breathing and fear states. Those with PTSD may either lose memory of aspects surrounding the traumatic event or they may remember the event with an unusual level of precision and attention to detail [6]. Hypervigilance (aka hyperarousal) is a key feature in PTSD [4]. Repeated physical violence and Sexual violence carry the greatest risk of developing PTSD at approximately 14%. Sudden and unexpected death or serious injury present a risk of about 5%-8% [2]. 85% of people with PTSD can experience alexithymia [5].

Complex-PTSD (CPTSD) is a more recently coined term and is still not officially recognised by some. It is a specification of PTSD which relates to Trauma, which involves repeated and prolonged exposure through a close relationship; the Trauma will involve the perversion or loss of that relationship. CPTSD typically will cover childhood or adolescent abuse perpetrated by caregivers or authority figures, roles meant to provide safety for the child/ adolescent. CPTSD will have a significant impact on interpersonal relationships, emotional regulation, identity and concept of self [2].

Other conditions associated with Trauma include dissociative identity disorder (DID) and Chronic pain. DID (dissociative identity disorder), previously known as multiple personality disorder, is strongly linked to severe, ongoing (childhood) trauma that was intentionally inflicted on someone [4]. Chronic pain is pain that lasts for more than six months. Chronic pain is linked to Trauma, depression, anxiety disorders and alcohol/substance abuse disorder. PTSD specifically has been indicated as a moderator for the relationship between trauma exposure and the development of chronic pain [7].

Chronic pain conditions include: fibromyalgia, back pain, headaches, chronic regional pain syndrome, neuropathic pain, cervical pain or generalised pain, to name a few. There are some sex differences as well, with women exposed to more intentional traumatic events and chronic pain being more prevalent in women than men. The suggested mechanism at play is that those with PTSD use avoidance as a coping strategy for pain, and are essentially less likely to practice self-care, whilst being overwhelmed by perceived danger [7]. Although PTSD may go undiagnosed, conditions such as hypertension, angina pectoris, tachycardia, heart disease, gastritis and arthritis are associated with Trauma [1]

6. Impact of Trauma to the Brain

The Hypothalamic-Pituitary-Adrenal (HPA) axis is a system in our bodies which becomes activated as part of the acute stress response. Activation of the HPA axis leads to increased cortisol levels. Several studies looking at blood cortisol levels in people with PTSD found mixed results. However, results looking at cortisol receptors have shown an association between cortisol receptors (metabolism) and PTSD [2].

The hippocampus is involved in memory, learning and fear regulation. There is a relationship between having a smaller than average hippocampus and susceptibility to developing trauma-like symptoms. The hippocampus is susceptible to stress. Animal studies have associated stress with brain (neuronal) damage and a reduced ability to grow neuronal tissue to heal after stress. Body chemicals involved in this process include an increase in blood cortisol (a steroid hormone) and glutamate (a neurotransmitter), as well as a decrease in brain-derived neurotrophic factor (BDNF) (a protein that interacts with neurotransmitters) [2].

The Amygdala processes fear and categorises emotions and experiences as either positive, negative or neutral. The Amygdala works with the hippocampus and the prefrontal cortex. There are physical developmental differences in the Amygdala of the brains of people with anxiety disorders or trauma-related disorders. Studies on fear have shown that as amygdala blood flow increases, blood flow to the prefrontal cortex decreases. Suggesting some competition or trade-off between these parts of the brain [2].

The prefrontal cortex is composed of two parts: the medial prefrontal cortex (MPFC) and the dorsolateral prefrontal cortex (DLPFC). The amygdala develops during adolescence [2], while we now know that the prefrontal cortex continues to develop up to and around the mid-twenties [8]. The prefrontal cortex reduces our reactivity to stress, specifically by reducing the activity of the Amygdala. The brains of people with PTSD may have a smaller prefrontal cortex [2].

Neurotransmitters and hormones related to trauma symptoms include: Norepinephrine (NE), Corticotropin–releasing hormone (CRH), Adrenocorticotropic hormone (ACTH), Neuropeptide Y (NPY), Gamma-aminobutyric acid (GABA), Allopregnanolone, Glucorticoids, Dehydroepiandrosterone (DHEA), 17β-estradiol and Serotonin (5-HT) [2].

7. Healing from Trauma’s adverse effects

Harris and Fallot (2001) introduced the concept of trauma-informed care. The system has five pillars: “safety, trustworthiness, choice, collaboration and empowerment”. Trauma-informed therapy focuses on root cause analysis and the creation of emotionally safe environments. Part of this approach is to consider the potential for past Trauma being a factor supplementary to the core issue presenting as requiring treatment. i.e. any/everyone could be a trauma survivor [1].

Trauma-informed care works to identify and re-establish social support systems since social support offers protection from the psychological impacts of Trauma. One of the issues with this is that Trauma often indicates that those social support systems may have already been lacking. If they were not before the Trauma, the Trauma could have impacted them either through secondary Trauma or the same traumatic event happening to multiple people within a social group [4]. On the other hand, the trauma-informed care system recognises the potential for negative social experiences having a negative impact on care; Specifically, trauma-informed care highlighted social support practices could inflict Trauma or re-traumatise. For example, disciplinary procedures in schools, the use of seclusion and restraints, practices in the criminal justice system and treatment of abused children within the welfare system [1].

Trauma-informed therapies include: dialectical behaviour therapy (DBT), mentalisation-based therapy (MBT), eye movement desensitisation and reprocessing (EMDR), Cognitive Behavioural Therapy (CBT), Mindfulness, and exposure therapy. Treatment aims to improve skill development regarding emotional regulation, interpersonal skills, attachment, trauma memory reprocessing, and psychological acceptance and handling distress. Trauma therapy targets the following emotions: Trauma, guilt, shame, anger, grief or sadness [1].

Exposure therapy sounds intense, but it’s not being exposed to the same traumatic event again; instead, it involves repeatedly recalling the event or exposure to stimuli associated in some way with the event. Exposure therapy targets “mistrust, self-blame, feeling of inadequacy,” and danger perception. Exposure therapy may be more effective for certain types of Trauma, i.e. Trauma experienced by civilians/refugees compared to military personnel, or traumatic events such as natural disasters or transportation accidents [1].

EMDR involves recalling the event with a specific focus on bodily sensations, images, thoughts and emotions in correlation with side-to-side eye movements. EMDR aims to address Trauma in the body, reprocess the Trauma, and desensitise oneself to it, using relaxation techniques to help stabilise emotions [1].

The stigma associated with Trauma and the Trauma itself make Trauma difficult to discuss and diagnosis difficult to obtain. There is a need to consider cultural factors in assessment and treatment [1].

REFERENCES:

[1] G. Yadav G, S. McNamara, S.Gunturu. Trauma-Informed Therapy. [Updated 2024 Aug 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://pubmed.ncbi.nlm.nih.gov/38861623/
[2] Feriante J, Sharma NP. Acute and Chronic Mental Health Trauma. [Updated 2023 Aug 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK594231/
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[4] 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/
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