Psychic Trauma, from Neurobiological Mechanisms to Treatment by Silvia Garozzo
Abstract This article explores the complex phenomenon of psychological trauma, analyzing its definitions, characteristics, and neurobiological underpinnings. Starting from a brief etymological examination of the term “trauma,” the article focuses on traumatic experiences as events that severely threaten an individual’s physical or psychological integrity, triggering intense emotional and cognitive reactions. The neurobiological correlates of trauma are then explored in depth, highlighting the structural and functional alterations at the brain level that can persist over time. Exposure to traumatic events can lead to the development of a wide range of psychiatric disorders, including post-traumatic stress disorder (PTSD), depression, generalized anxiety disorder, dissociative disorders, and some more. Finally, the article presents an overview of the main therapeutic strategies used to treat trauma and related disorders, emphasizing the importance of a multidisciplinary approach that considers both psychological and biological aspects.
What is Trauma and How is it Defined?
The term trauma derives from the Greek “traῦma” and literally means “wound”. As we know, this term takes on different meanings depending on the context in which it is used. For example, in the medical field, trauma refers to an injury produced in the body by any agent capable of sudden and violent action. It can be caused by accidents, falls, blows, gunshot wounds, etc.. Trauma, in medicine, can cause damage to various body tissues, such as bones, muscles, internal organs. The consequences of trauma can vary from mild to severe, and may require immediate medical attention.
In the psychological field, however, trauma indicates an emotionally devastating experience that can cause a profound disturbance of an individual’s psychic state. Traumatic events can be of various kinds, such as violence, abuse, natural disasters, sudden losses, etc.. Today it is important to know that we also consider other types of events as traumas, such as, for example, lack of care (neglect), but also many other relational traumas. Trauma can lead to a wide range of psychological symptoms, including anxiety, depression, post-traumatic stress disorder (PTSD), dissociative disorders, and other mental disorders.
Deepening the concept, we can ask ourselves what the characteristics of an event are to be defined as traumatic. Schematically, we can identify:
Intensity: The event is perceived as extremely threatening to one’s physical or psychological integrity.
Helplessness: The person feels helpless in the face of the event and unable to control it.
Emotional overload: The event causes an intense emotional reaction, often of fear, horror, or despair.
What we know today is that a traumatic event can have both short-term and long-term effects. In the short term, trauma can cause acute reactions such as shock, dissociation, intense anxiety. But if not reprocessed, in the long term the consequences of trauma can persist over time and significantly influence the person’s life, emotionally, relationally, and socially.
It is important to emphasize that not all stressful events are traumatic. An event becomes traumatic when it exceeds the individual’s capacity to cope with it and when it leaves a deep psychological wound.
In 1895, Freud said: “I think this man is suffering from his memories”. As Freud suggested, here, rather than traumas, we speak of traumatic memories. We speak, in fact, of traumatic memories rather than traumas because the perception of trauma and the extent of its consequences on those who suffer it are absolutely subjective experiences. The same event can have very different effects on different people.
Types of Trauma
Trying to make a distinction between different types of trauma, we can start precisely from the fact that an event can be perceived as trauma, not only depending on the magnitude of the event itself, but on many other factors. For example, perceiving an event as traumatic can depend on the fragility of the subject at the time the event occurs. It can depend on the age at which the trauma or traumas were suffered. It can depend on the eventual repetition of the event over time. It depends on the subject’s resilience and personal, social, and cultural resources. It depends, obviously, on the type of trauma. The lasting impact of trauma finally depends on how well or not the person has managed to reprocess the traumatic memory itself.
To better understand this, starting to understand the neurobiological basis of trauma, we will refer to the AIP model: Adaptive Information Processing, which explains well the variability and subjectivity we are talking about here. For now, let’s limit ourselves to making a first important distinction between traumatic memories. In EMDR therapy, for simplicity, a first important distinction is made, which is that we distinguish between Traumas with a capital T and traumas with a lowercase t. Where capital or lowercase does not refer to the importance of the trauma for the subject, but is only a linguistic strategy to distinguish two large groups of traumas.
We speak of Traumas with a capital T to define events in which the subject perceived a risk to their health or even survival or that of others. They may have directly suffered the trauma, or a person emotionally close to them may have suffered it. They may have witnessed the trauma directly or have information about it and still be traumatized. This is where the concept of Vicarious Trauma comes in, which is the traumatization from someone else’s trauma. This is an important concept for psychotherapists and many health professionals, but also, for example, for law enforcement, civil protection, and other categories of helping professions who are, precisely because of their work, often exposed to the possibility of experiencing vicarious traumas. It is very important that we are aware of this. Because in our clinical practice we must first and foremost take care of ourselves as therapists so that we can take the best possible care of our patients. Vicarious traumas are one of the elements to take into consideration when speaking about therapists’ personal therapy, supervision, and burnout prevention. Vicarious traumas are also very important for us to keep in mind and investigate when we work with at-risk categories. Think of police officers, emergency room doctors, just to give a few examples.
A situation that can be explanatory of the concept of vicarious trauma concerns the pandemic. During the 2020 lockdown, the EMDR Association was, as often happens during catastrophic events, on the front lines to manage the emergency. Specifically, on that occasion, all trained and expert EMDR therapists were invited to offer assistance to doctors and nurses who worked tirelessly in the COVID wards. We were invited to deal with the vicarious and personal traumas of doctors and nurses when we ourselves were traumatized and confused. Doctors and nurses were traumatized by what they experienced as individuals, but often also by the traumas they witnessed in patients. Helping them meant making them more effective in counteracting the great emergency in which hospitals, and all of us, found ourselves.
Let’s return to our first distinction, then, Traumas with a capital T are, for example: bereavements, abortions, violence, accidents, surgeries, earthquakes, natural disasters, and so on; but also the middle school bully who made me fall in front of everyone or slammed my head on the table. Speaking of bullies, however, the bully who made fun of me by calling me four-eyes in front of everyone will fall into the second category: Traumas with a lowercase t. Traumas with a lowercase t are all those unpleasant memories, generally relational episodes, that have contributed to our current discomfort, our negative beliefs about ourselves, the world, others, etc.. Traumas with a lowercase t are also relational memories with attachment figures in a dysfunctional attachment.
Neurobiology of Trauma
The AIP Model Adaptive Information Processing is the theory according to which all our brains automatically, with an intrinsic, physical, adaptive system that serves to learn from experience, reprocess everything that happens to us and archive it in memory, in order then to retrieve it when something that happens to us in the here and now connects to that archived memory. The possibility of comparison between now and then serves us to orient ourselves. This is something that happens automatically, with various automatic neurobiological systems that we will explore later, to all of us, from the maternal womb onwards. Generally, we do not realize this process until something goes wrong. When we are in a state of fragility and/or the event that occurs is very emotionally and physically impactful, then this process can go into a block. The event is so stressful that it blocks the system and blocks the processing of the event itself. When this happens, the memory remains fixed with all its cognitive, emotional, and bodily weight in an unprocessed state. The various aspects of the memory remain fixed with the same power as when we experienced it. This means that when we are faced in the here and now with something that takes us back to the unprocessed event because it resembles it in some way, we react both to what is happening to us in the here and now and to what happened to us then, and this causes disproportionate reactions and confusion. It creates a disturbance in our functioning. It goes without saying that the more unprocessed traumatic events we have, especially in childhood, the more fragile we are in facing others (hence the attachment traumas we will discuss shortly). Trauma, loss, and adverse childhood experiences can inhibit the normal reprocessing of subsequent unpleasant events, in an escalation of individual discomfort that can, as we will see, spill over into the systems in which the individual lives and onto children in particular if we do not break this chain. According to this model, problems, symptoms, and disorders are almost always related to the failure to reprocess traumatic events. According to this model, health comes through the reprocessing of unpleasant events that happen to us.
Let’s see how this system works specifically. When we experience an event, we experience it from various points of view. Our sense organs, our body, our emotions, and our thoughts are involved. The event we perceive includes images, sounds, moods, sensations, thoughts, beliefs, etc.. The first immediate reactions are bodily and emotional. We perceive internal and external sensations, and if the event is very impactful, what we perceive is very impactful. Here our prefrontal cortex normally intervenes, which, as Pagani says, acts as a first firefighter, so it slows down, dampens, and resizes our sensory and emotional reactions, generally allowing us to think. Subsequently, our brain begins to reprocess the information by doing what it does best: synapses. First, it stores the various parts of the event in various places. Think of emotions, for example, in our limbic system. Then, little by little, our brain, reprocessing what has happened, often in the background during the day and at night during the pre-REM and REM phases, makes a narrative of that event, and the synapses move more and more to the cortical level. When the reprocessing of the memory is finished, the memory is archived in memory. When a similar situation happens to us, we use that memory to compare with the here and now and orient ourselves. We learn from our experience. This happens continuously, always. When Lucangeli says that learning passes through affective relationships, she means precisely this. The more memories are relationally and affectively connoted, the more powerful they are in our brain. Lucangeli refers to pleasant memories, to school learning that must take place under the guidance of an affectionate teacher, but let’s think about attachment styles. To analyze the neurobiology of trauma, Porges’ polyvagal theory comes to our aid.
Porges’ Polyvagal Theory
The polyvagal theory, developed by neurophysiologist Stephen Porges, offers us a detailed map of our autonomic nervous system and how it reacts to stress and social relationships. This model helps us understand why sometimes we feel safe and connected, while other times we feel on alert or completely disconnected. At the center of the polyvagal theory is the vagus nerve, a cranial nerve that plays a fundamental role in regulating bodily functions and emotions. Porges identifies three circuits of the vagus nerve:
Dorsal vagus: Associated with the “freeze” or “dissociation” response. It is the oldest circuit from an evolutionary point of view and is activated in situations of imminent danger, when flight or fight are not possible.
Sympathetic system: Associated with the “fight or flight” response. It is activated when we perceive a threat and prepares the body for action, increasing heart rate, blood pressure, and adrenaline production.
Ventral vagus: Associated with safety and social connection. It is the most recent circuit from an evolutionary point of view and is activated when we feel safe and connected with others.
According to Porges, these circuits work in a hierarchy:
Ventral vagus: When we feel safe, the ventral vagus is active, allowing us to interact socially, express our emotions, and regulate our body.
Sympathetic system: If we perceive a threat, the sympathetic system is activated, preparing us to react.
Dorsal vagus: In situations of extreme danger or trauma, the dorsal vagus can take control, leading us into a state of dissociation or paralysis.
The polyvagal theory helps us understand how traumas can alter this hierarchy, causing people to remain stuck in states of hypervigilance (sympathetic system) or dissociation (dorsal vagus). This can contribute to the development of disorders such as post-traumatic stress disorder, anxiety, and depression.
Let’s see specifically what happens when we experience a trauma/stressful event.
The Stress Axis
All of us, from reptiles upwards in the evolutionary chain, are equipped with a stress management system. More precisely, we refer to the stress axis, which includes the hypothalamus, the pituitary gland, and the adrenal glands. How does this system work? When we perceive a danger/strongly stressful event (we now know that the more traumatized we are, the more we perceive events as stressful), our stress axis is activated. The perception can be instinctive or mediated by our interpretation of the situation (for example, if we carry dysfunctional beliefs from previous traumas). The stress axis, like the AIP system to which it is connected, is an automatic system, functional for survival, and reacts in a non-specific manner regardless of the type of stressor event. Our central nervous system considers a strong stress, a danger to survival, equivalent to a predator attack and causes a series of changes in our body that favor the fight/flight reaction. Let’s see how it works.
The stress axis, or HPA axis (Hypothalamus-Pituitary-Adrenal), is like an alarm system in our body. When we encounter a situation that we perceive as threatening or stressful, this system is activated to prepare us to react. Let’s see in a simplified way how it works following the various steps: Perception of stress: Our brain, particularly the amygdala, detects the stressful situation and sends a signal to the hypothalamus. Hypothalamus activation: The hypothalamus sends a signal to the pituitary gland. ACTH secretion: The pituitary gland, receiving the signal, releases a hormone called ACTH (adrenocorticotropic hormone). Adrenal gland stimulation: ACTH reaches the adrenal glands, stimulating them to produce cortisol, which is also called the stress hormone. Cortisol is released into the blood and produces a series of effects in the body, including: Increased blood sugar, which provides immediate energy to deal with the stressful situation. Suppression of the immune system to focus energy resources on the stress response. Increased blood pressure to improve circulation and muscle response. Increased heart rate to provide more oxygen to the muscles. Reduced digestive activity to focus energy on more urgent functions. But also increased respiratory rate (breathing becomes faster and shorter), release of adrenaline, release of lactic acid in the muscles, etc.. All these changes serve to make our body and brain able to react with attack or flight to danger.
It is important to think that this system is designed to remain active for a very short time and thus save us from danger. But what happens if these changes remain active for longer? For example, what were called somatizations develop, but it can also happen in a simplified way that the genes of an autoimmune disease are unmasked. In practice, the systems go haywire. And this is where the stress axis and the AIP model connect. Cortisol, in fact, released in large quantities by the activation of the stress axis, blocks the system of reprocessing the memory of what is happening. Cortisol causes the unprocessed memory to remain fixed. Our stress response blocks reprocessing, and we have the biochemical stasis of the memory. Paradoxically, this is an adaptive solution for our defense system. If that given event was so strong as to trigger a reaction of our stress axis that raised our cortisol level so much, then we must remember it well, because it is dangerous and we cannot risk experiencing it again. We remember that unprocessed or incompletely reprocessed information related to traumatic or stressful experiences means that the initial perceptions are stored essentially as they were in the input, along with the distorted thoughts or perceptions experienced at the time of the event.
How Trauma is Transmitted
We can clearly understand then how unprocessed traumas make us more fragile with respect to events and life. Unprocessed traumas are unfortunately handed down and passed on to children, through modeling, non-verbal communication, behaviors, and even epigenetics. They are transmitted from individual to individual, in the system, in generations, and even in the mother’s womb. Due to unprocessed traumas, we can build and get stuck in dysfunctional relationships. Unprocessed traumas worsen our psychophysical health. They are therefore an important risk factor. Consequently, the treatment of traumas, the reprocessing of traumas, is a very powerful protective factor for the individual, for the child, for the family. Reversing what we have said taking the AIP model as a guide: if it is true that adverse childhood experiences make us more likely to be less able to reprocess subjective traumatic events, then we can say that: Reprocessed and therefore integrated traumatic experiences are the basis of mental health.
Attachment Traumas
As we have seen, traumatic experiences (both Traumas with a capital T and also and especially traumas with a lowercase t) experienced during childhood can leave marks on the brain, on the representation of self and the world. To find references to this in a transversal way in different therapeutic approaches, let’s think, for example, of the dysfunctional thoughts of cognitive-behavioral psychotherapy, the existential position of Transactional Analysis, the designated patient in family therapy, and so on. As we know, the child’s experiences are mostly those lived in relation to Attachment Figures. It is easily deduced that traumatic experiences lived within relationships with parents have a profound impact on the life cycle and future interpersonal relationships. But what are what we call attachment traumas? Attachment traumas include: Emotional neglect Physical or sexual abuse by a parent Witnessing violence Early hospitalizations Early loss of a parent Rejection/abandonment Consequently, we can imagine how many clinical pictures we can find ourselves facing that present disorders related to a lack of reprocessing of past traumas.
Diagnoses Related to Traumatization
In the DSM 5 TR, to begin with, we find an entire diagnostic section on disorders that share a common trigger: exposure to a traumatic or stressful event. Specifically: Post-traumatic stress disorder (PTSD): the most well-known, characterized by a series of intrusive symptoms (flashbacks, nightmares), avoidance behaviors (avoiding places or situations that recall the trauma), alterations in mood and arousal (irritability, difficulty concentrating, hypervigilance). Acute stress disorder: similar to PTSD, but with a duration of less than three months. Adjustment disorder: a significant emotional or behavioral reaction to an identifiable stressor, such as difficulty performing daily activities, mood alterations, or disruptive behaviors. Reactive attachment disorder: typical of infancy, characterized by a pattern of inhibited behaviors towards caregivers, following inadequate or traumatic care experiences. Disinhibited social engagement disorder: similar to the previous one, but with a pattern of socially inappropriate and disinhibited behaviors towards strangers. These disorders are characterized by symptoms that are specifically related to trauma or stress and precisely: Intrusions: recurring thoughts, images, or memories of the traumatic event that intrude, meaning the patient feels they have no control over these thoughts, images, or memories but experiences them as an intrusion on their normal functioning. Avoidance: the tendency to avoid situations, people, or places associated with the trauma. As we know, avoidance is a psychological defense. To avoid experiencing those disturbing sensations, emotions, and thoughts, we avoid the stimuli that activate them, sometimes even becoming unable to function in school, work, social life, etc.. Alterations in arousal and reactivity: hypervigilance, difficulty concentrating, irritability, sleep disturbances. This is clear to us when we think about the neurobiological functioning we discussed earlier. Mood alterations: feelings of guilt, shame, emotional detachment. Here we also think of dissociation as a defense, in addition to avoidance. Cognitive alterations: difficulty remembering aspects of the traumatic event, negative thoughts about oneself or the world. But also difficulty concentrating, for example. Let’s add to these disorders, which in the DSM are specifically linked by the trauma factor, a designation that, as we know, is not yet found in the DSM, but which is profoundly clarifying regarding the consequences of attachment traumas: Complex PTSD, or C-PTSD. The concept of C-PTSD and its symptoms help us understand how traumatization underlies many dysfunctional psychological conditions, regardless of the individual nomenclature: from dissociation to depression, from eating disorders to personality disorders.
Complex PTSD (C-PTSD): Beyond PTSD
Complex Post-Traumatic Stress Disorder (C-PTSD) represents a conceptual evolution of PTSD, focusing on the effects of prolonged and repeated exposures to interpersonal traumas, typically in childhood. Unlike PTSD, which focuses on a single or time-limited traumatic event, C-PTSD manifests following complex and lasting traumas, such as child abuse, prolonged neglect, or domestic violence. Let’s see what differentiates a C-PTSD picture from simple PTSD. Distinctive Characteristics of C-PTSD: Identity alterations: feeling “fake,” difficulty integrating different aspects of self, dissociation. Difficulty in regulating emotions: extreme difficulty managing intense emotions, such as anger, fear, or shame. Disturbances in consciousness: alterations in the perception of time and space, feelings of depersonalization or derealization. Disturbances in interpersonal relationships: difficulty trusting others, problems in communication, social isolation. Self-destructive behaviors: tendency towards risky behaviors, substance abuse, eating disorders. Let’s see what the causes or risk factors are that can lead to the development of a C-PTSD picture: Repeated interpersonal traumas: physical, sexual, emotional abuse, neglect. Age at which they were experienced and consequent fragility: childhood traumas have a deeper and longer-lasting impact on personality development. Insecure attachment relationships: an insecure attachment with caregivers increases vulnerability to C-PTSD. Finally, also biological factors: neurobiological alterations related to emotion regulation and stress. What can be the long-term consequences of attachment traumas? To begin with, there is a recognized comorbidity: C-PTSD is often associated with other psychiatric disorders, such as depression, anxiety, and personality disorders. We also find a strong impact on daily life and functioning, for example, difficulties in relationships, work, social life, and parenting. And last but not least: intergenerational transmission: trauma can be transmitted to subsequent generations through epigenetic and behavioral mechanisms.
Indirectly Connected Diagnoses
While the previous diagnoses have a direct link to trauma, others may present a more indirect connection, in the sense that a traumatic experience can be a predisposing or aggravating factor. This is why assessment work is so important, where it is necessary to connect symptoms with traumas, because in these cases, unlike PTSD, the patient or patients rarely come to us stating that they have suffered a trauma and have been experiencing symptoms since then. This is why the initial investigation phase in our first interviews with patients is fundamental. Among the diagnoses that may have a traumatic origin are, for example: Major depression: often, major depressive episodes can be triggered or aggravated by traumatic events. Depressive disorders can be linked to dysfunctional thoughts about oneself, which in turn can have a traumatic origin. Generalized anxiety disorder: chronic anxiety can be a persistent response to past traumas. Often, for example, we find an anxiety disorder as a response to capital T traumas, which has the (dysfunctional) function of keeping alertness high and trying to control the environment to avoid reliving those traumas. Dissociative disorders: conditions characterized by a dissociation between different aspects of consciousness, identity, memory, and perception, often as a defense mechanism in response to severe trauma. This is precisely a classic defense mechanism against trauma. We recognize it easily, for example, in victims of sexual violence. Conduct disorders: in children and adolescents, antisocial behaviors can be a response to traumas suffered. The frustration, suffering, and fear that remain from trauma lead to these disorders as a (dysfunctional) attempt to manage and regulate emotions that have been altered by the lack of reprocessing of the traumas suffered. Eating disorders: anorexia nervosa and bulimia nervosa can be associated with sexual or emotional traumas, but also with attachment traumas. Somatoform disorders: conditions characterized by physical symptoms without a clear medical cause, can be linked to unprocessed traumas. Substance use: substance use can be a way to cope with the emotional pain caused by trauma.
Working on Trauma as a Protective Factor
As we have seen, traumas or losses, adverse childhood experiences can inhibit the normal reprocessing of memories. Those who have experienced a traumatic childhood (where by trauma, as we know, we mean both abuse and omission) are more subject to being more traumatized by life events. We have seen how traumas leave neurobiological traces that condition our approaches to subsequent events. As therapists, why is it so important to know this? We know that all disorders are in fact the multifactorial result of many elements. We know from epigenetics that our genetic makeup contains a lot of information, even about fragilities and possible pathologies that may not manifest. And that whether or not they manifest depends on many factors. The question is, how can we help people and ourselves? How can we positively influence our society? Each of us (not just therapists, all of us) can improve this world a little or worsen it, in the small sphere of what we can do. As therapists, we can do this every day in our work, and we set it as our goal. We have this somewhat narcissistic expectation of improving the lives of our patients. Obviously, together with our patients themselves. Returning to the factors that improve or worsen our state of health, the health of our relationships, the health of our society. What is within our power, as people, as therapists, is to increase protective factors and decrease risk factors. What is clear now is that unprocessed traumas make us more fragile with respect to events and life. That unprocessed traumas are handed down and passed on to children and trap us in dysfunctional relationships. Unprocessed traumas worsen our psychophysical health. They are an important risk factor. What we can therefore do is address traumas, know how they influence us, and how important the reprocessing of traumas is, which is the cure. The reprocessing of traumas is a very powerful protective factor for the individual, for the child, for the family.
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