Trauma Fænomenologi, teori og terapi Forelæsningsrækken: ”Psykologer i psykiatrien” Institut for Psykologi, KU September 13, 2013

Traumets universalitet Erfaringen af traumer er en essentiel del af det at være menneske Til trods for menneskets ekstraordinære evne til at overleve og tilpasse sig, så kan traumatiske erfaringer forandre den psykologiske, biologiske og sociale ligevægt i en sådan grad, at erindringer af særlige begivenheder farver alle oplevelser og destruerer værdsættelsen nuet PTSD genindfører ideen om at visse symptomer er resultatet af, at det har været vanskeligt/umuligt for individet at komme overens med oplevelser, som har været overvældende for personens evene til at ‘cope’ eller ‘symbolisere’ sin situation

Illustrative cases Case1 En kvinde som blev voldtaget udviklede ikke PTSD indtil hun måneder senere læste om, at voldtægtsmanden havder voltaget og dræbt en anden kvinde Case 2 En kvinde på vej til arbejdet I bil overværer ved et vejkryds, hvor hun stopper for rødt, at en anden bil kører et barn over og slår det ihjel. I ugerne derefter føler kvinden en anspændthed hver gang hun passerer lyssignalet og en måned efter begynder kvinden at køre en anden vej til arbejdet. Efter fire måneder ophører hun med at køre bil og efter et halvt år kan hun ikke mere gå på arbejdet.

Traumatisation All traumatised people develop their own peculiar defenses to cope with intrusive recollection and increased physiological arousal The choice of defenses is influenced gy: Developmental stage and psychic constitution Temperamental factors Contextual factor

Traumatisation The core issue in traumatisation is: The inabaility to integrate the reality of particular experiences (MEN hvilken realitet - indre/ydre, eller dialektikken imellem dem??) The resulting repetitive replaying of the trauma in: images, behaviours, feelings, physiological states, and interpersonal reality

Information processing (symbolisation) in PTSD Persistent intrusion of memories related to the trauma which interfere with attending to other incoming information; Active attempts to avoid specific triggers of trauma-related emotions and experience of a generalised numbing of responsiveness; A tendency to compulsively expose themselves to situations reminiscent of the trauma;

Information processing in PTSD Losing of the ability to modulated their physiological responses to stress in general which leads to a decreased capacity to utilise body signals as guides for action; Suffering from generalised problems with attention, distractibility, and stimulus discrimination; Alterations in their psychological defense mechanisms and in personal identity

Intrusions Flashbacks Intense emotions (panic, rage) and feelings of irretrivable loss, anger, betrayal, and helplessness Somatic sensations Nightmares Interpersonal reenactments Character styles Pervasive life themes

Compulsive re-exposure to the trauma Harm to others, e.g. violent criminals were physically or sexually abused as children Self-destructiveness Re-vicitimisation, e.g. women who were sexually or physically abused as children are more likely to be abused as adults

Inability to modulate “arousal”, inner turmoil, unsymbolised psychic material Traumatised individuals suffer from extreme physiological arousal in response ti a wide variety of stimuli Individuals with PTSD tend to move immediately from stimulus to response without often realising what makes them so upset; Individuals with PTSD experience intense negative emotions (fear, anxiety, anger, panic) in response to even minor stimuli. As a result, they either overreact and threatens other or shut down and freeze; Hyperarousal leads to generalisation of threat - the world becomes an unsafe place

Alterations of defence mechanisms and changes in personal identity Trama affect people’ sense of themselves and their relationship to their environment Many traumatised individuals blame themselves for having been traumatised. Assuming responsibility for the trauma allows feelings of helplessness and vulnerability to be replaced with an illusion of potential control; Trauma is usually accompanied by intense feelings of humiliation: to feel threatened, helpless and out of control is a vital attack on the capacity to be able to count on oneself

Changes in personal identity: Shame Shame is the emotion related to having let oneself down; The shame that accompanies rape, torture, abuse is so painful that it is frequently dissociated Victims may be unaware of the presence of shame, and yet it comes to dominate their interactions with the environment Denial of one’s feelings of shame, as well as those of other people, opens the door for further abuse (of others); Not being in touch with one’s shame leaves one vulnerable to further abuse from others

Trauma - Traumatisering Traumatiske oplevelse som en radikal ny erfaring, helt anderledes end tidligere erfaringer, og som individet slet ikke har forestillet sig at blive ramt af Traumet som en erfaring, der bekræfter individet bevidste og ubevidste anelser, og som individet derfor tidligere har forsøgt at undgå (benægten, fortrængning, undertrykkelse)

Trauma - kategorisering 1) Udviklings-traumer (lack of parental care, difficulties in establishing intimate relationships, midlife crises, etc.) 2) trauma fra psyko-sociale and socio-kulturelle forhold (burnout, unemployment, death of significant others, somatic and psychiatric disorders, etc.) 3) trauma fra extreme humane stressorer (social violence, concentration camp survival, rape and torture, natural catastrophes). Goldberger & Bretnitz. Handbook of stress. IUP, 1993

Akse IV: Psykosociale og miljømæssige problemer Problemer med det primære netværk: f.eks. dødsfald i familien; helbredsproblemer i familien; opbrud i familien ved separation, skilsmisse eller fraflytning; fjernelse fra hjemmet; forælder gengiftes; seksuelt misbrug eller fysisk mishandling; overbeskyttelse fra forældrene; omsorgssvigt af barnet; utilstrækkelig grænsesætning; overensstemmelser mellem søskende; fødsel af søskende. Problemer i forhold til socialt miljø: f.eks. dødsfald eller tab af ven; utilstrækkelig social støtte; bor alene; vanskelighed ved kulturel integration; diskrimination; tilpasning til skift i livsstil (såsom pensionering)   Uddannelsesmæssige problemer: f.eks. analfabetisme; indlæringsvanskeligheder; uoverensstemmelser med lærer eller klassekammerater; utilstrækkeligt skolemiljø. Erhvervsmæssige problemer: f.eks. arbejdsløshed; utilstrækkelig bolig; usikkert nabolag; uoverensstemmelser med naboer eller udlejer. Økonomiske problemer: f.eks. ekstrem fattigdom; utilstrækkelige økonomiske midler; utilstrækkelig sundhedsforsikring.

Akse IV: Psykosociale og miljømæssige problemer Uddannelsesmæssige problemer: f.eks. analfabetisme; indlæringsvanskeligheder; uoverensstemmelser med lærer eller klassekammerater; utilstrækkeligt skolemiljø. Erhvervsmæssige problemer: f.eks. arbejdsløshed; utilstrækkelig bolig; usikkert nabolag; uoverensstemmelser med naboer eller udlejer. Økonomiske problemer: f.eks. ekstrem fattigdom; utilstrækkelige økonomiske midler; utilstrækkelig sundhedsforsikring.

Akse IV: Psykosociale og miljømæssige problemer Problemer med adgang til sundhedsydelser: f.eks. utilstrækkelige sundhedsydelser; manglende adgang til transport til sundhedscentre; utilstrækkelig sundhedsforsikring. Problemer i forhold til samspillet med det juridiske system/kriminalitet: f.eks. arrestation; fængsling; retsforfølgelse; offer for kriminalitet. Andre psykosociale og miljømæssige problemer: f.eks. udsættelse for katastrofer, krig, andre fjendtligheder; uoverensstemmelser med ikke familiære omsorgsgivere såsom sagsbehandler, socialarbejder, læge; manglende adgang til sociale hjælpeforanstaltninger.

F43 Reaktion på svær belastning og tilpasningsreaktioner Årsagsfaktorer En exceptionelt traumatisk begivenhed som medfører en akut belastningsreaktion En betydende livsændring som medfører længerevarende belastning, der resulterer i en affektreaktion Mindre udtalt psykosocial belastning (life events)

DSM 5 – Criterion A: Stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence (1 required) Direct exposure. Witnessing, in person. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

DSM 5 – Criterion A: Stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties. This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

DSM 5 – Criterion B Intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (1 required) Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

DSM 5 – Criterion B Intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (1 required) Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli.

DSM 5 Criteron C Avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required) Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

DSM 5 Criterion D Negative alterations in cognition The alterations began or worsened after the traumatic event (2 required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs). Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.").

DSM 5 Criterion D Negative alterations in cognition Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame). Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions.

DSM 5 Criterion E Alterations in arousal and reactivity Alterations began or sorsened after the traumatic event (2 req) Irritable or aggressive behavior. Self-destructive or reckless behavior. Hypervigilance. Exaggerated startle response. Problems in concentration. Sleep disturbance.

DSM 5 Criterion F & G Persistence of symptoms in criteria B, C, D, and E for more than one month Significant symptom-related distress or functional impairment (e.g. social, occupational)

Trauma and dissociation DSM 5 Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream). Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").

PTSD - psykiatriske følgediagnoser Personlighedsændring efter katastrofeoplevelse Akutte og forbigående psykoser Vedvarende forandring af sindsstemning Forstyrrelser i integrationen af erkendelse, hukommelse, sansning og vilje Tilstand med vedvarende klager over dårligt legemligt helbred med ledsagende krav om undersøgelser og operationer, til trods for forsikringer om, at tidligere undersøgelser ikke har vist noget galt. Angstlidelser (panikangst, generaliseret angst)

PTSD Psykosociale følger Selvdestruktiv og impulsiv adfærd Fjendtlighed Social tilbagetrækning, isolation Følelse af håbløshed Somatisering Afmagt Et skadet forhold til omgivelser og netværk Følelse af at være under en konstant trussel Problemer med at styre, følelsesregulere og forstå egne børn

GENNEMBRUD AF TRAUMATISKE ERINDRINGER Flashbacks Intense Emotioner (panik, vrede, sorg) Somatiske sensationer (inkl proto-emotioner (Damasio) Mareridt Udad-ageren i samvær med andre Påvirkning af personligheden Etablering af gennemgående livstemaer Bessel van der Kolk 1996

Janet Freud dissociation repression Cs / Pcs Janet saw hysteria as “a malady of personal synthesis.” Ucs “Horizontal splits” “Vertical splits” 1

Figure 1 Subject - Discourse dimension Body - World dimension Subject - Group dimension Direct influence Indirect influence

Self-agency: Der står et Selv bag egne bevægelser og at Selv'et ikke indgår i andres bevægelser. Self-coherence: En erfaring af, at Selvet er ikke-fragmenteret, fysisk sammenhængende med grænser og et mål for integreret handlen. Self-affectivity: En erfaring af indre følelseskvaliteter (affekter), som kan eksistere side om side med andre oplevelser af Selv'et. Self-history: En erfaring af kontinuitet mellem fortid og nutid

Fraværet af Self-agency kan manifesteres i: Katatoni, hysterisk paralyse, derealisation og nogle paranoide tilstande. Fraværet af Self-coherence kan manifesteres i: depersonalisation, fragmentering og psykotisk oplevelse af fusion. Fravær af Self-affectivity kan ses i : anhedoni hos skizofrene. Fravær af Self-history kan ses i psykogene fugue og andre dissocierede tilstande.