The spring season brings harbingers of hope: sunny skies, budding trees, flowers reaching upward to the light. But spring’s most representative month, May, also brings a reminder that many people face darkness, regardless of the weather outside.
It’s Mental Health Awareness Month, a time to consider the needs of millions of people of all ages who face roadblocks to health such as depression, anxiety, sleep and eating disorders and many others that make everyday life difficult and sometimes debilitating.
One of the most important of these challenges is trauma: a reaction to a highly stressful event, like a serious accident, disaster, or death. Many of the sources of trauma have long been with us: wars, natural disasters, varieties of abuse and gruesome accidents among them. But in 2020, the world encountered the COVID-19 pandemic, which unleashed new waves, along with illness and death.
According to an October 2021 survey by the American Psychological Association, psychologists in 2020 reported large increases in demand for treatment of trauma- and stress-related disorders, as well as anxiety, depression and a host of mental health issues. The problems include post-traumatic stress disorder (PTSD): a reaction to a traumatic event that brings lingering challenges well after a person has experienced it.
For a better understanding of what trauma is, how it affects people, and how to treat it, we spoke with Dr. Steven Berkowitz, professor of Psychiatry at the University of Colorado School of Medicine. Berkowitz directs CU’s START Center, which is staffed by a clinical team that aims to provide “optimal treatment for people of all ages suffering from the effects of loss, trauma, chronic stress and adversity.”
The word itself comes from the Greek for “wound” or “injury,” Berkowitz said. A trauma, therefore, is a person’s reaction to an event, not the event itself.
“One way we talk about what we mean by trauma is that it’s an injury that is caused by an experience or experiences that results in a negative change in functioning,” Berkowitz said.
A person traumatized by surviving a mass casualty event, for example, might suffer recurring bouts of fear and paralyzing anxiety, while another who experienced the same event may be able to integrate the disruption and return to their normal activities.
Berkowitz said he and his colleagues hear from more people “the notion that they have been traumatized,” and the COVID-19 pandemic has contributed to that. But he added that there are many other factors involved.
“There are so many stressors in the world,” he said. “I think what people are talking about is this general, ongoing, cumulative and unrelenting stress. These stressors have made people feel like they are not functioning like they did before the pandemic.”
Berkowitz stressed that a PTSD diagnosis relies on a specific set of criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5. These include “exposure to actual or threatened death, serious injury, or sexual violence,” accompanied by reactions like avoidance, negative changes in mood, hypervigilance, difficulty thinking, or reckless behavior, among many others. The reactions last at least one month. The disturbances also must “significantly impair” a person’s social life and occupation and other important areas of daily activity.
No. Trauma and repeated stress can cause many other disruptive mental and behavioral issues, including depression, anxiety and substance use disorders, Berkowitz said. The key point for providers is to diagnose not only the specific disorder, but also to identify the source of the trauma or stress and the effects these pressures have on a person’s life.
“At the START Center, we develop an assessment based on major stressors, and for PTSD, anxiety, depression and many other factors, including substance use disorders,” Berkowitz said. “We know that all these disorders can be caused by stress and trauma.”
For PTSD, Berkowitz said, “a host” of recommendations by the American Psychological Association that include variations of cognitive therapy and other approaches, as well as anti-depressant medications, generally work well. These approaches may also help to treat anxiety and depression. However, he added that people suffering trauma-related disorders might face other challenges, such as poverty, lack of access to care, difficult family situations and other social determinants of health, that must be addressed.
“We know that people who have had complex trauma and had [mental health disorder] episodes throughout their lifetimes typically have other problems and are harder to treat,” Berkowitz said.
Yes. Berkowitz said that standard therapies don’t work well for a “significant number” of PTSD patients. “Other interventions are being explored,” he said. These include psychedelic drugs, such as psilocybin and ketamine. “We are actively working on that” and exploring approaches to body therapy, such as therapeutic massage, yoga, and breathing techniques, he said.
“We believe that traumatic exposures and reactions are all too common and probably represent the majority of patients who request psychiatric treatment,” Berkowitz said. He noted that a majority of adults have a history of childhood trauma and maltreatment, which makes it imperative to take a “lifespan approach” to working with patients of all ages.
“There is no question that our treatments need to be individualized to each patient,” he emphasized. “We meet everybody where they are at and meet with each other regularly to discuss how best to do it.”
Yes. “There are some universals,” Berkowitz said. These start with “grounding” patients. That means helping them “recognize where they are in time and space” and keeping their perceptions in the “here and now” rather than retreating to memories of “catastrophic events” about the past or projecting negative thoughts into the future, he said.
Therapists at the START Center also concentrate on helping patients decrease their stress and the physical symptoms it produces with effective breathing. Berkowitz said mindful breathing helps to engage the parasympathetic nervous system, which regulates the body during periods of rest and calm. It’s the counterpart to the sympathetic nervous system, which takes hold during times of stress and releases hormones like adrenaline and cortisol. The results, like increased heart rate and arousal, are obviously counterproductive for a person struggling with PTSD and other trauma-related disorders.
Finally, the center works to engage patients’ families in therapy, Berkowitz said. “I think one of the things that we do poorly in the mental health field generally is we don’t help to work on the ‘microsystem’ that they live in. If a patient’s support system isn’t part of the treatment, it’s unlikely that the person is going to be able to fully recover – even if it’s not a toxic environment.” For example, Berkowitz said, a patient’s family might not be hostile to their struggle with trauma but “just not get it,” leaving them unable to provide much positive support.
Yes. Berkowitz noted that the CU Department of Psychiatry created the Past the Pandemic program to help clinicians cope with the ever-present pressures of health care delivery that the COVID-19 pandemic ramped up to even higher levels. The department also launched the Colorado Educator Support initiative to assist teachers, administrators and other school workers dealing with the disruption and uncertainty caused by the pandemic.
Yes. Berkowitz pointed to the landmark 1998 Adverse Childhood Experiences (ACE) study, which concluded that adults who were exposed in childhood to varieties of abuse, violence and mental illness were more vulnerable as adults to leading causes of death, including heart, lung and liver disease.
“We know that people with PTSD have high rates of cardiovascular disease, high blood pressure, breathing problems and sleep apnea,” Berkowitz added.
Why is this so? The answer – at least in part – goes back to the sympathetic nervous system and its effects on the rest of the body.
“One way I explain it simplistically is our physiology responds to potential threats of injury – regardless of whether the danger is physical or psychological – in the same way,” Berkowitz said. That response, simplified as “fight or flight,” is a necessary short-term survival reaction. But if the body’s danger light stays on frequently or permanently, the stress can be damaging on many fronts, including the immune system.
“The stress response occurs whether you get sick or you are psychologically exposed,” Berkowitz said. “When you have a disorder like PTSD, where you are constantly in a dysregulated stress state, you’re dysregulated in your entire body. This can result in a wide range of chronic illnesses.”
Berkowitz pointed to the knotty connections between mental health and medical problems he described above. He also noted the Dunedin Study from New Zealand, which has tracked 1,000 infants born in the city of the same name in 1971 and 1972. The study, which recently marked its 50th anniversary, has produced mountains of research, including a 2009 report suggesting that individuals who endured adverse childhood events were at higher risk for “age-related disease.”
Berkowitz also noted that a new Dunedin study, released this year, found that adverse childhood events were a predictor of vaccine hesitancy and resistance and thus a contributor to the defining public health challenge of our time. The authors believe that mistrust of authority, built up by early episodes of mistreatment and abuse, explains the possible link.
In the long run, Berkowitz said, the key to mitigating trauma- and stress-related disorders is building healthier communities that recognize the importance of mental health and address questions about it openly.
“How do we create more resilient and cohesive people and not wait until they are symptomatic to help them?” he said. “We are not going to treat our way out of this crisis.”
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