TRAUMA

Trauma is an exposure to an event in which a person is confronted with actual/threatened death

or injury and threat to self or others’ physical well-being.
(APA, 2000)

Trauma is usually a life-threatening experience that is deeply distressing and overwhelms an

individual's ability to cope, often resulting in feelings of helplessness, loss of control, and intense
emotional or psychological disturbance. It can have lasting effects on a person's mental,
emotional, and physical well-being.

Traumatic events are experiences that are deeply distressing or disturbing, overwhelming an
individual's ability to cope effectively. These events can have a profound impact on a person's
mental, emotional, and physical well-being, often resulting in symptoms such as anxiety,
depression, flashbacks, nightmares, and difficulty functioning in daily life. Examples of
traumatic events include physical or sexual abuse, natural disasters, combat, serious accidents,
sudden loss of a loved one, and witnessing violence or death.

PTSD stands for Post-Traumatic Stress Disorder, which is a mental health condition that can
develop after experiencing or witnessing a traumatic event.

Not everyone who experiences a traumatic event will develop PTSD, and the risk factors for
developing the disorder can vary from person to person. These risk factors may include the
severity of the trauma, the presence of other mental health conditions, a history of previous
trauma or mental illness, and a lack of social support. Additionally, individual differences in
coping mechanisms and resilience can influence whether someone develops PTSD after a
traumatic event.

The symptoms of PTSD can vary in severity and may include:

1. Intrusive thoughts: Recurrent, distressing memories, flashbacks, or nightmares related to the

traumatic event.

2. Avoidance: Avoidance of reminders of the traumatic event, such as places, people, activities,
or conversations associated with the trauma.

3. Negative changes in thinking and mood: Persistent negative beliefs about oneself or the world,
distorted blame of oneself or others, feelings of detachment or estrangement from others, and
persistent negative emotional states like fear, guilt, shame, or anger.
4. Hyperarousal: Persistent symptoms of increased arousal and reactivity, such as difficulty
sleeping, irritability, angry outbursts, hypervigilance, and exaggerated startle response.

DSM-5 Diagnostic Criteria for PTSD

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more)
of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers
repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply
to exposure through electronic media, television, movies, or pictures, unless this
exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s). Note: In children older than 6 years, repetitive play may occur in which
themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s). Note: In children, there may be frightening
dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
 2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due
to dissociative amnesia, and not to other factors such as head injury, alcohol, or
drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others,
or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely
dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation), typically
expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication, alcohol) or another medical condition.

Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic
stress disorder, and in addition, in response to the stressor, the individual experiences persistent
or recurrent symptoms of either of the following:
 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as
if one were an outside observer of, one’s mental processes or body (e.g., feeling as
though one were in a dream; feeling a sense of unreality of self or body or of time
moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the
world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication)
or another medical condition (e.g., complex partial seizures).

Specify whether:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after
the event (although the onset and expression of some symptoms may be immediate).
Source: APA, 2013a, pp. 271–272.

1. Prefrontal Cortex (PFC):

● Location: The prefrontal cortex is located at the front of the brain, just behind the
forehead.
● Function: The PFC is involved in higher-order cognitive functions, including
decision-making, planning, impulse control, and social behavior. It also plays a
crucial role in regulating emotions and integrating information from other brain
regions.
● Role in Trauma Processing: In the context of trauma, the PFC is involved in
regulating emotional responses and cognitive appraisal of threatening stimuli.
Dysfunction in the PFC can impair emotion regulation and contribute to
symptoms such as hypervigilance, exaggerated startle responses, and difficulties
in executive functioning commonly seen in trauma-related disorders like PTSD.
2. Amygdala:
● Location: The amygdala is a small, almond-shaped structure located deep within
the temporal lobes of the brain.
● Function: The amygdala is a key component of the brain's limbic system and is
primarily responsible for processing emotions, particularly fear and threat
detection. It plays a crucial role in the body's stress response and the formation of
emotional memories.
● Role in Trauma Processing: During traumatic experiences, the amygdala can
become hyperactive, leading to heightened emotional arousal and the
consolidation of fear memories. This heightened amygdala activity can contribute
to the development of symptoms such as intrusive memories, flashbacks, and
exaggerated fear responses associated with PTSD.
 3. Hippocampus:
● Location: The hippocampus is located within the medial temporal lobe, situated
deep within the brain.
● Function: The hippocampus plays a central role in memory formation, spatial
navigation, and the consolidation of information from short-term to long-term
memory. It is particularly important for contextualizing memories and linking
them to specific spatial and temporal contexts.
● Role in Trauma Processing: In response to traumatic experiences, the
hippocampus may become impaired or dysfunctional, leading to difficulties in
memory encoding and consolidation. This can result in fragmented or incomplete
memories of the traumatic event and contribute to symptoms such as flashbacks,
dissociation, and difficulty discriminating between past and present experiences in
individuals with PTSD.
4. Hypothalamus: The hypothalamus is responsible for regulating the body's stress response
through the release of stress hormones such as cortisol and adrenaline. Traumatic
experiences can dysregulate the hypothalamic-pituitary-adrenal (HPA) axis, leading to
chronic stress and alterations in stress hormone levels.
5. Brainstem: The brainstem, particularly the locus coeruleus, plays a role in the body's
physiological response to stress and arousal. It regulates functions such as heart rate,
breathing, and the startle response. Dysfunction in the brainstem can contribute to
symptoms of hyperarousal and exaggerated startle responses seen in PTSD.

Overall, these brain regions interact in complex ways to process and respond to traumatic
experiences, with dysfunction or dysregulation within these neural circuits contributing to the
development and maintenance of trauma-related symptoms and disorders. Therapeutic
interventions targeting these brain regions aim to restore balance and function within the neural
circuitry implicated in trauma processing, promoting recovery and healing for individuals
affected by trauma.

EMDR
EMDR stands for Eye Movement Desensitization and Reprocessing. It's a psychotherapy
approach primarily used to treat trauma-related disorders, such as post-traumatic stress
disorder (PTSD), but it has also been applied to various other mental health conditions.

Founding and Development:

EMDR was developed by Francine Shapiro, Ph.D., in the late 1980s. Shapiro discovered the
therapeutic potential of bilateral stimulation (such as eye movements) in reducing the
intensity of disturbing thoughts and emotions. Through systematic research and clinical
practice, she developed the EMDR protocol as a comprehensive therapy for trauma.
Uses:
EMDR is primarily used to alleviate symptoms associated with traumatic experiences,
including intrusive thoughts, flashbacks, nightmares, hypervigilance, and emotional
distress. It has been widely studied and found to be effective in treating PTSD, but it has
also shown promise in addressing other conditions such as anxiety disorders, depression,
phobias, and addiction.

Goals:
The goals of EMDR therapy include:

1. Desensitization: Reducing the emotional intensity and distress associated with

traumatic memories.
2. Reprocessing: Facilitating the adaptive processing and integration of traumatic
memories, allowing individuals to make sense of their experiences and develop more
adaptive beliefs and responses.
3. Resolution: Achieving a sense of closure and empowerment in relation to past
traumas, leading to symptom reduction and improved functioning.

Main Principles and Features:

1. Bilateral Stimulation: One of the core features of EMDR is the use of bilateral
stimulation, which can involve eye movements, taps, or auditory tones. This bilateral
stimulation is believed to facilitate the processing and integration of traumatic memories
by engaging both hemispheres of the brain.
2. Structured Protocol: EMDR follows a structured, eight-phase protocol that guides the
therapeutic process from history-taking and treatment planning to reprocessing traumatic
memories and integrating positive beliefs.
3. Dual Attention: EMDR involves maintaining dual attention on both the traumatic
memory and external stimuli (such as the therapist's hand movements or auditory tones).
This dual attention is thought to help individuals maintain a connection with the present
moment while processing distressing material from the past.
4. Bilateral Processing: During the reprocessing phase, individuals engage in sets of
bilateral stimulation while simultaneously focusing on the traumatic memory, associated
thoughts, emotions, and bodily sensations. This process allows for the adaptive
reprocessing of the memory and the integration of new, more adaptive information.
5. Adaptive Information Processing (AIP) Model: EMDR is guided by the Adaptive
Information Processing model, which posits that trauma-related symptoms result from
unprocessed memories that are stored in an isolated or dysfunctional manner. EMDR
aims to facilitate the adaptive processing and integration of these memories, leading to
symptom reduction and emotional healing.
Overall, EMDR is a structured and evidence-based therapy approach that aims to alleviate
distress associated with traumatic experiences, promote adaptive processing of memories, and
facilitate psychological healing and growth.
The eight phases of EMDR therapy provide a structured framework for the therapeutic process,
guiding both the therapist and the client through the treatment journey. Below, I'll describe each
phase in detail and provide a case example to illustrate how EMDR might progress:

Phase 1: History-Taking and Treatment Planning

● Description: In this phase, the therapist gathers information about the client's history,
current symptoms, and treatment goals. The therapist assesses the client's readiness for
EMDR and develops a treatment plan tailored to the client's needs.
● Case Example: Sarah, a 35-year-old woman, seeks therapy for symptoms of PTSD
following a car accident. During the initial sessions, the therapist conducts a
comprehensive assessment of Sarah's trauma history, current symptoms, and coping
strategies. They collaboratively identify Sarah's treatment goals, which include reducing
distressing memories and improving her ability to cope with triggers.

Phase 2: Preparation
● Description: The therapist provides psychoeducation about EMDR and prepares the client
for the therapeutic process. This involves establishing rapport, teaching relaxation
techniques, and discussing strategies for coping with distress.
● Case Example: In preparation for EMDR, Sarah's therapist educates her about the therapy
process, including the use of bilateral stimulation and the rationale behind it. They teach
Sarah relaxation techniques, such as deep breathing and progressive muscle relaxation, to
help her manage distress during EMDR sessions.

Phase 3: Assessment
● Description: The therapist helps the client identify target memories or experiences to be
processed during EMDR. This may involve assessing the emotional intensity of
memories, associated negative beliefs, and related physical sensations.
● Case Example: Sarah and her therapist identify a specific traumatic memory from the car
accident for processing during EMDR. Sarah recalls the memory of the accident,
including the sounds of screeching tires and the sensation of impact, which she rates as
highly distressing. She reports feeling intense fear and a belief that she is not safe while
driving.

VOCs and SUDs are also assessed during this phase.In the context of EMDR therapy, "SUD"
stands for Subjective Units of Disturbance, and "VOC" stands for Validity of Cognition.

1. Subjective Units of Disturbance (SUD):

 ● Definition: SUD is a subjective rating scale used to measure the level of distress
or disturbance experienced by the client when recalling a specific memory or
experiencing a particular thought or sensation.
● Scale: The SUD scale typically ranges from 0 to 10, with 0 representing no
distress or disturbance and 10 representing extreme distress or disturbance.
● Application: During EMDR therapy, clients are asked to rate their level of distress
or disturbance associated with target memories, negative beliefs, or physical
sensations. This allows both the client and therapist to track changes in distress
levels over the course of treatment and monitor progress in desensitizing and
reprocessing traumatic material.
2. Validity of Cognition (VOC):
● Definition: VOC refers to the believability or truthfulness of a positive or adaptive
cognition (thought, belief, or statement) identified during EMDR therapy.
● Assessment: In EMDR therapy, clients are guided to identify and install positive
or adaptive beliefs to replace negative or maladaptive beliefs associated with
traumatic memories. The therapist assesses the validity of these positive
cognitions by asking the client to rate how strongly they believe the positive
cognition to be true on a scale from 1 to 7.
● Scale: The VOC scale ranges from 1 to 7, with 1 indicating low believability (not
true at all) and 7 indicating high believability (completely true).
● Purpose: Assessing the validity of positive cognitions helps ensure that the client
is internalizing and integrating new, adaptive beliefs that can facilitate healing and
promote resilience in the face of trauma-related challenges.

Phase 4: Desensitization
● Description: This phase involves reprocessing target memories using bilateral stimulation
while maintaining focused attention on the memory, associated thoughts, emotions, and
physical sensations. The goal is to reduce the emotional intensity and disturbance
associated with the memory.
● Case Example: Sarah engages in sets of bilateral stimulation (e.g., following the
therapist's hand movements) while recalling the traumatic memory of the car accident. As
she does so, she notices a decrease in the intensity of fear and distress associated with the
memory. She experiences shifts in her beliefs, such as realizing that the accident was not
her fault and that she can take steps to increase her sense of safety while driving.

Phase 5: Installation
● Description: In this phase, the therapist helps the client strengthen positive beliefs and
emotions associated with the target memory. This may involve identifying and
reinforcing adaptive beliefs and qualities + increasing self efficacy & increasing insight.
 ● Case Example: Sarah and her therapist work to strengthen Sarah's belief in her ability to
cope with driving-related anxiety. They identify positive qualities and coping strategies
that Sarah possesses, such as resilience and effective problem-solving skills. Through
bilateral stimulation and guided imagery, Sarah focuses on embodying these positive
qualities and beliefs.

Phase 6: Body Scan

● Description: The therapist helps the client notice and process any residual physical
tension or sensations associated with the target memory. This phase aims to ensure that
the processing is thorough and comprehensive.
● Case Example: Sarah attends to any remaining physical sensations or tension in her body
as she recalls the traumatic memory. With the therapist's guidance, she uses bilateral
stimulation to address and release any lingering somatic distress associated with the
memory, such as tightness in her chest or tension in her shoulders.

Phase 7: Closure
● Description: The therapist ensures that the session ends on a positive note and helps the
client stabilize before concluding. This may involve grounding techniques, relaxation
exercises, or discussing strategies for self-care between sessions.
● Case Example: At the end of the session, Sarah and her therapist review the progress
made during EMDR and discuss any insights or observations. Sarah practices
self-soothing techniques to help her feel grounded and centered before leaving the
session. The therapist provides reassurance and encouragement, emphasizing Sarah's
strengths and progress.

Phase 8: Reevaluation
● Description: In this final phase, the therapist assesses the client's progress and identifies
any remaining targets for EMDR processing. This may involve revisiting previously
processed memories or addressing new issues that emerge.
● Case Example: In subsequent sessions, Sarah and her therapist continue to work on
processing additional traumatic memories and addressing related symptoms. They
periodically reevaluate Sarah's progress, adjusting the treatment plan as needed to ensure
continued improvement and resolution of symptoms.

Overall, the eight phases of EMDR provide a structured and systematic approach to trauma
processing and healing, guiding both therapist and client through the therapeutic journey toward
recovery and resolution.