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Complex Trauma Or DESNOS Increasing in Inpatient Eating Disordered Populations

In inpatient settings I have been seeing much more serious trauma in clients who are currently admitting for treatment. In fact we’re seeing so much trauma that we think that all clinicians should be trained in EMDR, one of the most effective trauma interventions used at this time. Experienced clinicians are needed when it comes to working with PTSD and childhood trauma and they should have the best tools available. Because so many people with trauma are admitting with severe trauma, I have been doing vast amounts of research on new information available in regards to trauma and its treatment.

I have found that the subject of complex trauma or DESNOS, a diagnosis of extreme stress not otherwise specified is in fact much more common than a diagnosis of straight PTSD.

PTSD was originally developed as a diagnosis in the 1970s to explain the symptomology of Vietnam veterans returning home after the war. Research has shown that men are traumatized most frequently by accidents, war, assaults, and natural disasters, single event occurrences.

Women are most frequently traumatized by childhood sexual abuse. B.A. van der Kolk (2005) reported that between 17 and 33% of women in the general population had histories of sexual-physical abuse while women who were in psychiatric treatment reported 35 to 50%.

PTSD has captured only a partial snapshot of posttraumatic psychopathology. The PTSD diagnosis does not capture the facets of long-term, repeated trauma. People with a history of physical and sexual abuse over long periods of time report many psychological problems such as substance abuse, borderline and antisocial personality disorders, eating disorders, impulsivity, self-mutilation and suicidality. They will be chronically depressed with dissociative episodes of varying lengths of time. Extreme aggression and impulse control difficulties are also present.

PTSD clinically has referred to these other problems as co-morbid conditions, as if they have occurred apart from the PTSD symptoms. As a result the authors of the DSM-IV began to separate these other symptoms under a category of extreme stress not otherwise specified (DESNOS). They found that the earlier the trauma the more severe the symptoms of DESNOS. Studies also have shown that it is possible to experience DESNOS without having PTSD, certainly above and beyond PTSD.

DESNOS represents a psychological injury from long-term social and/or interpersonal trauma that is characterized by lack or loss of control, disempowerment, and the victim is unable to escape.

In many situations such as caring for a mentally ill person at home, a care- giver may develop symptoms themselves of traumatic stress from prolonged exposure to traumatic stress.

When a patient admits to treatment, pre-treatment testing is needed, such as the Beck Depression Inventory, the Eating Disorder Inventory III, the SCL-90 including testing for trauma and dissociation. If the client has a history of trauma, clinicians should immediately focus on stabilization techniques.

The therapist must have the attitude that nothing is more important than safety and stability. The therapist must assume the role of teacher or guide for the client. Trauma survivors cannot teach themselves how to be safe and stable because

they have no baseline, no meaningful experience of what the words “safe ” or “stable” mean. This is where a strong, centered, grounded therapist is necessary to be the teacher. They help the client learn to ground herself and to find a safe place where she can go and be protected under any circumstances.

The therapist teaches the client that no recovery from trauma is possible without paying attention to issues of safety, learning to care for herself, making connections to other human beings, and a finding a renewed faith in the universe. The therapist’s job is not just to be a witness to this process but to teach the patient how.

Interviewing a New Trauma Therapist – Questions For Dissociative Survivors to Keep in Mind

Are you looking for a new trauma therapist? Do you need to find a therapist that specializes in trauma disorders?

When you are interviewing new therapists, in addition to clarifying that they have the skills and training it takes to provide proper treatment for your trauma issues, it is also important to ask about their approach to trauma work. Make sure their views match or blend with your own views, otherwise there will be conflicts ahead. There are a number of different approaches to trauma work — just as there are tons of different recipes for how to make a loaf of bread. It isn’t that one way is “THE” right way. You and/or the therapist may have very strong opinions for what works best, but the point that matters is if you agree with how your therapist approaches the issues with you.

For example, if a survivor with DID / MPD said to me, “Help me get rid of all these pesky little parts that are irritating me. I want them totally gone and removed from my head.” Oh, well, you see… there are some therapists that would gladly approach therapy work with that goal in mind. I, on the other hand, would have a cow. A really big cow. If someone wanted me to help rid them of their insiders, I couldn’t do it. I wouldn’t do it. I don’t agree with that approach, and just couldn’t be convinced to go there. In that case, this person and I would be a therapeutic mismatch. We would not be aiming for the same goal, so it would not be a good idea for us to work together.

Before you share very much of your personal system information, please take the time to interview the therapist very closely. You must be VERY sure of the safety of the therapist before you disclose about yourself on those deep levels. There are lots of great therapists out there. There are also lots of clowns claiming they are trauma specialists. They may not be dangerous people, but they can do a lot of harm by not actually knowing how to treat trauma-related issues. Please be aware, there are also “double agents” out there — people who claim to be a helping person, but are actually working to support the dark side. Interview all therapists very very closely to make sure you find someone who is both safe and qualified.

When interviewing new therapists, some of the important areas to consider are:

Direct Experience:

  • How many years of experience do you have in working with trauma disorders?
  • How many dissociative survivors have you met?
  • How many survivors with dissociative identity disorder have you treated (as the primary clinician)?
  • What percentage of your practice has been filled by clients with trauma-related issues?
  • Do you have a web-site, any books, articles, or outside referral sources that can confirm your experience?

Education:

  • Where did you first learn about trauma and dissociation?
  • Who have you studied with, and/or who mentored or supervised your early years of trauma work?
  • What conferences and training programs have you attended?
  • What have you done to build and develop your expertise in the trauma field?
  • Where do you go for help if you have a clinical question?
  • Do you have a valid mental health license, and can you verify that your license is in good standing?

Approach:

  • In your opinion, what are the most important aspects of trauma work?
  • In your opinion, what do people need to do to process their trauma?
  • In your opinion, how long does it take to work through trauma-related issues?
  • What do you do if someone is stuck on a particular trauma-related issue?
  • How do you manage issues related to self-injury?
  • What are your office policies for emergency situations?
  • What are your policies and guidelines for regular therapy sessions?
  • If I need additional support between therapy sessions, what do you recommend?
  • What do you think of “so and so’s” approach to therapy? (insert the names of your favorite trauma therapists or authors)
  • What are your thoughts about ritualized abuse, cult abuse, and organized abuse?

Dissociative Specialty Questions:

  • How do you define Dissociative Identity Disorder?
  • In your words, what is involved in the treatment process for Dissociative Disorders?
  • When do you approach trauma / memory work?
  • In your opinion, when is a client not ready to do memory work?
  • What are your beliefs / perspectives about who the alters are?
  • Do you speak directly to insiders? Why, or why not?
  • Do you prefer all communication to go directly through the host / adult / front part? Why, or why not?
  • What kinds of homework will you expect my system to do outside of the therapy sessions?
  • What are your beliefs and approaches to integration?
  • How do you define “success” in terms of treatment goals for DID / MPD?
  • Have you ever worked with mind control issues? If so, what do you do?

Of course, as you go through the interview process, be sure to ask clarifying questions about the answers you are being given. Any therapist that understands trauma disorders is going to understand why you need to check them out thoroughly. Needing time to build trust is obvious, and having the same theoretical foundation is critical.

These are not personal questions. Keep your questions focused on the type of work that will happen in the therapeutic environment, and not on the therapist as a person.

Before you get emotionally attached to a therapist, please make sure that their approach fits with how you want to proceed with your own therapy.

Your healing journey belongs to you. You get to decide how it will look, and what paths you will take. Working with a therapist that fits with what you want is critically important. Otherwise, you will waste a lot of precious healing time struggling with opposite or conflicting goals. The journey will go much smoother if you and your trusted therapist approach your healing process from the same wavelength.

Not ADHD, Not Bipolar, Not Learning Disabilities – Trauma

There are numerous signs and symptoms that let us know when our child has been traumatized. As we review them, it will become apparent that many are also part of other more commonly diagnosed problems, such as ADHD, bipolar disorder, and depression. This has become a serious problem in the fields of medicine, mental health, and education. Children are being misdiagnosed and prescribed ineffective medications that often do not work because the original diagnosis was wrong. It is my hope that with more parents learning about trauma and its impact on children’s functioning at home and at school, we will stop the misdiagnoses and use of medications that have harmed many of our children.

Once traumatized, two different patterns of responding to the environment emerge. Some children appear hyper and highly irritable – an overaroused-looking pattern – while other children look shut down, withdrawn, or dissociated – an underaroused-looking pattern. Whether overaroused or underaroused, the key to understanding traumatized children is to know that their nervous system is unregulated and out of balance. It is revved high and wound tight.

One trauma survivor described the dichotomy of undersarousal in this way: “You feel like a duck. You’re sitting on the water all regal but you’re pedaling like hell underneath.” Another trauma survivor said that with underarousal, “It’s like your body stops, but your insides keep moving.” The underaroused pattern only looks like the trauma survivor is calm and less aroused than in the case of the overaroused pattern. Inside, however, the nervous system is just as revved.

Overarousal often looks like children have lost control of themselves, while underarousal looks like children have given up. Picture the child who is constantly getting up out of his seat, trying to get involved in other people’s business, putting his hands and feet where they are not wanted. Consider the child who looks for fights, using his body and face to intimidate, threaten and provoke. Think of the child who looks at people suspiciously and often complains that people are looking at him funny, trying to start a fight with him. These are the children who are overaroused, who get noticed, and who are more obviously traumatized.

Alternatively, think of the child who has given up. The one who does not seem to try anymore, who sits at his desk claiming he is bored, or does not care, or nothing matters, or there just isn’t anything he likes. Picture the child who is withdrawn from friends, teachers, or other adults, who looks like he is trying to disappear. This is the student who is underaroused or dissociated. He may stare blankly, daydream, look through you, not hear what you are saying, or forget what you just told him.

Some traumatized students may demonstrate one or the other response pattern most of the time, but others may display both of them at different times throughout the same day. Some children alternate between shutting down completely when something challenges them, and jumping out of their seat to look for a fight for no apparent reason. They may alternate between staring blankly for several minutes at a time, daydreaming, and then accusing their siblings or classmates of looking at them funny and threatening them violently.

Additional signs and symptoms of traumatization are as follows:

fears, anxieties, worries, nervousness, thoughts of doom psychosomatic complaints (sore tummy, headache, aches/pains) inattentiveness, distractibility, difficulty concentrating, confused, dazed daydreams, spacey, “floating through life” quality, out of body experiences tantrum behaviors, easily upset, difficult to soothe, excessive crying anger, rage, aggression, violence, threatens and/or attacks others selfinjurious behaviors (cutting, mutilating, threatens/attempts suicide) difficulty processing, learning, and retaining information difficulty retrieving information already learned compulsive behaviors (excessive talking, hitting others) eating disturbances (eating too much or too little) sleep disturbances (nightmares, sleepwalking, night terrors) attentionseeking behaviors anxiety disorders (school phobia, separation anxiety, OCD, panic attacks) ADHDlooking behaviors (can’t sit still, can’t concentrate, “ants in the pants”) reenactment of the trauma (obsessive thoughts regarding guns/death; looks for fights and/or dangerous situations, fearless, instigates punishments) difficult to engage, avoids or refuses to work perfectionist, rigid, inflexible (big upsets over small mistakes) enuresis (wets pants), encopresis (soils pants) selfmedicates (sniffs glue, smokes marijuana) bullies or is the “scapegoat” excessive clinging easily startled and jumpy irritable and agitated withdrawn from family and friends sad, listless, decreased activity extreme sensitivity to light and sound sexual acting out fear of going crazy

TRAUMA CHANGES THE BRAIN

The fact that trauma changes the brain, does not mean that with the right kinds of intervention we cannot do much to reverse the effects of trauma on the brain. That is very important to remember. With the right kind of help, children who have been traumatized can heal and regain much of their pre-trauma abilities.

Once traumatized, children’s baseline levels of arousal and anxiety become elevated or “stuck on high,” even when they look like they are underaroused. This is the result of several different neural and biochemical systems responding to the experience(s) of terror. For instance, people who have been traumatized develop abnormalities in the release of brain chemicals that regulate arousal and attention (van der Kolk, 2002). In untraumatized children, stress activates all the principle anti-stress hormones which enable active coping behaviors. In traumatized children, however, relatively low levels of these anti-stress hormones exist causing an inability to regulate or manage responses to stress (van der Kolk, 2002). This is why traumatized children are easily overwhelmed by the demands of their environment, especially school.

The elevated baseline levels of arousal and anxiety in traumatized students leaves them in a persistent and biologically-based state of low-level fear (Perry, Pollard, Blakley, Baker, & Vigilante, 1995). Their more sensitive system can now become highly aroused by what we may consider minor stressors, such as attending school and learning new academic material.

Research in the field of psychology has for decades made us aware of the need for an optimal level of arousal in order for learning to take place. Arousal has the potential to stimulate learning, memory, and performance when it is optimal, and has the potential to inhibit learning, memory, and performance when it is in excess of what can be comfortably regulated by the learner’s nervous system. When functioning within the optimal zone of arousal, children are able to process, integrate, and remember information. This is key to understanding children who have great difficulty learning and performing in the classroom.

High levels of arousal interfere with information processing in all people, not just children. Advocates in the field of health and medicine today recommend that patients bring a friend or family member with them to the doctor’s office when facing potentially life-threatening conditions. This is because we know how difficult it is for patients to process information while in a highly aroused state. Any one of us who has had to face this alone knows how little we remembered of what the doctor said. Only after getting into the safety of our own home, for instance, do we think of all the questions we had wanted to ask but forgot in the moment.

The traumatized child has difficulty processing verbal information especially. Various studies assessing trauma’s impact on the brain found increased activity in the right hemisphere, involved in nonverbal processing, while the activity of the left hemisphere, responsible for language processing, was decreased (Teicher, 2000; van der Kolk, 2002).

High levels of arousal cause our children to feel more anxious, and when more anxious, closer attention is paid to nonverbal than verbal cues (Perry et al., 1995). Traumatized children actually become fixated on nonverbal cues that may aid in their survival, even when no real threat in the present moment exists. Remember, traumatized children live in a state of low-level fear most of the time, readying themselves for the next threat, whether real or perceived. Their brain’s first and only concern when feeling threatened is survival, not reading, writing, or arithmetic. The curriculum and other classroom demands are ignored when the focus of the brain is survival.

By extension of their difficulty processing verbal information, traumatized children also have great difficulty following directions, recalling what was heard, and making sense out of what was just said (Steele & Raider, 2001). Focusing, attending, retaining and recalling verbal information are all difficult tasks for the traumatized child, as is problem-solving (Yang & Clum, 2000).

Finally, the chronic high state of arousal that traumatized children live in interferes with learning by interfering with the functioning of the hippocampus, that part of the brain that is responsible for memory. One study found that traumatized children have lower memory volume in their left-brain hippocampal areas (Bremmer, Krystal, Charnez, & Southwick, 1996) while another study found that the stress involved in trauma caused the release of hormones that damaged the left hippocampal area thereby increasing memory deficit. REM sleep, a critical agent in the consolidation of memory, is disturbed in those with unresolved trauma (Siegel, 2003).

It is nearly impossible for children to consolidate memories – working memory into short-term memory and short-term memory into long-term memory – when they cannot concentrate. Children are less capable of concentrating when they are in a chronic state of high arousal or anxiety. Both short-term (Starknum, Gebarski, Berent, & Schterngart, 1992) and verbal or explicit memory (Bremmer et al., 1996) suffer when people are in this state.

TRAUMA CAN BE HEALED

Yet so many continue to suffer for years, even decades – regardless of various forms of therapy. This is because most forms of therapy involve the so-called “talking cure” which engages the part of the brain least involved in the experience of trauma.

When we are impacted by a traumatic event, we become overwhelmed – not just psychologically, or in our mind – but physiologically as well, in our body. During overwhelm, we become governed by the oldest part of our brain that overrides our newer, more rational, cognitive brain to focus exclusively on survival. It is this part of the brain, our old brain that needs to be more engaged in the therapeutic process in order for therapy to work in the long-term.

Through the language of sensations – not thoughts or feelings, but sensations -it becomes possible to engage our old brain. When we incorporate the body and its physical sensations into therapy, trauma can be healed.

The pervasive view as a result of the commonly used medical model is that symptoms of post-traumatic stress constitute a lifelong disorder that can only be managed with medication and therapy. This is not the case. I have seen firsthand how these natural yet persistent responses to a traumatic event can be healed when the body and its sensations are integrated into treatment.

HOW YOU CAN HELP YOUR CHILD

The following list details the many things we can do to help heal our child’s post-traumatic stress:

1. First recognize that your internal state completely affects your child’s internal state. Children absorb the energy, calm or anxious, of their parents and other adults like a sponge absorbs water. Recognize that your own unresolved trauma may get triggered by your child’s experience and cause you to have an anxious internal state that will interfere with your child’s ability to heal. Get the help you need through the support of family and friends, or a professional, if need be, so you can be calm and well-resourced for your child.

2. Surround your child with affectionate loved ones who will act as a healing community for him or her. Do not allow your child to isolate. Healing takes place in communion with other people who remind us that we are not alone and that together we can get through anything.

3. Help orient your child to the world around him or her. Traumatized people tend to go into dark, internal places that only reinforce their suffering. Although being outdoors in nature can be very resourceful, whether inside or outside, have your child look around and notice whatever is around him or her. Play a simple game called, “I See, I Hear, I Sense,” during which you take turns naming something you see, something you hear, and something you sense inside your body. Take turns reporting a physical sensation you notice in your body, such as warm, cold, jumpy, calm, tight, tense, relaxed, strong, weak, solid, mushy, etc.

After your child reports a sensation, especially an unpleasant one, encourage him or her to focus on the sensation until it changes. It always does without having to make it happen. If the unpleasant sensation lasts more than a minute or two without shifting, simply have your child orient to the world around him or her again and the sensation will change (for more details about this important healing process, please read, “Why Students Underachieve: What Educators and Parents Can Do about It,” pages 123, 124).

4. In trauma, people lose their ground – their sense of connectedness to themselves, to the earth, to nature, and to other people. Help your child re-establish a sense of ground by having him or her sit in a chair with his or her feet firmly planted on the floor. Have your child notice how he or she is being supported by the chair and the floor. Have them locate their center of gravity in the abdomen area by having them place their hands on their belly and focus on their breathing. Encourage your child to fill his or her belly with air as he or she takes a deep breath in through the nose. Trauma often restricts breathing patterns to the chest area, keeping oxygen from the rest of the body. Having your child experience a fuller, deeper breath that nourishes a larger region of the body is a helpful intervention. Breathing in through the nose engages the part of the nervous system that helps calm and relax, whereas breathing in through the mouth engages the part of the nervous system responsible for accelerated heart rate and blood pressure. You can redirect your child’s breathing very simply so they experience a greater sense of ease.

5. Maintain a moderately quiet, safe place at home within which your child can live and work as peacefully as possible. Loud music or noises, especially yelling, can keep the arousal level of a traumatized child very high. Keep television news and other disturbing stories and images away from your child’s attention.

6. The high arousal levels of traumatized children require firm yet flexible limits and boundaries that allow them a certain amount of room to move. Although they will test these boundaries with various challenging behaviors, what they really crave is the containment that limits provide. Consistently apply the same consequence for the same behavior. The more traumatized children can predict exactly what will happen if they behave a certain way, the safer they will come to feel in their environment.

7. You cannot positively acknowledge your traumatized child too much. In order to develop a sense of competency, value, worth, pride, satisfaction, and strength, children need to earn positive recognition. Consistently reward your child for desirable behaviors, with a smile, a hug, and an encouraging word.

8. Use time-out intelligently, and ultimately, successfully by first teaching yourself and then your child to connect with bodily sensations in order to use them as signals. Bodily sensations of heat, rapid heart rate, tightness, or tension, for example, may signal the need for time away from others in a safe, non-punitive place. Having such a place to go to as a resource – without being banished there punitively – can help the nervous system do what it needs to do to calm and return to balance (this usually takes 20 minutes).

9. Help your child build and/or maintain and access resources, such as friends, loving family members, and activities they are good at that help them feel competent and successful, whether academic, athletic, artistic, or philanthropic/helpful to others. All children need to feel like they matter, that they are of value, and have an important contribution to make.

10. Offering quiet (very little talking) connection through gentle holding can help facilitate the release or letting go of stress and anxiety. When holding your child, you may notice your child trembling, shaking, giving off heat or sweating, even yawning excessively. These responses are not only normal but also healthy and should not be interrupted but simply watched and validated through brief statements like, “That’s it. That’s okay. Just let that happen. I am right here with you.” (More on this in “Why Students Underachieve: What Educators and Parents Can Do about It,” pages 62, 63.)

11. While it is unnecessary and sometimes harmful to have your child talk about a traumatizing event(s), if your child continually brings it up and wants to talk about it, it is important to emphasize at different points throughout the story what your child’s resources were – who or what was helpful to them or what their strengths were that contributed to their survival.

12. Educate your child’s teachers and doctors about what your child has been through and what his or her particular needs are. Be cautious about accepting lifelong labels and prescriptions for medication. There are many alternative understandings and treatments that offer greater hope and have far fewer side effects.

For more ideas, and to understand why they are helpful, please read “Why Students Underachieve: What Educators and Parents Can Do about It.” Pages 143-148 highlight what is important not to do with your traumatized child (although this section is part of the chapter on emotionally disturbed (ED) students, the fact that traumatized children and ED students respond in similar ways some of the time does not mean that your child is ED).

CONCLUSION

I hope this guide has made it clear that if we want to heal trauma, the language of sensations cannot be ignored. Traumatic events are experienced and recalled not just by our cognitive mind but also by our brain and body. The longer we engage only the cognitive mind in the healing process, which is what we do when we send our traumatized child to an anger management group or to a traditional talk therapist, the longer healing does not take place – especially not in the long term. This can actually create more damage than we ever imagined. New insights without the body’s capacity to follow through can set up troubled children for feelings of greater failure, shame, and helplessness because they now know better but find that they still cannot do better. No matter what their cognitive mind thinks is possible, their body has not been engaged in the healing process and, therefore, cannot physically tolerate the feelings and sensations of pain and discomfort that their daily lives evoke.

© Regalena Melrose, Ph.D. 2009