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Trauma, Physical Health, & Psychological Wellbeing in the Context of Adverse Life Events

Exposure to adverse or traumatic events in life is a common experience (van der Kolk & McFarlane, 1996). These events can vary from minor to severe, can affect individuals or communities, and people react to them in different ways. Many people are resilient, but some develop symptoms of posttraumatic stress disorder (PTSD), have lower physical health, higher rates of mental disorders, and lower psychological well-being. Furthermore, these reactions can vary in how they are expressed between cultural contexts, can be vastly different for everyone, and can both improve or worsen over time. PTSD relates to numerous biological processes, including brain chemistry and hormonal changes. McFarlane (2010) writes, “…PTSD is not simply a psychosocial disorder, but one underpinned by a major neurobiological disruption” (p. 8). In assessing the whole-person impact of PTSD, it is important to consider and treat a variety of factors.

Allostatic load refers to the cumulative stress on the hypothalamic pituitary adrenal axis (HPA) as well as the autonomic nervous system (McFarlane, 2010). Exposure to trauma may not elicit symptoms of PTSD, nor acute stress disorder (ASD), for a significant time (more than 6 months) after the event; this is called delayed-onset PTSD. Furthermore, those who have experienced depression or been diagnosed with ASD may be able to initially manage symptoms to the point of remission – only later to have a resurgence of symptoms. In the case of ASD, this would change the diagnosis to PTSD. Research speculates that this is related to another traumatic event, or even the cumulation of smaller stressors, until the system becomes overloaded. This commonly results in somatic manifestations.

Chronic pain without a medical cause has a strong relationship to PTSD (Andreski et al., 1998), largely thought of to be related to the allostatic load (McFarlane, 2010). In those with chronic pain and PTSD, there are also noticeable changes in the hippocampus, cortisol, amygdala, and gene expressions. These biologic reactions also correspond with fibromyalgia, chronic fatigue, and irritable bowel syndrome. Furthermore, individuals with PTSD are at an increased risk for hypertension and cardiovascular disease, connected with repeated traumatic triggering leading to hyperactivity of the sympathetic nervous system. Significantly higher levels of cholesterol and triglycerides have been found in people with PTSD, even when compared to individuals with depression (Karlovic et al., 2004). Individuals with PTSD are also more likely to be overweight or obese or have coronary heart disease (McFarlane, 2010).

In a study of pregnant Peruvian women, there was shown to be a high correlation between those that had both migraines and PTSD (Friedman et al., 2017). Interestingly, the authors explain that there are numerous overlaps in brain chemistry and hormones between both migraines and PTSD, including lower levels of cortisol, plasma, norepinephrine, higher levels of pro-inflammatory cytokines, and reduced or unstable levels of serotonin. A study of Syrian and Iraqi refugees similarly found increased pro-inflammatory cytokines among those who had PTSD, depression, or anxiety (Grasser et al. 2020).

All of these medical issues are frequently comorbid with individuals with PTSD. Interestingly, many of them also correspond with common cultural idioms of distress in collectivistic cultures, such as in Syria, who often describe trauma and mental distress symptoms as having headaches, racing or pressure on the heart, insomnia, unexplained pain, and stomach pain (Hassan et al., 2015). Systemic, social, cultural, and community factors should also be addressed – especially if one is from a collectivistic society, or the traumatic event impacted a group – a family, a community, or a whole culture or country, such as in the case of war and genocide.

Furthermore, general psychological well-being is also often dramatically reduced in conjunction with traumatic stress. Roberts et al. (2020) write that more than “80% of individuals with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more comorbidities” (p.417) in the general population. Common psychological comorbidities are depression, anxiety and panic disorder, substance use disorders, severe mental illnesses, and personality disorders, especially borderline personality disorder. ADHD is also a common comorbidity (van der Kolk & McFarlane, 1996). Furthermore, people impacted by PTSD tend to organize their whole lives around the trauma, such as recreating the pattern in their relationships, and avoiding any hint of a traumatic trigger, causing profound changes in their thoughts, feelings, and behaviors (van der Kolk & McFarlane, 1996). Adults with a large number of adverse childhood experiences have significantly increased risk of a poor mental well-being (Hughes et al., 2016). Such individuals also have shown to have significantly lower social well-being (Mosley-Johnson et al., 2019).

Clinical implications are that treatment and assessment needs to expand to consider all of these factors. Traditionally, the use of anti-depressants and cognitive behavioral therapy have been the norm in treating PTSD (McFarlane, 2010), and medical doctors treat physical problems as separate issues. The ideal treatment would occur shortly after the traumatic event, even if an individual has not yet expressed symptoms, to train one’s psychophysiology to regulate itself early on. A study of Tutsi genocide survivors showed high rates of PTSD and CPTSD, and their children also suffered secondary symptoms of trauma (Shrira et al., 2019). Both parents and offspring had lower rates of resilience when parents suffered from CPTSD. Had trauma focused interventions occurred shortly after the genocide, it is possible that intergenerational trauma may have been avoided. Additionally, co-morbid symptoms both psychological and physical should be addressed in holistic approaches. One promising recent therapeutic modality that seeks to do this is Somatic Experiencing, which has been found to reduce symptom severity of PTSD and depression (Brom et al., 2017) and in PTSD-related chronic pain and disability (Andersen et al., 2017).

Clearly, the implications of the havoc of PTSD are severe. “There is the potential for a pervasive disruption of an individual’s neurobiology and psychophysiology following exposure [of traumatic stress], and PTSD is only one end point…exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis” (McFarlane, 2010, p.7). Trauma-exposed individuals should be treated immediately even without symptoms and should be educated to self-assess over their lifespan. Holistic models which treat both physical and mental disruptions and comorbidities are paramount. Culture and environmental factors also should be carefully considered in assessment and treatment. Trauma changes us to our very core and in our entire well-being; increasing awareness and treating it as such is critical for both sufferers, and medical and mental health providers.

References

Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017). A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid post-traumatic stress disorder symptoms. European Journal of Psychotraumatology8(1). https://doi-org.tcsedsystem.idm.oclc.org/10.1080/20008198.2017.1331108

Andreski P, Chilcoat H, & Breslau N. (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res, 79, 131-8.

Brom, D., Stokar, Y., Lawi, C., Nuriel, P. V., Ziv, Y., Lerner, K., Ross, G., & Nuriel-Porat, V. (2017). Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study. Journal of Traumatic Stress30(3), 304–312. https://doi-org.tcsedsystem.idm.oclc.org/10.1002/jts.22189

Friedman, L. E., Aponte, C., Perez Hernandez, R., Velez, J. C., Gelaye, B., Sánchez, S. E., Williams, M. A., & Peterlin, B. L. (2017). Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women. The journal of headache and pain18(1), 67. https://doi.org/10.1186/s10194-017-0775-5

Grasser, L. R., Burghardt, P., Daugherty, A. M., Amirsadri, A., & Javanbakht, A. (2020). Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees. Behavioral Sciences10(4), 75. doi:10.3390/bs10040075

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hughes, K., Lowey, H., Quigg, Z. et al. (2016). Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey. BMC Public Health, 16,222. https://doi.org/10.1186/s12889-016-2906-3

Karlovic D, Buljan D, Martinac M et al. (2004). Serum lipid concentrations in Croatian veterans with post-traumatic stress disorder, post-traumatic stress disorder comorbid with major depressive disorder, or major depressive disorder. J Korean Med Sci, 19, 431-6.

McFarlane A. C. (2010). The long-term costs of traumatic stress: intertwined physical and psychological consequences. World psychiatry : official journal of the World Psychiatric Association (WPA)9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x

Mosley-Johnson, E., Garacci, E., Wagner, N., Mendez, C., Williams, J. S., & Egede, L. E. (2019). Assessing the relationship between adverse childhood experiences and life satisfaction, psychological well-being, and social well-being: United States Longitudinal Cohort 1995-2014. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation28(4), 907–914. https://doi.org/10.1007/s11136-018-2054-6

Roberts, S.E., Mueser, K.T., & Murray, L.K. (2020). Treatment considerations for PTSD comorbidities. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry research271, 121–123.   Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Symptoms of PTSD and Complex PTSD in Western Cultures & Syrian Culture

Post-traumatic stress disorder (PTSD) is a psychological disorder which is included in both the DSM and the ICD-11, but only the ICD-11 explicitly includes a distinction of Complex PTSD (CPTSD) (Cloitre et al., 2019). The inclusion of CPTSD is important, as it encompasses research on how PTSD manifests within prolonged or repeated trauma exposure, particularly in early childhood, but also include the impacts of cultural and collective trauma (Hirschberger, 2018), such as that which is experienced in mass catastrophic events such as war, genocide, slavery, colonization, racial trauma (Comas-Díaz et al., 2019), etc., and intergenerational trauma (Yehuda & Lehrner, 2018). The civil war in Syria, ongoing since 2011, is one example of such a significant collective trauma, which may have lasting intergenerational trauma effects. However, the Western medical-style model of diagnosis of mental illnesses does not explicitly account for cultural differences in how Syrians experience, understand, and express trauma.

Van der Kolk and McFarlane (1997), who provide a deep understanding of the multitude of ways that trauma can manifest beyond what manuals like the DSM provide or ICD-11 provide, write that “experiencing trauma is an essential part of being human; history is written in blood” (p.3). Traumatic experiences can vary in their intensity, and whether they develop into the pathology of PTSD depends on their context, and the coping skills of the individual experiencing the event. Some people can process such traumatic exposures in ways which allow them to return to healthy functioning, while others do not. Those that develop PTSD start to develop unhealthy defense mechanisms and behaviors to avoid even subtle reminders of the trauma, which can affect the entire way that they structure their lives. “The core issue is the inability to integrate the reality of particular experiences, and the resulting repetitive replaying of the trauma in images, behaviors, feelings, physiological states, and interpersonal relationships” (van der Kolk & McFarlane, 1997, p.7). In most cases, PTSD is spurned from a singular event, or tightly clustered events, while CPTSD occurs when there is repeated or prolonged exposure to traumatic situations, such as child abuse at a critical stage of development. Due to the nature of PTSD broadly, trauma victims tend to reenact (usually subconsciously) the trauma in other aspects of their lives, leading to continued traumatic experiences, further deepening the complexity of CPTSD (Foa et al., 2009).

Whole societies and cultures can also be traumatized and can follow “roughly similar patterns of adaptation and disintegration” (van der Kolk & McFarlane, 1997, p. 3) as traumatized individuals. States can react to traumatized populations in various ways – in the U.S. it is typically with some immediate compassion, but a fallback on an attitude of blaming victims as their own responsibility for the trauma, seeking to maintain the status quo, and projecting a message of safety for society (van der Kolk & McFarlane, 1997). When considering the case of Syria, the authoritarian regime has sought to eradicate trauma narratives and instead impose their own version of the story through such tactics as monopolizing higher education to maintain their power and enforce their political agenda. (Al Azmeth et al., 2020). Matos et al. (2021) found that “…war severely disrupted Syrians’ sense of collective self, and that they repeatedly engaged in search for meaning, appraisals of the war, and reappraisals of shattered beliefs, life goals, and sense of purpose, both during wartime and in resettlement” (p.1).

Vallieres et al. (2018) conducted a study of Syrian refugees in Lebanon, using the International Trauma Questionnaire (ITQ) and the ICD-11 in examining both CPTSD and PTSD levels and validity for this population. They found that CPTSD was more prevalent than PTSD, and that the ICD-11 and ITQ were cross-culturally applicable – with some limitations. The levels of traumatic exposure were high, with the events ranked as most distressing by participants being forced displacement, bombings, and losing loved ones both through unexpected deaths and forced separations. Participants shared that they felt that the questionnaire seemed to be understanding of their experience. One noted limitation was that common symptoms were amnesia and lack of concentration, but these weren’t addressed in the ITQ questionnaire. Participants also felt some of the questions were irrelevant to their situation and cultural context. It was also noted that completing the questionnaire was unfamiliar and challenging to many refugees – so it may be that the use of such assessments give poor reliability within this cultural context. Furthermore, the trauma of some participants made them hesitant in answering some of the questions, invoking what would appear to be paranoia and hypervigilance. The authors suggest that the use of such questionnaires or assessments may first require a building of rapport and trust with the person administering them. This challenges the Western model of research, in which the researcher is to remain unbiased and emotionally removed from the participants (Jhangiani & Tarry, 2014).

Syrians express trauma and mental illness differently from Western societies. A study on PTSD and CPTSD using the ICD-11 in the US did not include questions or measures on somatic symptoms (Cloitre et al., 2019). The above study on Syrian refugees by Vallieres et al. (2018) similarly did not include somatic symptoms. However, somatic descriptions were commonly found as expressions of mental illness, distress, and trauma in other studies (Barkil-Oteo, 2018; Borho et al., 2021; Hassan et al., 2015). Barkil-Oteo et al. (2018) state that traditional, even culturally adapted, measures were insufficient in capturing the true range of symptoms experienced by refugees, who, in addition to prior trauma exposures, have “both repeated and ongoing traumatic triggers (fear from the past, current uncertainties, new traumas)” (p.9). They noted high prevalence of fainting, dizziness, weakness, and chronic pain in this population which had been ruled out of medical causes. Patients often first presented with such physical complaints before sharing emotional or mental distress. Borho et al. (2021) found a high correlation between somatic complaints and traumatic exposures, stress, and depression and anxiety symptoms in Syrian refugees in Germany. Syrians “do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan et al., 2015, p. 22).  One explanation for this emphasis on psychical symptoms is that mental illness is not well understood and is highly stigmatized in Syrian culture. Furthermore, the cultural framework within both Islam and Christianity (the primary religions of Syria) is that suffering is a part of being alive and does not need special interventions unless it is severe. However, with the increased normalization of mental health within host countries and among communities of refugees, knowledge and awareness of mental health and PTSD are growing and losing some of their stigma.

Hasan et al. (2015) provide a comprehensive overview of culturally specific idioms of distress for Syrian peoples. For example, saying one is tired or their psyche is tired “refers to a general state of ill being and may stand for a range of emotional symptoms, but also for relationship difficulties” (Hassan et al., 2015, p. 22). Ruminative thoughts are attributed to the influence of the devil, and severe mental and emotional disorders are sometimes considered to be the work of mischievous or evil spirits such as jinn. Symptoms of mental distress, which can also be comorbid with PTSD and CPTSD include such things as anxiety, depression, cognitive difficulties, helplessness, anger or aggression, and extreme stress, are often described in proverbs or metaphors. Western-trained professionals may misconstrue these as psychotic indicators. An example of a somatic description of fear or anxiety is a literal sensation of one’s heart crumbling or falling. An example of a metaphorical description for helplessness is “the eye sees but the hand is short or cannot reach” (Hassan et al., 2015, p. 23).

There is very little research on Syrians’ mental health, including trauma rates and responses, from before the onset of the war in 2011. Therefore, much of the research today comes from Syrian refugees residing outside of Syria. Furthermore, nearly all the research is focused on trauma exposures and PTSD rather than CPTSD. As noted previously, notions of mental illness and trauma are becoming increasingly normalized in this population, so, the conceptualizations and experiences of trauma may also be shifting to align more with those of the host countries’. Collective trauma is extensive in the case of the Syrian war, and the primary coping method of social connection (Hassan et al., 2015) – of extreme importance in collectivistic cultures – is radically disrupted, damaging possible resilience pathways for many Syrians.

References

Al Azmeh, Z., Dillabough, J., Fimyar, O., McLaughlin, C., Abdullateef, S., Aloklah, W. A., … &      Kadan, B. (2021). Cultural trauma and the politics of access to higher education in    Syria. Discourse: Studies in the Cultural Politics of Education42(4), 528-543.

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A    tale of a Syrian refugee. American journal of psychiatry175(1), 8-12.

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees          with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21896. https://doi.org/10.1186/s12889-021-10731-x

Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M.     (2019). ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress   Disorder in the United States: A population‐based study. Journal of Traumatic Stress,   32(6), 833–842.

Comas-Díaz L, Hall, G. N., & Neville, H. A. (2019). Racial trauma: theory, research, and      healing: introduction to the special issue. The American Psychologist, 74(1), 1–5.

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD.        Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.).        New York, NY: The Guilford Press. 

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel,          J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel,          P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of      Syrians: A Review for Mental Health and Psychosocial Support staff working with     Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hirschberger, G. (2018). Collective trauma and the social construction of meaning. Frontiers of     Psychology, 9, 1441.

Jhangiani, R. & Tarry, H. (2014). Conducting research in social psychology. Principles of social     psychology – 1st international ed.             https://opentextbc.ca/socialpsychology/chapter/conducting-research-in-social-            psychology/

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better   person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective        trauma. Int. J. Environ. Res. Public Health18. https://doi.org/10.3390/ijerph18168481

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … & Hyland, P.       (2018). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable            within a treatment-seeking sample of Syrian refugees living in Lebanon?. Global Mental       Health5. DOI: 10.1111/acps.12973

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming            Experience on Mind, Body, and Society. New York, NY: The Guilford Press.  Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role   of epigenetic mechanisms. World Psychiatry, 17(3), 243–257