June is, among other designations, also PTSD Awareness Month. As a trauma-informed outpatient behavioral health clinic, the CLC's Center for Resilience (CFR) has a particular heart and passion for the work of healing Post-Traumatic Stress Disorder (PTSD), and as the center’s director, I have had the privilege of witnessing the dedication and skill of our clinicians as they serve trauma survivors of all ages.
However, one thing that stands out time and again with many of our families as they begin care is how many people do not know the signs and symptoms of PTSD, and often the diagnosis catches them by surprise when they hear the words. Most of our referrals come from forensic interviews as the result of abuse, neglect or exploitation. PTSD is often associated with first responders or victims of single-incident events, so many survivors and families initially don't understand the differences between what experts call “Big T” trauma and “little t” traumas.
Trauma Types: “Big T” versus “little t”
“Big T”
According to the National Institute for Mental Health (NIMH), Big T traumas are identified as those events directly threatening life or bodily integrity; whereas 'little t' traumas are events and experiences that exceed one’s ability to cope and compromise our emotional functioning. The Diagnostic and Statistical Manual (DSM-V TR) does not yet identify a distinction between “PTSD” and “Complex PTSD” or “Developmental Trauma,” despite being first recognized in the 1980’s. While this is true, many helping professionals already see and understand the significant differences in both cause and treatment.
If we look at Big T traumas, it’s fairly easy to understand what it means when we hear someone has been in a violent incident, has had a car accident, has been mugged or attacked in some way. The resulting PTSD that can occur is directly linked to a significant event, and we often have compassion, clarity and understanding of the emotional, and even neurobiological, wounding that happens for those individuals.
Some, but not all, individuals who suffer from a Big T trauma events have a community or support system who validates their experience. The support persons are able to verify the proportionality of the response to the event, they are more apt to offer comfort and companionship, if not encouragement and ongoing resources as the person heals. A Big T trauma is a singular event.
“Little t”
In contrast, 'little t' traumas often occur in environments characterized by systemic abuse or generational trauma. These traumas consist of ongoing, repetitive events that impact an individual continuously. In such settings, dysfunction and physical or emotional impairments—such as emotional, physical, or sexual abuse and neglect—are not only normalized but often kept secret.
Not only are these ongoing events invalidated and obscured, but the support system one might rely on—such as family and friends—often includes the perpetrator(s) and others complicit in perpetuating the abuse and neglect. This type of dysfunctional environment frequently gives rise to complex PTSD or developmental trauma.
It is also important to understand that an individual can also experience Big T and little t traumas in their lifetime, further exacerbating and/or compounding the affect and trajectory of their PTSD symptoms.
CFR’s Approach to Treating Trauma
At the CFR, many of our cases are the result of ongoing, systemic abuse and neglect, which means we most often treat complex-PTSD. Furthermore, many cases originate from homes where caregivers themselves suffer from complex PTSD, highlighting the generational patterns of trauma that become normalized and perpetuated. These patterns persist because previous generations often lacked the knowledge or resources to break the cycle and heal from ongoing abuse and dysfunction.
PTSD Signs and Symptoms
What are the signs and symptoms of PTSD, and how do they differ between PTSD resulting from "Big T" traumas versus "little t" traumas?
Though the specific criteria for PTSD requires the assessment of a treating professional, here are a few things to note:
• Both kinds of trauma (Big T or little t) can result in PTSD symptoms
• Both can result in flashbacks, recurring memories and/or distressing thoughts
• Both put a person at high risk for physical symptoms due to the body’s stress response
• Both can create avoidance symptoms
• Arousal and reactivity symptoms are heightened, including startle responses
• Irritability and aggressive reactions are also frequently heightened
• Risky and impulsive behaviors are common with those having PTSD
• It’s not uncommon for persons to have memory issues, including significant gaps
• Sufferers often experience low self-concepts and high experiences of guilt
• It’s often common to have no or low positive emotional experiences
• People often engage in social isolation and suffer from depression
• There’s often a reduction in enjoyment from previous hobbies or areas of interest
• Complex-PTSD, in particular, comes with a diminished sense of self concept, diminished sense of self-efficacy (personal belief in one’s own power to change) and increased rates of suicidality
In Dr. Arielle Schwartz’ “The Complex PTSD Workbook” she outlines the most common experiences for individuals suffering from C-PTSD:
• Cognitive Distortions including inaccurate beliefs about self or the world
• Emotional Distress including overwhelm, anxiety, helplessness, deep loneliness, shame, sense of unfairness or injustice, etc.
• Disturbing Somatic Sensations in the body that are the result of psychological distress.
• Disorientation in beliefs, emotions, and body sensations that can distort distinction between the past and the persent.
• Avoidance that can look like shutting out or pushing away uncomfortable sensations, memories or emotions; resulting in denial, repression, dissociation or addictive behaviors.
• Interpersonal problems resulting in a pattern of dysfunctional relationships and family systems.
• Brain structure is developmentally impacted by the abuse and neglect which can lead to deficits in social and/or academic skills.
Children and Youth with PTSD
Specifically for kids and teens, the observable trauma symptoms can be mistaken for behavior issues or developmental impairments alone, and it’s not uncommon for youths to be given a diagnosis of attention deficit hyperactivity disorder, oppositional defiant disorder, or other neurodivergent disorders.
Though the criteria for these disorders might be met and even understandable on their own, it’s not entirely appropriate to couch the condition in one of these diagnoses and omit the contribution of a traumatic event or ongoing traumatic and/or abusive environment. In fact, if we look at what trauma creates in the body, it’s not hard to understand the following links between trauma and what we often see in children and teens:
• Ongoing trauma creates a hypervigilant response in the body as a result of the body needing sensory data to be heightened in order to activate the fight or flight response. If one grows up in a home or environment where abuse or violence is intermittently present, hypersensitivity to body language, facial expressions, or other sensory cues for impending danger would need to be ‘on’ all the time in order to prepare to keep one safe.
• Ongoing traumatic environments put the body in a kind of ‘idle’ mode creating a baseline of stress that’s much higher than the population not suffering from trauma. This idling mode means the body is in a ‘decreased but ongoing level’ of stress all the time, pumping adrenalin and cortisol through the body at low levels and then spiking those levels when signs of more acute stress is signaled. These ongoing surges have a detrimental impact on body and brain development. Additionally, during a stress response the body shuts down or reduces systems within the body that are not imperative to safety. Digestion, circulation, metabolism, even higher-level brain functioning is not nearly as essential in this mode as the brain’s fight or flight response or the muscular and cardiovascular functions that will help us fight or flee from danger. This stress response is the basis for the ACE Scale that measures the correlation between adverse childhood experiences and potential future health issues.
• Finally, we also see bed wetting, increased clinginess with a caregiver, acting out of trauma and even selective mutism associated with children or adolescents suffering from PTSD.
How To Help Someone with PTSD
So, what do we do if we or someone we know is suffering from any signs of PTSD? If we know someone has experienced a traumatic event, we encourage them to seek help from a helping professional; this can be a doctor, therapist, social worker, or any other trained clinician.
If we know someone is suffering as the result of a traumatic or abusive environment, we can contact a reporting agency by calling the local law enforcement or child and family services in our own community.
As a potential support person, we offer non-judgmental presence, which means we listen to what the person expresses without criticism or advice. We ask questions about what we are seeing and feeling if we are concerned, and we encourage without pressuring someone onto a path of healing.
If and when someone seeks care for PTSD, one will find many modalities and approaches. In addition to finding a safe, supportive helping professional to talk about the experiences and ongoing challenges, many clinicians can offer treatments through eye-movement desensitization and reprocessing (EMDR), Brainspotting, Trauma Focused – Cognitive Behavioral Therapy (TF-CBT), as well as mindfulness techniques to manage the frequent experiences of anxiety and ongoing dissociation.
Because children process differently than adults, experiential modalities, such as play therapy, art therapy and sand play therapy, are often used to allow children to explore the deeper, subconscious experiences of trauma without having to find language they have yet to develop or understand.
At the Center for Resilience, we are also trained in and utilize the Neurosequential Model of Therapeutics, or NMT, to help build a brain map for complex trauma’s impact on neural development. Through this model, created by Dr. Bruce Perry, our practitioners can then recommend activities and interventions to caregivers, teachers and therapists in order to directly target the areas of the brain most effected by the trauma a person has experienced based on what occurred and when it happened in that person’s development.
For more information about PTSD or resources, visit these websites:
• https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd
Learn more about the CLC Center for Resilience at: https://www.childrenslegacycenter.org/our-services
