Clinicians, Be Trauma-Informed.

Updated: Oct 3, 2020

The importance of Integrating Trauma-Informed Care into Functional Medicine


Adverse childhood experiences have a dose-dependent relationship with many of the chronic illnesses facing medicine today, including chronic environmental illnesses. Having a history of trauma and chronic stress can influence all aspects of an individual’s life, affecting mental, physical, and emotional health, relationships, and one’s ability to adopt and implement health-focused habits and behaviors. A growing body of research demonstrates the connection between a history of trauma and the increase in an individual's risk for chronic physical, mental, and behavioral health issues, including dementia. Many patients with neurologic illness, mental health symptoms, neuropsychiatric illnesses such as PANS and PANDAS, and chronic illness due to environmental toxins such as mold, have emotional trauma as a root cause, or can be ameliorated with limbic system downregulation. As the vital connections between chronic illness and past traumatic experiences begin to emerge, policymakers and healthcare providers alike are beginning to adopt a trauma-informed approach to healthcare to improve patient engagement and long-term health outcomes while lowering costs of care enhancing patient empowerment. 

You can implement simple steps to build stress resilience in your patients by fostering a trauma-informed relationship with them. The qualities of this relationship foster collaboration, choice, trust, and safety for patients who may have a history of micro, macro, or complex traumas.


This document includes...

  1. Trauma Defined

  2. Examples of Traumatic Experiences

  3. What does trauma look like?

  4. What is complex PTSD?

  5. What are the acute and chronic physiological effects of trauma?

  6. Model for trauma-informed medical care

  7. Symptoms of Acute Traumatic Stress

  8. How to recognize the possibility that trauma is at the root of the problem you are seeing 

  9. Chronic Effects of Traumatic Stress

  10. What to do for your patient who has a history of trauma

  11. How to speak to your patients in a trauma-informed way

  12. How to know when and how to refer by asking questions and offering gentle suggestions

  13. What is post-traumatic growth?

  14. Relaxation strategies that you can do in the office if your patient gets activated

  15. Suggested Authors

  16. List of References


Introduction

Incorporating a trauma-informed approach into your practice can improve your patient health outcomes and your well-being as well. This handout includes a brief definition of trauma in its different forms, the acute and chronic physiologic effects of trauma, and practical recommendations for physicians and other integrated clinicians looking to adopt a trauma-informed approach. Trauma recovery can be very delicate, so it needs to be approached slowly and with great care, staying carefully tuned-in to yourself and your patient. Most patients will need referrals to outside providers who are psychologists or psychotherapists specifically trained in trauma release techniques which reduce limbic system activation, diminish HPA Axis tone as well as balance the tone of the vagus nerve. The trauma relief models I prefer are Brainspotting, EMDR, Somatic Experiencing, Trauma-Informed Yoga Therapy, Vagus Nerve regulation, and other data-driven approaches.


Trauma Defined.

Trauma can be defined as any event that alters how we process, react to, and recall memories, by overwhelming the individual’s central nervous system. Additionally, trauma is defined as any event in which a person feels helpless and unsafe. It’s not only something which happens in the brain, it’s something which happens in the body as well. It is not only an occurrence that happened in the past; instead, trauma is an event that leaves an imprint upon the body and the brain which persists to the present day. Trauma expert Bessel van der kolk says that “trauma is not the story of something that happened back then. It is the current imprint of that pain, horror, and fear living inside people.” It is an experience that one is incapable of integrating and assimilating into their life after the event (4). Trauma primarily affects areas in the brain which control automatic or basic functions that impact survival impulses. That is why so often the sleep/wake cycle, general arousal, breathing, feeding, and the whole limbic system which controls memory and emotion are affected. That is also why the limbic system release techniques, or strategies to relieve trauma, are directed at calming this part of the brain. On a cellular level, it's likely that Dr. Robert Naviaux’s “Cell Danger Response” speaks to what happens to the body when it perceives an unrelenting threat.


Clinical Pearl: If a patient comes to you with chronic sleep issues, and you've ruled out other etiologies, implemented successful sleep hygiene, referred for Cognitive Behavioral Therapy for Insomnia, and had no success, think to refer for trauma psychotherapy. 


Types of maladaptive stressors, or traumas, themselves vary. Toxic stress can originate from childhood overt traumas such as neglect, physical threat, or loss of a loved one, to everyday quiet but persistent distress, such as shame, workload, relationship conflict, pain, financial burden, or unhealthy diet. These seemingly everyday stressors must not be overlooked as they can have equally harmful effects as more overt trauma. Other contributors to stress are family responsibilities, and both personal and family health concerns. Although we react to a myriad of stressors in varying ways, one of the common pathways we all share is our biological stress response system, and trauma should be seen as a physiologic cascade which persists as a biological imprint. This imprint affects brain development, the HPA axis, hormones, the immune system, and epigenetic changes as well. The imprints of intergenerational trauma and cultural marginalization cannot be overstated. Almost any experience can cause trauma to develop when a person’s unique ability to cope is exceeded and there is no one there to help. Feeling helpless in the presence of a stressor can determine whether an event is experienced as a trauma. When our capacity for dealing with stress falters, and the normal stress recovery curve doesn’t happen, trauma manifests. 


Examples of Traumatic Experiences 

  • Growing up in an environment where nobody sees, protects, and helps you cope with the reality of life.

  • Gestational or birth challenges such as mental illness in the mother or malnourishment of the fetus. 

  • Having insecure attachment relationships as a child to primary caregivers

  • Physical, sexual, or emotional abuse.

  • Any natural disaster such as being in an earthquake, hurricane, or flash flood. 

  • A sudden, unexplained separation from a loved one.

  • The death of a loved one.

  • Childhood neglect.

  • Intergenerational trauma.

  • Discrimination, racism, and oppression.

  • Violence in the community, war, or terrorism.

  • Witnessing the abuse or violation of a loved one.

  • Poverty.

  • Automobile accident.

  • Disorganized attachment, abandonment, neglect.


Recognize the possibility that trauma is at the root of the problem you are seeing. 

People react differently to stressors of all types, and early life experiences can play a critical role in people’s physiologic “set-up” to cope with stress later in life. In the 1990s the Adverse Childhood Experiences (ACE) study, done by the CDC and the Kaiser Family Foundation, found that childhood trauma is much more common than we had realized. In addition, they concluded that experiences such as neglect and divorce are associated with adulthood behavioral problems, including substance use disorders, depression, chronic illnesses, learning disabilities, and shorter lifespans, in a dose-response manner. When a child was exposed to childhood abuse or household dysfunction, they had an increased risk of developing physical health issues later in life, such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease, disproportionately from those who had no early childhood adverse experiences (1). Early childhood stress can also cause mental health issues in adulthood, such as mood disorders, substance abuse, and suicidality (1, 2). 

In addition, the risk for ACE’s is particularly elevated amongst certain populations that possess specific socio-cultural markers, including people who identify as BIPOC (Black, Indigenous, People of Color), lower socioeconomic status or unemployed, those with less than a high school level education, queer folk, and differently-abled individuals (3). Developmental trauma within any population can be a very subtle, persistent, and harmful risk factor that compromises one’s resilience to mental and physical illness later in life.


Clinical Pearl: Administer the ACE’s Questionnaire, review it, and inquire briefly about childhood experiences and traumas. Do not delve and go slowly. Ask a more general question such as, “tell me three things about your mother”, or “three things about your father”. Patients often do not “feel stressed”, but you might notice that they carry longstanding anxiety in their bodies. This could be a clue that they are carrying old trauma patterns.


What does trauma look like?

Trauma can manifest emotionally, cognitively, and physically. Although the traumatic event may be in the distant past, someone who is traumatized may continue to experience a physiological stress response. Our brains and bodies get amped-up, ready to respond to the trauma-inducing stressor, and our nervous system remains primed to complete the trauma response. Our endogenous nervous system makes attempts at survival by reacting with either a fight, flight, freeze, or fawning response. Many patients become afraid of their environments and generalize their fear responses. This can often be seen in patients with anxiety disorders, or those with PANS or PANDAS. Other responses to trauma can be to become immobilized (freeze) or to try to please and appease those around you (fawning), in an effort to stay safe. Although the event may be over, regardless of the compensatory response to the trauma, the body does not necessarily return to equilibrium. This can look like hypervigilance, irritability, anxiety, depression, helplessness, and even numbness or dissociation. It is important to start to see your patients through this lens. 


Trauma default behaviors are an indication that the body’s natural impulse to complete the trauma and find safety was thwarted. Without help, the body cannot complete the response needed to escape, fight against, or otherwise resolve the trauma it experienced. A key component in trauma healing is to complete the physiologic response which was thwarted during the traumatic incident and integrate the new narrative into conscious awareness. This installs the newly integrated information into the frontal lobes and directs the looping away from the limbic arousal system.


When we have unresolved traumas, emotions can swing rapidly and become intense and overwhelming. These effects are often intensified when trauma develops in response to severe, acute events like war, natural disasters, or interpersonal violence. When traumatized and feeling afraid, angry, or out of control, we may withdraw, cutting off those closest to us. In the wake of wars that leave scores of veterans suffering from PTSD, the emotional and cognitive effects of trauma are well-known and widely discussed in the media. However, we often neglect to acknowledge and adequately address the toll of less severe traumas on our bodies and minds (4). 


For example, children raised with a lack of emotional attunement from their parents, who are humiliated, criticized, or raised with shame and a feeling of helplessness, can experience trauma. Children can also experience trauma from a home fraught by parental arguing. In addition, in utero, perinatal and birth trauma can have a long-lasting impact upon a young nervous system. Whether very mild or pervasive, unresolved trauma is stored in the body and the brain. These clusters of trauma disorders have been described by many as complex PTSD and developmental trauma disorder.


Clinical Pearl: The magnitude of trauma varies, and for each person, the lingering imprints on the nervous system are uniquely expressed. Trauma looks like anxiety in some patients, depression in others, and hypersensitivity to pain in others. Obsessive health concerns can have their roots in fear and trauma as well, and interact with biological etiologies. Keep an open mind about what you're seeing in terms of symptom complaints. For example, substance abuse can be rooted in family addictive patterns, including emotional dysregulation, genetic coding, early family trauma, and intergenerational trauma. 


What is Complex PTSD?

Complex PTSD or C-PTSD can happen when an individual has experienced repeated or ongoing traumatic events. Although complex trauma can occur at any life stage, it often stems from developmental trauma beginning in infancy. An infant’s nervous system is entirely dependent upon caregivers to create feelings of safety, connection, and calm. When one grows up with dysregulated, abusive, or neglectful caregivers, the child’s vulnerable nervous system is shaped in order to survive. 

Dr. Arielle Schwartz explains that “Most often, there is a combined wound, in which you experience deficient nurturance from loving caregivers coupled with inadequate protection from dangerous situations or people.” When a child grows up in an environment of abandonment, chaos, rejection, or fear, there is the potential for significant and chronic repercussions regarding the individual’s physical, mental, and emotional health. Oftentimes, suppressed memories of physical or sexual abuse can lead to intense emotions and bodily sensations without a well-developed way to verbally explain the traumatic experience (6). These feelings and sensations can be difficult to understand and often, their root cause can be misinterpreted as something aside from a history of trauma. Parts of the traumatic memories may be unclear or forgotten, which can evoke feels of self-doubt and low self-confidence. Past experiences of developmental trauma may be influencing the ability of your patient to take care of themselves as an adult, as this ability or lack thereof, tends to reflect how they were cared for as a child (6). 

What are traumas acute and chronic physiological effects?

Trauma manifests as maladaptive chronic stress and overwhelms an individual’s coping capacity, leading to long term effects on health and wellbeing. This is often combined with biological root causes which need to be identified and treated, especially with chronic illnesses, such as environmental illness. Thinking may be affected by a persistent ‘brain fog” or problems can develop with focus and attention, and one may develop additional cognitive challenges.. The person might become distractible, struggle to concentrate on tasks that once interested them, and they may have difficulty remembering things. The individual might forget the events surrounding the trauma, as these memories become inaccessible to our consciousness. The normal, protective responses to threats or high levels of stress, (fight, flight, fawn, or freeze), can be activated regardless of whether these threats are real or perceived. An individual with a history of trauma may continue to react with the biologic defensive response even during objectively non-threatening situations, and the Cell Danger Response (Robert Naviaux) 7, may underlie this reaction.


The term adaptive stress describes the intelligent way in which the body responds to the immediacy of adverse or traumatic life experiences; however, when that stress response does not resolve, it leads to lingering symptoms.  In individuals who are working with adaptive stress, the body’s coping mechanism for processing stress-inducing experiences is activated and they possess the agency to terminate or conquer the stressor. These individuals are able to complete the biologic stress response, reaching a state of relief or accomplishment and returning to homeostasis efficiently. 


However, as seen in those with a history of trauma, maladaptive or chronic stress reflects long-term or unrelenting conditions of physical or mental exertion and a protracted-time when the body does not get a chance to rest or experience relief and recovery. Clinicians often see this in patients with chronic environmental illness who end up feeling an unrelenting barrage of threat from their environment. Rather than just being “stressed,” their bodies are “stressed out,” and no relief is experienced in the body or the mind. In these situations, one does have a sense of agency and cannot find calm. This is when prolonged physical, mental, and emotional strain take a physiological toll on the body and the brain. This physiological toll is where trauma comes in; when a person feels helpless in the face of adversity, a traumatic imprint happens in the brain and nervous system.  Often, this stress is not even conscious. S