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When You’re Safe, But You Don’t Feel Safe Yet

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Trauma often reshapes our systems. The event is over, but the body, mind, and emotions may not process “the over” information at the same speed. While everyone else is moving on with their lives, you may be drinking your coffee one morning and realize that your heart is racing for no reason. A sound, a smell, a message, a look can trigger you, and suddenly your body reacts; you are in the very same moment. Even if your mind says it’s over, your body may disagree. Because trauma is more than a memory, it is a change in the nervous system’s perception of safety. Even if the danger has passed, your system may still operate according to the possibility that something will happen. It is as if once the alarm system is activated, it starts to perceive even the smallest sensation as a fire. But it does not mean that the system is broken. It means that your brain and body are using survival strategies to protect you. The problem is that these strategies do not shut down even after the danger has passed. This can manifest itself in your daily life in reactions such as nervousness, startle, restlessness, avoidance, sleep problems, intense anxiety, outbursts of anger, or freezing, often without making sense of it. Sometimes these symptoms are very visible; at other times, they linger quietly in your inner world and seep into your life. 

At this point, an important distinction is that not all traumatic experiences are the same, and not all traumatic events turn into a clinical picture named Post Traumatic Stress Disorder (PTSD). Post-traumatic reactions exist on a spectrum; for some people, symptoms ease over time and allow the person to rebuild their life. In others, the nervous system struggles to get out of survival mode even after the danger has passed. In PTSD, the literature lists certain symptoms such as re-experiencing (flashbacks, nightmares, involuntary recollections), avoidance (staying away from places, conversations, emotions that remind one of the event), changes in emotions and thoughts (negative beliefs about oneself and the world, guilt, feelings of disconnection) and increased arousal (irritability, alertness, outbursts of anger, sleep and concentration problems). These symptoms persist, intensify, or begin to significantly affect the person’s daily life. Therefore, instead of seeing PTSD only as “the effect of the event”, it is important to evaluate their progress over time and how they affect the person’s functioning in life. In this therapy sketch, we will take a closer look at the diagnostic criteria for PTSD, the most common symptoms, and how this picture turns into an experience for the person.

Trauma Then vs. Trauma Now

When we look at the mental health literature, we see that trauma is often defined in terms of the nature of the events we experience. Especially when we look at diagnostic tools such as the DSM, we see that a traumatic event is mostly defined as a situation you experience “exposure to actual or threatened death, serious injury or sexual violence” (APA, 2022). This definition of trauma is particularly used for the diagnosis of post-traumatic stress disorder (PTSD). In addition, when assessing for trauma, many researchers and clinicians also consider the impact of events on the individual. The event you experienced may not be universally considered a violent event, but it may still have caused significant destruction in your life and taken many things away from you, and in this sense, it may have been traumatic.

Although trauma has probably been a part of people’s lives for as long as they have existed, interestingly, the diagnosis of post-traumatic stress disorder (PTSD) is actually quite a new concept. The PTSD definition was introduced to the DSM, a diagnostic tool frequently used by therapists, in the 1980s, when we started to focus more on the soldiers returning from Vietnam and the mental health challenges they experienced. Importantly, the definition of what constitutes a traumatic event has been significantly broadened, largely due to critical social movements. Their advocacy for survivors of various forms of violence has been crucial in ensuring that events like sexual assault are recognized as traumatic in diagnostic tools, moving beyond the prior limitation of the term solely to occurrences such as wars and natural disasters (Brown, 2017). Since the 80s, the symptoms of PTSD, their possible causes and development, and their effects on the human body, mind, emotions, and brain continue to be intensively researched. And today, our understanding of trauma expanded beyond just the event. However, eventhoughtrauma informed perspectives shift our understandingto more individualized nature of trauma, DSM-5 and ICD criterias still one of the most core frameworks for trauma, particularly regarding symptoms and duration. 

So, what is PTSD according to diagnostic criteria?

According to DSM-5 (APA, 2022), if you exhibit a significant majority of the following groups of symptoms for more than one month after exposure to a traumatic event, you may meet criteria for PTSD. The DSM-5 gives a total of 20 symptoms for PTSD and groups them under 4 categories. Here are way simpler explanations for these categories:

1) PTSD develops after highly traumatic events: In order to be diagnosed with PTSD (according to DSM-5 criteria), you must have experienced a major traumatic event or witnessed it (by seeing it yourself, hearing about it happening to someone close to you, or being constantly exposed to details of it, etc.). This major event could involve a real risk of death or being under threat of death, serious injury, or sexual violence. You begin to show certain stress responses if you have developed PTSD. These can be grouped into at least four categories.

2) Your body replays the trauma: When you experience PTSD, your body essentially replays the traumatic event over and over again. For example, the memory of the traumatic event or events can be very stressful, and remembering them can feel intrusive in a terrible way. You may have recurring dreams and nightmares about this event and related topics (APA, 2022). 

  • Flashbacks: The “flashbacks” that likely come to mind when you think of PTSD are actually in this group. When you experience flashbacks, you may feel as though you are reliving the trauma. You may see the trauma very realistically in your mind; it can be quite vivid, as if you are back there again. Flashbacks may occur even without an obvious trigger, or they may be triggered by something like a smell associated with the traumatic event. At times, this can become so realistic and vivid that it may be very difficult for you to distinguish your flashbacks from reality (APA, 2022). 
  • Triggers: Along with this, if you encounter something that reminds you of the trauma, whether in your own mind or outside, it may create a very intense and distressing stress response and physical reactions in you (APA, 2022).

3) You try your hardest to avoid details about the trauma: According to another group of symptoms described in DSM-5, if you have developed  PTSD, you may actively begin to seriously avoid things related to the trauma, both in your own mind and in the outside world. Seeing or thinking about these things may have become so painful that it leads to strong avoidance behavior. You may try to avoid anything related to the trauma (APA, 2022).

4) Your cognition and mood change: If you are living with PTSD, you do not experience re-experiencing and avoidance symptoms in isolation. These are often accompanied by very strong cognitive and emotional reactions (APA, 2022).

  • Cognitive reactions: Even though you experience flashbacks and intrusive memory symptoms, you may also be unable to recall certain details of the traumatic event, as if they had been erased from your mind. Your perspective on yourself and the world may have changed dramatically, becoming excessively negative. You may have doubts about the causes of what you experienced and may even blame yourself (APA, 2022).
  • Emotional reactions: The impact does not remain only in your thoughts. You may also feel quite heavy and negative emotionally. You may no longer be interested in things you used to enjoy or in new experiences, and you may feel detached from the outside world. For some, this can become so overwhelming that experiencing anything positive may feel almost impossible (APA, 2022).

5) You become irritated in your body, hypervigilant, and even self-destructive at times: When you experience trauma, your reaction is not only expressed through your emotions and thoughts. Your whole body may start reacting to it. According to DSM-5, if you are living with PTSD, you may experience:

  • Physical reactions: You may feel angrier and have outbursts, even if it is not how you used to react to what happens in your life. You may feel overstimulated in your body, feeling like you are on overdrive. You may experience poorer sleep quality and decreased attention. You may notice that you have become hypervigilant, constantly feeling on edge, and overanalyzing everything. You may also feel like you started to engage in more self-destructive behaviors. Just as important, you may feel unsafe even when there is no actual threat (APA, 2022).

As you can see, PTSD just does not effect single domain. It affects how we think, how we behave, and feel. These reactions are not coincidental. As we mentioned above, it leads the brain and nervous system to react in a particular way by affecting many brain regions and networks.

How does PTSD affect our brains?

Recent updates in neuroscience help us better understand the changes our brains go through after trauma. Research consistently shows that our brains reflect certain changes that may be due to the trauma we are exposed to, compared to people who have not been exposed to similar traumatic events, and these changes may be contributing to the symptoms of PTSD.  (Hinojosa et al., 2024; Stoklosa et al., 2024 ). Many of these changes cluster around the brain’s fear and memory networks.

  • Fear circuitry: The amygdala, a brain region that supports functions such as emotional regulation, may become hyperactive and decrease in volume in people experiencing PTSD. 
  • Memory & Executive Functioning networks: The hippocampus, a key brain region in learning and memory formation and maintenance, may undergo alterations and volume reductions. Moreover, several brain networks that support our executive functions, such as attention and decision making, may go through changes in their activity and structure for people struggling with PTSD. 

Fortunately, these changes in the brain may not be permanent. This is because the brain is plastic and adaptive. Yes, trauma can shape the nervous system over time, but with the right methods, the system can reorganize again. And it is science-proven. For example, individuals undergoing treatments focused on trauma and PTSD symptoms, such as trauma-informed cognitive therapy,  tend to exhibit reduced hyperactivity and less influence from the affected neural networks when compared to their activity before treatment (Hinojosa et al., 2024).

What does healing look like?

    There are many evidence-based therapy modalities that mental health professionals use in PTSD treatment. Here are the most common ones:

    • Prolonged Exposure: This approach allows the person to gradually address the trauma memory and situations that remind them of the trauma in a safe environment. PE generally targets the fear-conditioning system, the part of the brain that learns danger and keeps sounding the alarm every time a trigger appears. Over time, the brain learns that the moment is in the past, and the alarm system begins to calm down (Foa et al, 2019). 
    • Trauma- Focused Cognitive Therapy(TF-CBT): TF-CBT works with the cycle of thoughts, feelings, and avoidance behavior that often follows trauma. When triggers show up, the person avoids them because their system is trying to protect them from feeling too much. Avoidance can bring relief in the moment, but it also endorses the thought that the danger is still there. o the nervous system stays on alert, even long after the event has passed. TF-CBT centers thoughts, emotions, and avoidance behavior to lose grip of triggers, and overtime body slowly relearns what safety feels like (Allen et al., 2020).
      • Cognitive Processing Therapy (CPT): CPT can be categorized under TF-CBT and works with thoughts that remain in the mind after trauma, such as “I blame myself”, “the world is dangerous, “and “I can’t trust anyone”. The aim is not to repress what happened, but to reorganize the meaning of the trauma so that the person can look at themselves and life from a balanced perspective and a safe place (Godfrey et al., 2021).
    • Eye Movement Desensitization Reprocessing (EMDR): EMDR is based on the principle that traumatic memories may be stored in the brain without being processed in a sufficiently integrated way. Therefore, the memory may trigger the body and mind not as a past experience, but as if it is happening again today. The aim of EMDR is not to make you forget the trauma, but to support more integrated processing of the memory in the brain and to help the nervous system learn to be safe again. Thus, over time, the triggers will no longer cause alarm with the same intensity (Wilson et al., 2018).
    • Attachment, Regulation and Competency Model (ARC): ARC is a relationship- and nervous system-focused approach, particularly for childhood trauma and developmental trauma. ARC treats healing and rebuilding a sense of safety as a step-by-step process, rather than something that happens all at once. Throughout the therapy, safe attachment, emotion regulation, and competence skills are stacked on top of each other like “building blocks”. As this foundation is strengthened, the child (and caregiver) helps to reduce the trauma from ruling life (Blaustein & Kinniburgh, 2010).

    The common point is “Feeling Safe Again.”

    These are the most basic trauma therapies, but there are many trauma therapies in the literature. If you wonder the reason for such diversity, it is very valuable to have many evidence-based modalities for trauma, because trauma does not look the same for everyone, and not everyone heals in the same way. But most of these modalities share a common goal: to help the brain rewire itself and the nervous system learn to feel “safe” again. The methods may differ, but the goal is to reduce the brain’s perception of danger, to lessen the impact of triggers, and to allow the person to return to a sense of control, balance, and connection.

    Takeaways 

    • People who are exposed to traumatic events may develop a clinical condition called Posttraumatic Stress Disorder (PTSD), with key symptoms such as reexperiencing traumatic memories, avoidance of reminders, changes in emotions and thought and increased arousal.
    • Reexperiencing due to PTSD can manifest as flashbacks, nightmares, or involuntary recollections. 
    • PTSD-related symptoms are often associated with changes in brain areas responsible for fear regulation, memory, and executive functioning. These alterations in the brain may both cause and be influenced by the symptoms commonly experienced with PTSD.
    • With effective treatment, certain forms of brain hyperactivity may be reduced, and affected networks may exert less influence on symptoms.

    References

    • American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
    • Brown, L. S. (2017). Contributions of feminist and critical psychologies to trauma psychology. In American Psychological Association eBooks (pp. 501–526). https://doi.org/10.1037/0000019-025
    • Hinojosa, C. A., George, G. C., & Ben-Zion, Z. (2024). Neuroimaging of posttraumatic stress disorder in adults and youth: progress over the last decade on three leading questions of the field. Molecular Psychiatry, 29(10), 3223–3244. https://doi.org/10.1038/s41380-024-02558-w
    • Koenen, K. C., Ratanatharathorn, A., Ng, L., McLaughlin, K. A., Bromet, E. J., Stein, D. J., Karam, E. G., Ruscio, A. M., Benjet, C., Scott, K., Atwoli, L., Petukhova, M., Lim, C. C., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Bunting, B., Ciutan, M., De Girolamo, G., Kessler, R. C. (2017). Posttraumatic stress disorder in the World Mental Health Surveys. Psychological Medicine, 47(13), 2260–2274. https://doi.org/10.1017/s0033291717000708
    • Stoklosa, I., Marwaha, R., Stokłosa, M., Zacharzewska-Gondek, A., Piegza, M., Gorczyca, P., & Wieckiewicz, G. (2024). Neuroimaging in Post-Traumatic Stress Disorder (PTSD): a Narrative Review. Archives of Medical Science, 21(1), 32–41. https://doi.org/10.5114/aoms/188377
    • Foa, E., Hembree, E., Rothbaum, B., & Rauch, S. (2019). Prolonged Exposure Therapy for PTSD. https://doi.org/10.1093/med-psych/9780190926939.001.0001.
    • Godfrey, K., & Albright, D. (2021). Cognitive Processing Therapy. Social Work. https://doi.org/10.1093/obo/9780195389678-0297
    • Allen, B., Riden, E., & Shenk, C. (2020). Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Cognitive Behavioral Therapy in Youth: Tradition and Innovation. https://doi.org/10.1007/978-1-0716-0700-8_5.
    • Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. (2018). The Use of Eye-Movement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic Stress Disorder—A Systematic Narrative Review. Frontiers in Psychology, 9. https://doi.org/10.3389/fpsyg.2018.00923.
    • Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. Guilford Press.
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