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WOMEN IN MIND: Trauma and Health


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Presented by The Royal's Dr. Fotini Zachariades at our annual Women in Mind Conference.

She is a Clinical, Health, and
Rehabilitation Psychologist currently at the Women’s
Mental Health Program at The Royal

Published in: Health & Medicine
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WOMEN IN MIND: Trauma and Health

  1. 1. Trauma and Health Fotini Zachariades, Ph.D., C.Psych. Psychologist, Women’s Mental Health Program ROMHC November 15, 2013
  2. 2. Overview • Definition & sources of trauma • Trauma & women- epidemiology • Physical health & the biology of trauma • Trauma & mental health comorbidity • Developmental considerations and attachment • Further psychological and social aspects of trauma
  3. 3. Definition of Trauma • Occurs when threat overwhelms an individual’s adaptive internal and external coping resources (Fallot & Harris, 2009) • Experience of ‘acts of omission’ and/or ‘acts of commission’ (childhood) (Briere, 2002) • Broader conceptualization of trauma
  4. 4. Sources of Trauma • • • • • • • • • • Emotional, physical, or sexual abuse, abandonment/neglect (children) Sexual assault, domestic violence, experiencing or witnessing violent crime Institutional abuse Cultural dislocation/immigration Terrorism, war, violence against a specific group (e.g., genocide) Natural disasters Grief/loss Chronic stressors such as racism, poverty Accidents, medical procedures, severe injuries/illnesses Any situation where one person misuses power over another (Ackley & Covington, 2008)
  5. 5. Trauma & Women – Some Epidemiological Data I • Estimated that around 872 979 Canadians currently have PTSD • 76.1% report some form of trauma exposure in their lifetime • Women twice as likely as men to develop PTSD
  6. 6. Trauma & Women – Some Epidemiological Data II • PTSD more prevalent in women across the lifespan, in the general population women experience PTSD for longer duration than men • Lifetime prevalence rates: women 9.7%, men 3.6% • 12-month prevalence: women 5.2%, men 1.8% • 6-month prevalence among adolescents: girls 6.3%, 3.7% for boys
  7. 7. Impact of Adverse Childhood Events (ACE) Study (n)=17,000 • High ACE scores= more likely to develop mental health problems, abuse substances, have chronic physical illnesses, die early • Women significantly more likely to have high ACE score: > 50% more likely than men to have an ACE score of 5 or more (Felitti et al., 2010)
  8. 8. ACE StudyFindings related to women • Women with an ACE score of 4 or more: > almost 9 times more likely to become victims of rape > 5 times more likely to become victims of domestic violence • 54% of depression in women related to childhood abuse • 2/3 of suicide attempts associated with ACEs: > women are 3 times more likely to attempt suicide than men across the lifespan (Felitti et al., 2010)
  9. 9. ACE Study
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  11. 11. Trauma & Women – Some Epidemiological Data III • Women have greater chance of exposure to interpersonal trauma: > 14–20% of women will be raped at least once in their lifetime > 25–28% will experience intimate partner violence > 8–24% will be stalked by someone > 25-35% will have experienced sexual abuse in childhood
  12. 12. Process of Trauma TRAUMATIC EVENT Overwhelms the Physical & Psychological Systems Intense Fear, Helplessness or Horror RESPONSE TO TRAUMA Fight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing, Hypervigilance, Hyper-arousal SENSITIZED NERVOUS SYSTEM CHANGES IN BRAIN CURRENT STRESS Reminders of Trauma, Life Events, Lifestyle Painful emotional state RETREAT SELF-DESTRUCTIVE ACTION DESTRUCTIVE ACTION Isolation Dissociation Depression Anxiety Substance Abuse Eating Disorder Deliberate Self-Harm Suicidal Actions Aggression Violence Rages (Ackley & Covington, 2008)
  13. 13. Trauma & Physical Health I • Physical reactions are automatic and are not controlled by us • Brain reactions are also automatic • Body stores reactions: > the body then reacts as though it is back re-living traumatic events of the past
  14. 14. Trauma & Physical Health II • Trauma has negative effects on physical health • May promote poor health through complex interaction between biological and psychological mechanisms • Likely that relationship exists between the experience of trauma and an increase in utilization of medical services for physical health problems • Higher health care costs among women reporting childhood abuse/neglect histories
  15. 15. Trauma & Physical Health III • Reports of childhood abuse/neglect related to increase in physician diagnosed medical conditions • History of childhood abuse increases risk of cardiovascular disease: > Link especially strong for women with nine-fold increase
  16. 16. Trauma & Physical Health IV • Women with PTSD: > more hospital outpatient visits > higher rates of hospitalizations and surgical procedures > longer hospital admissions > less likely to be married > more likely to experience disability, chronic pain, obesity, smoke, and abuse alcohol
  17. 17. Trauma & Physical Health V • Women trauma survivors may frequently report: > Chronic pain > Gynecological difficulties > Gastrointestinal problems > Asthma > Heart palpitations > Headaches > Musculoskeletal difficulties
  18. 18. Psychoneuroimmunology I • Research in field of PNI provides useful framework for understanding effects of trauma on health • Illness as a consequence of severe stress • Chronic stress results when there is: > too frequent and intensive an activation of the physiological system > not enough time to rest and repair
  19. 19. Psychoneuroimmunology II • Inability to shut off stress response system- lack of adequate response due to exhaustion • Burnout: state of physical, emotional, and mental exhaustion resulting from intense involvement over long periods of time in situations that are emotionally demanding (Pines & Aronson, 1981)
  20. 20. Psychoneuroimmunology III • Ongoing experience of physical symptoms over longer term • Prior trauma “primes” physiological inflammatory response system so that it reacts more rapidly to subsequent life stressors • Elevated inflammation has etiologic role in many chronic illnesses • Changes seen as a cost of chronic stress vary depending on coping strategies, resources, lifestyle, life stressors, interacting with genetics and early life events
  21. 21. Allostasis I •Allostasis refers to body’s attempt to maintain stability through stress and change •Introduced as modification of homeostasis: In allostatic model adaptation achieved through change; physiological and behavioural states change in response to context •Allostasis maintained through stress hormones, immune system, and neurological responses- defensive function for protection during acute need
  22. 22. Allostasis II • When body is overwhelmed by stressors, allostatic load (body “wear and tear”) can occur • Our systems are set up to do this in short-term: > over time the cost of maintaining this is damage • Such underlying physiological changes have pathophysiological consequences: > over time trauma can increase allostatic load by chronically activating HPA axis and SNS
  23. 23. Allostatic Load Potential gender differences in physiological stress reactivity: Women may be more reactive to social stressors (e.g., rejection) (Stroud et al., 2002)
  24. 24. Biology of Trauma I • Immune system responds to threat by releasing proinflammatory cytokines • Cytokines increase inflammation and serve adaptive purpose of helping body heal wounds and fight infection • Both physical and psychological stress (such as trauma) can trigger inflammatory response
  25. 25. Biology of Trauma II • In case of severe/overwhelming stress the normal built-in checks and balances of the stress response fail, leading to high levels of inflammation • Elevated levels of these and other inflammatory markers associated with increased risk of health problems (CHD, MI, chronic pain syndromes, premature ageing, impaired immune function, impaired wound healing, Alzheimer’s disease)
  26. 26. Biology of Trauma III • In response to threat SNS responds by releasing catecholamines (norepinephrine, epinephrine,dopamine) - ‘fight or flight’ response triggered • HPA axis responds with chemical cascade: > hypothalamus releases corticotrophin releasing hormone (CRH) > CRH causes pituitary to release adrenocorticotropin hormone > Adrenal cortex releases cortisol
  27. 27. Biology of Trauma IV PFC: prefrontal cortex, AMY: amygdala, lat HYP: lateral hypothalamus, SNS: sympathetic nervous system, PNS: parasympathetic nervous system, RSA: respiratory sinus arrhythmia, SCR: skin conductance response, vlat PAG: ventrolateral periaqueductal gray Norrholm & Jovanovic, 2010
  28. 28. Non-PTSD PTSD Cortical region Limbic Region Brainstem Region Cortical region Limbic Region - - Memories stored in amygdala result in flashbacks, nightmares, over time smaller hippocampus SNS and PNS get locked on at equal levels, creates dissociation. Brainstem Region Increased functioning in limbic and brainstem regions and decreased functioning in cortical regions in PTSD compared to non-PTSD subjects. (Solid colours indicate increased functioning, lighter shaded areas indicate decreased functioning). (Dawson, 2007)
  29. 29. Stress Response • Traumatic stress alters and dysregulates key systems forming the stress response • 3 components of stress response:  Catecholamines (norepinephrine, epinephrine, dopamine)- ‘flight or fight’ response  Hypothalamic-pituitary-adrenal (HPA) axis  Immune response
  30. 30. HPA Axis Dysregulation I • Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation in response to chronic stress “confused” stress response • Low serotonin leads to less inhibition of aggression, low mood • High serotonin leads to decreased appetite, less need for sleep, increased agitation • Adrenaline and noradrenaline turn on, leading to increased “hyperfocus” and attention • Combined these increase cardiac output and dopamine sustains the needed energy level • Higher levels of opiates in system subdue the pain being experienced • Immune cells are redistributed so that they can easily reach a site of injury
  32. 32. HPA Axis Dysregulation III • High levels of adrenaline, serotonin disturbance: keyed up, agitated, irritable to aggressive, reduced sleep efficiency (sleep disturbance may be gateway to illness), for some food, smoking, alcohol etc., to regulate system • Dopamine decreases: fatigue & anhedonia, for some related to impulsivity/self-harm (we lose interest in what we used to love and are too tired to be healthy as it takes too much work) • Higher levels of opiates (but less effective): numbing, blunting, depersonalization, risk of addictive behaviours (substance abuse, gambling, shopping)
  33. 33. HPA Axis Dysregulation IV • Behaviours we use to cope may lead to an increase in health risk e.g., substance use • Reduced efficiency, poor judgement (we have to work harder now to do what we did before and we start making poorer choices, keeping the negative spiral going) • Oxytocin (“attachment” hormone): protective or risk factor for women, with HPA dysregulation there is preliminary evidence indicating decreased circulation leading to increased social isolation/withdrawal (which further decreases resources) & for some use of substances to stabilize system
  34. 34. Secondary Outcomes I • Secondary outcomes of chronic HPA axis dysregulation (physiological inflammatory responses) • Can be grouped in 4 categories: > Reduced immunity > Vasoactive > Procoagulant > Inflammatory
  35. 35. •Reduction in NK cells & Tlymphocytesopportunistic infections •Insulin conserves metabolism during challenge, leptin resistance, with increased food intakeobesity •Inhibition of digestive processesdiverticulitis, ulcerative colitis, digestive tract bleeding, IBS •Decreased bone myelinationosteoperosis Serotonin: •Suppresses reproductioninfertility Serotonin: • Vasoconstricts peripheral blood vessels • Increases fasting glucose levels, impaired glucose tolerance • HypocoaguabilityMI and stroke
  36. 36. Trauma & Mental Health Comorbidity • 79% women diagnosed with PTSD have at least one comorbid psychiatric disorder • PTSD may go undiagnosed or can be misdiagnosed as another disorder that may mask underlying PTSD
  37. 37. Substance Use • High co-occurrence of PTSD and substance abuse • Rates of co-morbidity between PTSD and substance use disorders to range anywhere from 20% to 75% • PTSD can elicit substance abuse (e.g., for coping), which can make client more vulnerable to further trauma • Recovery from substance use can trigger PTSD or memories the substance had been blunting • ‘Self-medication’ with drugs and alcohol to reduce arousal symptoms or to dull the sense of fear and inability to cope
  38. 38. Depression & Hostility I • Given high rates of mental health comorbidities in trauma/PTSD, important to consider psychological factors such as depression and hostility that can also trigger physiological inflammatory response • Their effects can impair health even if the individual does not meet criteria for PTSD
  39. 39. Depression & Hostility II • Depression: > risk factor for CVD, cardiovascular events, cardiacrelated mortality > coagulation related to depression and cardiovascular risk in perimenopausal women (n= 3292) (Matthews et al., 2007) • Hostility also associated with heart disease
  40. 40. Depression & Hostility III • Combination of depression and hostility adds to negative health effects: > Study (Suarez, 2006) of 135 healthy patients with no symptoms of diabetes: women with higher levels of depression and hostility had higher levels of fasting insulin, glucose, and insulin resistance, independent of other risk factors for metabolic syndrome (BMI, age, fasting triglycerides, exercise regularity, ethnicity)
  41. 41. Sleep I • Sleep disorders are common among trauma survivors (e.g., in women primary-care patients who were sexual abuse survivors) • Poor sleep is also associated with increased inflammation, and could be another way that trauma impacts health • Sleep problems increase the risk of CHD, type-2 diabetes, and hypertension • Sleep loss reduces lymphocyte count and natural killer cell activity, making patients more vulnerable to infection
  42. 42. Sleep II • Poor sleep quality compromises immune, metabolic, and neuroendocrine function, chronically activates the HPA axis, and can increase mortality risk • Sense of security with a partner found to promote improved sleep as this can facilitate downregulation of vigilance and alertness- long-term sleep deprivation could be a health risk factor for women who are not in stable, secure relationships (trauma survivors frequently report relationship dissatisfaction)
  43. 43. Developmental Considerations & Attachment I • Trauma response can be passed down through generations : Transgenerational effects of pregnancy: Vasoconstriction Reduced arterial blood flow Complications of pregnancy E.g., gestational hypertension, intrauterine growth restriction Adaptation HPA axis dysregulation
  44. 44. Developmental Considerations & Attachment II • Infant emotional experiences mainly stored/processed in the right hemisphere during the formative stages of brain development • Right hemisphere extensively connected with the emotion processing limbic system and with the ANS which regulates the functions of organs • Energy-expending sympathetic and energy-conserving parasympathetic circuits of the ANS generate the involuntary bodily functions representing the somatic components of emotional states
  45. 45. Developmental Considerations & Attachment III • Nonverbal right brain plays primary role in regulating physiological, endocrinological, neuroendocrine, cardiovascular, and immune functions- its operations are essential to the coping functions supporting survival, and therefore to the human stress response • Disruption of attachment bonds in infancy leads to a regulatory failure and “impaired autonomic homeostasis” • Security of attachment bond is main protection against trauma-induced psychopathology
  46. 46. Developmental Considerations & Attachment IV • Traumatized infants miss opportunities for socio-emotional learning during critical periods of right brain development • Infant's psychobiological response to trauma involves hyperarousal and dissociation • Parasympathetic dominant state of conservation-withdrawal is an important regulatory process for maintaining homeostasisinvolves metabolic shutdown and low activity levels • Parasympathetic mechanism mediates the detachment of dissociation
  47. 47. Developmental Considerations & Attachment V • Not just the trauma but infant's defensive response to trauma (i.e., dissociation) inscribed in right brain memory system • Mothers of such infants likely suffered trauma- in this way such imprinting of terror and dissociation can serve as mechanism for intergenerational transmission of trauma • Survival mode of conservation-withdrawal changes the bioenergetics of the developing brain- an infant brain that is chronically shifting into survival modes has little energy available for growth
  48. 48. Developmental Considerations & Attachment VI • Altered development of right hemisphere in individuals with poor attachment histories- deficits in perceiving emotional states of others, appraising internal cues of bodily states, evaluating signals of safety and danger (re-traumatization risk) • Difficulties in ‘mentalization’ lead to limited ability to reflect on emotional states • Disrupted early attachments, early trauma/abuse typically evident in those diagnosed with BPD- high correlation of PTSD and BPD
  49. 49. Developmental Considerations & Attachment VII • The higher regions of the right prefrontal cortex can attenuate emotional responses at the most basic levels in the brain • Such modulating processes of emotional experience can occur in psychotherapy through interpreting and labeling emotional expressions: - the system that underlies psychotherapeutic change is in the nonverbal right as opposed to the verbal left hemisphere
  50. 50. Self Trauma Model (STM) (Briere, 2002) • Primary impacts of childhood abuse/neglect on subsequent psychological functioning: (1) Negative preverbal assumptions and relational schemata (2) Conditioned emotional responses to abuse-related stimuli (3) Implicit/sensory memories of abuse (4) Narrative/autobiographical memories of maltreatment (5) Suppressed or “deep” cognitive structures involving abuse-related material (6) Inadequately-developed affect regulation skills
  51. 51. Trauma Themes • • • • • • • Safety- internal external Empowerment Connection (Aloneness) Normal reactions (Shame) Mind-body connection- emotional attunement Substance abuse Woman-centered: in the aftermath of trauma women report the following: - “Losing control” of life - Re-experiencing - Self-image changes - Depression - Relationship problems - Sexuality issues (Ackley & Covington, 2008)
  52. 52. STM Therapeutic Strategies I • • • • • • • • Therapeutic Window Exploration & consolidation Goal sequence: safety & support Self-awareness & positive identity Boundary issues Affect modulation & affect tolerance Disturbed relatedness Gradual exposure to abuse-related material (Briere, 2002)
  53. 53. STM Therapeutic Strategies II • Activation • Disparity • Processing & Resolution- cognitive & affective, developing coherent narrative • Grounding: - strategies to “bring back” from dissociation into current reality and feelings, awareness of here and now, what is experienced is in the past and not happening now (Briere, 2002)
  54. 54. STM (Briere, 2002) • - • Notion of “self before trauma”: interventions working through traumatic stress can overwhelm those with insufficient internal resources process of accessing and processing traumatic memories necessitates basic affect tolerance and regulation skills in absence of such resources, exposure to traumatic material can surpass the therapeutic window- lead to increased dissociation, tension-reduction activities, therapy drop-out STM approach allows trauma work to occur naturally as a function of the therapeutic relationship and the survivor's decreasing need for avoidance, facilitating staying within the therapeutic window
  55. 55. Trauma-Informed Practices • Consider trauma • Avoid triggering trauma reactions or inadvertently re-traumatizing • Adjust staff and organizational behaviour to support individual’s coping capacity • Empower trauma survivors to manage symptoms so to be enabled to access, retain, and benefit from services • Emphasize safety, choice, trustworthiness, collaboration, and empowerment
  56. 56. Vulnerability/Risk & Resilience/Protective Factors • Factors related to vulnerability and resilience: > Experiences of sexual assault and pre-existing mental health issues are related to greater susceptibility to lifetime PTSD, with prevalence being higher in women > External factors such political, social, economic and environmental instability, and lack of resources also increases susceptibility
  57. 57. Vulnerability/Risk factors Internal characteristics Being female Low sense of safety Low sense of social support Pre-existing mental health issues External factors Lower educational level Immigrant status Previous traumatic events Severity of exposure (severe or prolonged trauma) (Ahmed, 2007)
  58. 58. Resilience/Protective Factors Internal characteristics Self-esteem Trust Resourcefulness, Self-sufficiency Self-efficacy, Sense of mastery Internal locus of control Secure attachments Optimism Interpersonal abilities (social skills, problem-solving skills, impulse control) External factors Safety Strong role models Emotional support & secure attachments (Ahmed, 2007)
  59. 59. Relationship of biological, psychological, & social factors (McEwan & Seeman, 1999)
  60. 60. Case Example 1 Summary: •57-year-old, married woman diagnosed with breast cancer •Underwent mastectomy, treated with chemotherapy and radiation therapy •Ongoing stressors contributing to and exacerbating current symptoms and distress: - broke shoulder recently leading to decreased physical activity - in 2009 three siblings passed away (sister died from breast cancer, brother suddenly died of MI, another sister also died of an MI during her brother’s funeral) - following these events discovered she was diagnosed with breast cancer - initial mammogram missed tumour, ultrasound lead to her diagnosis 1 month later - underwent mastectomy, not aware would be undergoing this until just prior to surgery
  61. 61. Case Example 2 Symptoms of post-traumatic stress: - distressing recollections of cancer experience (intrusive thoughts involving radiation therapy and surgery for mastectomy, nightmares about this surgery, and reminders of prior fears of radiation experienced during childhood related to growing up during cold war and being warned about radiation and practicing bomb drills) - avoidance of thoughts about surgery (also attempts not to look at her scar) and radiation therapy - somewhat restricted range of affect associated with cancer experience (particularly in terms of surgery and mastectomy scar) and deaths of siblings - sleep disturbance - some irritability
  62. 62. Case Example 3 Symptoms of depression: - dysphoria, increased fatigue, and decreased interest, appetite, energy, and concentration - symptoms of depression likely exacerbated by current experience of poor body image due to mastectomy Symptoms of generalized anxiety: - worries that are sometimes difficult to control, often centring on experience of radiation therapy and fears of effects of radiation therapy - feeling restless or on edge - decreased concentration - muscle tension - sleep disturbance - some irritability - experience of current stressors is exacerbated by experience of past stressors (being placed in foster home at age of 4 years, experiencing neglect as a child as parents abused alcohol)
  63. 63. Case Example 4 • Additional medical conditions: hypertension, hypercholesterolemia, hypothyroidism, and diabetes (relatively well-controlled) • Lifestyle Habits: does not engage in any exercise currently due to fatigue since completing radiation therapy, ceased smoking (approximately 6 weeks prior to intake assessment), “social drinker,” denied any substance use • Coping: engages in primarily distraction coping (i.e., reads, uses the computer, watches television), shoulder injury restricted some of her usual coping activities (painting) • Adequate social support: through close relationships with foster mother, 4 female friends, 2 sisters, husband, and 2 of her 3 adult daughters
  64. 64. Case Example 5 Summary/Impression: Experiencing symptoms of post-traumatic stress, generalized anxiety, and depression. Current symptoms can be understood in context of pre-existing vulnerability to affective distress associated with difficult childhood experiences (early childhood neglect, fears related to radiation exposure/bomb threats), and are exacerbated by her experience of ongoing stressors (i.e., the death of three siblings in 2009, being inadequately prepared for undergoing a mastectomy, body-image issues related to the mastectomy and scar, and insufficient information regarding radiation therapy)
  65. 65. Case Example 6 Psychotherapeutic intervention involves: - processing salient aspects of her cancer experience, including unexpectedly having a mastectomy (and associated body image issues), and her experience of radiation treatment (and associated childhood fears regarding radiation exposure) - processing grief related to the death of her siblings, and the impact of this on her coping strategies and interaction with adjustment to cancer experience - anxiety and stress management techniques, including cognitivebehavioural approaches, and application of these to improving sleep - specific management of traumatic stress-related symptoms: cognitive & affective processing, grounding and affect regulation
  66. 66. Case Example 7 Team Recommendation: - Feels she has been inadequately informed about cancer treatments thus far, therefore concretely explaining what she can likely expect will facilitate decreased anxiety, foster sense of empowerment/control - Tendency towards intellectualizing her experiences, important to be aware that she may thus appear to minimize affect, hinders adjustment process and development of adaptive coping strategies, may change health trajectory & outcome
  67. 67. (Antoni et al., 2006)
  68. 68. Conclusion • Implications for assessment & treatment • DSM-5: Trauma and Stressor-Related Disorders: - Reactive Attachment Disorder - Disinhibited Social Engagement Disorder - Posttraumatic Stress Disorder - Acute Stress Disorder - Adjustment Disorders - Other Specified Trauma- and Stressor-Related Disorder: Persistent Complex Bereavement Disorder - Unspecified Trauma- and Stressor-Related Disorder • Trauma-informed care- gender-informed care
  69. 69. References Ackley, C., & Covington, S.S. (2008). Women, substance abuse and trauma: An integrated treatment approach. 3rd National Conference on Women, Addiction and Recovery. Tampa, Florida. Ahmed, A.S. (2007). Post-traumatic stress disorder, resilience and vulnerability. Advances in Psychiatric Treatment, 13, 369-375. American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders, (5th ed.). Washington, DC: Author. Antoni, M.H., Lutgendorf, S.K., Cole, S.W., Dhabhar, F.S., Sephton, S.E., McDonald, P.G., Stefanek, M., & Sood, A.K. (2006). The influence of bio-behavioural factors on tumour biology: Pathways and mechanisms. Nature Reviews Cancer, 6, 240-248. Beutel, M.E., Stern, E., & Silbersweig, D.A. (2003). The emerging dialogue between psychoanalysis and neuroscience: Neuroimaging perspectives. Journal of the American Psychoanalytic Association, 51, 773-801. Bonin, M.F., Norton, G.R., Asmundson, G.J., Dicurzio, S., & Pidlubney, S. (2000). Drinking away the hurt: The nature and prevalence of PTSD in substance abuse patients attending a community-based treatment program. Journal of Behavior Therapy and Experimental Psychiatry, 31, 55-66.
  70. 70. References Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J.E.B. Myers, L. Berliner, J. Briere, C.T. Hendrix, T. Reid, & C. Jenny (Eds.) (2002). The APSAC handbook on child maltreatment, 2nd Edition. Newbury Park, CA: Sage Publications. Dawson, J. (2007). Final summary, proposed ecological trauma theory, implications for safe interventions and future research. Accessed at: Fallot, R., & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self-assessment and planning protocol. Community Connections. Accessed at: Felitti, V.J., et al. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare. In R. Lanius & E. Vermetten (Eds.), The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press.
  71. 71. References Gurevich, M., Devins, G.M., & Rodin, G.M. (2002). Stress response syndromes and cancer: Conceptual and assessment issues. Psychosomatics, 43, 259-281. Hoersch, M.D. (2011). The impact of trauma on women and girls across the lifespan. Healthy Women, Healthy Hoosiers: Healthcare Practice Across the Lifecourse. Iribarren, J., Prolo, P., Neagos, N., & Chiappelli, F. (2005). Post-traumatic stress disorder: Evidence-based research for the third millennium. Evidence-Based Complementary and Alternative Medicine, 2, 503 - 512. Jacobson, L.K., Southwick, S.M., & Kosten, T.R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158, 1184 -1190. Kendall-Tackett, K. (2008). Inflammation and traumatic stress: A likely mechanism for chronic illness in trauma survivors. Trauma Psychology Newsletter, 12-14. Kendall-Tackett, K. (2009). Psychological trauma and physical health: A psychoneuroimmunology approach to etiology of negative health effects and possible interventions. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 3548. Kessler, R.C., et al. (2005). Prevalence, severity, and comorbidity of 12-months DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627.
  72. 72. References Kessler, R.C., et al. (1995). PTSD in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Kilpatrick, D.G., Ruggiero, K.J., Acierno, R., Saunders, B.E., Resnick, H.S., & Best, C.L. (2003). Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71(4), 692-700. Kubiak, J. (2010). PTSD: From assessment to treatment. Orlando Veterans Affairs Medical Center. Matthews, K. A., Schott, L. L., Bromberger, J., Cyranowski, J., Everson-Rose, S. A., & Sowers, M. F. (2007). Associations between depressive symptoms and inflammatory/hemostatic markers in women during the menopausal transition. Psychosomatic Medicine, 69, 124–130. McEwen, B., & Seeman, T. (1999). Allostatic load and allostasis. Allostatic Load Working Group. Moses, D.J., et al. (2003). Creating trauma services for women with co-occurring disorders. Experiences from the SAMHSA Women with Alcohol, Drug Abuse and Mental Health Disorders who have Histories of Violence Study.
  73. 73. References National Association of State Mental Health Program Directors. (2013). Engaging Women in Trauma-Informed Peer Support: A Guidebook. Accessed at: National Center for PTSD. (2011). Epidemiology of PTSD. Accessed at: National Comorbidity Survey. (2005). NCS-R appendix tables. Accessed at: Norrholm, S.D., & Jovanovic, T. (2010). Tailoring therapeutic strategies for treating posttraumatic stress disorder symptom clusters. Neuropsychiatric Disease and Treatment, 6, 517-532. Pines, A., & Aronson, E. (1981). Burnout: From tedium to personal growth. Free Press: New York. Schore, A.N. (2002). Advances in neuropsychoanalysis, attachment theory, and trauma research: Implications for self psychology. Psychoanalytic Inquiry, 22, 433-484. Statistics Canada. (2002). A report on mental illness in Canada.
  74. 74. References Stroud, L.R., Salovey, P., Epel, E.S. (2002). Sex differences in stress responses: Social rejection versus achievement stress. Biological Psychiatry, 52, 318-327. Suarez, E. C. (2003). Joint effect of hostility and severity of depressive symptoms on plasma Interleukin-6 concentration. Psychosomatic Medicine, 65, 523–527. Treloar, A.S. (2011). Therapeutic groups with adult trauma survivors. Van Ameringen, M., Mancini, C., Patterson, B., & Boyle, M.H. (2008). Post-traumatic stress disorder in Canada. CNS Neuroscience & Therapeutics, 14, 171–181. Welzant, V. Management of complex PTSD/DID. Women’s College Hospital. (2013). Trauma is a women’s health issue. Accessed at: is-a-wome
  75. 75. Questions?