# data[].attributes.attachment_link.title
Trauma Informed Teaching for D75 Populations-min

# data[].attributes.body
https://vimeo.com/822057228/b28e4b4611

# data[].attributes.attachment_link.title
Trauma Informed Teaching for D75 Populations

# data[].attributes.body
https://www.mentimeter.com/app/presentation/alc6971rijr3t14sifqetac5ekrd1iwg

# data[].attributes.attachment_link.description
Interact with your audience using real-time voting. No installations or downloads required - and it’s free!

# data[].attributes.attachment_link.description
Interact with your audience using real-time voting. No installations or downloads required - and it’s free!

# data[].attributes.attachment_link.title
The Trauma-Informed Toolkit for Educators * New York City Children's Theater

# data[].attributes.attachment_link.description
Facebook Twitter Pinterest LinkedIn Digg Gmail

# data[].attributes.attachment_caption
SAMHSA's Concept of Trauma and Guidance for a Trauma-Informe Approach

# data[].attributes.attachment_link.description
In this classic work of developmental psychology, renowned psychiatrist and the co-author of the #1 New York Times bestseller What Happened to…

# data[].attributes.attachment_caption
What Happened To You by Dr Bruce Perry and Oprah Winfrey

# data[].attributes.attachment_caption
Kids Do Well If They Can - Ross Greene article

# data[].attributes.attachment_link.title
Dr Daniel Siegel presenting a Hand Model of the Brain

# data[].attributes.attachment_link.readable_text
"In some cases and for some kids, having that information can be life-saving," says Lauren Rivera, a professor of management and organizations at the Kellogg School.

But according to new research from Rivera and András Tilcsik of the University of Toronto's Rotman School of Management, discrimination prevents families from gaining such crucial knowledge. Their study found that public school principals are less responsive to parents of disabled children when it comes to providing information about schools. This is especially true when the parent of a disabled child is perceived to be Black.

"While we find there is differential responsiveness on the basis of disability status, as much of the literature on disability in education shows, this effect is highly racialized," Rivera says, creating an interlocking set of barriers for Black disabled children.

The reality of discrimination against those with disabilities is not new, of course. Previous research has found that people with disabilities face significant obstacles in the labor market-they earn less than their nondisabled counterparts and are under-employed based on their credentials. Rivera and Tilcsik's new study shows these challenges begin long before people enter the workforce.

"It's not just that disability discrimination hurts people in the labor market," Rivera says. "Disability discrimination begins much earlier, and it actually affects the educational opportunities and options available to students, especially in a context of school choice."

An underfunded special education mandate

In the United States, the rights of disabled children are protected not only under the Americans with Disabilities Act, but also under the Individuals with Disabilities Education Act (IDEA). IDEA states that school districts must provide a "free and appropriate public education" to students with disabilities, with the specific supports needed for each child outlined in a legally binding document called an Individualized Education Program (IEP).

When Congress reauthorized IDEA in 1990, it set a goal of covering 40 percent of the law's costs, but it has never reached that threshold. As a result, states and school districts carry most of the costs of special education, with each state allocating funding in slightly different ways. Due to the limited federal assistance, funding for disabled children is often scarce and seen to be in competition with funding for everything else schools need.

While school districts are responsible for creating IEPs, school principals are responsible for implementing IEPs in practice, which is why Rivera and Tilcsik decided to focus their research on them. They are also responsible for making tough choices about how to distribute valuable resources within their school.

"Principals control a lot of resources that directly affect the fate of students with and without disabilities," Rivera says. "They are the gatekeepers: they control who gets what classroom space on what floor of the building, staffing, and whether to spend money meeting one child's IEP versus investing it in programs that serve a larger percentage of the student body."

Disability discrimination at the schoolhouse gate

Rivera and Tilcsik designed an experiment to test how disability status influences the school-search process. Because race discrimination and disability discrimination have historically been intertwined in the United States, they also decided to study race in this context.

They sent emails from fictitious prospective parents asking for school tours to more than 20,000 principals at public schools in four states. There were multiple versions of the email, varying the fictitious child's gender, disability status (as indicated by whether or not the parent mentioned an IEP), and the perceived race of the parent writing the emails. Half were signed by Tyra Williams (a name widely perceived to be Black, according to experimental pretests) and half by Amy Williams (a name widely perceived to be white); both names were perceived as being similar in social class.

Rivera and Tilcsik chose to focus on school tours, which are "one of the most common ways that, across class and across race, parents research schools to see if they're a good fit for their child," Rivera says.

Tours are especially important for parents of children with disabilities, because schools typically have very little publicly available information about what specific special-education services they offer. Seeing schools in person and talking one-on-one to staff at a tour is one of the best ways for parents to understand whether the right supports will be available to their children.

In the study, an email reply that offered a tour or other meeting was considered a positive reply, while nonresponses or replies declining to meet were treated as negative replies.

The results of the email audit showed a clear pattern: principals were less responsive to parents of children with disabilities. They responded to 53.5 percent of the emails that did not mention an IEP, but to only 41.8 percent of the emails that did mention an IEP. Among the emails mentioning an IEP, 44.1 of "Amy's" emails received a positive reply, as compared with 39.5 percent of "Tyra's."

Understanding principals' responses

While the email study showed that principals respond differently to parents of children with disabilities, and especially to Black parents, "we can't actually gain traction on why," Rivera explains. So they ran a second study with a new group of 578 principals designed to understand what was driving the effect.

This time, principals were given a survey ostensibly aimed at getting their views on a variety of issues for a research project. In actuality, the researchers had nested within the survey a series of questions about disabled children and their parents that was the true focus.

As part of this section of the survey, principals saw one of the same eight emails used in the previous study, mentioning either a disabled or nondisabled son or daughter and signed by either Amy or Tyra Williams. Then the survey asked whether and how the principal would have replied to that email if they had actually received it, as well as several questions about the principal's perceptions of both parent and child from the email.

The results of the survey replicated the findings from the email audit, with principals significantly less likely to respond to emails mentioning an IEP, an effect that was stronger when the parent was perceived to be Black.

The survey also shed light on why principals reacted the way they did. Overall, "the discrimination that we observe on the basis of disability status stems from perceptions of the children as more difficult and burdensome to educate," Rivera explains. Though of course unfair and inexcusable, she says these feelings likely stem from the fact that "schools are responsible for paying for students, both monetarily and in terms of staff time."

While the disability discrimination was driven by perceptions of children, Rivera and Tilcsik were surprised to discover the racial discrimination component was driven by perceptions of parents. Black parents of children with disabilities were perceived as being less valuable school community members than white parents of students with or without a disability. "They were seen as less likely to volunteer in the classroom, less likely to participate in fundraising, and there was some evidence that they were perceived as more difficult to work with," Rivera says.

In other words, the discrimination stemmed from multiple interacting biases. "It's not only that multiply-marginalized groups experience more discrimination," Rivera says. "It's that the discrimination might also come from multiple places." That is, the discrimination faced by Black parents of disabled children emerges from a combination of negative stereotypes about disability and negative stereotypes about race.

Building and funding a more just system

Though Rivera finds the results of the study hugely disheartening, "schools should never have been put in this position to begin with," she says: forced to address complex needs with inadequate resources.

Alleviating disability discrimination in schools will require bigger-picture changes, such as getting Congress to finance the IDEA at the level it promised, Rivera believes. With improved school funding, educating disabled children wouldn't be viewed as taking something away from nondisabled students, she argues. What's needed is more for everyone: "How can we provide schools with more resources, so that it's not seen as a zero-sum game?"

# data[].attributes.attachment_link.title
For Students with Disabilities, Discrimination Starts Before They Even Enter School

# data[].attributes.attachment_link.description
"In some cases and for some kids, having that information can be life-saving," says Lauren Rivera, a professor of management and organizations at the Kellogg School. But according to new research from Rivera and András Tilcsik of the University of Toronto's Rotman School of Management, discrimination prevents families from gaining such crucial knowledge.

# data[].attributes.attachment_link.readable_text
Patreon members and YouTube channel members had access to this video on October 22, 2021. The video's public release will be November 24, 2021.
Transcript
Hey humans Lyric here, and this week, I am going to be talking about one of my least favorite subjects ever - school.

School is the one thing that, though I don't dream very often, if I have some sort of reoccurring nightmare, it is likely to be about school; and unfortunately, a lot of Autistic and NeuroDivergent people share these similar sentiments about education.

If you would like to know a little bit more about my personal experience with school, and why education, the way it was for me, was a very traumatic experience - please do stay tuned.

The way I learn was a problem for teachers. I am not someone who sits completely still, ever. My hands are miming under the table right now, as, as we speak here, I've got them out of the way, so as they hopefully are not distracting, and because it feels a bit comfortable - the angle. I am trying not to mask as much as I used to, but it is something that happens, quite naturally, without even realizing I'm doing it because masking has so programmed into me, I am really realizing the more I try to unmask.

That that's something that started in school, because when I was younger, my hands and my feet would have been more active, but I had teachers who scolded me for flapping my hands, who tied my feet to my chair, when I was moving my feet under my desk, because it was making a noise when I was tapping my foot. I learned from an early age when I entered school, that the way my body moves is inappropriate.

Before I came to school, none of this was an issue. I could lay on the floor and read and study by myself in a room, singing and talking to myself, verbally stimming, and drawing circles on the floor with my feet in the carpet, and it would have been a non-issue.

But, when I entered school, I was made aware that I am an annoyance and inconvenience for the people around me. Which was an instantly traumatizing experience.

I am Autistic, I have ADHD, and I am also hyperlexic, and I have social anxiety.

All of these things are a cocktail, that impact my life, and interact with one another. Part of my cocktail in school, that was causing me a lot of trouble, is being hyperlexic, having an far advanced reading level, and an advanced vocabulary reading at a college level in first or second grade.

Because my reading level was so advanced, adults and teachers around me expected me to be way more mature than I actually was, and expected me to do great in every class and every subject.

However, I am someone who struggles to pay attention to things that do not catch my attention. If a topic does not interest me, despite the fact that I can read far above grade level, if I read about it, I read and nothing sinks in.

It's as if my memory does not absorb information that my brain has decided is uninteresting or irrelevant. I am either an expert at something, or I am complete and utter garbage at it. I'm an all or nothing person. There is no in-between with me.

I was very good at the subjects I was good at: English, reading, art, certain types of mathematics, but not all math, but I was also very, very bad at the subjects that I wasn't good at. History, the way history is taught here in Texas, it was horrible. I couldn't, I couldn't make myself care, but you're expected to be able to force your brain to focus on things and I wasn't able to.

Because I was hyperlexic, it was assumed that I was not applying myself, and that I was being lazy, and I could do these things, if I would just apply myself. On top of everything else, I am someone who has audio processing difficulties.

Being in a room full of noisy busy children, trying to listen to a teacher speak at the front of the room, is very difficult if you are unable to hear words, word for word.

When I get overwhelmed, it can sound like the teacher from Charlie Brown is talking to me. "Wa wa wa wa wa wa."

I know you're talking because your lips are moving, but I don't understand a word you say, oh.

I made up that song. Not really. It's another song, but I changed the words.

I often would do really well, set to study and read something on my own, assuming it was something that could catch my interest, but listening to a teacher, speak at the front of the room wasn't ideal for me. Sometimes it would literally put me to sleep, to try and be expected to listen to a teacher, talk at the front of the room. I would just get so exhausted, because of my audio processing difficulties.

I discovered that I could draw, or doodle, or read ahead, or do other things, to keep myself engaged, but often drawing, or doodling, or reading ahead, was taken by the teacher in authority, as a sign of being disrespectful, or not paying attention.

My NeurodDivergent attention does not look like NeuroTypical attention. I don't need to look at you to think or focus. In fact, not looking at you, makes it a lot easier for me to think and process. A lot of teachers, when I was growing up, would expect me to look at them, so that they knew I was listening.

To be looking at them was me pretending to listen, while not actually listening - counterproductive to my learning.

In addition, I was stripped of a lot of autonomy when I entered school. We're trying to teach Autistic and NeuroDivergent kids to have autonomy, to be able to speak up for their needs, and get their own needs met, but this was not the message I received.

At home if I needed to go to the bathroom, I just went to the bathroom. I didn't need to ask permission, or excuse myself, to get my basic human needs met, but in school, bathroom breaks were scheduled and limited. You're only allowed to have so many bathroom breaks in a week, or a semester, or a given time period, depending on how old you are.

For a child who has stomach issues, being punished and scolded for needing to go to the bathroom, and needing extra bathroom breaks, was an extremely traumatic experience.

I still try to break the habit of not going to the bathroom until the very last minute, and feeling like having the need to go to the bathroom is a problem, because school taught me that I shouldn't have to go to the bathroom very much, and I should repress the need to pee.

Why, why did we do this to kids? People got to pee. Kids got to pee too.

I was holding my pee at school for unhealthy amounts of time, because I was afraid of being scolded by the teacher for asking to go to the bathroom.

Some of my worst bullies in school, we're actually the teachers, and I'm not just talking about tying my legs to the chair and not letting me pee.

I'm talking about, when I went to to the teacher for help, because the other kids were picking on me, and bullying me, and calling me names. The teacher told me that, maybe if I stopped acting so weird, and would act normal, the other kids wouldn't bully and pick on me so much.

I left school believing I was a broken person. I left school thinking I was incapable of learning. I left school with very low self-esteem, and I have been recovering from school ever since.

I now know that I can learn lots of things, if I'm passionate about them, and I study them, in my own way, on my own pace.

I am not the failure. The public education system in Texas failed me.

Education systems, all over the world, fail many Autistic and NeuroDivergent students like me, even still to this very day.

Thanks for hanging out with me this week. I know this video got serious really quick, but NeuroDivergent Education is a very serious topic.

I hope educators will see this, and learn something, so we can start making some changes to fix these issues.

I guess that's my plea for you, my helpful viewers, to share this video, share it far and wide, share it with educators, and people who work in education systems, to help them be aware of something that they might not understood.

A huge, thank you to everyone for sharing, commenting, liking, subscribing, giving your video suggestions and inspiration for these videos, and my Patreon subscribers, and YouTube subscribers, and those of you who do the little, a little bit of monetary subscription, to help me with things like the website hosting, and the closed captioning, and the transcripts - which are on my website at NeuroDivergent Rebel dot com.

I could not produce the quality content I do without your help. So, I am really grateful. This, this blog is literally made possible by the support of viewers like you. So as always, I am grateful for my viewers.

I will see you all next Wednesday bye humans and creatures.

Help me get the word out!!! - If you like what I do, and would like more, please consider subscribing on Patreon. This blog is made possible by support from readers like YOU! (Sharing my content is also, equally helpful!)

With gratitude, Lyric

# data[].attributes.attachment_link.title
Autism & NeuroDivergent Trauma in Public Education - My Autistic Experience

# data[].attributes.attachment_link.description
My NeurodDivergent attention does not look like NeuroTypical attention. I don't need to look at you to think or focus. In fact, not looking at you, makes it a lot easier for me to think and process. A lot of teachers, when I was growing up, would expect me to look at them, so that they knew I was listening.

# data[].attributes.attachment_link.readable_text
Abstract

Posttraumatic stress disorder (PTSD) occurs in 12-25% of survivors of acute life-threatening medical events such as heart attack, stroke, and cancer, and is associated with recurrence of cardiac events and mortality in heart attack survivors. This article reviews the current state of knowledge about PTSD after such events, and proposes an Enduring Somatic Threat (EST) model of PTSD due to acute life-threatening medical events to address underappreciated differences between PTSD due to past, discrete/external traumatic events (such as combat) and PTSD due to acute manifestations of chronic disease that are enduring/internal in nature (such as heart attack and stroke). The differences include the external versus internal/somatic source of the threat, the past versus present/future temporal focus of threatening cognitions, the different types and consequences of avoidance behavior, and the different character and consequences of hyperarousal. Although important differences between the two types of PTSD exist, the EST model proposes that the underlying fear of mortality maintains PTSD symptoms due to both discrete/external and ongoing/somatic events. Finally, this article offers a research agenda for testing the EST model, with a particular focus on areas that may improve cardiovascular prognosis and health behaviors in survivors of heart attack and stroke.

I have never been the same since. I suffer from extreme anxiety, hyper vigilance and a host of other psychological symptoms related to my cardiac history. I am hyper aware of every extra or missed heart beat which brings me right back to the original arrhythmia. I struggle on a daily basis to do the most basic things.

Sophia, NYC, Comment in response to "Heart Attack Survivors May Develop PTSD," Tara Parker-Pope, New York Times, June 20, 2012.

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by an exposure to a discrete traumatic event that has generally occurred in the past, such as combat, disaster, or sexual assault, and is characterized by symptoms such as re-experiencing (e.g., intrusive thoughts, nightmares, flashbacks), cognitive or behavioral avoidance of reminders of the event (e.g., avoiding thinking about the event, avoiding places or people associated with the event), and physiological hyperarousal (e.g., difficulty sleeping, heightened startle reflex). It is associated with abnormal amygdala, prefrontal cortex, and hippocampal function ( Shin, Rauch, & Pitman, 2006) as well as abnormal neuroendocrinologic characteristics ( Yehuda, 2006). In the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition; DSM-IV) ( American Psychiatric Association, 1994), life-threatening illness was recognized as an event that can elicit PTSD, however, important differences between PTSD due to discrete past events and PTSD due to ongoing medical illness have not been fully appreciated.

Today in the U.S., there are 21 million veterans and about 1.5 million active duty service people ( United States Department of Defense, 2013). Only a proportion of those have seen combat and are thereby vulnerable to combat-induced PTSD, though the nature of "combat" exposure in the current conflicts is difficult to quantify. By comparison, according to the American Heart Association, there are currently more than 17 million survivors of acute manifestations of cardiovascular disease in the U.S. alone, with 1.2 million more added each year, all of whom have survived a life-threatening acute medical event ( Roger et al., 2012).

The health consequences of PTSD due to acute life threatening illness are substantial. In survivors of cancer or stroke, the development of PTSD is associated with poorer physical functioning, and mental and physical quality of life ( Goldfinger et al., 2013; Shelby, Golden-Kreutz, & Andersen, 2008). In acute coronary syndrome (i.e., myocardial infarction or unstable angina) patients who develop PTSD due to the event, they are at double the risk of ACS recurrence and mortality in the subsequent three years relative to their counterparts who do not develop PTSD ( Edmondson et al., 2012). A number of mechanisms likely explain these associations, including sleep disruption ( Shaffer, Kronish, Burg, Clemow, & Edmondson, 2013), poor medication adherence ( Kronish, Edmondson, Goldfinger, Fei, & Horowitz, 2012; Shemesh et al., 2001), autonomic imbalance ( Gander & von Kanel, 2006), and increased systemic inflammation ( von Kanel et al., 2010).

In all of the studies of PTSD due to a medical event or diagnosis, PTSD has been measured using traditional PTSD screening instruments or clinical interviews keyed to a single event in the past (i.e., the diagnosis and treatment of cancer or the experience of myocardial infarction or stroke). However, a number of researchers have questioned whether PTSD due to a medical event may have features that diverge conceptually and experientially from traditional models of PTSD. For example, the re-experiencing symptoms of PTSD due to a medical illness are often focused on enduring threats of recurrence and functional decline rather than on a discrete event in the past whose danger has passed, and the avoidance, negative alterations in cognition or mood, and hyperarousal symptoms may present in a different manner and with different psychological, behavioral, and health consequences ( Green et al., 1998). However, while the phenomenon currently (and perhaps rightly) labeled PTSD due to acute medical illness does not fit neatly into the traditional PTSD framework, it is also substantially distinct from other somatic fear-based phenomena such as hypochondriasis or somatic anxiety-neither of which are rooted in an identifiable traumatic trigger or have present a substantiated threat of mortality.

This article reviews the current state of knowledge about PTSD after such events, and proposes an Enduring Somatic Threat (EST) model of PTSD due to acute life-threatening medical events to address underappreciated differences between PTSD due to past, discrete/external traumatic events (such as combat) and PTSD due to acute manifestations of chronic disease that are chronic/somatic in nature (such as heart attack and stroke). The differences include the external versus somatic source of the threat, the past versus present/future temporal focus of threatening cognitions, the different types and consequences of avoidance behavior, and the different character and consequences of hyperarousal. Although important differences between the two types of PTSD exist, the EST model proposes that the underlying fear of mortality maintains PTSD symptoms due to both discrete/external and ongoing/somatic events. As can be seen in Table 1 , a number of diagnostic criteria must be met to be diagnosed with PTSD.

Table 1

Criteria

A. Stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence: (1 required)

1.Direct exposure.
2.Witnessing, in person.
3.Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4.Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

B. Intrusion symptoms

The traumatic event is persistently re-experienced: (1 required)

1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
2.Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
3.Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
4.Intense or prolonged distress after exposure to traumatic reminders.
5.Marked physiologic reactivity after exposure to trauma-related stimuli.

C. Avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)

1.Trauma-related thoughts or feelings.
2.Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

D. Negative alterations in cognitions and mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
2.Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.").
3.Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4.Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
5.Markedly diminished interest in (pre-traumatic) significant activities.
6.Feeling alienated from others (e.g., detachment or estrangement).
7.Constricted affect: persistent inability to experience positive emotions.

E. Alterations in arousal and reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)

1. Irritable or aggressive behavior.
2. Self-destructive or reckless behavior.
3. Hypervigilance.
4.Exaggerated startle response.
5.Problems in concentration.
6.Sleep disturbance.

F. Duration

Persistence of symptoms (in Criteria B, C, D and E) for more than one month.

G. Functional significance

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Scope

EST was developed to explain the maladaptive psychological and behavioral sequelae that often follow life-threatening medical illnesses that are currently classified as symptoms or correlates of PTSD. The most relevant phenomena are those psychological sequelae whose features diverge from classical conceptions of PTSD symptoms or correlates, and those behavioral sequelae with unique features or consequences in survivors of life-threatening illness. Finally, EST proposes an underlying commonality that may give rise to both classical presentations of PTSD and the unique presentation of PTSD-like sequelae of life-threatening medical events.

Propositions

The following three propositions draw on quantitative and qualitative investigations of medically-induced PTSD, and on existential social psychological and behavioral medicine theories of PTSD and health behavior, including cognitive worldview models of PTSD ( Dalgleish, 2004), the Terror Management Health Model ( Goldenberg & Arndt, 2008), and Anxiety Buffer Disruption Theory ( Edmondson, Chaudoir, et al., 2011; Pyszczynski & Kesebir, 2011).

Proposition 1: Event Dimensions. There exist at least two distinctions between discrete/external traumatic events and medical traumas. First, discrete/external traumas are represented psychologically as having occurred in the past while medical traumas are perceived as ongoing events of somatic origin that are recalled whenever attention is directed toward the body. Second, discrete/external traumas are directed at the individual from the outside while medical traumas reside within.

Proposition 2: Character of Symptoms. PTSD symptoms due to medical events differ from those due to discrete/external traumatic events due to their divergent temporal focus, the nature and consequences of avoidance behaviors, and the relative necessity of vigilance to signals of threat.

Proposition 3: Source of Distress. While the dimensions of the triggering event and the character of PTSD symptoms differ between discrete/external trauma events and ongoing medical traumas, the underlying source of distress for both is the terrifying awareness of mortality that is made conscious by traumatic events of either type.

Proposition 1: The uniqueness of medical trauma as a triggering event

Life-threatening medical illness possesses all of the hallmarks of a potentially PTSD-inducing event, but differs in important ways from discrete/external past traumatic events ( Smith, Redd, Peyser, & Vogl, 1999). The term life-threatening implies satisfaction of Criterion A1, and though Criterion A2 (see Table) has been abandoned in DSM-V, research has shown that many survivors report intense fear, helplessness, or horror ( Palmer, Kagee, Coyne, & DeMichele, 2004). Unlike the prototypical traumatic events such as combat or sexual assault that have long been known to induce PTSD symptoms, however, medical traumas are rarely discrete events with a defined endpoint. Once a discrete/external event has concluded, the physical threat has usually subsided. Although a combat veteran who experiences traumatic violence may thereafter develop a heightened awareness of the possibility of non-combat violence in the world, she recognizes that the event that triggered her PTSD symptoms is over, and that safe places exist wherein the threat of future violence is exceedingly unlikely. In contrast, traumatic life-threatening illness is often the acute manifestation of a permanently disrupted physiological system whose consequences may last for years and place an ongoing threat squarely in the body of the survivor, from whence no safe haven exists ( Fox et al., 2006; Goldberg et al., 2004; Tang, Wong, & Herbison, 2007).

For example, the cancer experience often begins with suspicious test results, and continues through cancer detection and diagnosis, and treatment that may be long-lasting, invasive, and painful. Following the completion of active treatment and recovery, many patients must continue to undergo regular oncologic check-ups for many years. Although cancer recurrence rates vary, they are substantialfor many forms ( Baker, Denniston, Smith, & West, 2005; Smith et al., 1999). Thus, the traumatic character of the cancer experience does not reflect the horror of a discrete event, but rather arises from an often years-long experience of vulnerability, pain, and fear. Further, the nature of the disease is such that continued vigilance to threat is both statistically rational and prescribed by medical authorities.

Similarly, acute coronary syndromes and strokes are acute indicators of chronic disease that recur with great frequency ( Ay et al., 2010; Fox et al., 2006; Goldberg et al., 2004; Jørgensen, Nakayama, Reith, Raaschou, & Olsen, 1997; Pedersen, van Domburg, & Larsen, 2004; Sacco, Wolf, Kannel, & McNamara, 1982; Tang et al., 2007), and require chronic disease management and continued daily vigilance to physiological markers of cardiovascular functioning and life-long adherence to medication regimens ( Redfern, Briffa, Ellis, & Freedman, 2009; Smith Jr et al., 2011; Vedin et al., 2012).

ACS patients often report include intense fear ( Bennett, Owen, Koutsakis, & Bisson, 2002), perceived life threat, lack of control, ( Doerfler, Paraskos, & Piniarski, 2005) helplessness and chest pain during the ACS event ( Wiedemar et al., 2008), and those factors are associated with increased risk for PTSD, which is present in 1 out of every 8 ACS survivors ( Edmondson et al., 2012). These types of peri-traumatic factors (fear, perceived control, pain) are also highly predictive of subsequent PTSD symptoms due to discrete/external events. Although very few studies of medically-induced PTSD have assessed less traditional perceptions of the medical event as an ongoing somatic threat, those that have done so find that perceptions of a heart attack as central to the patient's identity, that the event is more chronic than acute and has major consequences for the future, as well as negative emotional representations of the illness are strongly predictive of subsequent PTSD symptoms ( Sheldrick, Tarrier, Berry, & Kincey, 2006). Such results suggest an important role for the perception of an enduring somatic threat in medically-induced PTSD. Currently, little is known about the long-term course or severity of PTSD due to cardiovascular events. Wikman and colleagues( Wikman, Bhattacharyya, Perkins-Porras, & Steptoe, 2008) found that 12% of 213 participants screened positive for ACS-induced PTSD at 12 months post-ACS, and that 12.8% of 179 of those participants screened positive for ACS-induced PTSD at 36 months. However, while PTSD symptoms were relatively stable, there were participants who screened positive at 12 months who did not at 36 months, and vice versa, as only 63% of the variance in 36 month PTSD symptoms were explained by 12 month PTSD symptoms. In a different study with the longest follow-up to date, Ginzburg & Ein-Dor found that half of those who developed PTSD initially still screened positive 8 years later ( Ginzburg & Ein-Dor, 2011). Thus, we require more information about the incidence, prevalence, and course of PTSD symptoms due to acute, life-threatening medical illnesses to understand if these symptoms are similar to, or diverge from the course taken by symptoms due to more traditionally conceived traumas.

Further, for discrete non-medical traumas, the trauma confronts the individual from the outside, so that in its aftermath the individual can find havens of safety away from the threatening context in which to recover and begin reintegrating into former life patterns. However, for survivors of life-threatening illness, the source of the threat is within the body itself, and as such is ever-present.

The temporal distinction between discrete events in the past and ongoing somatic threats has led some researchers to question the conceptual fit of PTSD in medical populations ( Anja Mehnert & Koch, 2007; Mundy & Baum, 2004), as PTSD prevalence estimates in studies of cancer patients are substantially lower when present- and future-oriented intrusive thoughts or nightmares are not allowed to fulfill Criterion B (reexperiencing) ( Green et al., 1998). However, other research on the factor structure of responses to PTSD symptom inventories has suggested that PTSD symptoms in medical populations tend to conform to DSM-IV symptom clusters ( Cordova, Studts, Hann, Jacobsen, & Andrykowski, 2000; DuHamel et al., 2004). Since investigations of PTSD due to medical events began in earnest first in cancer survivors and the traditional conceptualization of PTSD was generally accepted, subsequent research in ACS and stroke patients has tended to ignore temporal distinctions in symptom expression and treat medically-induced PTSD as if the medical trauma were a discrete past event ( Edmondson et al., 2012; Edmondson, Richardson, et al., 2013). The EST model proposes a fundamental distinction between traumatic discrete/external events and ongoing/somatic ones that may have important consequences for the identification of PTSD (or PTSD-like disruptions) in survivors of acute life-threatening medical events. That distinction may also have consequences for the character and consequences of PTSD symptoms after acute life-threatening medical events.

Proposition 2: Unique symptom features of medically-induced PTSD

PTSD can be usefully thought of as an overgeneralization of an intense fear response to a conditioned stimulus, and a failure of fear extinction once the actual threat has subsided. This model for understanding PTSD due to discrete/external, past events has proven highly useful for developing successful psychotherapy approaches based on fear extinction paradigms (eg., prolonged exposure). However, the fear extinction paradigm-at least for exposure-based PTSD treatments-- is predicated on the notion that the threat itself has passed, and that the diminished fear response to traumatic cues represents a match between the true nature of the threat and the individual's cognitive orientation to it. That is, exposure-based approaches seek to situate the traumatic event within a defined temporal-spatial context that is removed from the individual's present context so that he or she can adopt a more adaptive cognitive stance toward what is understood as a psychologically uncomfortable but physiologically benign memory of the past.

In contrast, PTSD due to medical events represents an exaggerated and maladaptive fear response to a valid and ongoing threat to an individual's existence. Whereas successful extinction of the fear response to a past discrete/external event rightly places the threat of mortality in the past so that the individual can resume a normative attitude toward death as something that will occur somewhere in the distant future, modulation of the fear response to an ongoing/somatic threat must acknowledge that the threat of mortality persists. Indeed, the lifelong continued medical maintenance of secondary risk is prefaced on the fact that the acute medical event signaled an ongoing vulnerability within the body itself that must be monitored. This primary distinction between PTSD due to discrete/external, past events and ongoing/somatic ones is apparent in the unique character of PTSD symptoms due to medical events.

Reexperiencing symptoms

Diagnostic criteria for PTSD specify that re-experiencing symptoms are keyed to "memories." Since the vast majority of research on medically-induced PTSD has been conducted from the traditional discrete traumatic event perspective, little is known about the character of ongoing present and future-oriented "reexperiencing" symptoms such as intrusive thoughts and nightmares. However, studies that have reported qualitative data on present- and future-oriented symptoms suggest that the acute medical event (ie., cancer diagnosis) is not cognitively distinct from ongoing concerns about present and future threats implied by the event, even if assessed (?) years later ( Matsuoka et al., 2002). Indeed, fear of cancer progression, physical symptoms, doctors appointments, and other future-oriented concerns have been shown to be strongly correlated with past-oriented intrusion symptoms in breast cancer patients ( A. Mehnert, Berg, Henrich, & Herschbach, 2009). In another study, in which anxious cancer patients were asked to identify their most troubling intrusive thoughts, 81% of intrusions reported were future oriented (e.g., I am going to die, the cancer will not go away) ( Whitaker et al., 2009). In our research, we have found that a substantial proportion of cancer survivors (mean time since treatment end was 2 years) still think about cancer at least once a day (47%) and many think about it multiple times a day (14%). In that study, participants who thought most about cancer on a daily basis reported almost a full standard deviation worse mental health quality of life (SF-12 MCS) relative to those who reported rarely thinking about it ( Edmondson, Park, Blank, Fenster, & Mills, 2008; Park, Edmondson, Fenster, & Blank, 2008).

Aside from the above distinctions between the character of re-experiencing symptoms due to discrete/external past events versus that of re-experiencing symptoms due to acute life-threatening events, there is some evidence that the consequences of re-experiencing symptoms may themselves be differentially life-threatening for survivors of some types of acute life-threatening medical events. In a study of 247 ACS patients, we found that 11% screened positive for ACS-induced PTSD. Although screening positive for PTSD at 1 month post-ACS was not itself a statistically significant independent risk factor for a recurrent ACS event or mortality, participants who reported high re-experiencing symptoms were at more than 3-fold increased risk for recurrent ACS or mortality in the 42 months after their index ACS event ( Edmondson, Rieckmann, et al., 2011).

Avoidance symptoms

The avoidance cluster of PTSD symptoms, like the other clusters, was observed first in survivors of discrete/external traumatic events. In the case of combat veterans, survivors may avoid thinking or talking about their combat experiences, may avoid loud noises or outdoor environments that serve as reminders of the combat zone in which they served, or avoid friends they made in the armed services. Although these strategies may not be successful in keeping distressing thoughts at bay, and often represent a significant detriment to quality of life, their continued use suggests that they provide negative reinforcement. Symptoms of avoidance in patients with PTSD due to acute life-threatening illnesses that indicate an ongoing somatic threat are more difficult to conceptualize. For survivors of heart attack or stroke, how does a person avoid an awareness of an irregular heart beat or slightly elevated blood pressure?

A year before DSM-IV made life-threatening illness a qualifying event for PTSD, Shalev and colleagues described the phenomenon in 4 patients, and noted that PTSD was associated with avoidance of future medical treatment ( Shalev, Schreiber, Galai, & Melmed, 1993). Since then, a growing number of studies have shown that PTSD symptoms are associated with nonadherence to secondary prevention medications in both ACS ( Shemesh et al., 2004) and stroke survivors. For example, stroke survivors with PTSD symptoms suggestive of likely PTSD diagnosis were almost 3 times as likely to be nonadherent to their prescribed medications as those without PTSD symptoms years after the index stroke event ( Kronish et al., 2012). Another study from that cohort of stroke survivors found that the association of PTSD to nonadherence was mediated by increased concerns about medications (ie., they disrupt my life, fear of side effects), but not their understanding of the necessity of those medications for secondary prevention. That finding suggests that nonadherence to medications may represent a deeper ambivalence created by conscious or unconscious associations between medications and the event itself ( Edmondson, Horowitz, Goldfinger, Fei, & Kronish, 2013). EST posits that PTSD due to life-threatening medical events is associated with nonadherence to medical treatment because such treatments serve as potent reminders of the initial event and ongoing somatic threat represented by their chronic disease.

Hyperarousal symptoms

Hypervigilance to threat cues, difficulty sleeping, and irritability are the prototypical hyperarousal symptoms of PTSD, and are relatively common in survivors of discrete/external traumatic events. However, little research has focused on hyperarousal symptoms in medically-induced PTSD. Anecdotal data (see the opening quote of this article) suggest that whereas hyperarousal symptoms due to discrete/external events are distressing physiological responses to powerful memories, hyperarousal symptoms due to medically-induced traumas are both focused on - and contributory to -- somatic cues of threat. PTSD due to ACS or stroke is the best illustration of the unique character of hyperarousal symptoms in medically-induced PTSD, because of the positive feedback loop between anxiety and sympathetic/cardiovascular activity such as increased heart rate and blood pressure. When a heart attack survivor is hypervigilant to cardiovascular indicators of threat, the anxiety caused by any fluctuation in those highly variable indicators itself causes increased sympathetic and thus cardiovascular activity.

Proposition 3: Fear of death underlies both past and future oriented symptoms

The defining characteristic of traumatic events is that they force a psychological confrontation between an individual and mortality. Some cognitive/worldview models of PTSD and social psychological theories such as terror management theory consider the fear of mortality the primary driver of anxiety ( Dalgleish, 2004). Such theories suggest that humans collectively rely on worldviews to assuage the fear of death, but that those worldviews falter in the face of traumatic events ( Janoff-Bulman, 1989).

For example, according to "shattered assumptions" theory (Janoff-Bulman, 1992), individuals develop fundamental, yet unarticulated, assumptions about the world and themselves (i.e., worldviews) that allow for healthy human functioning. The most important assumptions include beliefs in a just, benevolent, predictable world in which the individual possesses competence and worth. The worldview's primary function is to provide the individual with meaning, self-esteem, and the illusion of invulnerability. Both worldview models of PTSD and terror management theory (TMT) suggest that worldviews provide people with a sense of meaning, structure, purpose, and invulnerability (Solomon et al., 1991). The profound awareness of mortality that accompanies traumatic events has the potential to incite psychological "terror" if individuals are unable to suppress thoughts about their own inescapable mortality through redoubled investment in worldviews that promise literal or symbolic immortality ( Pyszczynski & Kesebir, 2011).

For all of these existential, worldview-based theories, traumatic events force survivors to confront, with a newfound immediacy, the fact that their "self" and their body are one and the same. While the destruction of intuitive dualism, and the awareness of mortality that accompanies it, are problematic for many trauma survivors, those who survive acute life- threatening medical events that imply enduring somatic threat are particularly vulnerable. In documenting his death from cancer in the memoir Mortality, Christopher Hitchens sums up the conflict.

Always prided myself on my reasoning faculty and my stoic materialism. I don't have a body, I am a body. Yet consciously and regularly acted as if this was not true, or as if an exception would be made in my case.

Particularly for medically-induced PTSD, difficulty suppressing awareness of the ongoing threat of mortality that exists in the body may be heightened by hypervigilance toward somatic threat cues. An important line of research for understanding the association between somatic focus and awareness of mortality has emerged in recent years, and has shown that reminders of the body's corporeality induce death-related thoughts and profound psychological reactions ( Cox, Goldenberg, Pyszczynski, & Weise, 2007). In one of the most striking studies to illuminate the link between a focus on the body and mortality concerns, a means for understanding the ironic association between PTSD and nonadherence to medication in ACS and stroke survivors can be found. Goldenberg and colleagues showed that after mortality was made salient for women participants, reminders of their body's fallible nature reduced intentions to conduct breast self-examinations (BSE). In a second study, they found that conducting BSEs increased death-thought accessibility, and reminders of the body's fallible nature decreased the time women spent conducting BSEs ( Goldenberg, Arndt, Hart, & Routledge, 2008). Similarly, for women high on neuroticism reminders of mortality and the fallibility of the body caused increased desire to avoid thinking about mammography, and in a second study, caused increased discomfort during a mammography ( Goldenberg, Routledge, & Arndt, 2009). Observations that mortality awareness may have ironic effects on health behaviors led to the development of the terror management health model (TMHM), which lays out the conditions under which psychological confrontations with the physical body can undermine symbolic defenses against mortality and, ironically, serve as barriers to health promotion behaviors ( Goldenberg & Arndt, 2008).

Future Directions

EST can inform unique physiological and behavioral challenges associated with psychological and medical management of patients with PTSD due to life-threatening illness. Although there are a number of personality (e.g., neuroticism), psychological (e.g., prior anxiety or mood disorder), demographic, and social or situational factors (family conflict, job or work related issues or losses) that may predispose survivors of acute medical events to develop PTSD, those factors are also predictors of PTSD due to discrete/external traumatic events, and thus do not appear to offer unique insight into medically-induced PTSD. EST predicts that the degree of life-threat subjectively experienced by the individual at the acute onset of the traumatic medical event is the most powerful prognostic factor for later PTSD. Second, the medical prognosis associated with the event will help to determine the severity and duration of PTSD symptoms. Third, more frequent experiences of somatic symptoms that can serve as reminders of impending mortality and will predict the frequency, severity, and duration of PTSD symptoms. Fourth, patients with PTSD will experience increased awareness of -- and physiological reactivity to --somatic indicators of disease, will attempt to avoid reminders of mortality through cognitive or behavioral attempts to disengage from the body (e.g., distraction, substance use), will avoid medical treatments associated with the event, and will be at greater risk for recurrence of acute exacerbations of disease (e.g., recurrent ACS). As such, the previously observed associations between medically-induced PTSD and medication non-adherence can be explained by explicit or implicit aversive associations between secondary prevention medications and the traumatic event, and ironically, with mortality.

A research agenda based on the EST model should first test whether the proposed uniqueness of trauma due to medical events, relative to discrete past traumatic events, is confirmed by patient experience using both qualitative and quantitative research methods. Second, it should further illuminate important differences in PTSD onset, symptom character, risk and maintaining factors, and chronicity between PTSD caused by ongoing/somatic and discrete/external past events. In particular, the influence of the enduring character and somatic source of the traumatic threat should be investigated. Similarly, research should disentangle the dual influences of the ongoing nature and somatic source on the presentation of PTSD symptoms, perhaps by comparing PTSD symptom reports of medical patients with survivors of motor vehicle accidents, for whom a threat of "recurrence" is also ongoing. Third, a thorough investigation of the role of mortality fears in the initiation, maintenance, and symptom expression should be conducted, with particular emphasis on the role of heightened somatic vigilance in the disruption of normative fear extinction in survivors of life-threatening illness.

Conclusions

Across a number of different acute life-threatening medical events, recent meta-analyses suggest that 12-25% of survivors develop significant PTSD symptoms ( Edmondson & Cohen, 2013; Edmondson et al., 2012; Edmondson, Richardson, et al., 2013). Given the frequency with which these events occur, medically-induced PTSD thus represents the lion's share of the PTSD burden in most developed countries. Based on these estimates, as many as 168,000 ACS patients and more than 200,000 stroke survivors will develop clinically significant symptoms of PTSD this year in the U.S. alone. It is important to note that, unlike PTSD due to many discrete/external traumatic events, PTSD due to acute life-threatening medical events develops at least in part while patients are in our hospitals. The way that we structure those hospitals and deliver care should take into account that those factors may contribute to patients' PTSD symptoms in the future ( Edmondson, Shimbo, Ye, Wyer, & Davidson, 2013). Aside from the obvious mental health and quality of life consequences of the disorder, cardiovascular disease patients who develop PTSD also experience increased cardiovascular risk. For example, as mentioned above, ACS-induced PTSD has been associated with a doubling of risk of recurrence and mortality ( Edmondson et al., 2012), and stroke-induced PTSD has been associated with behavioral risk factors such as nonadherence to medications ( Kronish et al., 2012).

To date, PTSD symptoms due to acute medical events have been assessed with measures designed to assess PTSD due to a discrete past event that occurred outside the individual, rather than an enduring somatic threat of mortality. That strategy overlooks important distinctions between the two phenomena, and fails to identify potentially important avenues for intervention and medical management of patients at increased medical and psychological risk. By acknowledging the unique qualities of medically-induced PTSD, researchers and clinicians can open new avenues for understanding and treating this highly prevalent but largely overlooked response to common life-threatening illnesses.

A recent systematic review and meta-analysis ( Nenova et al., 2013) suggested that 68% of the 19 randomized controlled trials (RCTs) so far tested for reduction of PTSD symptoms in cancer survivors showed no effect, and only 1 study showed a consistent reduction across all PTSD symptom clusters. To date, only one pilot RCT of cognitive behavioral therapy for PTSD due to cardiovascular disease has been conducted, which was powered only to assess safety of the approach in cardiac patients ( Shemesh et al., 2011). If the research agenda laid out by the EST model uncovers the expected associations between medical symptoms, somatic focus, and enduring mortality fears, clinicians should look for ways to modify existing PTSD treatments in order to acknowledge the actual ongoing somatic threat experienced by survivors, address the present- and future-focus of medically-induced PTSD symptoms, discuss the meaning of and appropriate response to somatic symptoms, and be aware of avoidance strategies that patients might employ to reduce psychological discomfort but that may ironically increase their recurrence and mortality risk.

Acknowledgments

Funding: This work was supported by grants HL-088117 and HL117832 from the National Institutes of Health, Bethesda, MD. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or the National Institutes of Health. Supported in part by Columbia University's CTSA grant No.UL1RR024156 from NCRR/NIH. No additional external funding was received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 4th ed. American Psychiatric Association; Washington, D.C.: 1994. [Google Scholar]

Shemesh E, Annunziato RA, Weatherley BD, Cotter G, Feaganes JR, Santra M, Rubinstein D. A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness. 2011. [PubMed]

Vedin O, Hagström E, Stewart R, Brown R, Krug-Gourley S, Davies R, Held C. Secondary prevention and risk factor target achievement in a global, high-risk population with established coronary heart disease: baseline results from the STABILITY study. European Journal of Preventive Cardiology. 2012 [[PubMed] Google Scholar]

# data[].attributes.attachment_link.title
An Enduring Somatic Threat Model of Posttraumatic Stress Disorder Due to Acute Life-Threatening Medical Events

# data[].attributes.attachment_link.description
Posttraumatic stress disorder (PTSD) occurs in 12-25% of survivors of acute life-threatening medical events such as heart attack, stroke, and cancer, and is associated with recurrence of cardiac events and mortality in heart attack survivors.

# data[].attributes.attachment_link.readable_text
We know that Post- Traumatic Stress Disorder ( PTSD) is very real. A good working definition of PTSD is as follows: "an anxiety disorder initiated by an exposure to a discrete traumatic event that has generally occurred in the past ... and is characterized by symptoms such as re-experiencing, cognitive or behavioral avoidance of reminders of the event, and physiological hyperarousal"(Edmondson, 2014).

Scholars have long known that people who live with chronic illness are at a greater risk of experiencing PTSD-like symptoms. However, the trigger for these symptoms is not a one-time event that occurred in the past; rather, chronic disease is an ongoing threat to safety. Researchers thus have proposed a model of PTSD that accounts for this difference entitled the Enduring Somatic Threat ("EST") model of PTSD. This blog post explains both the EST model and treatment recommendations.
Why the Link Between Chronic Illness and Trauma Matters
It's estimated that 12 to 25 percent of people who experience life-threatening illness develop medically-induced PTSD (Edmondson, 2014). We know that health consequences of PTSD include diminished mental and physical quality of life. Of particular note is that PTSD produces neurobiological alterations - including higher inflammation levels - that negatively affect health (Koenen & Galea, 2015). PTSD also can affect adherence to medical treatment, as people who use avoidance tactics to manage PTSD symptoms are less likely to take their medication, implement lifestyle changes, and see their doctors for follow-up visits (Edmondson, 2014).
Medical Illness as a Triggering Event
Most traumas come from the external environment: a natural disaster, an attacker, a war. Medical trauma comes from within. Our bodies are the source of danger, and, as such, it can seem that a safe haven is not available to us (Edmondson, 2014). Shock, disbelief, terror, heightened anxiety about the future, and disillusionment in the medical establishment are prevalent (Cordova, Riba & Spiegel, 2017). Perhaps most salient is the changed understanding of our own vulnerability to pain, suffering and death. Our previous worldview - in which the world and our place in it were things we understood - has been shattered by illness, and our perception of safety has been altered irrevocably (Edmondston, 2014).
PTSD Symptoms
Re-experiencing is exactly what it sounds like: a mental re-living of the trauma. It can include intrusive thoughts, flashbacks and nightmares. For many people living with chronic illness, re-experiencing is particularly alive during interactions with doctors and hospitals. Driving by the hospital may cause panic; the prospect of both testing and treatment procedures creates tremendous anxiety. Some of us have particular memories - a botched procedure, a hospital stay in which our pain was unrelenting, an unsympathetic doctor. Others of us have fragments of memory that have not been processed and don't make a coherent narrative; we only know that we are terrified.

Hyperarousal symptoms for chronically ill people often manifest as an intense awareness of bodily sensations. A fair number of the clients I see have been dismissed by their physicians as hypochondriacs; their acute attention to somatic discomfort is not properly identified as a trauma symptom. Difficulty sleeping and irritability are also hallmarks of PTSD hyperarousal.

Avoidance occurs as a way of managing the intense anxiety that accompanies re-experiencing and hyperarousal. We find ways to avoid the hospital. Perhaps we miss doctor appointments and fail to schedule follow-up testing. We also find ways of avoiding our bodies. Maybe we self-medicate with alcohol or "forget" to pick up our prescriptions. The fear that we experience when we think about our illness and feel its impact on us is so great that avoiding anything to do with it seems like the only way to manage.

An important side-note: Prior trauma increases the risk of illness-related PTSD (Cordova, Riba, & Spiegel, 2017). If you've had prior trauma in your life, including cumulative developmental trauma experienced in childhood, there's a good chance that it's going to come up again as part of your illness experience.
Treatment of Illness-Related PTSD
The EST model of PTSD recognizes that chronic illness presents an enduring rather than discrete threat. The dangers that we have experienced in the past due to our illness likely will re-emerge. Thus, treatment should focus heavily on developing coping skills. For some people, this will be pretty straightforward. For others, particularly those with developmental trauma, this will be more difficult.

A good psychotherapist can help you build coping strategies that will help you feel safer and more in control. Some of these strategies include self-talk, support networks, and multi-step plans to see you through medical crises. As you feel more in control, hyperarousal should decrease.

Good psychotherapy also will help you to diminish re-experiencing symptoms by supporting you in developing a narrative of your illness experience. Those fragmented flashbacks need to be named, felt, and placed into the story of your life in order to be integrated.

Finally, psychotherapy will address avoidance symptoms both behaviorally and emotionally. You deserve access to your body in a way that doesn't always hurt, and a good therapist can help you find and maintain that access.

Researchers in this field have recognized something called " post-traumatic growth " (Edmondston, 2014). That is, people can and do use adverse events such as chronic illness to make positive changes in themselves, their relationships, and their worldview. In my own psychotherapy practice, it's been my privilege to witness this growth in many of the chronically ill people I see.
What are your experiences of illness-related trauma? How are you managing these experiences? Please share in the comments.

# data[].attributes.attachment_link.description
We know that Post- Traumatic Stress Disorder ( PTSD) is very real. A good working definition of PTSD is as follows: "an anxiety disorder initiated by an exposure to a discrete traumatic event that has generally occurred in the past ...

# data[].attributes.attachment_link.readable_text
Published by Penguin Random House

A Conversation with Bessel van der Kolk
Q. You've been working with traumatized children and adults for many years and have seen significant changes in how mental illness and trauma are treated. What have you learned from neuroscience, attachment research, and interpersonal neurobiology about how to help children and adults recover from toxic stress?
A. Trauma is ubiquitous in our society. Over 500,000 children are reported for abuse and neglect each year. One out of four Americans reports having been left with bruises after having been hit as a child, one out of five was sexually molested, one out of eight has witnessed severe domestic violence, and a a quarter grew up with alcoholism or drug addiction. Almost every inmate in our prison system, by far the largest in the world, has a serious history of prior trauma. Half a million women are raped each year, half of them before they are adolescents.

These experiences leave traces on people's biology and identity and have devastating social consequences-medical illnesses, problems with school and work performance, drug addiction and a variety of psychiatric illness. In fact, the Centers for Disease Control and Prevention calculate that childhood trauma is our single largest public health issue-more costly than cancer or heart disease-and one that is largely preventable by early prevention and intervention.

In order to overcome trauma people need to feel safe enough to open up their hearts and minds to others and become engaged with new possibilities. This can only be done if trauma survivors, and their communities, are helped to confront and confess the reality of what has happened and are helped to feel safe again. In many non-Western cultures this involves communal rhythmical activities, such as dancing, athletics, and collective prayer. Communal rituals of acknowledgment, support, and repentance can play a substantial role in healing from trauma.

Treatments that focus solely on decreasing a few PTSD symptoms, or on drugs to obliterate feelings, ignore the importance of integrating the traumatic experience in the overall arc of one's life, and they fail to help survivors reconnect with their communities. The scientific evidence for the efficacy of these therapies, while widely promulgated and practiced, is, in fact, quite disappointing.

Probably the most important challenge in recovering from trauma is learning to regulate oneself. We can activate this innate capacity by utilizing breath, touch, movement, and rhythmical engagement with one's fellow human beings, such as yoga, tai chi, and dancing, methods that are not widely utilized in medical settings or in school systems.
Q. In your book you talk about the effect of trauma on the brain. What changes occur in the brain in response to trauma? What happens when someone experiences a flashback?
A. Neuroscience research has shown that traumatized individuals are prone to activate brain areas involved in fear perception, and to have deficits in the areas involved in filtering out relevant from irrelevant information, as well as in the perception of bodily sensations. These changes do not occur in the rational part of the brain, and do not really seem to benefit merely from being aware of the error of one's ways.

The impact of trauma is located in the survival part of the brain, which does not return to baseline after the threat is over. This part of the brain is by definition unreasonable-you do not stop being hungry by reminding yourself how fat you are, and it's pretty difficult to talk yourself out of being angry, shut down, or in love.

One of the most devastating effects of trauma is that people's biology changes into a biology of threat; this is expressed on multiple levels, in stress hormones, immunology and what the brain selects to pay attention to. The intrinsic reward system changes, as do "attractors"-what turns you on or leaves you cold. As a consequence, traumatized people stay on hyper alert; they feel chronically unsafe and in danger, and they have problems feeling calm and enjoying the moment and they are out of touch with their surroundings. Trauma can make it difficult to have comfortable reciprocal relationships with one's children, partners, and coworkers.

Through brain imaging technology, we can visualize how traumatized people even have problems processing ordinary, nonthreatening information, which makes it difficult to fully engage in daily life and to learn from experience. As a result, they are frazzled, unfocused, and tend to repeat the same nonproductive behavior patterns, with the same miserable results.

Trauma affects the entire human organism-thinking, feeling, relationships, and the housekeeping of one's body. Trauma survivors are vulnerable to a host of medical illnesses and chronic pain syndromes, insomnia, drug and alcohol addiction, depression, obesity, and other issues related to optimal functioning of the entire organism, and the capacity for self regulation and self-care.
Q. What do you wish more people understood about trauma?
A. First of all, is important to understand is how ubiquitous trauma is in our society, what devastating effects it has on family life, workplace productivity, the facility to learn and take initiative, the ability to stay calm and focused, and the capacity to be compassionate with one's fellow man.

As a society we cannot afford to ignore trauma and keep our heads in the sand. There are, in fact, countries where governments have taken the science of trauma (and its prevention and treatment) seriously, with results to prove how well that works. For example, Norway has fifty-one citizens per hundred thousand in jail; the US, 951. Their students also have higher test scores and higher graduation rates from high school and college, and their society has a fraction of our crime rate.

I think that the general public tends to associate trauma with the military and terrorism, but the vast majority of traumas occur within families, schools, and neighborhoods, the very people whom they depend on for safety and security. Most traumatized women and children, for example, are traumatized by their intimates. Another important issue is that trauma has a different impact, depending on the age and relative maturity of the affected individual. The brains of traumatized kids develop in a "use-dependent" manner-they become experts in dealing with threat, and have problems with self-regulation, play, and the sort of imaginative creativity that is necessary to become productive members of society.

Trauma is a deeply communal problem: we are fundamentally social animals, and trauma profoundly affects people's capacity to get along with others and be a cooperative and enjoyable member of the tribe.
Q. You have worked with war veterans and at the beginning of your career worked with Vietnam vets before PTSD was an official diagnosis. What do you think of the current prescribed treatment by the Veteran Affairs office for trauma?
A. I currently treat only a few veterans and I am not intimately familiar with what is happening at the Veterans Administration. The VA is a pretty closed system-people who work at the VA rarely attend my workshops or lectures, or those of my close colleagues.

I hear that their main focus is on cognitive behavioral treatments, and on desensitizing people to their memories. These treatments, research shows, are not particularly effective. That is not surprising, given that being traumatized is not an issue of faulty cognition-the problems emanate from parts of the brain that have little to do with cognition.

The biggest problem for veterans is to fully engage in their current lives. The Body Keeps the Score provides a number of ways to reengage - some are ancient, like yoga, theater, and martial arts, while others, like neurofeedback, are based on the latest advances in neuroscience.
Q. What benefits does yoga offer patients in treatment? Are they universal?
Doctors at the VA and the DoD prescribe vast amounts of drugs, even though there is scant evidence that drugs significantly help traumatic stress. Drugs can obscure posttraumatic symptoms but not resolve them.

This issue is even more concerning in the treatment of traumatized children. The poorer you are the more likely it is that you will be given psychiatric drugs to control your behavior. These drugs can have devastating effects on children's capacity to learn, engage and feel good in their bodies.
Q. What do you hope to accomplish with The Body Keeps the Score? What do you want readers to take away from it?
A. Yoga is just one of many time-honored ways to help people experience ownership of their bodies and to feel safe and in control. Our most recent research study on this subject showed that yoga had better results than any drug studies so far for PTSD. That is not to say that everybody should practice yoga-one size never fits all-but every trauma survivor would do well to engage in practices that increases their inner bodily sense of control, safety, and flexibility.

In order to overcome trauma we have to befriend and be in touch with ourselves-our sensations and our emotions. Neuroscience research has shown that the only way we can consciously access that disturbed survival brain is through our interoceptive pathways - through the part of the brain that helps us to feel what is going on deep inside of ourselves.

A. I hope that all traumatized individuals, and their loved ones, will find this book helpful for comfort, understanding, and guidance. That politicians and policy makers will read this book to help them understand the devastating effects of early deprivation and punitive school systems on the health and welfare of our country, as well as the predictable consequences of putting our young men and women in harm's way.

That parents of adopted kids will understand what their children are dealing with, and serve as a guide to solutions.

That educators and school systems will implement trauma-based interventions for children who come from abuse and neglect, and thereby become agents of change to help all children become productive members of society. My greatest hope is that all school systems will teach the four R's: reading, writing, rhythmatic, and self-regulation. That from K to 12 all kids will be taught to experience how they can regulate themselves though their breath, movements, and synchronized interactions with others, and learn how their bodies, brains, and minds react to overwhelming stress with recognizable patterns that can be managed through self-regulation practices, more than with drugs or alcohol.

That it will inspire our armed forces to become as expert in helping returning warriors to once again become peaceful and productive civilians, as they are in transforming adolescents into members of magnificent fighting units.

That physicians will appreciate the role of trauma in the disintegration of bodily systems, and learn what they can do about it.

That mental health professionals will acknowledge the relationship between trauma, drug addiction, and numerous psychiatric "disorders" and incorporate effective trauma treatments in their practice.

That law enforcement and criminal justice personnel will read it to understand their own responses, and that of the people they are dealing with.

That psychiatrists will integrate the scientific knowledge that our brains are meant to help us cooperate and thrive in a community, and realize that their job is to help patients deal with the devastating effects of trauma on mind, brain, and body.

I hope that this book will help us all acknowledge the fact that our zip code has a more profound effect on health and well-being then our genetic code. In short, the goal of this book is to help us to become a trauma-informed society that will confront and deal with our largest public health issue: psychological trauma.

# data[].attributes.attachment_link.description
Published by Penguin Random House Q. You've been working with traumatized children and adults for many years and have seen significant changes in how mental illness and trauma are treated. What have you learned from neuroscience, attachment research, and interpersonal neurobiology about how to help children and adults recover from toxic stress?

# data[].attributes.attachment_link.readable_text
Some aspects of the experiences of students with disabilities may be best understood through a trauma-informed lens. Not all children with disabilities have been traumatized, neglected, or abused, although-tragically-many have (Jones et al., 2012). We do not wish to "pathologize disability." Rather than focus on traumatic events in the lives of students with disabilities, we encourage schools and educators to adopt a trauma-sensitive approach for all students. When schools design curricula and institute schoolwide changes to become trauma-sensitive, students with disabilities are particularly likely to benefit.

Defining Traumatic Stress in Children

In adults, the defining symptoms of Posttraumatic Stress Disorder (PTSD) include re-experiencing, emotional numbing, and hypervigilance. Children who experience trauma present differently, influenced in part by their age and developmental level. A child may not be able to describe a traumatic event, but might re-enact the event through repetitive play, demonstrate sexualized or aggressive behavior, encounter unpleasant physical sensations, or experience sudden attacks of anger, fear, or sadness (van der Kolk, 2015).

Children's basic neurodevelopmental capacities develop differently under adverse or traumatic circumstances. The concept of Developmental Trauma Disorder proposed by van der Kolk (2017) offers a broader conceptualization of trauma that includes effects on attachment, biology, affect regulation, dissociation, behavioral regulation, cognition, and self-concept/personality. Informed by research on toxic stress (Johnson et al., 2013; Shonkoff et al., 2012) and complex trauma (Cook et al., 2005), researchers have continued to consider the impacts of trauma on development. At present, the umbrella term Trauma- and Stressor-Related Disorders (TSRD) is used by mental health professionals to capture the various conditions that can arise when exposure to stressors or trauma has a significant and negative impact on individuals' lives and influences their everyday functioning (APA, 2013).

It can be difficult to differentiate the features of TSRD from the features of other neurodevelopmental disorders such as Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and learning disabilities (Prock & Fogler, 2018). A learner's outburst in the classroom can be attributed to various factors, such as difficulty with an assignment, a conflict with a peer or teacher, or feeling frustration with the child's own physical or neuro-developmental limitations. In the presence of traumatic triggers that may not be evident to classroom staff, the learner's anger can result in confusion for the staff, declines in staff morale, or "symptom chasing" (such as not recognizing a TSRD-related dissociation and instead treating it as "inattention.") Unfortunately, behaviors exhibited by students with disabilities are often mis-attributed to "poor conduct" when they are, in fact, traumatic stress reactions. For example, a child engaging in repetitive behaviors may be perceived as "noncompliant" or a student with autism may be required to stop rocking; yet these may be strategies that these students use to manage traumatic stress reactions.

Interactions Between Trauma and Disability

The "Adverse Childhood Experiences Study" (ACES) found that certain stressful early childhood events and experiences can impact health and developmental outcomes (Felitti et al., 1998). Although the presence of a disability isn't formally considered to be an ACE, children with a wide range of disabilities are at greater risk for abuse and neglect (Jones et al., 2012). The experience of having a disability, while not inherently "traumatic," can lead to traumatizing experiences for some students and their families.

Children who have experienced trauma often have significant difficulty with self-regulation (Saxe et al., 2005), including difficulty controlling emotions, behavior, and attention. It's important to note that developmental challenges-such as ADHD or anxiety disorders-can be exacerbated by trauma (Fogler & Phelps, 2018). Students with disabilities are both more likely to experience traumatizing events, such as abuse or neglect, and to have greater difficulty with self-regulation after a traumatic event has occurred.

Becoming Trauma-Sensitive

Trauma-sensitive schools create an environment where all children feel safe and secure. When students with disabilities feel safe and have a sense that they "belong" in their school environment-whether or not they have experienced trauma-they feel less isolated and are better able to develop social competence and positive coping skills. The effectiveness of the services that schools can provide is also increased when schools adopt a trauma-sensitive approach (Gregory & Nichols, 2018). Trauma-sensitive schools also recognize the impact of trauma on students' developing brains (Plumb, Bush, & Kersevich, 2016). They emphasize understanding students' learning needs in combination with their needs to support, manage, and regulate their emotions, attention, and behaviors.

The following are examples of cases that are familiar to us as psychologists who have worked with schools. All names are pseudonyms.

Maria is a 9-year old with Down Syndrome and a history of traumatic stress who receives special education support in a mainstream elementary school setting. When she becomes overwhelmed, Maria tries to escape from tasks or from the situation, which can be quite disruptive. When Maria was provided some options, she felt safer and could better regulate herself. By alternating between her teacher's "plans" to teach a lesson and Maria's "plan" to take breaks-augmented with a visual chart-both Maria and the teachers and staff she worked with felt more secure in the classroom environment.

Jerry is a 12-year-old middle school student with a history of institutionalization and fetal alcohol exposure. For Jerry, an outward sign that he is having a trauma-related response and is feeling dysregulated is that he appears particularly disheveled and more irritated than usual. When he presents this way in school, Jerry's teachers know that he benefits from extra support during transitions between classes, especially in crowded hallways. Allowing Jerry a small comfort behavior (stopping at the nurse's office) and arranging for one of his preferred teachers to "happen to run into him" to chat in the hallway helps calm Jerry and reduces the likelihood he will become verbally or physically aggressive.

The Role of the School

It is beyond the scope of practice for school leaders or teachers to "identify" or "treat" trauma. However, it can be critically important for school staff to recognize the signs and symptoms of traumatic stress and know when to refer the student and family for professional help. The following principles can cultivate a trauma-sensitive school environment:

Empower teachers to provide information about what works for a student with a disability in their classrooms, drawing from their experiences and understanding of their students.

Encourage staff to notice and document the antecedents, behaviors, and contingencies that might trigger a student's traumatic stress response. Encourage teachers to be curious detectives discovering a student's "dysregulation signature" (shifts in awareness, affect, and actions that can signal that a traumatic stress reaction might be occurring or-better yet-might be about to occur and can therefore potentially be interrupted with a skillful intervention) (Saxe et al., 2005).

Create ways for school team members to engage in this "detective work" together, comparing notes and debriefing about escalation and de-escalation episodes with particular students.

Encourage school teams to develop greater awareness of school-based triggers of the student with a disability and troubleshoot solutions to minimize the student's dysregulation responses. For example, in the case of Jerry, the crowded hallways triggered Jerry's agitation.

The Role of Teachers

There are specific approaches teachers can take to transform their classrooms into trauma-sensitive spaces.

Be authentic and self-forgiving. Teachers working with students who may be having a reaction to a traumatic event may be afraid of "making the wrong move" or retraumatizing the child. It is important to exercise their best-intended judgment as educators. It can be difficult to respond with reassuring care to an emotionally overwhelmed child, particularly when we are nervous. Yet, being their best authentic selves is the best way for teachers to convey caring and safety to a traumatized child (Prock & Fogler, 2018).

Convey a sense of safety. Through our calming words, in-class "quiet corners," and well-timed breaks, teachers can help students with disabilities to calm their overactive emotional systems, allowing their learning, attention, and higher-order cognition to come back "online" (Harvard Center on the Developing Child, 2020).

Foster resilience. Help students with disabilities master their fear constructively and seek appropriate help when needed. This may mean teaching a student nonverbal signals to indicate distress or identifying a go-to social story that can calm a student.

Restore emotional equilibrium following triggering events. After being dysregulated, students will often be in shock, unable to process the incident (Saxe et al., 2005). Lengthy discussions are likely to retrigger the student, particularly among learners with communication challenges. Instead, teachers are encouraged to wait until after the student has calmed. Then it will be easier for the student to make amends or make plans for how to better manage similar situations in the future.

Take care of yourself. Know when to step aside. For teachers who have been hurt, physically or emotionally, by a student with a disability who has experienced a traumatic stress episode, it can be exceedingly difficult to restore a sense of calm, nonjudgmental reassurance. Alternative team members may need to step in.

Flexible Adaptation

Creating a trauma-sensitive school that is inclusive of students with disabilities is challenging but achievable. Teamwork, emotional support, understanding "problem behaviors" as a response to emotional distress, an attitude of curiosity about unexpected behaviors, and a strong sense of compassion will serve educators well. When trauma presentations combine with other disabilities, it is especially important to create an environment where all students feel safe to learn. We encourage teachers and school administrators to maintain a school environment that promotes safety and embraces an attitude of flexible adaptation to children's needs.

Reflect & Discuss

➛ Are teachers at your school trained for trauma-sensitive discipline, particularly seeing that "problem behaviors" may be strategies a student with a disability uses to cope? Do classroom teachers discuss behavior with special ed teachers?

➛ In what ways could creating more trauma-sensitive environments and interactions improve your school's work with students with disabilities?

# data[].attributes.attachment_link.title
Supporting Students with Disabilities in Trauma-Sensitive Schools

# data[].attributes.attachment_link.description
Some aspects of the experiences of students with disabilities may be best understood through a trauma-informed lens. Not all children with disabilities have been traumatized, neglected, or abused, although-tragically-many have (Jones et al., 2012). We do not wish to "pathologize disability."