Understanding Sociological and Neurobiological Theories Related to Trauma

Psych Congress Steering Committee Member Kali Cyrus, MD, MPH, joined with Rachel Ross, MD, PhD, to elaborate on their Psych Congress 2021 session, “Rethinking Approaches to Trauma for the 21st Century: Underlying Neurobiology and Practical Applications to Big “T” and Little “t” Traumas. Their session explored sociological and neurobiological theories related to trauma, and how racism plays a role in impacting mental health.

Dr Cyrus is an assistant professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, and Rachel Ross is an assistant professor, Departments of Psychiatry, Neuroscience, and Medicine at Albert Einstein College of Medicine, and part of the Psychiatric Research Institute of Montefiore and Einstein in the Bronx, NY.

Question: What are the key differences between neurobiology of acute and chronic trauma?

Answer: The major difference is that in acute trauma, the various systems involved (sympathetic nervous system, hypothalamic-pituitary-adrenal axis, immune system) have the opportunity to return to baseline functioning. When a trauma is chronic, this doesn’t happen — a new baseline is set, which might include changes in protein expression that influence brain activity. This changes the way the system (and a person) respond normally and to new acute or ongoing trauma.

Q: While difficult to summarize in 1 paragraph, what are the foremost ways that racism fits in to the description of trauma?

A: The experience of racial oppression is a type of trauma. In early childhood, it may be considered an adverse childhood event, or a multiplier of adverse childhood events. It is chronic, most Black people in the US have some experience of racism on a weekly basis. It can be an individual experience or a communal one, like the news clips of police brutality. There are multiple ways that a person can experience racism, ranging from a simple annoyance (microaggression) that makes a person feel unwelcome to a significant disruption of safety, such as a police stop for nonmoving traffic violation that leads to death.

Q: How do clinicians assess the impact of trauma?

A: Clinicians should use the diagnostic criteria but also work to practice recognizing nuances and alternative representations of client’s trauma.

A client experiencing distress related to racial trauma may have symptoms that signal uneasiness, a feeling of being on edge, or distress overall; they may not consciously connect those to specific experiences or settings where they encountered racism.

Therefore, clinicians should express curiosity about the who/what/when/where of client’s day to day with particular interest to environments where clients may be the “only” or one of few individuals with an underrepresented identity. Often these contexts that contain triggers to racial trauma or distress related to having a minority identity. This requires clinicians with majority identities (White, heterosexual, male) to ask questions related to race and differences. There is growing research that include validated racial trauma scales, which include language to help clinicians who may be looking for ways to appropriately assess clients’ distress related to racism.

Q: What should clinicians consider when treating post-traumatic stress disorder (PTSD) that results from racial trauma?

A: Consider it within the construct of standard trauma — specifically complex and chronic trauma that can underly complex PTSD. As we know, there is no single or standard treatment of trauma and most research suggests that a multimodal approach is best.

Clinicians should try to treat symptoms like insomnia or panic/anxiety with appropriate pharmacological means but should also employ 1 of the validated therapy approaches for trauma. In our session, we mentioned a few resources for adaptations of empirically supported PTSD treatments for racism-related stress like prolonged exposure for African Americans, cognitive behavioral therapy approaches to multicultural therapy, American Psychological Association’s intersectional approach, and the DSM-5 Cultural Formulation.

Q: What tips do you have for clinicians in bringing up race and racism into the therapeutic space?

A: The most important tip we can offer is that there is no perfect way to bring up race and racism, and that you will make mistakes. If there is a mistake or rupture — respond in a humble, nondefensive manner to regain trust and repair with the client. Putting in the time to do some homework on the different forms of overt and covert oppression and how discrimination shows up in the lives of people of color currently and historically is essential to this work. Clinicians should not expect their clients to educate them on the basics; they should be proactive in bringing up race or identity even if the client does not. It is important for clinicians to acknowledge biases within society, institutions (including academic medical centers), the field of mental health, and themselves.

Dr. Kali Cyrus is a psychiatrist who currently sees patients in Washington D.C.. Through her company, Dynamics of Difference, she also offers consultation on managing conflicts stemming from identity differences. She is also a respected leader in highlighting the ways in which discrimination impacts health through her political advocacy with the Committee to Protect Medicare, academically as an Assistant Professor at Johns Hopkins Medicine, and in the mainstream media using videos, opeds, and speaking engagements. Read more about her at www.kalidcmd.com.

Rachel A. Ross, MD, PhD is an assistant professor in the departments of Psychiatry, Neuroscience, and Medicine at Albert Einstein College of Medicine, and part of the Psychiatric Research Institute of Montefiore and Einstein in the Bronx, NY. Her primary academic interest is focused on understanding how stress influences food-based decision making and metabolic outcomes, and how certain stigmatized bodily and behavioral responses to external and internal stressors can lead to disease states, such as anorexia nervosa or obesity. She maintains a clinical practice seeing patients who struggle with these issues with a trauma-informed perspective. She is passionate about education, mentorship, social and racial justice, and asking good questions with science. For more information about her systems research on the interface of stress and metabolism, check out her website rosslab.einsteinmedneuroscience.org.