Trauma and Depression: A Q&A with Karen Goodall, Hope Christie and Rachel Happer

As part of Depression Detectives, we’re holding weekly Q&As with scientists and experts who work on depression or related topics. Our Q&A last week was with three researchers from the University of Edinburgh who study trauma – Karen Goodall, Hope Christie and Rachel Happer.

Q&A

Hi all!

Karen: Hi everyone! I am Karen Goodall. I am a senior Lecturer at the University of Edinburgh. My research is focused on childhood adversity attachment and wellbeing and mental health in adulthood.

It’s really great to be here – we are looking forward to chatting with you!

Hope: Hi everyone! Thanks for coming along this evening 🙂 my name is Dr Hope Christie, I am a Global Challenges Research Fellow at the University of Edinburgh, which is a long winded way of saying I do a lot of work with people in different countries – mainly South Africa.

My work focuses on parents who have experienced something traumatic and may have developed post traumatic stress disorder (PTSD) as a result. I’m interested in how parents feel their trauma and PTSD has affected them, their parenting and their family dynamic.

I’m also excited to be here chatting with everyone this evening!

Rachel: Hi everyone. I’m Dr Rachel Happer. I’m a Clinical Psychologist. I’ve spent the last twenty years working with children, young people and adults who have experienced trauma, particularly trauma that has occurred within interpersonal relationships. My research interests are compassion, shame and institutional roles in abuse.

 

Depression Detectives member S (DD S): Hello, thank you so much for coming!

For starters, what are the ‘headlines’ of the relationship between trauma and depression?

Rachel: Depression is often the outward symptoms that someone might see, trauma is the body’s response to experiences that are difficult to manage.

Karen: There are a large number of studies that point to a relationship between trauma and depression. Particularly trauma in childhood seems to be relevant.

It’s also worth mentioning that depression is one outcome but there are other outcomes linked to trauma such as anxiety disorder or substance use. But it is important to say that not everyone who has experienced trauma will become depressed and vice versa.

DD C: would you say this is mainly connected with attachment or other factors?

Karen: That’s a really interesting question. We tend to think of attachment relationships as risk or protective factors. Trauma seems to be more potent if it is interpersonal, especially if it is related to a parent. On the other hand a secure relationship with another person can protect against the stress of trauma.

I think I should also mention that insecure attachment relationships might play a role in developing depression. However, in children and young people there is evidence that the extreme stress of trauma can lead to impacts on the neurodevelopmental system.

It is also important to mention that we tend to think of trauma as ‘an event’. In fact trauma can be the absence of something, such as good parental care.

DD A: In the context of childhood traumas from parental care (or lack thereof), and given that these have a huge impact on mental health, what approaches could be taken to intervene at this stage? As children may not be able to identify that something wrong/bad is going on!

Hope: Just to add onto the great answers Karen and Rachel have given, it is most often the case that mental health difficulties such as depression and anxiety are often co-morbid or share similar symptoms to post trauma symptoms as well. This can sometimes lead to trauma symptoms being overlooked if you are going to your GP for example.

DD S: Does everyone who’s experienced trauma experience depression at some point? If not, why do some and not others?

Rachel: Each person’s journey through trauma is unique. Whether or how some experiences the impact of trauma will depend on many things including the supports they have around them, the response someone receives to disclosure of trauma, how quickly someone receives the right help, the other resources in their life, the scale and impact of trauma.

 

DD N: Does depression that stems from trauma present differently in any ways to other causes of depression?

Rachel: I would always see someone’s experiences as unique to them. Depression has some key features that have quite a biological underpinning and PTSD type trauma also has some key features such as flashbacks and nightmares.

However, trauma, particularly unresolved, can have a lifelong impact. Both trauma and depression can be impacted upon by the quality of a person’s relationships.

Hope: Great question! I would say that no, that there is no difference in the way that depression presents. Typically what we see is that depression comes second to the trauma. Depression and trauma do share similar symptoms to each other in terms of low mood, withdrawing from relationships or social situations, etc. But there are differences as well, in terms of the root causes of each and how we may treat them

DD N: Thanks for both of those responses. That makes sense. Does that then have implications for treatment of depression? For example making it more complex to get to the underlying issues. And what are the strategies that could be used to help get a diagnosis that reflects causes of depression as well as the depression itself?

Karen: This is quite a complex question. Generally, depression may have multiple causes but typically it will be the symptoms that are treated. I’m not sure that it would be too easy to get an alternative diagnosis but certainly having the space to be able to talk to someone about what happened to you would be the first step in starting to address core issues. Antidepressants can play a role and can support someone who is undertaking other types of therapies but you would also want to be thinking ideally about a therapy that addresses the core issues.

 

DD A: Can you give us a summary of what current literature tells us about childhood attachment and trauma related mental health issues in adulthood?

Karen: Great question! There is a very big literature on insecure attachment and mental health which shows that people who are insecurely attached are more prone to mental health conditions in general. This is because through attachment relationships we learn lots of skills such as how to regulate emotions, what we think of ourselves and the world and how we can trust other people. In this way, people who have a secure attachment may be a bit more resistant to stress, but if we haven’t had those experiences, we can be more prone to finding things stressful. This is one of the ways in which people can become depressed – through stress.

 

DD I: As part of our Top 10 questions in the group (as we try to narrow in on our 1 research question) we have:

How does ‌chronic‌ depression/dysphoria‌ differ ‌from,‌ ‌say‌ ‌a‌ ‌single‌ ‌episode,‌ or‌ ‌discrete‌ ‌episodes‌ ‌of‌ ‌reactive‌ ‌depression? Are there markers (biological, psychological, behavioural, and current or in a person’s history e.g. trauma) that distinguish them?

Can you say anything that might speak to that question eg. research that has been published or gaps that still exist?

Rachel: Big question! Trauma is really about what has happened to someone, either in recent years and in childhood. Chronic depression, reactive depression and single episode all could have a trajectory that arises from trauma, particularly if trauma is not resolved. People often take many years to reach the most effective trauma focused psychological work.

DD I: We know. We are just exploring/trying to narrow things down in the group just now.

Do you know of any markers of trauma (other than the person remembering themselves).

What if it happened very young?

Karen:  That is a very good question indeed because we tend to think that what we don’t remember can hurt us. However it is clear from the research that trauma in early life has a very pervasive effect. In terms of markers, I don’t think you could point to any specific presenting factor and say that it is related to trauma with certainty. What you might expect though is the usual symptoms of difficulties relating to others, making sense of oneself, being prone to anxiety and difficulties in regulating emotions.

DD E: Would these symptoms necessarily be flagged as trauma-related if the individual didn’t feel able to disclose? And separately, since things like struggling to make sense of your identity are often attributed to adolescence or just a part of growing up – at what point is that distinguishable?

Karen: On the whole, I think the impact of trauma tends to be under-rated. For example, when a person goes to a GP with depression, there is not usually the time to ask about what happened to that person in the past or currently and the symptoms of depression are just treated. It is very difficult for people to disclose a history of trauma and often they might not even see it as relevant to their current symptoms. But no, in general practice I don’t think they would be immediately recognised as trauma related. There is a big push currently to ask more about histories but it is tricky.

DD C: I’d add to this that someone may not define their experiences as trauma. It took me many years of therapy before I accepted that I had a traumatic childhood (disorganised attachment, no safe person or safe places….) and it’s only since accepting this term that I’ve been able to reframe things enough to recover. I guess what I’m saying is that it’s easier to define depression, since that’s a bunch of well-defined symptoms, than trauma, which relies on an account of what happened in the past. I wonder how this affects the ability to research trauma-related depression – who defines the existence of trauma in the history?

DD E: I have been in the same boat – I’d be really curious to hear the response to this one!

Karen: I couldn’t agree more. It is much easier to diagnose depression than recognise trauma. In terms of research, many questionnaires will not ask directly ‘did you experience trauma’ but instead might ask about more subtle things such as ‘did you fear either of your parents’. This type of trauma tends to be additive. From my own perspective, I am very interested in emotional abuse because some of the behaviours are ‘normal’ behaviours that happen in all families, such as swearing, shouting etc. It only becomes emotional abuse when it is at the higher end or carries on for a long time.

I also whole-heartedly agree that many people may not define their own childhood as traumatic as we tend to think it is normal. Recognising that you weren’t supported or you were exposed to potentially dangerous situations etc. can be a first step in understanding responses such as chronic loneliness, unmanageable fear or depression.

DD C: “some of the behaviours are ‘normal’ behaviours that happen in all families” and also we only have experience of our own families so we have no clue what it is like to be a child of parents who are less abusive. Another reason we can’t recognise our own trauma. So how does the brain know that it is being traumatised when the person is reacting to what is essentially a normal situation for them? I didn’t know that other families didn’t treat their children like that until I became part of my husband’s family in my 30s!

Oops, we were typing at the same time and you have answered me! 🙂

DD C: How would you address this issue of recognised/undiagnosed trauma? If people present to their GP and all they are offered is anti-depressants or 6 sessions of counselling, then no one will get to the root of the problem and yet another person is failed by the system….

 

DD E: Hello Can you explain what the impact is on the brain when trauma is experienced and does it contribute to dementia in later life?

Karen: I am not an expert on dementia. However, it is clear that when extreme stress is experienced through trauma, it increases what is called allostatic load – wear and tear on the brain and stress regulation systems. Trauma and multiple adverse experiences in childhood such as loss have been linked to physical health such as heart disease and diabetes. It would not surprise me if it were related to dementia but I have to admit that I don’t know this literature in much detail 🙂

 

DD I: Possibly slightly off topic (if so just ignore)

In our Top 10 we also have a couple of questions about parenting, if you are able to speak to those at all?

a) What‌ ‌are‌ ‌the‌ ‌specific‌ ‌problems‌ ‌that‌ emerge‌ ‌from‌ ‌having‌ ‌a‌ ‌parent‌ ‌with‌ ‌depression,‌ ‌and‌ ‌what‌ ‌can‌ ‌be‌ ‌done‌ ‌to‌ help‌ ‌counter‌ ‌these‌ ‌effects?‌ ‌

b) Can‌ ‌parents‌ ‌learn‌ ‌and‌ ‌teach‌ ‌healthy‌ ‌emotional‌ ‌behaviours‌ ‌and‌ ‌positive‌ ‌strategies‌ ‌(e.g.‌ ‌through‌ ‌therapy),‌ ‌even‌ ‌if‌ ‌they‌ ‌can’t‌ ‌always‌ ‌do‌ them‌ ‌themselves?‌ ‌

Hope: Good questions!

I think we can all agree that being a parent is a really difficult job and most of the time parents are really doing the best they can with the tools they have.

a) There is an extensive amount of literature covering depression and parenting. Pointing to parents (mostly mothers – as they have been most studied in regards to this topic) experiencing a number of impairments in their parenting particularly around the parent-child relationship/bonding, as well as being more withdrawn or irritable with the child. In terms of counteracting these effects, there isn’t a one-size-fits-all solution, but social support/support from friends and family is consistently found to be a good protective factor.

b) Again, parents work with what they have. If they themselves were never modelled healthy behaviours, positive coping strategies and emotion regulation in their own childhood, then it is unfair to expect them to be able to model that perfectly for their child. I would also like to add that perhaps depression/trauma/anxiety may impair certain parenting behaviours, but this does not mean that people are bad parents. They will still be trying their hardest and will want the best for their child. Therapy can help parents reflect on their own behaviours for them to model this for their child, but their child may also pick up these things from other family and friends around them as well.

Hope this answers your questions! 😊

 

DD E: This is somewhat of a broader question (and less in the specific scope of depression), but as complex trauma and C-PTSD was mentioned in the Depression Detectives group earlier – I’m wondering what your stances are on that topic? Specifically that effects of complex trauma can present in less “classical” ways (i.e. emotional dysregulation as opposed to flashbacks) and symptoms such as this emotional dysregulation and associated SI/DSH behaviour can end up being labelled as borderline personality disorder. Do you think that they are separate conditions, or just different names for the same thing? If too big a question feel free to ignore this!

DD C: I’m really interested in this, too, thanks for asking. I find it difficult to tell the difference between borderline and complex PTSD… I think, to me, it seems that borderline seems to mostly have underlying complex PTSD? Would love to hear the experts’ views on this…

DD E: This is especially interesting too due to the stigma commonly associated with personality disorder – whereas complex PTSD seems to carry less stigma!

Rachel: I would never want to ignore this question. This is what I have spent my working life talking about, learning about and trying to get people to understand.

Complex trauma is an organisation framework that brings together a set of responses that include emotional dysregulation, difficulties around trust in relationships and a fragmented sense of self. It is most often associated with trauma that has occurred in close, care giving relations, especially in childhood. When children are hurt by those that are meant to care they not only experience the trauma itself and the associated violations but they also have no refuge from the fear. In addition they miss out on the safe relationships where children learn about regulation, who they are, and how to build trusting, safe relationships. If you look at Borderline personality disorder against the context of what individuals have experienced many of the symptoms rare about managing unmanageable situations, feelings and experiences.

DD E: In this vein then, would you say taking a trauma-led approach to BPD is a valuable one? As therapies currently tend to take a behavioural approach (I’m thinking DBT and the like).

Rachel:  I would say a trauma-led approach should be essential in any approach to working with someone who has received a diagnosis of BPD. I would like to see a much stronger emphasis on trauma around work with these individuals. BPD is often associated with a lot of trauma in relationships both in childhood and adulthood, trauma that has occured at developmentally vulnerable times and from someone in a position of trust. The trauma is not always event based, it can also be about what someone has not received such as with neglect. That is not to say interventions like DBT don’t work but they treat emotional regulations and support alternative coping strategies to coping such as self-harm. I think it is also important to know what has happened to someone so they can make sense of how they are feeling and seeing the world and themselves. More self-compassion is key.

 

DD E: Are there treatments available to help those affected by trauma. Ive heard of EMDR – is this something that would help traumatisation? Im thinking psychological treatments

DD E: Not an expert here (so may be overstepping, sorry!) but as someone currently going through EMDR it can be really really effective for processing traumatic memories. The way it was described to me is that traumatic memories get “stuck” and cause lasting distress as they haven’t been processed, and EMDR is a way to un-stick them.

DD A: I’m really interested to hear the answer to this too. I found EMDR very helpful and curious to know others’ experiences.

Rachel: EMDR is an exposure based intervention and so is particularly helpful for processing fear based symptoms such as flash-backs and nightmares. It can be helpful for the right person. The shame that is so often attached to trauma, especially interpersonal trauma often takes longer to shift and need time, a safe relationship and the opportunity to explore beliefs about self, others and the world. Survivors of trauma carry a lot of blame and I take a compassion focused approach.

So good to hear about people getting access to trauma-specific interventions. This is so important. EMDR is one of these, glad it was helpful. So many get other aspects treated first i.e. substance use, low mood, self-harm. And it takes so long for someone to ask “what happened to you?”.

 

DD E: Is EMDR available on the NHS and if so is there a long waiting list? Or even a recommendation of private therapy?

Rachel: EMDR is available in many NHS psychological services especially trauma specific services. What is available and how long the wait will depend on the NHS Health Board. EMDR has a UK Association that can recommend therapists.

DD A: at the end of my CBT sessions my NHS therapist asked if I wanted to try some sessions of EMDR (she was doing a course in it for her job).

 

DD S: The link one of you shared earlier, about ACEs, listed big traumatic events, like child abuse, violence, etc. But what about ‘normal’ traumas, that almost everyone experiences at some point – e.g. the end of a serious relationship. And then ordinary stressful events – losing your wallet, missing a train, failing an exam – which can feel like a big deal at the time.

What is the difference between stressful life events and trauma? Is it just the size or number that makes them different?

Rachel: Interesting question and one that is often asked. There are a number of ways in which the experience of trauma can affect individuals that can have an impact of better or poorer outcomes. These include the direct impact of the trauma/s, whether the trauma impacts on an individuals ability to cope and whether it impacts on relationships. The impact of stressful life events is often cumulative, little things chip away and impact on resilience. Trauma is often experienced as threatening and leads people to believe that the world is threatening and unsafe place. This can lead people to avoid relationships and experienced hat might help.

Hope: Hi, that is a good question! We tend not to look at traumas as ‘big’ or ‘small’ etc, because as you said, everyone’s experience is different and what feels like a big deal to someone, might not feel like much at all to someone else.

Typically when someone has experienced a traumatic event, there is about a four week period the the trauma taking place and perhaps traumatic symptoms starting to develop. This four week period is important, because as you quite rightly pointed out, it may have felt like a big deal in the moment, but as time goes on you are able to carry about your normal life and it doesn’t really bother you. However, there are perhaps other traumas that happen in your life, that will tend to stick with you a bit more. You may find that you start experiencing flashbacks or nightmares, you might start actively avoiding reminders of the trauma, or feeling like you are constantly on edge or feeling jumpy all the time. If these symptoms start developing in that four-week window and continue to get persistent or make it difficult for you to function in your daily life then you may need to seek additional professional support for this experience.

Hope this answers your question 😊

DD S: Thank you both. Yes, that is useful.

 

DD E: Do siblings (one male, one female from the same family) react differently to a severe traumatic accident?

DD M: I would say this is all tied up with the culture they are growing up in. Because there are no significant differences for male/female brains

Hope: A good question here and an interesting one! It is difficult to say, are you suggesting here that both the siblings experienced the same trauma? Or maybe one did and one didn’t?

Either way, you can develop PTSD either through directly experiencing an event, or through witnessing an event taking place.

There is evidence to suggest that females are more vulnerable to developing PTSD post-trauma, but there are also a variety of other factors such as poor social support, and previous experiences of trauma.

I’m not sure I can answer your question specifically, as there are a lot of other factors to consider, but it may be the case that siblings from the same family would react differently to a traumatic experience, as they themselves are different as people.

Karen: There is evidence that females tend to be depressed more than males and they tend to be exposed to trauma more often. However, in terms of siblings, and the same event, it would depend very much on the individuals involved as siblings have different genetic make-ups, personalities, support circles and so on.

 

DD S: I’m interested in your point that trauma might not be ‘an event’. I’ve often imagined that the ongoing experience of growing up, eg, in a violent and unpredictable home, and having no real place of safety, would be much worse than the ‘one-off’ trauma of experiencing a terrorist attack, or another act of violence. Is this what you see in the research? How does continuous and prolonged trauma differ from a one-off event?

Karen: Great point. A ‘one-off’ event is of course extremely stressful but even high levels of stress can be managed if people have developed good self regulation skills and have support. For children and young people, whose brains and stress regulation systems are still developing, ongoing chronic trauma through neglect or abuse or loss can put an intolerable load on a young person who has not yet developed these skills. This continuing stress can actually start to affect the way the brain and other body systems function, making that person potentially more vulnerable to stress, depression and PTSD in the future.

Always important to add, however, that this is not inevitable and people can recover from trauma.

I also wanted to add that living in poverty is traumatic, as is neglect which can feel life threatening to a young person. Of the different types of trauma, a recent meta analysis showed that emotional abuse is more strongly linked to depression than other types of abuse. We tend not to think about the impact of emotional abuse too much but it can be very pervasive and potentially damaging to a child.

DD S: What about if both the imaginary people are adults? I mean, eg, the stress of living in an abusive relationship vs a one-off traumatic event?

Karen: It is very difficult to categorise the effects of trauma. I see what you mean that a one-off traumatic event may present less chronic stress in some cases than ongoing fear-related events (such as an abusive relationship). However, people respond to trauma in different ways that reflect their past, their relationships etc. so for one person something might lead to mental health impacts, where it doesn’t for another person. That said, abusive relationships are particularly toxic due to the constant exposure to fear.

 

DD I: What research methods do you use? (We are just considering what methods to use in our group)

Karen: It depends really on what your question is 😉 We use survey methods a lot to collect data on variables that are likely to be contributory. Other methods might include stress tests, observations of interactions etc. What specifically are you trying to research?

Hope: In my work I use a mixture of both quantitative approaches (e.g., questionnaires) and qualitative approaches (e.g., interviews). I think using a mixture of both is really helpful when trying to address a topic like mental health and parenting. For example, I had one mum talk to me about some questionnaires I had given her asking about the level of communication she had with her child. The questions asked things like “my child looks at me when I say their name or am talking to them”, “my child does what their told the first time they are asked”, “when I speak I feel like my child is listening”, etc. She said to me during her interview she was concerned about those questions, because her child was autistic. So her child didn’t always listen to her first time, and didn’t always look at her when she was speaking to them, but not because their communication as mother and child was poor, but because of her child’s autism. Something like this wouldn’t have been captured via the questionnaire alone, but was discussed during the interview. So I think it is always beneficial to use both where possible 😊

Karen: To add to this, there are a lot of questionnaires on trauma or Adverse Childhood Experiences (ACES – which you might have heard of). These can be very triggering to some people however so need to be used very cautiously.

 

DD E: Is there much in the way of support groups for trauma/ACEs? I only know of one!

Rachel: Scotland has a National Trauma Strategy which you can read about on the web. There is a strong drive to get as many people as possible to be trauma informed. Organisations like Health in Mind can run helpful groups.

 

DD E: I am interested in trauma experiences in different places/cultures. Are some cultures more likely to be protective or induce depression? I was interested in the South African context and someone mentioned before about poverty being traumatic and the UK has a big problem with that.

Hope: Yes, you are correct that lower socioeconomic status can make people more vulnerable to trauma exposure and subsequent PTSD development. This has a lot to do with the context that you live in as well. You may be more at risk to being exposed to dangerous situations. In South Africa, it is an interesting one (I’ll try and not go on forever about it, although I really could!), you’re right that culture plays a significant role. With the parents that I have specifically worked with they were Black African parents, who culturally believed that you dealt with trauma within the family and you did not speak about the trauma as you would bring shame on the family if you did. They also lived in a really unsafe environment where their exposure to trauma was continuous, which was also difficult. In addition, a lot of the South African parents I worked with didn’t really understand what their trauma symptoms were, or didn’t make the connection between their trauma and then having nightmares for example. So you’re right, culture and context has a huge influence.

DD E:  Very interesting. So people recognising trauma and that some of their feelings are a result of trauma will help them to cope/recover better?

Hope: It can do in certain cases, yes. It gives you a bit more of a sense of control and an understanding of where these symptoms are coming from.

 

DD N: That’s all we’ve got time for I’m afraid! Rachel, Hope and Karen, thanks so much for coming and answering our questions, this has been great

Karen: Thank you so much for inviting us. We’ve really been kept on our toes with these insightful questions. It was a real pleasure!

Rachel: It is really important for all of those who have experienced trauma to be given understanding, support and the right access to psychological approaches. Many symptoms are coping strategies that were essential at the time. Survivors of trauma carry so much self blame. they need our compassion not our judgement.

Hope: Thank you so much everyone for all your interesting questions, this has been great 😃

DD C: Thank you so much! I wish we could meet and chat things through properly as this format is really hard to keep up with (especially when my 7 year old daughter had a massive meltdown and needed soothing so I was very late!!)

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