Personality Disorder Resources

by Aunt Becky | May 6, 2019

What Is Personality?

Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.

While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behavior.

Explanations for personality can focus on a variety of influences, ranging from genetic explanations for personality traits to the role of the environment and experience in shaping an individual’s personality.

Environmental factors that can play a role in the development and expression of personality include such things as parenting and culture. How children are raised can depend on the individual personalities and parenting styles of caregivers as well as the norms and expectations of different cultures.

So what actually makes up a personality? Traits and patterns of thought and emotions play important roles, and some of the other fundamental characteristics of personality include:

• Consistency: There is generally a recognizable order and regularity to behaviors. Essentially, people act in the same ways or similar ways in a variety of situations.
• Psychological and physiological: Personality is a psychological construct, but research suggests that it is also influenced by biological processes and needs.
• It impacts behaviors and actions: Personality does not just influence how we move and respond in our environment; it also causes us to act in certain ways.
• Multiple expressions: Personality is displayed in more than just behavior. It can also be seen in our thoughts, feelings, close relationships, and other social interactions.

Personality is not just who we are, it is also how we are.

What Is A Personality Disorder?

A person’s personality may be influenced by experiences, environment (surroundings, life situations) and inherited – genetic – characteristics. A person’s personality typically stays the same over time.

While personality disorders differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. Personality disorders are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a “normal” personality and one that leads to significant impairment.

A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time. Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.

Some types of personality disorder were in previous versions of the diagnostic manuals but have been removed. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder or masochistic personality disorder (characterized by behaviors consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.

Now, there are 10 specific types of personality disorders. Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from what is expected. The pattern of experience and behavior begins by late adolescence or early adulthood and causes distress or problems in functioning.

Without treatment, personality disorders can be long-lasting. Personality disorders must affect at least two of the following areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

What Causes Personality Disorders?

The development of personality disorders in certain people – and not others from a similar background – remains the subject of much debate among researchers and scientists, however, research suggests that genetics, abuse, and other factors may contribute to the development personality disorders.

In the past, many people believed that people who have personality disorders were lazy, the devil, or evil. Thankfully, new research has begun to explore such potential causes as genetics, parenting, and peer influences in the development of personality disorders:

Genetic Factors: Researchers are beginning to identify some possible genetic factors behind personality disorders. New developments into the role of genetics in mental health and personality disorders occur every single day.

• (for example) One research team has identified a malfunctioning gene that may be a factor in obsessive-compulsive disorder.
• Other researchers are exploring genetic links to aggression, anxiety and fear — traits that may play a role in the lives of those who have personality disorders.

Childhood trauma. Findings from one of the largest studies of personality disorders, offer clues about the role of childhood experiences in the development of personality disorders.

• One study found a link between the number and type of childhood traumas and the development of personality disorders. People with borderline personality disorder, for example, had especially high rates of childhood sexual trauma.

Verbal abuse. Even verbal abuse can have an impact. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, told them they didn’t love them or threatened to send them away.

• Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.

High reactivity: Sensitivity to light, noise, texture and other stimuli may also play a role in developing personality disorders

• Overly sensitive children, who have what researchers call “high reactivity,” are more likely to develop shy, timid or anxious personalities.
• However, high reactivity’s role is still far from clear-cut. Twenty percent of infants are highly reactive, but less than 10 percent go on to develop social phobias.

Peers. Certain factors can help prevent children from developing personality disorders.

• Even a single strong relationship with a relative, teacher or friend can offset negative influences from peers, say psychologists.

As researchers continue to make new discoveries about the roles of genetic, environmental factors, and abuse in personality disorders, we will be able to understand, identify, and treat people who have personality disorders more effectively.

What Are TheTypes of Personality Disorders?

Before jumping into characterization of these 10 personality disorders, it should be emphasized that they are more the product of historical observation than of scientific study, so that they are rather vague and imprecise constructs. As a result, these personality disorders rarely present in their classic textbook form, but instead tend to blur into one another. Their division into three clusters in DSM-5 is intended to reflect this tendency – any given personality disorder most likely to blur with other personality disorders within its cluster.

The majority of people with a personality disorder never come into contact with mental health services, and those who do usually do so in the context of another mental disorder, or at a time of crisis; commonly after self-harming or breaking the law. Nevertheless, personality disorders are important to health professionals, because they predispose people to other mental health disorders and affect the presentation and management of existing mental disorders. Personality disorders also result in considerable distress and impairment, and so may need to be treated on their own.

These personality disorders have been divided into three clusters, Cluster A, Cluster B, and Cluster C. Each cluster has personality disorders (not all listed here) that fall within them.

Cluster A: Paranoid, Odd, or Eccentric Behavior

Cluster A is comprised of paranoid, schizoid, and schizotypal personality disorders.

Paranoid Personality Disorder:

Those who suffer with paranoid personality disorder interpret the actions of others as deliberately threatening or demeaning. People who have paranoid personality disorder are often unforgiving, distrusting, and prone to aggressive outbursts (without justification) as they see others as disloyal, condescending, unfaithful, or lying. People with paranoid personality disorder may be jealous, secretive, guarding, and scheming, and may seem emotionally cold or extremely serious.

Paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partners. As a result, a person with paranoid personality disorder seems guarded, suspicious, and constantly on the lookout for clues or suggestions to validate their fears. They will also has a strong sense of personal rights: they are overly sensitive to setbacks and rebuffs, are easily shamed and humiliated, and persistently bears grudges. Unsurprisingly, they tends to withdraw from others and to struggle with building close relationships.

The principal ego defense in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. A large, long-term twin study found that paranoid PD is modestly heritable, and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD.

Schizoid Personality Disorder:

People who suffer from Schizoid Personality Disorder are solitary introverts that seem cold, distant, and withdrawn. People who have schizoid personality disorder spend much time lost in their own thoughts and feelings and feel fearful of intimacy with others.

The term “schizoid” means that a person a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD acts detached and are aloof and prone to introspection and fantasy. They have no desire for social or sexual relationships, they are indifferent to others and to social norms and conventions, and lacks a visible emotional response.

A competing theory about people who have schizoid PD is that they are actually highly sensitive with a rich inner life: they experience a deep longing for intimacy, but find initiating and maintaining close relationships too difficult or distressing, and so they go back into their inner world. People with schizoid PD rarely present for medical treatment, because despite their reluctance to form close relationships, they are mostly well-functioning and untroubled by their apparent oddness.

Schizotypal Personality Disorder:

Those who suffer Schizotypal Personality Disorder exhibit a pattern of peculiarities, with odd mannerisms while speaking or dressing. Schizotypal PD is characterized by oddities of appearance, behavior, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia People who have schizotypal personality disorder often have wildly paranoid beliefs and, as such, have difficulties with relationships and feel marked anxiety while in social situations. They may not react at all (or react inappropriately) during a conversation, or instead, they may talk to themselves. People with schizotypal personality disorder may also believe that they can see the future or read minds, have odd beliefs, magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations.

People with schizotypal PD often fear social interaction and think of others as harmful. This may lead them to develop so-called ideas of reference — that is, beliefs or intuitions that events and happenings are somehow related to them. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others, whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult.

People with schizotypal PD have a higher than average probability of developing schizophrenia, and the condition used to be called “latent schizophrenia.”

Cluster B: Dramatic, Erratic, or Emotional Behavior

Borderline Personality Disorder:

In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self and, as a result, experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, moods, self-image, interpersonal behaviors,  emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behavior. Suicidal threats and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. Borderline PD was named as people who suffered from it were believed to be walking the border between neurotic (anxiety) disorders and psychotic disorders, like schizophrenia and bipolar disorder. I

Research seems to show that people who have borderline personality disorder as a result of childhood sexual abuse, which makes it much more common in women, in part because women are more likely to suffer sexual abuse. However, feminists have argued that borderline PD is more common in women, because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behavior tend instead to be labeled with antisocial PD.

Abrupt, extreme mood swings, an unstable, fluctuating self-image, and stormy relationships are common for a person with borderline personality disorder. People with borderline personality disorder often view the world in black and white – all good or all bad. Someone with borderline personality disorder may have an intense relationship, only to have it devolve over a simple perceived slight. Extreme fear of abandonment may lead to extreme dependency upon others and self-injurious behaviors may be used as manipulation or as a means to get attention.

Antisocial Personality Disorder:

Until Kurt Schneider broadened the concept of personality disorders to include those who “suffer from their abnormality,” being diagnosed with a “personality disorder” was more or less synonymous with antisocial personality disorder. Those with Antisocial Personality Disorder ignore social rules of behavior and act out their problems as they desire. People with Antisocial Personality Disorder are callous, irresponsible, and impulsive. Generally speaking, someone with antisocial personality disorder may have a history of legal problems, aggressive or violent relationships, and a belligerent attitude. Those with antisocial personality disorder often have no regard for others, no respect for others, and feel no remorse about their actions.

Antisocial PD is found to occur much more often in men than in women and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt, and fails to learn from experience. In many cases, they have had no difficulty finding relationships – and can even appear superficially charming (as a “charming psychopath”) – but these relationships are usually fiery, turbulent, and short-lived.

As antisocial PD is the mental disorder most closely correlated with crime, they are likely to have a criminal record or have a history of being in and out of prison.

Narcissistic Personality Disorder:

For people who have narcissistic PD, the affected individual has an overblown feeling of self-importance, a tremendous sense of entitlement, absorbed by fantasies of grandeur, and an excessive need to be admired, and seek constant attention. This person is jealous of others and expects them be jealous in return. This person also lacks empathy and readily lies and exploits others to achieve their aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, or insensitive. If this person feels obstructed or ridiculed, they can fly into a fit of destructive anger and revenge. This is called “narcissistic rage” and can have disastrous consequences for all involved.

People with Narcissistic Personality Disorder are overly sensitive to failure and often complain of mild somatic (non-specific, medical-type) symptoms, such as headaches or stomach aches.

Histrionic Personality Disorder:

People with histrionic PD lack a sense of self-worth and depend on attracting the attention and approval of others for their well-being. They often seem to be overly-dramatizing or “playing a part” in a bid to be heard and seen. Indeed, “histrionic” derives from the Latin histrionicus, which means “about to the actor.” People with histrionic PD may take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they can place themselves at risk of accident or exploitation. Their dealings with others often seem insincere or superficial, which in the longer term can adversely impact their social and romantic relationships.

This is especially distressing, as they are sensitive to criticism and rejection and react badly to loss or failure. A vicious circle may take hold in which the more rejected they feel, the more histrionic they become — and the more histrionic they become, the more rejected they feel. These people want to be the center of attention in any group, and become very angry if they are not. People with histrionic PD have shallow relationships and may use their social skills to manipulate others around them.

It can be argued that a vicious circle of some kind is at the heart of every personality disorder and, indeed, every mental disorder.

Cluster C: Anxious or Fearful Disorders

Obsessive-Compulsive (Anankastic) Personality Disorder:

First and foremost, obsessive-compulsive personality disorder is not the same thing as obsessive-compulsive disorder.

Anankastic  PD is characterized by an excessive preoccupation with details, rules, lists, order, organization, or schedules; perfectionism so extreme that it prevents a task from being completed. Their unending and devotion to work and productivity costs many their interpersonal relationships. A person with anankastic PD is typically doubting and cautious, rigid and controlling, humorless, and miserly. Their underlying anxiety arises from a perceived lack of control over a world that they don’t understand, and the more they try to exert control, the more out of control they feels. As a consequence, they have little tolerance for complexity or nuance, and tends to simplify the world by seeing things as either all good or all bad (often referred to as black and white thinking).

Their relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that they makes upon loved ones.

Dependent Personality Disorder:

Dependent PD is characterized by a major lack of self-confidence, often show patterns of dependent and submissive behavior, and have an excessive need to be cared for by another person or persons. People with dependent personality disorder need a lot of help to make everyday decisions and often surrenders important life decisions to others. They greatly fear abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees themselves as inadequate and helpless, and gives up any personal responsibility and submits themselves to one or more protective others. They imagine that they are at one with these protective other(s), whom they idealize as competent and powerful, and towards whom they behave in a manner that is ingratiating and self-effacing. Those who have Dependent Personality Disorder will rarely initiate projects or work independently.

People with dependent PD often end up with people with a cluster B personality disorder, who feed on the unconditional high regard in which they are held. Overall, people with dependent PD maintain a naïve and child-like perspective and have limited insight into themselves and others. This entrenches their dependency, leaving them vulnerable to abuse and exploitation. These people require extreme advice and reassurance and are easily hurt by disapproval or criticism. People with Dependent Personality Disorder feel helpless when alone and may be devastated when a relationship ends, due in part to their strong fear of rejection.

Avoidant Personality Disorder:

People with avoidant PD believe that they are socially inept, unappealing, or inferior, and fear being embarrassed, criticized, or rejected. People with Avoidant Personality Disorder often avoid any activities that involve interpersonal contact as they’re afraid of saying something wrong, they worry they’ll cry in front of others, and are very hurt when they are disapproved of by others. These people are sensitive to rejection and avoid meeting others and engaging in activities unless they are certain that they’ll be liked or good enough; they’re restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual – or imagined – rejection by parents or peers during their childhood.

Research is showing that people who have avoidant PD excessively monitor internal reactions – of their own and those of others – which prevents them from engaging naturally or fluently in social situations. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions.

They feel extremely uncomfortable in social situations, are timid, and are afraid of being criticized.

These people may have no close relationships beyond their family (although they’d like to) because they’re too afraid of their inability to relate well to others.

Other Ways Of Classifying Personality Disorders:

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as attribution, its impact on social functioning, and severity of the disorder.

Impact on Social Functioning: Social function is affected by many other aspects of mental functioning than just that of personality. But, whenever there is persistently impaired social functioning in conditions in which it wouldn’t be expected, evidence suggests that this may be more likely to be created by personality abnormality than by other clinical variables.

Attribution: Many people who have a personality disorder don’t see any abnormality in their functioning and will continue to believe that there is no abnormality with how the person functions. This group of people have been called the “Type R,” or “treatment-resisting personality disorders,” as opposed to the Type S or treatment-seeking ones, who are very interested on altering their personality disorders and often clamor for treatment  The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.

Severity of the Personality Disorder: The extent to which the dysfunctions in the below areas are associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

Aspects of personality functioning that contribute to severity determination in Personality Disorder (Adapted from the ICD-11 Clinical Descriptions and Diagnostic Guidelines for Personality Disorder) include the following:

Degree and pervasiveness of disturbances in functioning of aspects of the self:

• Stability and coherence of one’s sense of identity (such as: the extent that the sense of self is always changing and inconsistent or overly rigid and fixed).
• Ability to maintain an overall positive and stable sense of self-worth.
• Accuracy of one’s view of one’s characteristics, strengths, and limitations.
• Capacity for self-direction, ability to plan, choose, and implement appropriate goals.
• Degree and pervasiveness of interpersonal dysfunction across various types of relationships such as, romantic relationships, school/work, parent-child, family, friendships, peer contexts
• Interest in engaging in relationships with others.
• Ability to understand and appreciate others’ perspectives.
• Ability to develop and maintain close and mutually satisfying relationships.
• Ability to manage conflict in relationships.
• Pervasiveness, severity, and chronicity of emotional, cognitive, and behavioral manifestations of the personality dysfunction

Emotional manifestations:

• Range and appropriateness of emotional experience and expression.
• Tendency to be emotionally over- or under-reactive to stimuli
• Ability to recognize and acknowledge unwanted emotions (such as anger, sadness).

Cognitive manifestations

• Accuracy of situational and interpersonal appraisals, especially under stress.
• Ability to make appropriate decisions in situations of uncertainty.
• Appropriate stability and flexibility of belief systems.

Behavioral manifestations

• Flexibility in controlling impulses and modulating behavior based on the situation and consideration of the consequences.
• Appropriateness of behavioral responses to intense emotions and stressful circumstances (such as a propensity to self-harm and/or violence).

Common Traits of A Person Who Has A Personality Disorder (per Out Of The Fog):

The list below contains descriptions of some of the more common traits of people who suffer from personality disorders, as observed by family members and partners. Examples are given of each trait, with descriptions of what it feels like to be caught in the crossfire.

Of note: these descriptions are not intended for diagnosis. Refer to the DSM-V or ICD-11 Criteria for Personality Disorders for clinical diagnostic criteria. No one person exhibits all of the traits and the presence of one or more of these traits is not evidence of a personality disorder.

One common criticism is that this list of traits seems so “normal” – more like traits of an unpleasant person than traits of a mentally ill person. This is no accident. Personality disordered people are normal people. Approximately 1 in 11 people meet the diagnostic criteria for having a personality disorder. Personality-disordered people don’t fit the stereotypical models for people with mental illnesses but their behaviors can be just as destructive. These descriptions are offered in the hope that non-personality-disordered family members, caregivers and loved-ones might recognize some similarities to their own situation and discover that they are not alone. Many thanks to Out of the Fog for their amazing list of personality traits. These traits may include:

How Are Personality Disorders Diagnosed?

Every person has a characteristic manner of thinking, feeling, and way relating to others. Some of these personality traits can be so dysfunctional as to warrant a diagnosis of personality disorder. The World Health Organization’s International Classification of Diseases (ICD- 10) includes ten personality disorder diagnoses. Three issues of particular importance for the diagnosis of personality disorders are their differentiation from other mental disorders, from general personality functioning, and from each other. Each of these issues is discussed in turn, and it is suggested that personality disorders are more accurately and effectively diagnosed as maladaptive variants of common personality traits.

Researchers have been unable to identify a qualitative distinction between normal personality functioning and personality disorder. DSM-IV and ICD-10 provide specific and explicit rules for distinguishing the presence versus absence of each of the personality disorders, but the basis for these thresholds are largely unexplained and are weakly justified. The DSM-III schizotypal and borderline personality disorders are the only two for which a published rationale has ever been provided.

Characterizing the 10 personality disorders is difficult, but diagnosing them reliably is even more so. For example, how far from the norm must personality traits deviate before they can be counted as disordered? How significant is “significant impairment”? And how is “impairment” to be defined?

Whatever the answers to these questions, they are bound to include a large part of subjectivity. Personal dislike, prejudice, or a clash of values can all play a part in arriving at a diagnosis of personality disorder, and it has been argued that the diagnosis amounts to little more than a convenient label for undesirables and social deviants.

It is important to understand the difference between personality styles and personality disorders. A person who is shy or likes to spend time alone does not necessarily have an avoidant or schizoid personality disorder. The difference between personality style and a personality disorder often can be determined by assessing the person’s personality function in certain areas, including

• Work
• Relationships
• Feelings/emotions
• Self-identity
• Awareness of reality
• Behavior and impulse control

If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders, the doctor might use various diagnostic tests- such as X-rays and blood tests- to rule out physical illness as the cause of the symptoms.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a personality disorder. The doctor or therapist bases his or her diagnosis on the person’s description of the symptoms and on his or her observation of the person’s attitude and behavior. The therapist then determines if the person’s symptoms point to a personality disorder as outlined in the DSM-5.

According to DSM-5, a personality disorder can be diagnosed if there are significant impairments in self and interpersonal functioning together with one or more pathological personality traits. In addition, these features must be (1) relatively stable across time and consistent across situations, (2) not better understood as normative for the individual’s developmental stage or socio-cultural environment, and (3) not solely due to the direct effects of a substance or general medical condition.

Treatment of Personality Disorders:

People with personality disorders might not seek treatment on their own; and as a result, many go untreated. One reason for the failure to seek treatment might be that many people with personality disorders can function normally in society, outside of the limitations of their disorder.

Most personality disorders are constant, unrelenting, and very hard to cure. However, treatment can help relieve some of the more disturbing symptoms of many types of personality disorders.

Treatment varies depending on the type of disorder, but psychotherapy (a type of counseling) is the main form of treatment. In some cases, medication might be used to treat extreme or disabling symptoms that might occur. Medications that might be used include antidepressants, anti-psychotics, anti-anxiety drugs, and impulse-stabilizing medications.

Psychotherapy focuses on evaluating faulty thinking patterns, and teaching new thinking and behavior patterns. Therapy also aims to improve coping and interpersonal skills.

There are many options for treatment for those who have a personality disorder. These treatments may include therapies (individual, group, or family), which focus upon helping to see how their thought processes may lead to or cause their symptoms. Therapies may also help people with personality disorders learn to become more flexible in their thoughts and behaviors.

Certain types of psychotherapy are effective for treating personality disorders. During psychotherapy, an individual can gain insight and knowledge about the disorder and what is contributing to symptoms, and can talk about thoughts, feelings and behaviors. Psychotherapy can help a person understand the effects of their behavior on others and learn to manage or cope with symptoms and to reduce behaviors causing problems with functioning and relationships. The type of treatment will depend on the specific personality disorder, how severe it is, and the individual’s circumstances.

Commonly used types of psychotherapy include:

• Psychoanalytic/psychodynamic therapy
• Dialectical behavior therapy
• Cognitive behavioral therapy
• Group therapy
• Psychoeducation (teaching the individual and family members about the illness, treatment and ways of coping)

There are no medications specifically to treat personality disorders. However, medication, such as antidepressants, anti-anxiety medication or mood stabilizing medication, may be helpful in treating some symptoms. More severe or long lasting symptoms may require a team approach involving a primary care doctor, a psychiatrist, a psychologist, social worker and family members.

Outlook for Those With Personality Disorders: 

It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.

In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.

One study investigated some aspects of “life success” (status, wealth and successful intimate relationships) and showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.

There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.

Issues For People Who Have Personality Disorders:

In Children:

Early stages and preliminary forms of personality disorders also require a multi-dimensional and early treatment approach if this disorder is to be successfully managed. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.

Research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Children today are less likely to encounter clinicians and researchers who are simply avoiding use of the PD construct in youth. However, these children and families may encounter under-appreciation of the developmental context in which these syndromes occur.

That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.

At Work:

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace—potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers.

However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.

In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

• Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
• Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
• Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.

According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.

Versus Mental Disorders:

The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively. But they may also occur on a spectrum of other mental illnesses.

• Paranoid, schizoid or schizotypal personality disorders have be observed to be premorbid antecedents of delusional disorders or schizophrenia.
• Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse control disorders, eating disorders, ADHD, or a substance use disorder.
• Avoidant personality disorder is seen with social anxiety disorder.

Coping With Personality Disorders:

In addition to actively participating in a treatment plan, some self-care and coping strategies can be helpful for people with personality disorders.

• Learn about the condition. Knowledge and understanding can help empower and motivate.
• Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety.
• Avoid drugs and alcohol. Alcohol and illegal drugs can worsen symptoms or interact with medications.
• Get routine medical care. Don’t neglect checkups or regular care from your family doctor.
• Join a support group of others with personality disorders.
• Write in a journal to express your emotions.
• Try relaxation and stress management techniques such as yoga and meditation.
• Stay connected with family and friends; avoid becoming isolated.

Challenges For People Who Have Personality Disorders (Including Loved Ones And Therapists):

The management and treatment of personality disorders can be a challenging and controversial area, as the difficulties are enduring and affect multiple areas of functioning. Challenges often involve interpersonal issues, and there can be difficulties looking for and finding help from area organizations, especially when trying to engage in a therapeutic relationships with a treatment team. Alternately, a person may not consider that they have a mental health problem. On the other hand, community mental health services may view people who have personality disorders as too complex or difficult, and may directly or indirectly exclude people with such diagnoses or associated behaviors.

The disruptiveness that people with personality disorders can create in an organization makes these, arguably, the most challenging conditions to manage.

Many people who have personality disorders don’t believe that they have them. This perspective can be caused by the person’s ability to see him or herself clearly, and unfortunately, there is major social stigma and discrimination related to the diagnosis of a personality disorder.

The term “personality disorder” involves a wide range of issues, each with a different level of severity or disability; thus, personality disorders require fundamentally different approaches and understandings.

Consider that while some disorders or people are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lies self-harm and self-neglect, while at the other people with PDs may commit violence and crime. There can be other factors such as problematic substance use, dependency, or behavioral addictions. A person may meet the criteria for multiple personality disorder diagnoses and/or other mental disorders, either at certain times or continually, making coordinated input from multiple services a requirement.

Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. People may be perceived as negative, rejecting, demanding, aggressive or manipulative.

Social skills, coping efforts, defense mechanisms, or deliberate strategies; of moral judgments, or the consideration for motivations for specific behaviors or conflicts can be incredibly challenging in people who have personality disorders and those who treat them. The vulnerabilities of a client (and therapist) may get lost in actual or apparent strength and resilience.

There is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression, and therapeutic relationships. However, there may be difficulty acknowledging the different worlds and views that both the client and therapist may believe in. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. An example of one extreme is this: people who may have been exposed to hostility, deceptiveness, rejection, aggression, or abuse in their lives, may be made confused, intimidated, or suspicious by presentations of warmth, intimacy, or positivity. On the other hand, reassurance, openness, and clear communication are usually helpful and needed.

It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.

Coping With A Loved Ones Personality Disorder:

Family members can be important in an individual’s recovery and can work with the individual’s health care provider on the most effective ways to help and support. But having a family member with a personality disorder can also be distressing and stressful. Family members may benefit from talking with a mental health provider who can provide help coping with difficulties.

It may help to tailor how you approach someone based on the stage of acceptance they appear to be in.

Unawareness: Most people living with a personality disorder don’t realize they have one, even if they realize they aren’t easy to live with. It’s best to share your concern by giving someone specific examples of problem behaviors and follow up by offering the resources needed to find a doctor, or make or attend an appointment.

Denial. Most people who are told they have a personality disorder don’t believe it. It isn’t uncommon for them to get angry or defensive. Keep trying to share your concerns if someone is refusing help.

Resistance. When people first begin to accept there’s a problem, they fight the belief that it’s a serious problem. People with personality disorders often resist getting medical treatment as they believe they can change their behaviors on their own. At this stage, encourage a family member or friend to make medical help a part of their personal treatment plan.

Flakiness. Once they start therapy or medication, people with personality disorders often skip or stop treatment without warning. Be there to remind them that no one is perfect, no one is always at the top of their game, and that tomorrow offers new chances to make healthier choices.

Acceptance. After receiving the support needed to overcome denial, resistance and struggles with staying in treatment, patients with these disorders may come to a place of acceptance. In these situations, treatments are seen as a top priority and appreciated as tools for healthy living.

Coping With A Teen Who Has A Personality Disorder:

It’s sometimes difficult to tell the difference between childhood behaviors, teen angst and true personality disorders. When in doubt, it’s best to get a professional opinion. Talking to a child or teen before or after that stage can be daunting. It’s recommended that loved ones are:

• Be mindful of labels. No one wants to be defined by an illness.
• Learn as much as you can so you can pass on information instead of assumptions.
• Focus on feelings and behaviors.
• Emphasize they have a treatable medical condition.
• Stay positive by choosing words like “challenges” instead of “problems.
• If your child is on medication, talk with them about side effects they might be having.
• Invite your child to talk to you whenever questions arise. The worst-case scenario is having to say, “I’m not sure, but we can find out the answer.

Childhood Trauma Resources

by Aunt Becky | Apr 11, 2019

What Is Trauma?

Trauma is any injury, physically or emotionally inflicted upon a person. Trauma has both a medical and a psychiatric definition. For the purposes of this site, we will focus primarily upon psychological trauma and its effects.

Emotional, or Psychological, Trauma is an intense, emotional reaction to a traumatic or severe situation. Trauma may be caused by stressful events such as natural disasters, incidences of abuse, assault, or death. Trauma can also be caused by more minor events, like a car accident or sports injuries.

A traumatic event involves a single event, or a repeating pattern of events that completely overwhelm an individual’s ability to cope or integrate the emotions involved in that experience. That feeling of being overwhelmed can last days, weeks, even years as the person struggles to cope.

Trauma can be caused by a number of events, but there are a few common aspects. There’s often a violation of the person’s familiar ideas about the world and of their rights, which puts the person into a state of extreme confusion and insecurity.

Psychological trauma may be accompanied by physical trauma or exist independently.

Trauma, while often involving a threat to life or safety, can also involve any situation that leaves you feeling stressed or alone, even if it didn’t involve physical harm. It’s not the objective facts that determine if an event is traumatic, but the subjective emotional experience of the event. The more frightened and helpless you felt at the time, the more likely that you will feel traumatized afterwards.

A traumatic event or situation creates psychological trauma when it overwhelms the individual’s ability to cope, and leaves that person fearing death, annihilation, mutilation, or psychosis. The individual may feel emotionally, cognitively, and physically overwhelmed. The circumstances of the event commonly include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss.

This definition of trauma is fairly broad. It includes responses to powerful one-time incidents like accidents, natural disasters, crimes, surgeries, deaths, and other violent events. It also includes responses to chronic or repetitive experiences such as child abuse, neglect, combat, urban violence, concentration camps, battering relationships, and enduring deprivation. This definition intentionally does not allow us to determine whether a particular event is traumatic; that is up to each survivor. This definition provides a guideline for our understanding of a survivor’s experience of the events and conditions of their life.

There are two components to a traumatic experience: the objective and the subjective:

It’s is the subjective experience of the objective events that constitutes the trauma. The more you believe you are endangered, the more traumatized you will be. Psychologically, the bottom line of trauma is overwhelming emotion and a feeling of utter helplessness. There may or may not be bodily injury, but psychological trauma is coupled with physiological upheaval that plays a leading role in the long-range effects.

In other words, trauma is defined by the experience of the survivor.

Two people could undergo the same noxious event and one person might be traumatized while the other person remained relatively unscathed. It is not possible to make blanket generalizations such that “X is traumatic for all who go through it” or “event Y was not traumatic because no one was physically injured.” In addition, the specific aspects of an event that are traumatic will be different from one individual to the next. You cannot assume that the details or meaning of an event, such as a violent assault or rape, that are most distressing for one person will be same for another person.

Trauma comes in many forms, and there are vast differences among people who experience trauma. But the similarities and patterns of response cut across the variety of stressors and victims, so it is very useful to think broadly about trauma.

What Conditions Co-Occur in Children And Adults Who Have Experienced Childhood Trauma?

Adults who experienced childhood trauma are at a greater risk for a number of complications and co-occurring disorders that may require diagnosis and treatment:

• Chronic pain and physical illnesses like diabetes or heart disease
• Depression
• Anxiety disorders
• Obsessive-compulsive disorder
• Substance use disorders
• Post-traumatic stress disorder and other trauma-related mental illnesses
• Dissociative disorders
• Self-harm
• Suicide

What Are Some Statistics About Childhood Trauma?

60% of adults report experiencing abuse or other difficult family circumstances during childhood.

26% of children in the United States will witness or experience a traumatic event before they turn four.

Four of every 10 children in American say they experienced a physical assault during the past year, with one in 10 receiving an assault-related injury.

2% of all children experienced sexual assault or sexual abuse during the past year, with the rate at nearly 11% for girls aged 14 to 17.

Nearly 14% of children repeatedly experienced maltreatment by a caregiver, including nearly 4% who experienced physical abuse.

1 in 4 children was the victim of robbery, vandalism, or theft during the previous year.

More than 13% of children reported being physically bullied, while more than 1 in 3 said they had been emotionally bullied.

1 in 5 children witnessed violence in their family or the neighborhood during the previous year.

In one year, 39% of children between the ages of 12 and 17 reported witnessing violence, 17% reported being a victim of physical assault and 8% reported being the victim of sexual assault.

More than 60% of youth age 17 and younger have been exposed to crime, violence and abuse either directly or indirectly.

More than 10% of youth age 17 and younger reported five or more exposures to violence.

About 10% of children suffered from child maltreatment, were injured in an assault, or witnessed a family member assault another family member.

About 25% of youth age 17 and younger were victims of robbery or witnessed a violent act.

Nearly half of children and adolescents were assaulted at least once in the past year.

Among 536 elementary and middle school children surveyed in an inner city community, 30% had witnessed a stabbing and 26% had witnessed a shooting.

Young children exposed to five or more significant adverse experiences in the first three years of childhood face a 76% likelihood of having one or more delays in their language, emotional or brain development.

As the number of traumatic events experienced during childhood increases, the risk for the following health problems in adulthood increases: depression; alcoholism; drug abuse; suicide attempts; heart and liver diseases; pregnancy problems; high stress; uncontrollable anger; and family, financial, and job problems.

People who have experienced trauma are:

• 15 times more likely to attempt suicide
• 4 times more likely to become an alcoholic
• 4 times more likely to develop a sexually transmitted disease
• 4 times more likely to inject drugs
• 3 times more likely to use antidepressant medication
• 3 times more likely to be absent from work
• 3 times more likely to experience depression
• 3 times more likely to have serious job problems
• 2.5 times more likely to smoke
• 2 times more likely to develop chronic obstructive pulmonary disease
• 2 times more likely to have a serious financial problem

What Is a Traumatic Event?

A traumatic event is a frightening, dangerous, or violent event that poses a threat to a child’s life or bodily integrity. Witnessing a traumatic event that threatens life or security of a loved one can also be traumatic, particularly for young children as their sense of safety depends on the safety of their guardians.

Traumatic experiences can lead to strong emotions and physical reactions that may persist long after the event is over. Children may feel terror, helplessness, or fear, as well as physiological reactions such as heart pounding, vomiting, or loss of bowel or bladder control. Children who experience an inability to protect themselves or who lacked protection from others to avoid the consequences of the traumatic experience may also feel overwhelmed by the intensity of their physical and emotional responses.

Who Is At Greater Risk For Childhood Trauma?

Some groups of children and families are disproportionately represented among those experiencing trauma, which means that they may be exposed to trauma at particularly high rates or be at increased risk for repeated victimization and traumatic experiences. For some populations, co-occurring issues and unique adversities can complicate recovery from trauma.

Others may face major challenges related to access to services or require services that are specially adapted for their needs.

Trauma and Substance Abuse:

There is a strong connection between traumatic stress and substance abuse that has implications for children and families, whether the user is an adolescent or a parent or caregiver.

Research studies have shown that adolescents who engage in problematic substance use are more likely to experience traumatic events and develop PTSD, depression, violent behavior, suicide, and other mental health problems compared to those who do not use substances. Additionally, adolescents exposed to traumatic events are more vulnerable to problematic substance use. Psychoactive substances can both dull the effects of stress and place teens at increased risk for experiencing trauma.

Caregiver substance use carries many risks for child and adolescent development. Starting even before children are born, parental substance use increases children’s risk for later mental health problems and victimization. Children and adolescents with substance-using parents may be exposed to other high-risk situations, such as violence in the home and community.

Economic Stress:

Whether living in urban, suburban, or rural settings, people face the reality of economic downturns: being laid off, being unable to find a job, having difficulty supporting a family, or the closing of community organizations or local services upon which they depend. Economic challenges can affect feelings of safety, the ability to remain calm, relationships with others, and hope and belief that things will improve. When times are uncertain, people feel frustrated, angry, scared, or hopeless; they may have to plan new ways to overcome obstacles.

As children hear, see, and read about what is happening in their homes, communities, and the world, they experience economic stress alongside their parents; when their parents are worried, children begin to worry too.

Military and Veteran Families:

Children of military and veteran families experience unique challenges related to military life and culture. These include deployment-related stresses such as parental separation, family reunification, and reintegration; disruption of relationships with friends and neighbors due to frequent moves; and adaptation to new schools and new community resources.

Added to this, some children face the trauma of a parent returning home from combat with injuries or illness; others must face their parent’s death. Research indicates that although most military children are healthy and resilient and have positive outcomes, certain deployment stresses put some groups at risk: young children; children with preexisting health and mental health problems; children whose parents serve in the National Guard, are reserve personnel, or have had multiple deployments; children who do not live close to military communities; children who live in places with limited resources; children in single-parent families with that parent deployed; and children in dual-military parent families with one or both parents deployed.

Intellectual and Developmental Disabilities:

Research indicates that youth living with intellectual and developmental disability (IDD) experience exposure to trauma at a higher rate than their non-disabled peers. Children with IDD appear to be at an increased risk for physical abuse, physical restraint, seclusion, sexual abuse, and emotional neglect. Additionally, this psychological distress comes second to medical problems and procedures and is more common among children living with IDD than their typically developing peers, as they also may have chronic medical problems that necessitate surgeries and other invasive procedures.

When trauma occurs with children and families with IDD, it is challenging to effectively address the psychological impact of the event.

Homeless Youth:

As many as 2.5 million youth per year are homeless. Along with losing their homes, community, friends, and routines – and their sense of stability and safety – many homeless youth are also victims of violence or other traumatic events. While coming from a variety of backgrounds, research suggests that most of these youth have experienced early and multiple traumas. Their responses to these events have been shaped—at least in part—by age, gender, ethnicity, and sexual orientation.

This history of trauma in turn can cause significant mental health problems, including depression, anxiety disorders, PTSD, suicidal ideation, attachment issues, and substance abuse disorders. Once they arrive on the street, many youths are re-traumatized. Then they struggle to recover from earlier traumatic events at the same time that they are trying to survive in a hostile street environment replete with countless dangers, including an increased likelihood of substance abuse and a vulnerability to being trafficked.

LGBTQ Children and Teens:

Lesbian, gay, bisexual, transgender, and queer, or questioning (LGBTQ) youth experience trauma at higher rates than their straight peers. Common traumas experienced by these youth include bullying, harassment, traumatic loss, intimate partner violence, physical and sexual abuse, and traumatic forms of societal stigma, bias, and rejection. Historically, professionals have failed to recognize and meet the needs of traumatized LGBTQ youth, leading to poor engagement and ineffective treatments that, in some cases, perpetuate the youth’s traumatic experiences.

What Experiences Might Be Traumatic?

• Physical, sexual, or psychological abuse and neglect (including human trafficking)
• Bullying is a deliberate and unsolicited action that occurs with the intent of inflicting social, emotional, physical, and/or psychological harm to someone who often is perceived as being less powerful.
• Natural and technological disasters or terrorism
• Family or community violence
• Sudden or violent loss of a loved one
• Substance use disorder (personal or familial)
• Refugee and war experiences (including torture)
• Serious accidents or life-threatening illness
• Military family-related stressors (e.g., deployment, parental loss or injury)

When children have been in situations where they feared for their lives, believed that they would be injured, witnessed violence, or tragically lost a loved one, they may show signs of child traumatic stress.

How Does Trauma Affect Children?

While adults work hard to keep children safe, dangerous events still happen. This danger can come from outside of the family (such as a natural disaster, car accident, school shooting, or community violence) or from within the family, such as domestic violence, physical or sexual abuse, or the unexpected death of a loved one.

Traumatic experiences are often shattering and life-altering for children. These experiences may effect all levels of functioning and result in an array of distressing symptoms:

Physical Symptoms of Exposure to Trauma Can Include:

• nervousness,
• tiredness
• headaches
• stomach aches
• nausea
• palpitations
• pain
• difficulty sleeping
• nightmares
• worsening of existing medical problems

Emotional Symptoms of Exposure to Trauma Can Include:

• fear
• anxiety
• panic
• irritability
• anger
• withdrawal
• numbness
• depression
• confusion
• hopelessness
• helplessness

Academic Symptoms of Exposure to Trauma Can Include:

• inability to concentrate or remember
• missing school
• poor academic performance.

Relational Symptoms of Exposure to Trauma Can Include:

• emotional barriers between caregivers and children
• distrust and feelings of betrayal
• attachment problems

Nearly all trauma survivors have acute symptoms following a traumatic event, but these generally decrease over time.

Factors That Impede Processing Childhood Trauma:

• Previous exposure to trauma: This may include neglect, physical abuse, sexual abuse, or abrupt separation from a caregiver.
• Duration of exposure to trauma: A one-time exposure, such as a car accident, results in very different responses than exposure over several years, such as domestic violence.
• The longer the exposure, the more difficult the healing process.
• Severity of exposure: An incident that happens directly to a child or in front of a child will have different impacts than an incident that happened to someone else or one a child was told about later. The more severe the exposure, the more difficult it will be to heal.
• Prior emotional and behavioral problems: Pre-existing problems with being able to pay attention, being hyperactive, fighting or not following rules, or a prior history of depression or anxiety may complicate a child’s response to a traumatic event.
• Caregiver’s response after the exposure: It matters whether a caregiver validates the child’s experience or blames the child, or if the caregiver is able to provide comfort and reassurance instead of having difficulty responding to the child. When a caregiver experiences a high level of distress, a child often responds similarly. Caregiver’s support is one of the most important factors in a child’s recovery from trauma.

What Is Childhood Traumatic Stress?

Children who suffer from childhood traumatic stress have been exposed to one or more traumas over their lifetime and develop a reaction that lasts longer than the traumatic event; this reaction affects their everyday life.

Traumatic reactions can include a variety of responses, such as intense and ongoing emotional upset, depressive symptoms or anxiety, behavioral changes, difficulties with self-regulation, problems relating to others or forming attachments, regression or loss of previously acquired skills, attention and academic difficulties, nightmares, difficulty sleeping and eating, and physical symptoms, such as aches and pains.

Older children may use drugs or alcohol, behave in risky ways, or engage in unhealthy sexual activity.

Children who suffer from traumatic stress often have these types of symptoms when reminded in some way of the traumatic event.

While many of us may experience reactions to stress some of the time, when a child is experiencing traumatic stress, these reactions interfere with the child’s daily life and ability to function and interact with others. At no age are children immune to the effects of traumatic experiences. Even infants and toddlers can experience traumatic stress. The way that traumatic stress manifests will vary from child to child and will depend on the child’s age and developmental level.

Without treatment, repeated childhood exposure to traumatic events can affect the brain and nervous system and increase health-risk behaviors (such as smoking, eating disorders, substance use, and high-risk activities).

Research shows that child trauma survivors can be more likely to have long-term health problems (such as diabetes and heart disease) or to die much younger than average people. Traumatic stress can also lead to increased use of health and mental health services and increased involvement with the child welfare and juvenile justice systems.

Adult survivors of traumatic events may also have difficulty in establishing fulfilling relationships and maintaining employment.

Factors That May Increase The Likelihood Of Children’s Recovery From Trauma (Resilience Factors)

Individual Traits:

• Easy temperament
• Feeling of control over one’s life
• High self-esteem/self-confidence
• Sense of humor
• Optimism
• Sociable
• Intelligent

Family Traits: 

• Safe, warm, caring, supportive environment
• High expectations for achievement
• Good communication
• Strong family cohesion
• Reasonable structure and limits
• Strong relationship with at least one caregiver

School-Based Traits

• Considers school a safe place to be
• Warm, caring, supportive environment
• High expectations for achievement
• Significant adult committed to child
• Academic achievement
• Models from peers of developmentally appropriate behavior
• Good relationships with peers
• Involvement and participation in school community/activities

Community Traits: 

• Safe community (or safe places to go)
• Access to resources and supports (e.g., church, mentor, clubs)
• Involved in community activities

 Factors That May Interfere With Children’s Recovery From Trauma (Risk Factors):

Individual Traits

• Difficult temperament (e.g., fussy, irritable, sensitive)
• Sense of a lack of control over life events
• Dependency beyond what is age-appropriate
• Low self-esteem/self-confidence
• Feeling of uncertain or poor future outcomes
• Shy/difficulty making friends

Family Traits:

• Physical or sexual abuse, neglect, domestic violence
• High levels of parental distress
• Lack of parental support
• Expectation that child will fail or act out
• Lack of structure, limit-setting
• Negative relationships with caregivers

School-Based Traits

• Exposure to school violence
• Lack of support from adults at school
• Poor academic performance
• Difficulty with peer relationships
• Lack of participation in school community/activities

Community Traits

• Violence in the community
• Unable to identify a safe place to go
• Unable to identify resources or supports in the community
• Disconnected from the community

Childhood Trauma: Reminders and Adversities

Traumatic experiences can set in motion a cascade of changes in children’s lives that can be challenging and difficult. These can include changes in where they live, where they attend school, who they’re living with, and their daily routines. They may now be living with injury or disability to themselves or others. There may be ongoing criminal or civil proceedings they must cope with.

Traumatic experiences leave a legacy of reminders that may persist for years. These reminders are linked to aspects of the traumatic experience, its circumstances, and its aftermath.

Children may be reminded and triggered by persons, places, things, situations, anniversaries, or by feelings such as renewed fear or sadness.

Physical reactions can also serve as reminders and triggers, for example, increased heart rate or bodily sensations.

Learning children’s responses to trauma and loss triggers is an important tool for understanding how and why children’s distress, behavior, and functioning often fluctuate over time. Trauma and loss reminders can reverberate within families, among friends, in schools, and across communities in ways that can powerfully influence the ability of children, families, and communities to recover.

Addressing trauma and loss triggers is critical to enhancing ongoing adjustment.

Childhood Trauma: Risk and Protective Factors

Fortunately, even when children experience a traumatic event, they don’t always develop traumatic stress. Many factors contribute to symptoms, including whether the child has experienced trauma in the past, and protective factors at the child, family, and community levels can reduce the adverse impact of trauma. These may include:

• Severity of the event. How serious was the event? How badly was the child or someone she loves physically hurt? Did they or someone they love need to go to the hospital? Were the police involved? Were children separated from their caregivers? Were they interviewed by a principal, police officer, or counselor? Did a friend or family member die?
• Proximity to the event. Was the child actually at the place where the event occurred? Did they see the event happen to someone else or were they a victim? Did the child watch the event on television? Did they hear a loved one talk about what happened?
• Caregivers’ reactions. Did the child’s family believe that he or she was telling the truth? Did caregivers take the child’s reactions seriously? How did caregivers respond to the child’s needs, and how did they cope with the event themselves?
• Prior history of trauma. Children continually exposed to traumatic events are more likely to develop traumatic stress reactions.
• Family and community factors. The culture, race, and ethnicity of children, their families, and their communities can be a protective factor, meaning that children and families have qualities and or resources that help buffer against the harmful effects of traumatic experiences and their aftermath. One of these protective factors can be the child’s cultural identity. Culture often has a positive impact on how children, their families, and their communities respond, recover, and heal from a traumatic experience. However, experiences of racism and discrimination can increase a child’s risk for traumatic stress symptoms.

What Are Some Effects Of Trauma Among Children?

Unexpectedly losing a loved one or being involved in a natural disaster, motor vehicle accident, plane crash, or violent attack can be overwhelmingly stressful for all of us – especially our children. A traumatic event can undermine their sense of security, leaving them feeling helpless and vulnerable, especially if the event stemmed from an act of violence, such as a physical assault, mass shooting, or terrorist attack. Even kids or teens not directly affected by a disaster can become traumatized when repeatedly exposed to horrific images of the event on the news or social media.

No matter the age of your child, it’s important to offer extra reassurance and support following a traumatic event. A child’s reaction to a disaster or trauma can be greatly influenced by their parents’ response, so it’s important to educate yourself about trauma and traumatic stress.

The more you know about the symptoms, effects, and treatment options, the better equipped you’ll be to help your child recover. With your love and support, the unsettling thoughts and feelings of traumatic stress can start to fade and your child’s life can return to normal in the days or weeks following the event.

What is Acute Traumatic Stress?

Acute trauma is generally a onetime event, such as a car accident or a natural disaster. Because children’s responses to acute trauma vary, awareness of the wide array of possible responses allows caregivers to provide a sense of safety and security, and support healing.

We each have an “alarm system” in our brain that signals us when we might be in danger. When our brain perceives danger, it prepares our body to respond. Our response often depends on the nature of the danger, but we are likely to react in one of three ways:

1. Fight
2. Flight
3. Freeze

Two parts of our brain respond to danger:

The “doing brain” signals the need for action, while the “thinking brain” tries to solve the problem and make a plan.

When the brain perceives danger, the “thinking brain” makes an assessment. If it’s a false alarm because there is no real danger, the “thinking brain” shuts the alarm off and we move on.

If there is actual danger, the “doing brain” signals the body to release chemicals, to provide energy for us to respond.

When this happens, the “thinking brain” shuts off to allow the “doing brain” to take over.

As a result of this alarm system, people often experience intense emotional responses after a traumatic event. These responses are generally short-lived and most people eventually return to their usual level of functioning after the event. To cope with traumatic exposure, people often need time and support to process the event. During this time, any reminder of the event may lead to a reactivation or increase in their responses.

Some people are unable to recover from acute trauma in a timely way. As a result, they are more likely to develop an Acute Stress Disorder or Post-Traumatic Stress Disorder. The type, severity, and duration of exposure to traumatic stress will influence the course of recovery. The situation is compounded for children by their developmental stages.

What Are Childhood Developmental Stages?

As children grow and mature, they are faced with age-specific challenges they must master before moving along to the next stage.

At each developmental stage, a child is faced with different tasks that build upon one another: a toddler learns to explore his world; school-aged children are interested in making friends; an adolescent tries to separate and become more independent.

When faced with traumatic stress, a child’s energy is diverted and she has less capacity to master developmental challenges.

Most children rebound from traumatic experiences and continue to achieve expected developmental milestones. One of the crucial ways children are able to heal is with support from caregivers to make them feel safe, secure, and protected. The level of support a child receives from a caregiver is the most significant factor in how well a child fares after a traumatic event.

Children’s Developmental Stages

Early Childhood (0 – 5 years) The tables below outline primary developmental tasks and how they may be impacted by exposure to an acute traumatic stressor. These tables include developmental tasks from birth to age twelve, and are not inclusive of every developmental task that may occur.

Histrionic Personality Disorder Subtypes (As Suggested by Million)

What Is Complex Trauma in Children?

Children experience complex traumatic stress when they have had prolonged exposure to trauma, (as would occur if the child suffers regular physical or sexual abuse), experience multiple traumatic events over time, or when different traumatic events occur at the same time (such as separation from a parent or caregiver that’s followed by physical abuse, neglect).

Complex trauma profoundly impacts children’s physical, emotional, behavioral, and cognitive development. It impairs their ability to feel safe in the world and to develop sustaining relationships.

Traumatic experiences change the way the brain functions. According to Judith Herman: “Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition, and memory. Moreover, traumatic events may sever these normally integrated functions from one another.”

The brain’s alarm system prepares the body to respond to danger. The “thinking brain” assesses the situation to determine if there is danger or not.

For children who have experienced multiple traumatic events, such as physical abuse, sexual abuse, or witnessing domestic violence, this danger alarm goes off too often. When faced with repeated alarms, the “thinking brain” gets tired of checking things out, and assumes that the signal always means real danger, which causes the “thinking brain” to shut down and allows the “doing brain” take over.

False alarms or “triggers” can be set off when children hear, see, or feel something that reminds them of previous traumatic events. In the brains of children who have complex trauma, are trained to recognize these triggers, because in the past when they heard, saw, or felt that way, it meant they had to react quickly to a dangerous situation.Triggers can range from loud sounds such as sirens or yelling to smells, subtle facial expressions, or hand gestures. Triggers vary from child to child and are unique to each child’s experience

These triggers may not seem alarming to others, they don’t always seem to make sense to an outsider, including other children. Most of the time, children do not understand why they are acting this way.

Whatever the trigger, it sets off the alarm and the body “fuels” itself to prepare to deal with danger. When the danger is real, this response is helpful. When the body prepares, but there isn’t any danger, the child is left with pent up energy and no outlet. As a result, children may feel angry, want to fight, or hide in a corner to get far away from what their body perceives as danger.

How Does Complex Trauma Effect Children’s Developmental Milestones?

Attachment and Complex Trauma In Children

Attachment is the long-enduring, emotional bond between a child and a primary caregiver, as their caregiver serves as the child’s source of safety, provides for the child’s needs, and guides them in understanding themselves and others. In turn, the child meets the caregiver’s need to provide nourishment and guidance. This is a natural and automatic process that begins from the moment a child is born and a caregiver looks into the infant’s eyes.

Healthy attachments provide the building blocks for later relationships and a child’s ability to master developmental tasks by:

Regulating Emotions And Self-Soothing: A child learns how to calm down when a caregiver uses soothing techniques such as rocking, holding, and cooing. Over time, the child learns how to calm down by himself.

Developing Trust In Others: When the caregiver and child are attuned to each other, the caregiver knows how to respond to the child’s needs and the child learns that he can depend on others, which leaves the child with a sense the world is predictable and safe.

Encouraging Children To Freely Explore Their Environment: As the child has already learned that they can rely on others, they feels safe to explore the world knowing that someone will be there if they are in distress or needs help. This exploration is the way children learn.

Helping Children Understand Themselves And Others: The caregiver-child relationship provides the child with a model for understanding who she is, who the caregiver is, and how the world works. Because the caregiver responds, the world is seen as a safe place where people can be trusted and depended upon.

Teaching Children That They Can Have An Impact On Their World: Through interactions with the caregiver, the child learns that he has an impact on others. The child smiles and the caregiver smiles back; the child laughs and the caregiver plays with her; the child cries and the caregiver picks her up.

This natural process of attachment may be eroded by complex trauma in various ways:

• The caregiver may be the source of the trauma.
• The availability, reliability, or predictability of the caregiver may be limited.
• The child may not learn to regulate his emotions or calm himself down when experiencing intense emotions.
• The child’s ability to learn by exploring the world may take a back seat to the child’s need for protection and safety.
• The child begins to see the world as dangerous, leading to a sense of vulnerability and distrust of others.

As the child has little sense of her impact on others, their lack of control over her life leads to a sense of hopelessness and helplessness.

Coping With Acute And Complex Traumatic Stress in Children:

Suddenly losing a loved one or being involved in a natural disaster, motor vehicle accident, plane crash, or violent attack can be overwhelmingly stressful for children. A traumatic event can undermine their sense of security, leaving them feeling helpless and vulnerable, especially if the event stemmed from an act of violence, such as a physical assault, mass shooting, or terrorist attack. Even kids or teens not directly affected by a disaster can become traumatized when repeatedly exposed to horrific images of the event on the news or social media.Whatever the age of your child, it’s important to offer extra reassurance and support following a traumatic event.

A child’s reaction to a disaster or trauma can be greatly influenced by their parents’ response, so it’s important to educate yourself about trauma and traumatic stress. The more you know about the symptoms, effects, and treatment options, the better equipped you’ll be to help your child recover. With your love and support, the unsettling thoughts and feelings of traumatic stress can start to fade and your child’s life can return to normal in the days or weeks following the event.

When caring for a child who has recently experienced an acute traumatic event, it is helpful to think about meeting the child’s needs for safety, stabilization, and support.

Safety

Acute traumatic experiences challenge children’s idea that the world is a safe and predictable place. When scary things happen, children rely on caregivers to keep them safe. These are some of the ways you can help children feel safe:

Help the child find safe places to go when they’re feeling overwhelmed. At school, perhaps a safe place is in the reading corner, where the child can sit comfortably, look at books, or listen to music until they feel calm again. Perhaps it’s the guidance counselor’s office, the nurses office, or an area of the room separate from the main activities of the class. Ask the child what would make them feel safe when they’re feeling afraid, overwhelmed, or sad. Make sure if the child shows signs of acute traumatic stress (acting up, crying, withdrawing) that you ask the child if they would want to go to the safe place to calm down.

Find safe people for the child to talk with when they feel overwhelmed, asking the child who they feel comfortable being with when they’re upset. Reduce unnecessary secondary exposures and separations.

Routines can be a lifesaver. Tell children what to expect throughout the day, leading them to understand when the routine changes, always helps children feel comforted and secure.

It’s important to note that these children need to feel safe everywhere they go. Some children may feel safe in the classroom, but become overwhelmed in other environments. Helping children throughout the day and beyond the classroom may require communicating with other school personnel about how to accomplish this.

Be aware of Mandated Reporter laws. Many caregivers are required to report suspected abuse to child welfare authorities. Be aware of the laws in your state and work with your team to determine when you should file a report to protect a child.

Stabilization

Children who have been traumatized require stabilization to provide a sense of predictability, consistency, and safety – the very things that are lost when a traumatic event occurs. Stabilization allows children to process their experience and be able to move on.

Create a routine. Structure and predictability help children feel safe and secure.

• Start and end each day in the same way.
• Write down a schedule to be posted next to the child’s bed, on a classroom bulletin board, or at the child’s desk.
• Provide support so that the child and family feel safe and secure
• Help the child to return to typical routines (such as school) as soon as possible

Create a support system for the child; when children are supported by the people around them, their feelings of distress often decrease.

• Maintain a connection with children’s support network. Teachers and primary caregivers should communicate consistently with each other.
• A support system can include a child’s teachers, primary caregivers, as well as family members, guidance counselor, friends/peers, clergy, pediatrician, and neighbors.
• Advocate a supportive role by caregivers and others
• Maintain healthy relationships with the child’s primary caregivers and other close relatives/friends
• Create a supportive milieu for the spectrum of reactions and different courses of recovery
• Encourage and support help-seeking behaviors

Ensure the child’s physical needs are met. Traumatic experiences often affect physical health and emotional health.

• During acute stress following trauma, children may experience headaches, stomach aches, and muscle aches. Determine first if there is a medical cause for these symptoms. If none are found, provide comfort and reassure the child that these feelings happen to many children after a traumatic event. Be matter-of-fact with the child and beware that non-medical complaints too much attention may increase them.
• At home, be sure children sleep nine to ten hours a night, eat well, drink plenty of water, and get regular exercise.
• At school, be sure children drink plenty of water, have a well-balanced lunch, and get exercise during the school day.

 Recognize “triggers.”

Triggers are events/reminders/cues that cause children to become upset again (such as rain or thunder for children who experienced a hurricane). These reminders may seem harmless to other people, but they can be devastating to survivors. These triggers will vary from child to child.

• If a child becomes upset, it may be helpful to explain the difference between the event and reminders of the event.
• Protect children from reminders of the event as much as you can, particularly media coverage.
• Avoid secondary trauma by reducing the child’s exposure

Provide clear and honest answers.

• Be sure children understand the words you use. Find out what other explanations children have heard about the event and clarify inaccurate information. If the danger is far away, be sure to tell the child that it is not nearby. Avoid details that will scare the child.
• Use developmentally appropriately terms when talking about the event and the trauma

Practice relaxation techniques

Deep breathing, listening to soothing music, and muscle relaxation will help children relieve some of their stress.

Children may have trouble sleeping.

• Young children may be scared to be away from their caregivers, particularly at bed or nap times. Reassure the child that she is safe. Spend extra quiet time together at bed or nap time.
• Let the child sleep with a dim light on. Some young children may not understand the difference between dreams and real life, and will need reassurance and help in making this distinction.
• School age children may have sleeping problems due to nightmares. Ask the child to tell you about the bad dreams. Explain that many children have bad dreams after a traumatic event and the dreams will go away.

Self-Care is key

• It is important that caregivers take care of themselves.
• Dealing with traumatized children may trigger intense and difficult feelings in caregivers, leaving them feeling depleted and exhausted.

Minimize media impact:

Children who’ve experienced a traumatic event can often find relentless media coverage to be further traumatizing. Excessive exposure to images of a disturbing event—such as repeatedly viewing video clips on social media or news sites—can even create traumatic stress in children or teens who were not directly affected by the event.

• As much as you can, watch news reports of the traumatic event with your child. You can reassure your child as you’re watching and help place information in context.
• Limit your child’s media exposure to the traumatic event. Don’t let your child watch the news or check social media just before bed, and make use of parental controls on the TV, computer, and tablet to prevent your child from repeatedly viewing disturbing footage.
• Avoid exposing your child to graphic images and videos. It’s often less traumatizing for a child or teen to read the newspaper rather than watch television coverage or view video clips of the event.

Engagement:

You can’t force your child to recover from traumatic stress, but you can play a major role in the healing process by simply spending time together and talking face to face, free from TV, games, and other distractions. Do your best to create an environment where your kids feel safe to communicate what they’re feeling and to ask questions.

• Provide your child with ongoing opportunities to talk about what they went through or what they’re seeing in the media. Encourage them to ask questions and express their concerns but don’t force them to talk.
• Young children may have trouble expressing their feelings. Encourage them to put their feelings into words, such as anger, sadness, and worry about the safety of friends and family. Don’t force them to talk, but let them know that they can at any time.
• School age children may have concerns that they were to blame or should have been able to change what happened, and may hesitate to voice these concerns to others. Provide a safe place for them to express their fears, anger, sadness. Remind them that they can cry or be sad. Don’t expect them to be brave or tough. Offer reassurance and explain why it wasn’t their fault.
• Facilitate open but not forced communication with the child about his/her reactions to the traumatic event
• Focus on constructive responses
• Talk to child in developmentally appropriate terms
• Acknowledge and validate your child’s concerns. The traumatic event may bring up unrelated fears and issues in your child. Comfort for your child comes from feeling understood and accepted by you, so acknowledge their fears even if they don’t seem relevant to you.
• Young children may not have the words to express their fears, but may be able to process their emotions through play and drawing.
• School age children may retell or play out the traumatic event repeatedly. Allow the child to talk and act out these reactions. Let them know that many children respond to events like this in similar ways. Encourage positive problem-solving in play or drawings.
• Encourage children to write or draw. Suggest to children that they write about or make drawings of their experiences without forcing them to do so.
• Engage in positive distracting activities such as playing sports, games, reading, and hobbies
• Reassure your child. The event was not their fault, you love them, and it’s OK for them to feel upset, angry, or scared.
• Don’t pressure your child into talking. It can be very difficult for some kids to talk about a traumatic experience. A young child may find it easier to draw a picture illustrating their feelings rather than talk about them. You can then talk with your child about what they’ve drawn.
• Be honest. While you should tailor the information you share according to your child’s age, honesty is important. Don’t say nothing’s wrong if something is wrong.
• Do “normal” activities with your child that have nothing to do with the traumatic event. Encourage your child to seek out friends and pursue games, sports, and hobbies that they enjoyed before the incident. Go on family outings to the park or beach, enjoy a games night, or watch a funny or uplifting movie together.

Encourage physical activity:

Physical activity can burn off adrenaline, release mood-enhancing endorphins, and help your child sleep better at night.

• Find a sport that your child enjoys. Activities such as basketball, soccer, running, martial arts, or swimming that require moving both the arms and legs can help rouse your child’s nervous system from that “stuck” feeling that often follows a traumatic experience.
• Offer to participate in sports, games, or physical activities with your child. If they seem resistant to get off the couch, play some of their favorite music and dance together. Once a child gets moving, they’ll start to feel more energetic.
• Encourage your child to go outside to play with friends or a pet and blow off steam.
• Schedule a family outing to a hiking trail, swimming pool, or park.
• Take younger children to a playground, activity center, or arrange play dates.

Eat Well:

The food your child eats can have a profound impact on their mood and ability to cope with traumatic stress. Processed and convenience food, refined carbohydrates, and sugary drinks and snacks can create mood swings and worsen symptoms of traumatic stress. Conversely, eating plenty of fresh fruit and vegetables, high-quality protein, and healthy fats, especially omega-3 fatty acids, can help your child better cope with the ups and downs that follow a disturbing experience.

• Focus on overall diet rather than specific foods. Kids should be eating whole, minimally processed food—food that is as close to its natural form as possible.
• Limit fried food, sweet desserts, sugary snacks and cereals, and refined flour. These can all exacerbate symptoms of traumatic stress in kids.
• Be a role model. The childhood impulse to imitate is strong so don’t ask your child to eat vegetables while you gorge on soda and French fries.
• Cook more meals at home. Restaurant and takeout meals have more added sugar and unhealthy fat so cooking at home can have a huge impact on your kids’ health. If you make large batches, cooking just a few times can be enough to feed your family for the whole week.
• Make mealtimes about more than just food. Gathering the family around a table for a meal is an ideal opportunity to talk and listen to your child without the distraction of TV, phones, or computers.

Rebuilding trust and safety:

Trauma can alter the way a child sees the world, making it suddenly seem a much more dangerous and frightening place. Your child may find it more difficult to trust both their environment and other people. You can help by rebuilding your child’s sense of safety and security.

As children look to their caregivers to provide safety and security. Try not to voice your own fears in front of the child. Remind the child that people are working to keep them safe. Help the child regain confidence that you aren’t leaving him and that you can protect him.

The child may need on-going support long after the traumatic experience has occurred.

• Create routines. Establishing a predictable structure and schedule to your child’s or teen’s life can help to make the world seem more stable again. Try to maintain regular times for meals, homework, and family activities.
• Minimize stress at home. Try to make sure your child has space and time for rest, play, and fun.
• Manage your own stress. The more calm, relaxed, and focused you are, the better you’ll be able to help your child.
• Speak of the future and make plans. This can help counteract the common feeling among traumatized children that the future is scary, bleak, and unpredictable.
• Keep your promises. You can help to rebuild your child’s trust by being trustworthy. Be consistent and follow through on what you say you’re going to do.
• If you don’t know the answer to a question, don’t be afraid to admit it. Don’t jeopardize your child’s trust in you by making something up.
• Remember that children often personalize situations. They may worry about their own safety even if the traumatic event occurred far away. Reassure your child and help place the situation in context.

When Do I Seek Help For Childhood Traumatic Stress?

Usually, your child’s feelings of anxiety, numbness, confusion, guilt, and despair following a traumatic event will start to fade within a relatively short time. However, if the traumatic stress reaction is so intense and persistent that it’s interfering with your child’s ability to function at school or home, they may need help from a doctor, preferably a trauma specialist.

Warning signs include:

• Six weeks have passed, and your child is not feeling any better
• Your child is having trouble functioning at school
• Your child is experiencing terrifying memories, nightmares, or flashbacks
• The symptoms of traumatic stress manifest as physical complaints such as headaches, stomach pains, or sleep disturbances
• Your child is having an increasingly difficult time relating to friends and family
• Your child or teen is experiencing suicidal thoughts
• Your child is avoiding more and more things that remind them of the traumatic event

How Is Childhood Traumatic Stress Treated?

Immediate support for a child who has experienced trauma can help prevent many of the negative consequences. In some cases, the nurturing and support of parents and other family or caregivers is enough to avoid long-term harm. For those children who need professional care, mental health professionals may use cognitive behavioral therapy or trauma-focused therapies to help them learn to cope in healthy ways.

Cognitive-behavioral therapies are still the leading choice by most therapists, especially as the available research tends to be far stronger than research looking at psychoanalytic or purely medication-based treatment, which doesn’t address the underlying issues related to the trauma.

Although there are other CBT approaches that are used to treat trauma in children and adolescents including exposure therapy, art therapy and EMDR, a CBT-type approaches seem to work best for dealing with post-traumatic symptoms. All CBT methods that have been developed specifically for younger clients, there are some common features:

• Education to teach children about traumatic stress and the effects it can have on them
• Relaxation techniques
• A trauma narrative that encourages children to describe their experience in detail
• Cognitive restructuring to correct thoughts about the traumatic experience.

For all of the recognized CBT approaches for treating traumatized children, it is vital that children be encouraged to face their traumatic experience gradually and only in a way that they can handle emotionally. Since all children do not develop emotionally at the same pace, a therapist must tailor the treatment to the child’s level of emotional and cognitive development. If not, the therapist could end up doing more harm than good by re-traumatizing and re-exposing their child patients.

While CBT was first developed for trauma in adults and later adapted to adolescents, the special needs that adolescent trauma patients have has inspired the development of treatment methods focusing on children and adolescents alone. These treatment approaches include:

Multi-modality trauma treatment (MMTT) – was developed in 1998, MMTT is based on the idea that trauma at a young age can disrupt normal physical and emotional development and uses age-appropriate CBT strategies to help children or adolescents cope with trauma.  Usually seen in school settings, these programs have a format that can include education, narrative writing (writing about the traumatic experience), exposure, relaxation techniques, and cognitive restructuring. Empirical studies of MMTT have shown marked reduction in trauma symptoms with similar results for symptoms of depression, anger and anxiety. The advantage of using this type of therapy is that it was specifically developed for traumatized adolescents; however the nature of this therapy tends to focus on adolescents who have experienced only one traumatic event, but may be used in children who have experience many different traumas.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) – developed in 2006, this type of treatment was developed specifically for children between the ages of three and eighteen who have experienced trauma. Treatment using TF-CBT can include a number of sessions involving the child alone or the child and a parent/caregiver. The goal of this type of therapy is to help children and adolescents learn coping skills that will help them deal with traumatic memories. In treatment, children receive education, are taught relaxation skills, as well as affective expression and modulation, and cognitive coping skills. Children are also encouraged to use trauma narration and to cognitively process the trauma, use exposure to master trauma reminders, have parent/child sessions, and increase their feelings of safety.

Stanford Cue-Centered Therapy (SCCT) – Developed Stanford School of Medicine’s Early Life Stress Research Program, this is a short-term treatment approach that uses one-on-one therapy for children and adolescents dealing with trauma. It was created to treat problems with a child’s cognitive, affective, behavioral, and physical functioning, and uses cognitive-behavioral techniques, relaxation training, narrative use, and parental coaching. The goal of this type of therapy is to reduce the child’s negative thoughts and beliefs as well as sensitivity to traumatic memory. This form of therapy encourages children to build coping skills including relaxation and self-empowerment, and helps children to learn how trauma affects them, while teaching them that they are able to control how they respond to traumatic triggers.

Seeking Safety was developed for use with substance abuse and trauma in adults and adolescents, Seeking Safety was specifically adapted for treating adolescents and, like the other treatment models, uses education, training in specific coping skills, and cognitive restructuring. Parental involvement is only needed in one Seeking Safety session.

Seeking Safety has five principles:

1. Personal safety is a priority
2. Integrated trauma and substance abuse therapy
3. Focusing upon the child’s needs
4. Attention to the therapeutic process
5. Focuses on thoughts, behaviors, interpersonal interactions, as well as case management.

Tips For Caregivers Of Children Who Have Acute And Complex Trauma:

Caring for children after a traumatic event is incredibly stressful. Caregivers or parents work to make sure their children’s needs are met, which can be draining and rewarding at the same time. Many caregivers report that they become extremely frustrated with the things they cannot control.

To understand self-care, you must understand what self-care is not:

• Self-care is not an “emergency response plan” to be activated when stress becomes overwhelming.
• Self-care is not about acting selfishly (“It’s all about me!”).
• Self-care is not about doing more or adding more tasks to an already overflowing “to-do” list. Healthy self-care can renew our spirits and help us to become more resilient.
• Self-care is most effective when approached proactively, not reactively.

Think of self-care as having three basic aspects: awareness, balance, and connection — the “ABC’s” of self-care.

Awareness:

Self-care begins while being quiet. By quieting our busy lives and entering into a space of solitude, we can become awareness of our own needs, then act accordingly. This is the contemplative way of the desert, rather than the constant activity of the city. Too often we act first, without real understanding, then wonder why we feel more burdened rather than relieved.

Balance:

Self-care is a balancing act between action and mindfulness. Balance guides decisions about embracing or relinquishing certain activities, behaviors, or attitudes. It also informs the degree to which we give attention to the physical, emotional, psychological, spiritual, and social aspects of our being. In other words, how much time we spend working, playing, and resting. Think of this healthy prescription for balanced daily living: eight hours of work, eight hours of play, and eight hours of rest!

Connection:

Healthy self-care cannot take place solely within oneself. It involves being connected in meaningful ways with others and to something larger. We are interdependent and social beings. We grow and thrive through connections that occur in friendships, family, social groups, nature, recreational activities, spiritual practices, therapy, and a myriad of other ways.

There is no formula for self-care. Each of our “self-care plans” will be unique and change over time. As we seek renewal in our lives and work, we must listen well to our own bodies, hearts, and minds as well as to trusted friends. Caregivers should rely on other adults and support systems (such as a support group or church) to help meet their own emotional needs so they will have enough energy to support a child who is stressed.

Hotlines For Childhood Trauma:

Childhelp National Child Abuse Hotline

800-4-A-CHILD (800-422-4453)
The mission of the Childhelp hotline is to provide help or answer questions about child abuse or neglect 24 hours a day.

FEMA Disaster Aid Hotline

800-621-FEMA
This hotline is available to provide direct and financial assistance to individuals, families, and businesses in an area whose property has been damaged or destroyed by disaster.

National Center for Missing and Exploited Children

800-THE-LOST (800-843-5678)
The mission of the National Center for Missing and Exploited Children is to help prevent child abduction and sexual exploitation; provide assistance with finding missing children; and assist victims of child abduction and sexual exploitation, their families, and the professionals who serve them 24 hours a day.

Center For Victims of Crimes

800-FYI-CALL (800-394-2255)
The National Center for Victims of Crime provides information, education, and referrals to local resources across the country. The hotline is available Monday through Friday from 8:30 am to 8:30 pm and is offered in numerous languages.

National Domestic Violence Hotline

800-799-SAFE (800-799-7233) and 800-787-3224 (TDD)
The mission of the National Domestic Violence Hotline is to provide crisis intervention, safety planning, information, and referrals for individuals experiencing domestic violence. The hotline is available 24 hours a day, and assistance is offered in numerous languages.

Mental Health America

800-969-6MHA (6642)
The mission of MHA is to promote mental wellness for the health and well-being of the nation. MHA offers information and resources on numerous mental health topics.

National Organization for Victim Assistance

800-TRY-NOVA (800-879-6682)
NOVA’s mission is to promote rights and services for victims of crime and crisis. The hotline provides information and referrals and is available 24 hours a day.

Homelessness Resource Center

617-467-6014
The Center is focused on the effective organization and delivery of services for people who are homeless and who have serious mental illnesses by providing technical assistance and training.

National Sexual Assault Hotline

800-656-HOPE (800-656-4673)
This hotline is operated by the Rape, Abuse & Incest National Network (RAINN), which also carries out programs to help prevent sexual assault, assist victims, and ensure that perpetrators are brought to justice.

National Suicide Prevention Lifeline

800-273-TALK (800-273-8255)

This suicide prevention service is available to anyone in suicidal crisis and is available 24/7.

National Teen Dating Abuse Helpline

866-331-9474 and 866-331-8453 (TTY)
This hotline was created to help teens ages 13-18 that experience dating abuse and it is available 24/7.

SAMHSA’s National Clearinghouse for Alcohol and Drug Information

800-729-6686
The Clearinghouse is a one-stop resource for information about substance abuse prevention and addiction treatment.

SAMHSA’s Substance Abuse Treatment Facility Locator

800-662-HELP (4357); 800-487-4889 (TDD); 877-767-8432 (Español)
A searchable directory of drug and alcohol treatment programs that shows the location of facilities around the country that treat alcoholism, alcohol abuse, and drug abuse problems.

Witness Justice

800-4WJ-HELP (800-495-4357)
Witness Justice is a national grassroots organization that provides assistance, support, and advocacy for survivors of violence and trauma.

Additional Childhood Traumatic Stress Resources:

Center For Trauma, Assessment, Intervention Services, and Treatment: The purpose of our Center is to provide national expertise on interventions for the developmental effects of trauma across child-serving settings, including child welfare, behavioral health, educational and juvenile justice settings.

Child Mind Institute offers Free Trauma Resources in a number of languages, all of which can be used to help the child recover from the trauma and heal the family as well.

Child Welfare.Org offers a number of free programs for children and their families who are coping with different types of trauma.

Substance Abuse and Mental Health Services Administration: This US government site helps to identify a number of different types of trauma, including reading on military families, substance abuse, for families, and for educators.

Eating Disorders Resources

by Aunt Becky | Mar 19, 2019

What Are Eating Disorders?

Eating disorders are illnesses in which the people experience severe disturbances in their eating behaviors and related thoughts and emotions. People with eating disorders typically become pre-occupied with food and their body weight.

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people’s eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder

Eating disorders affect several million people at any given time, most often women between the ages of 12 and 35; however there is burgeoning research that indicates more and more men are developing eating disorders as well.

There are three main types of eating disorders: anorexia nervosa, bulimia nervosa and binge eating disorder.

People with anorexia nervosa and bulimia nervosa tend to be perfectionists with low self-esteem and are extremely critical of themselves and their bodies. They usually “feel fat” and see themselves as overweight, sometimes even despite life-threatening semi-starvation (or malnutrition). An intense fear of gaining weight and of being fat may become all-pervasive. In early stages of these disorders, patients often deny that they have a problem.

In many cases, eating disorders occur together with other psychiatric disorders like anxiety disorders, panic disorder, obsessive compulsive disorder, and alcohol and drug abuse problems. New evidence suggests that heredity may play a part in why certain people develop eating disorders, but these disorders also afflict many people who have no prior family history. Without treatment of both the emotional and physical symptoms of these disorders, malnutrition, heart problems and other potentially fatal conditions can result. However, with proper medical care, those with eating disorders can resume suitable eating habits, and return to better emotional and psychological health.

While eating disorders may seem to be about beauty, weight, and image, they’re actually about control or avoidance of stress and emotional issues. Eating disorders may be a result of being unable to express strong feelings and emotions.

Those who suffer from eating disorders generally try to hide the problem, but there are signs of a problem if you know what to look for. Early detection and treatment of eating disorders makes for an easier recovery. It’s important to note that, while you may confront someone whom you suspect has an eating disorder, you cannot force someone with an eating disorder into treatment. Making an effort to be a caring, compassionate support system is often the best thing that can be done when a loved one suffers from an eating disorder.

Eating disorders involve extreme disturbances in eating behaviors, such as gorging, following rigid diets, throwing up after meals, and counting calories obsessively; they are more than just an unhealthy eating habit. The core of eating disorders involves self-critical, distorted attitudes about weight, body image, and food, all of which lead to the damaging eating behaviors.

Food, for those with eating disorders, is used to deal with painful emotions. Restricting food (as is the case with anorexia nervosa) is used to feel in control. Overeating soothes sadness, anger, and loneliness. Purging combats feelings of self-loathing and helplessness. Over time, food and weight obsessions dominate the life of someone with an eating disorder.

What Are Some Common Warning Signs of Eating Disorders?

In the early stages of an eating disorder, it may be really hard to ascertain the difference between an eating disorder and normal weight concerns and dieting. As an eating disorder progresses, the red flags and warning signs become more apparent. Those who suffer eating disorders are particularly good at hiding their disorders, so knowing the common warning signs may help to spot an eating disorder.

• Hoarding high-calorie food
• Constant dieting – even when thin
• Rapid unexplained weight gain or loss
• Preoccupation with body or weight
• Binging – usually performed in secret
• Purging – disappearing after every meal or frequent trips to the bathroom
• Obsession with food, calories or nutrition
• Usage of laxatives, diuretics, or diet pills
• Compulsive exercising
• Making excuses to get out of eating
• Eating tiny portions or refusing to eat
• Intense fear of being fat
• Distorted body image
• Strenuous exercising (for more than an hour)
• Hoarding and hiding food
• Eating in secret
• Disappearing after eating—often to the bathroom
• Large changes in weight, both up and down
• Social withdrawal
• Depression
• Irritability
• Hiding weight loss by wearing bulky clothes
• Little concern over extreme weight loss
• Stomach cramps
• Menstrual irregularities—missing periods
• Dizziness
• Feeling cold all the time\
• Sleep problems
• Cuts and calluses across the top of finger joints (from sticking finger down throat to cause vomiting)
• Dry skin
• Puffy face
• Fine hair on body
• Thinning of hair on head, dry and brittle hair
• Cavities, or discoloration of teeth, from vomiting
• Muscle weakness
• Yellow skin
• Cold, mottled hands and feet or swelling of feet

What Are Some Common Myths About Eating Disorders?

There are many myths about the causes eating disorders, how serious they are, and who develops an eating disorder. Let’s dispel them now:

Are eating disorders a choice?

Eating disorders are not a choice. They are complex medical and psychiatric illnesses that people don’t opt to have. Eating disorders are bio-psycho-social diseases, which means that genetic, biological, environmental, and social elements all play a role.

• Several decades of genetic research show that biological factors are an important influence in who develops an eating disorder. A societal factor (like the media-driven thin body ideal) is an example of an environmental trigger that has been linked to increased risk of developing an eating disorder.
• Environmental factors also include physical illnesses, childhood teasing and bullying, and other life stressors.
• Eating disorders commonly co-occur with other mental health conditions like major depression, anxiety, social phobia, and obsessive-compulsive disorder. Additionally, they may run in families, as there are biological predispositions that make people more vulnerable to developing an eating disorder.

Are eating disorders really that serious?

Eating disorders have the highest mortality rate of any psychiatric illness. Besides medical complications from binge eating, purging, starvation, and over-exercise, suicide is also common among individuals with eating disorders. Potential health consequences include heart attack, kidney failure, osteoporosis, and electrolyte imbalance. People who struggle with eating disorders also have intense emotional distress and a severely impacted quality of life.

The consequences of eating disorders can be life-threatening, and many individuals find that stigma against mental illness (and eating disorders in particular) can obstruct a timely diagnosis and adequate treatment.

Doesn’t everyone have an eating disorder?

Although our current culture is highly obsessed with food and weight, and disordered patterns of eating are very common, clinical eating disorders are less so.

About 20 million women and 10 million men will struggle with an eating disorder at some point during their lives. A study in 2007 found that:

• 0.9% of women and 0.3% of men had anorexia during their life
• 1.5% of women and 0.5% of men had bulimia during their life,
• and 3.5% of women and 2.0% of men had binge eating disorder during their life

If eating disorders are linked to my genetic makeup, how do I recover?

Biology isn’t destiny. There is always hope for recovery.

While biological factors do play a large role in the onset of eating disorders, they are not the only factors.

The predisposition towards disordered eating may reappear during times of stress, but there are many good techniques people who have eating disorders can learn that will help manage their emotions and keep behaviors from returning.

Early intervention is a key part of eating disorder prevention, and helps reduce serious psychological and health consequences. Recovery from an eating disorder can be a long process and requires a qualified team of professionals and the love and support of family and friends.

Aren’t eating disorders a ‘girl thing’?

Eating disorders can affect anyone, regardless of their gender or sex.

While eating disorders are more common in females, researchers and clinicians are becoming aware of a growing number of males and non-binary individuals who now are seeking help for eating disorders. A 2007 study by the Centers for Disease Control and Prevention found that up to one-third of all eating disorder sufferers are male, and a 2015 study of US undergraduates found that transgender students were the group most likely to have been diagnosed with an eating disorder in the past year (Diemer, 2015).Eating disorders most often affect girls and women, but boys and men can also have an eating disorder.

One out of every four pre-teen kids with anorexia is a boy.  Binge eating disorder affects females and males about equally.

It’s currently unclear whether eating disorders are actually increasing in males and transgender populations or if more of those people who are suffering are seeking treatment or being diagnosed. As some physicians may have preconceptions about who eating disorders affect, their disorders have generally become more severe and entrenched at the point of an actual diagnosis.

Don’t you have to be underweight to have an eating disorder?

People who have eating disorders come in all shapes and sizes – many of those people happen to be normal or overweight.The two best-known types of eating disorders are anorexia nervosa and bulimia nervosa and can occur separately or in the same person, additionally, binge-eating is another type of eating disorder.

Aren’t people with eating disorders super vain?

It’s not actually vanity that drives people with eating disorders to obsess about their food. Eating disorders are a product of feelings of shame, poor body image, anxiety, and powerlessness.

Do parents cause eating disorders?

Organizations from around the world, including the Academy for Eating Disorders, the American Psychiatric Association, and NEDA, have published materials that indicate that parents don’t cause eating disorders.

Parents, especially mothers, were frequently blamed for their child’s eating disorder, but recent research discovered that eating disorders have a firmer biological root. Eating disorders develop differently for each person, and there is no single set of rules that parents can follow to guarantee prevention of an eating disorder, however there are things everyone in the family system can do to play a role in creating a recovery-promoting environment. such as including parents and other family members in the treatment process.

Can someone be too young or too old to develop an eating disorder?

Eating disorders can develop or re-emerge at any age. Eating disorder specialists are reporting an increase in the diagnosis of children, some as young as five or six. Many eating disorder sufferers report that their thoughts and behaviors started much earlier than anyone realized, sometimes even in early childhood. Although most people report the onset of their eating disorder in their teens and young adulthood, there is some evidence emerging that people are being diagnosed at younger ages.

It’s not clear whether people are actually developing eating disorders at younger ages or if an increased awareness of eating disorders in young children has led to improved recognition and diagnosis.

Men and women at midlife and beyond are being treated for eating disorders, either due to a relapse, ongoing illness from adolescence or young adulthood, or due to the new onset of an eating disorder.

Doesn’t recovery from an eating disorder take a long time?

Recovery time from any mental illness varies from person to person. Some people get better relatively quickly, while others take longer to improve. While not everyone who has an eating disorder will recover fully, many people do improve with treatment. Even with full recovery, many people with eating disorders find that they have to take steps to make sure they stay well. This can include:

• planning meals
• regular check-ins with a therapist, dietitian, or doctor
• medication
• proper support
• proper education
• stress management

What Are The Types of Eating Disorders?

Currently, doctors have discovered that there are 6 types of eating disorders.

Anorexia Nervosa is an eating disorder characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many people, a  distorted body image.Avoidant Restrictive Food Intake Disorder (ARFID), once referred to as “selective eating disorder,” involves limitations in the amount and/or types of food consumed without any distress about body shape or size, or fears of being overweight.

Bulimia Nervosa is characterized by a cycle of binge eating and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

Binge eating disorder is the most common eating disorder in the United States and is characterized by episodes of eating large quantities of food; a feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and not regularly using unhealthy compensatory measures to counter the binge eating.

Orthorexia was coined in 1998 to describe an obsession with proper or ‘healthful’ eating.

Pica is an eating disorder that involves eating items that are not typically thought of as food and that do not contain significant nutritional value, such as hair, dirt, and/or paint chips.

Rumination disorder involves the regular regurgitation of food that occurs for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

Unspecified feeding or eating disorder (UFED) applies to presentations where symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class.

What Is Anorexia?

Anorexia nervosa is an eating disorder characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many people, a distorted body image. People who have anorexia generally restrict the number of calories and the types of food they eat. Some people with the disorder also exercise compulsively, purge via vomiting and laxatives, and/or binge eat.

Anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Historians and psychologists have found evidence of people displaying symptoms of anorexia for hundreds or thousands of years.

Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with anorexia. You cannot tell if a person is struggling with anorexia by looking at them. A person does not need to be emaciated or underweight to be struggling. Studies have found that larger-bodied individuals can also have anorexia, although they may be less likely to be diagnosed due to cultural prejudice against fat and obesity.

Most turn to this obsession as a sense of control in a reality where they feel they have none.

People with anorexia nervosa may see themselves as overweight, even when they are dangerously underweight. People with anorexia nervosa typically weigh themselves repeatedly, severely restrict the amount of food they eat, often exercise excessively, and/or may force themselves to vomit or use laxatives to lose weight. Anorexia nervosa has the highest mortality rate of any mental disorder.

Anorexia, with severity in relation to length of time, is a potentially life-threatening disorder marked by extreme fasting or restriction of food intake, often eating as little as 200 calories a day. Anorexics have an intense fear of weight-gain; even while underweight, they see themselves as fat. Females with anorexia develop amenorrhea, or the absence of menstruation.

While many people with this disorder die from complications associated with starvation, others die by suicide.

If you or someone you know is in crisis and needs immediate help, call the toll-free National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255), 24 hours a day, 7 days a week.

This eating disorder can affect males, females, and non-binary people, however, 90-95% of those diagnosed are girls and women and of these, it’s estimated that 5-20% of people affected by this eating disorder will die,

Do I Have Anorexia?

If you think you may have anorexia, please make an appoint to see your doctor as soon as possible. Delaying treatment can make recovery a bit more challenging. Your doctor will probably ask you if you have experienced any of the below questions:

• Have you recently noticed a drastic decrease in weight?
• Do you struggle with maintaining a healthy self-esteem?
• Are you overly concerned about gaining weight?
• Do you find yourself refusing or making excuses not to eat?
• Are you self-conscious about your body image?
• Do you exercise excessively?
• Do you obsess over dieting?
• Have you been distancing yourself from friends and family?
• Are you often depressed?
• Have you noticed dry or yellow tinted skin?

How Is Anorexia Diagnosed?

To be diagnosed with anorexia nervosa according to the DSM-5, the following criteria must be met:

1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Even if all the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present. Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia.

Other diagnostic criteria can include:

• A person 15% below their ideal weight
• Person with an intense fear of being fat, even though they are underweight
• He/She/They may have a distorted view of their body or deny that their low weight is a problem
• (among women) missing at least 3 periods in a row
• People who have anorexia may or may not also binge and purge, use laxatives, or other means of losing weight

 If left untreated anorexia can have devastating effects.

When the body is starved of proper nourishment, the system slows down to conserve energy and can lead to injury of the organs, and even death.

What Are The Dangers Of Anorexia?

Systemic Symptoms: 

• Heart rates drop to an abnormally slow rate
• Blood pressure drops
• Blood count becomes abnormal
• Risk of heart failure increases
• Risk of osteoporosis and reduction in bone density
• Muscles deteriorate
• Body suffers from dehydration, leading to kidney failure

Physical Symptoms

• Extreme thinness
• Irregular periods in women
• Lower testosterone in men
• Feeling weak, fatigued, or dizzy, or experiencing fainting spells
• Dry skin that may also take on yellowish tint
• Bluish color on the tips of the fingers
• Dry hair and hair loss
• Downy hair that grows over the skin in order to keep warm

Anorexia affects all of the organs in the body. If left untreated, the body becomes severely malnourished. This can result in damage that is not treatable, even if the disease is taken under control.

Emotional Symptoms

• Lying about whether or not you have eaten
• Irritability
• Withdrawing from social activities
• Emotionally flat affect
• Obsessing over weight gain
• Feeling insecure about the way you look
• Decreased interest in sex
• Feeling depressed
• Thoughts of suicide

If the above resonates with anything you’re experiencing, it’s time to see a doctor.

Medical attention doesn’t have to be scary. Think of it as a moment of clarity that’s bringing you closer to your desired result of being a healthy, happy human being.

Mortality and Binge Eating Disorders:

It is well known that anorexia nervosa is a deadly disorder, but death rate varies considerably between studies. This variation may be due to length of follow-up, or ability to find people years later, or other reasons. In addition, it has not been certain whether other subtypes of eating disorders also have high mortality. Several recent papers have shed new light on these questions by using large samples followed up over many years. Most importantly, they get around the problem of tracking people over time by using national registries which report when people die.Overall people with anorexia nervosa had a six fold increase in mortality compared to the general population. Reasons for death include starvation, substance abuse, and suicide.

In summary, these findings underscore the severity and public health significance of all types of eating disorders.

What Is Bulimia?

Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

How is Bulimia Diagnosed?

According to the DSM-5, the official diagnostic criteria for bulimia nervosa include:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a discrete period of time (such as within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
  • A feeling of lack of control over eating during the episode (such as a feeling that one cannot stop eating or control what or how much they are eating).
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa

It’s really important to remember that people with bulimia may be anywhere from underweight, to normal weight, to overweight.

Common Warning Signs That Of Bulimia: 

Emotional and behavioral 

• Generally speaking, new behaviors and attitudes indicate that weight loss, dieting, and control of food are becoming primary concerns
• Evidence of binge eating, such as disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
• Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
• Appears uncomfortable eating around others
• Develops food rituals (including eating only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)
• Skips meals or takes small portions of food at regular meals
• Fears of eating in public or with other people
• Steals or hoards food in strange places
• Drinks excessive amounts of water or non-caloric beverages
• Uses excessive amounts of mouthwash, mints, and gum
• Hides body with baggy clothes
• Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories
• Creates lifestyle schedules or rituals to make time for binge-and-purge sessions
• Withdraws from friends and activities
• Shows extreme concern with body weight and shape
• Frequent checking the mirror for feared flaws in appearance
• Secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most people would eat under similar circumstances); feels lack of control over ability to stop eating
• Purges after a binge (such as self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, fasting)
• Extreme mood swings

Physical Symptoms of Bulimia:

• Unusual swelling of the cheeks or jaw area
• Calluses on the back of the hands and knuckles from self- induced vomiting
• Teeth are discolored, stained from vomiting
• Noticeable fluctuations in weight, both up and down
• Body weight is typically within the normal weight range; may be overweight
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
• Dizziness
• Bloating from fluid retention
• Fainting/syncope
• Feeling cold all the time
• Sleep problems
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dry skin
• Dry and brittle nails
• Swelling around area of salivary glands
• Fine hair on body
• Thinning of hair on head, dry and brittle hair
• Muscle weakness
• Cold, mottled hands and feet or swelling of feet
• Menstrual irregularities — missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
• Poor wound healing
• Increased infections due to poor immune response

Many people with bulimia nervosa also struggle with co-occurring conditions, such as:

• Self-injury (cutting and other forms of self-harm without suicidal intention)
• Substance use and abuse
• Impulsivity (risky sexual behaviors, shoplifting, drugs)
• Diabulimia (intentional misuse of insulin for type 1 diabetes)

What Is Binge Eating Disorder?

Binge eating disorder (BED) is a severe, life-threatening, and treatable eating disorder that is characterized by recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a feeling of a loss of control during the binge; experiencing shame, distress, or guilt afterwards; and not regularly using unhealthy compensatory measures (e.g., purging) to counter the binge eating. It is the most common eating disorder in the United States.

BED is one of the newest eating disorders formally recognized in the DSM-5. Before the most recent revision in 2013, BED was listed as a subtype of EDNOS (now referred to as OSFED). The change is important because some insurance companies will not cover eating disorder treatment without a DSM diagnosis.

What Are The Diagnostic Criteria for Binge Eating Disorder?

According to the DSM-5, the official diagnostic criteria for bulimia nervosa include:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
  • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• The binge eating episodes are associated with three (or more) of the following:
  • Eating much more rapidly than normal.
  • Eating until feeling uncomfortably full.
  • Eating large amounts of food when not feeling physically hungry.
  • Eating alone because of feeling embarrassed by how much one is eating.
  • Feeling disgusted with oneself, depressed, or very guilty afterward.
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least once a week for 3 months.
• The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

What Are The Warning Signs for Binge Eating Disorder?

Emotional and Behavioral Signs and Symptoms

• Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food.
• Appears uncomfortable eating around others
• Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• Fear of eating in public or with others
• Steals or hoards food in strange places
• Creates lifestyle schedules or rituals to make time for binge sessions
• Withdraws from usual friends and activities
• Frequently diets
• Shows extreme concern with body weight and shape
• Frequent checking in the mirror for perceived flaws in appearance
• Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating
• Disruption in normal eating behaviors, including eating throughout the day with no planned mealtimes; skipping meals or taking small portions of food at regular meals; engaging in sporadic fasting or repetitive dieting
• Developing food rituals (e.g., eating only a particular food or food group [e.g., condiments], excessive chewing, and not allowing foods to touch).
• Eating alone out of embarrassment at the quantity of food being eaten
• Feelings of disgust, depression, or guilt after overeating
• Fluctuations in weight
• Feelings of low self-esteem

Physical Symptoms of Binge Eating Disorder

• Noticeable fluctuations in weight, both up and down
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Difficulties concentrating

What Are The Health Risks of Binge Eating Disorder?

The health risks of BED are most commonly those associated with clinical obesity, weight stigma, and weight cycling (aka, yo-yo dieting). Most people who are labeled clinically obese do not have binge eating disorder. However, of individuals with BED, up to two-thirds are labelled clinically obese; people who struggle with binge eating disorder tend to be of normal or higher-than-average weight, though BED can be diagnosed at any weight.

What Is Orthorexia? 

While not formally recognized in the Diagnostic and Statistical Manual, awareness about orthorexia is on the rise. The term ‘orthorexia’ was coined in 1998 and means an obsession with proper or ‘healthful’ eating. Although being aware of and concerned with the nutritional quality of the food you eat isn’t a problem in and of itself, people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being.

Without formal diagnostic criteria, it’s difficult to get an estimate on precisely how many people have orthorexia. We still don’t know whether orthorexia if is a stand-alone eating disorder, a type of existing eating disorders like anorexia, or a form of obsessive-compulsive disorder. Studies have shown that many people with orthorexia also have been diagnosed with obsessive-compulsive disorder.

What Are Some Of The Symptoms of Orthorexia?

• Compulsive checking of ingredient lists and nutritional labels
• An increase in concern about the health of ingredients
• Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
• An inability to eat anything but a narrow group of foods that are deemed ‘healthy’ or ‘pure’
• Unusual interest in the health of what others are eating
• Spending hours per day thinking about what food might be served at upcoming events
• Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available
• Obsessive following of food and ‘healthy lifestyle’ blogs on social media
• Body image concerns may or may not be present

What Are The Health Consequences of Orthorexia?

Like anorexia, orthorexia involves restriction of the amount and variety of foods eaten, making malnutrition likely. Therefore, the two disorders share many of the same physical consequences.

How Is Orthorexia Treated?

There are currently no clinical treatments developed specifically for orthorexia, but many eating disorder experts treat orthorexia as a variety of anorexia and/or obsessive-compulsive disorder. Thus, treatment usually involves psychotherapy to increase the variety of foods eaten and exposure to anxiety-provoking or feared foods, as well as weight restoration as needed.

What is Avoidant Restrictive Food Intake Disorder?

Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5, and was previously called “Selective Eating Disorder.” ARFID is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of being overweight.

While many children go through phases of picky or selective eating, a person with ARFID does not consume enough calories to grow and develop properly and, in adults, to maintain basic body function. In children, this results in stalled weight gain and vertical growth; in adults, this results in weight loss. ARFID can also result in problems at school or work, due to difficulties eating with others and extended times needed to eat.

How is ARFID Diagnosed?

According to the DSM-5, ARFID is diagnosed when:

• An eating or feeding disturbance (such as, apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.
• The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
• The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
• The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

What Are The Risk Factors for Developing ARFID?

As with all eating disorders, the risk factors for ARFID involve a range of biological, psychological, and sociocultural issues. These factors will interact differently in different people, which means two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Researchers know much less about what puts someone at risk of developing ARFID, but here’s what they do know:

• People with autism spectrum conditions are much more likely to develop ARFID, as are those with ADHD and intellectual disabilities.
• Children who don’t outgrow normal picky eating, or in whom picky eating is severe, appear to be more likely to develop ARFID.
• Many children with ARFID also have a co-occurring anxiety disorder; these children are also at high risk for other psychiatric disorders.

What Are The Warning Signs of ARFID?

Behavioral and psychological 

• Dramatic weight loss
• Dresses in layers to hide weight loss or stay warm
• Reports constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
• Reports consistent, vague gastrointestinal issues (“upset stomach”, feels full, etc.) around mealtimes that have no known cause
• Dramatic restriction in types or amount of food eaten
• Will only eat certain textures of food
• Fears of choking or vomiting
• Lack of appetite or interest in food
• Limited range of preferred foods that becomes narrower over time (i.e., picky eating that progressively worsens).
• No body image disturbance or fear of weight gain

Physical

Because both anorexia and ARFID involve an inability to meet nutritional needs, both disorders have similar physical signs and medical consequences.

• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Menstrual irregularities—missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
• Female after puberty loses menstrual period
• Dizziness
• Fainting/syncope
• Feeling cold all the time
• Sleep problems
• Dry skin
• Dry and brittle nails
• Fine hair on body (lanugo)
• Thinning of hair on head, dry and brittle hair
• Muscle weakness
• Cold, mottled hands and feet or swelling of feet
• Poor wound healing
• Impaired immune functioning

What Are The Health Consequences of ARFID?

In ARFID, the body is denied the essential nutrients it needs to function normally.  Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences. The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death.

Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body

What is Pica?

Pica is an eating disorder that involves eating items that are not typically thought of as food and that do not contain significant nutritional value, such as hair, dirt, and paint chips.

• It is unclear how many people are affected by pica. It most likely is more prevalent in developing countries.
• Pica can affect children, adolescents, and adults of any genders.
• Those who are pregnant and craving nonfood items should only be diagnosed with pica when their cravings lead to ingesting nonfood items, and the ingestion of those items poses a potential medical risk (either due to the quantity or type of item being ingested).
• Pica can be associated with intellectual disability, trichotillomania (hair-pulling disorder), and excoriation (skin picking) disorder
• There are no laboratory tests for pica. Instead, the diagnosis is made from a clinical history of the patient.
• Diagnosing pica should be accompanied by tests for anemia, potential intestinal blockages, and toxic side effects of substances consumed (i.e., lead in paint, bacteria or parasites from dirt).

What Are The Warning Signs of Pica?

• The persistent eating, over a period of at least one month, of substances that are not food and do not provide nutritional value.
• The ingestion of the substance(s) is not a part of culturally supported or socially normative practice (e.g., some cultures promote eating clay as part of a medicinal practice).
• Typical substances ingested tend to vary with age and availability. They may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice.
• The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects—or putting small objects in their mouth—is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with pica.
• Generally, those with pica are not averse to ingesting food.

What Are The Risk Factors for Pica?

• Pica often occurs with other mental health disorders associated with impaired functioning (e.g., intellectual disability, autism spectrum disorder, schizophrenia).
• Iron-deficiency anemia and malnutrition are two of the most common causes of pica, followed by pregnancy. In these individuals, pica is a sign that the body is trying to correct a significant nutrient deficiency. Treating this deficiency with medication or vitamins often resolves the problems.
• A medical professional should assess if the behavior is sufficiently severe to warrant independent clinical attention (e.g., some people may eat nonfood items during pregnancy, but their doctor may determine that their actions do not indicate the need for separate clinical care).

How is Pica Treated?

The first-line treatment for pica involves testing for mineral or nutrient deficiencies and correcting those. In many cases, problematic eating behaviors disappear as deficiencies are corrected. If the behaviors aren’t caused by malnutrition or don’t stop after nutritional treatment, a variety of behavioral interventions are available.

Scientists in the autism community have developed several different effective interventions, including redirecting the person’s attention away from the desired object and rewarding them for discarding or setting down the non-food item.

What Is Rumination Disorder?

Rumination disorder involves the regular regurgitation of food that occurs for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out. Typically, when someone regurgitates their food, they do not appear to be making an effort, nor do they appear to be stressed, upset, or disgusted.

How is Rumination Disorder Diagnosed?

The DSM-5 criteria for rumination disorder are:

• Repeated regurgitation of food for a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
• The repeated regurgitation is not due to a medication condition (e.g., gastrointestinal condition).
• The behavior does not occur exclusively in the course of anorexia nervosa, bulimia nervosa, BED, or avoidant/restrictive food intake disorder.
• If occurring in the presence of another mental disorder (e.g., intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

What Is The Treatment for Rumination Disorder?

Once a physical cause for rumination disorder has been ruled out, the most common way rumination disorder is treated involves a combination of breathing exercises and habit reversal. A child with rumination disorder is taught to recognize the signs and situations when rumination is likely, and then they learn diaphragmatic breathing techniques to use after eating that prevent them from regurgitating their food. They eventually learn to prevent the rumination habit by replacing it with deep breathing techniques.

Seeking Treatment for Eating Disorders:

Recovery from an eating disorder can be a long process that requires not only a qualified team of professionals, but also the love and support of family and friends. It is not uncommon for someone who suffers with an eating disorder to feel uncertain about their progress or for their loved-ones to feel disengaged from the treatment process. These potential roadblocks may lead to feelings of ambivalence, limited progress, and treatment drop out. Therefore, knowing about the Stages of Change Model, as defined by Prochaska and DiClemente, will help everyone involved better negotiate the road to recovery.

The Stages of Change in the process of recovery from an eating disorder are a cycle rather than a linear progression. The person may go through this cycle more than one time or may need to revisit a particular stage before moving on to the next. They may also go through the stages for each individual eating disorder symptom. In other words, if they are recovering from anorexia, they could be in the Action Stage for restrictive eating (e.g., eating three meals a day along with snacks, engaging in social eating, and utilizing support system) while, at the same time, they could be going through the Contemplation Stage for body image and weight concerns (e.g., becoming aware of how body image is tied to self-esteem and self-worth, defining oneself as a body or number, and identifying the negatives of striving for the “perfect body”). This is precisely why recovery from an eating disorder is complex and individualized.

If you are a parent or friend of someone struggling, you no doubt suffer right along with them, so it is crucial for you to pay attention to your own needs as well as be present for your child or friend during her recovery process.

What Are The Stages of Change?

There are five Stages of Change that occur in the recovery process: Pre-Contemplation, Contemplation, Preparation, Action, and Maintenance. Let’s examine them further.

1) The Pre-Contemplation Stage is evident when a person does not believe they have a problem. Close family and friends are bound to pick up on symptoms such as restrictive eating, the binge/purge cycle, or a preoccupation with weight, shape, and appearance even before the person admits to it. They may refuse to discuss the topic and deny they need help. At this stage, it is necessary to gently educate the person about the devastating effects the disorder will have on their health and life, and the positive aspects of change.

• Do not be in denial of your child or friend’s eating disorder.
• Be aware of the signs and symptoms.
• Avoid rationalizing their eating disordered behaviors.
• Openly share your thoughts and concerns with your child or loved one.

2) The Contemplation Stage occurs when an person is willing to admit that they have a problem and are now open to receiving help. The fear of change may be very strong, and it is during this phase that a psychotherapist should assist the person in discovering the reason they have an eating disorder so they can understand why it is in their life and how it no longer serves them. This, in turn, helps the person move closer toward the next stage of change.

• If your child is under the age of 18, insist that they receive professional help from a qualified eating disorder specialist.
• Educate yourself about the disorder.
• Be a good listener.
• Do not try to “fix” the problem yourself.
• Seek your own encouragement from a local eating disorder support group for family and friends.

3)The Preparation Stage the person transitions into the Preparation Stage when they are ready to change, but aren’t sure how to do it. Time is spent establishing specific coping skills such as appropriate boundary setting and assertiveness, effective ways of dealing with negative eating disorder thoughts and emotions, and ways to tend to their personal needs. Potential barriers to change are identified. This is usually when a plan of action is developed by the treatment team, (i.e. psychotherapist, nutritionist, and physician) as well as the person and designated family members. This generally includes a list of people to call during times of crisis.

• If supporting a loved one in their recovery, identify what your role is in the recovery process.
• Explore your own thoughts and beliefs about food, weight, shape, and appearance.
• Ask your child/loved one and the treatment team how you can be best involved in the recovery process and what you can do to be supportive.
• ACTION STAGE

4) The Action Stage begins when the person is ready to start their strategy and confront the eating disorder behavior head on. By now, they are open to trying new ideas, behaviors, and are willing to face fears in order for change to occur. Trusting the treatment team and their support network is essential to making the Action Stage successful.

• Follow the treatment team’s recommendations.
• Remove triggers from your environment: no diet foods, no scales, and no stress.
• Be warm and caring, yet appropriate and determined with boundaries, rules, and guidelines.
• Reinforce positive changes without focusing on weight, shape, or appearance.

5) The Maintenance Stage evolves when the person has sustained the Action Stage for approximately six months or longer. During this period, they actively practice new behaviors and new ways of thinking as well as consistently use both healthy self-care and coping skills. Part of this stage also includes revisiting potential triggers in order to prevent relapse, establishing new areas of interests, and beginning to live their life in a meaningful way.

• Applaud your loved one’s efforts and successes.
• Continue to adjust to new developments.
• Redefine the boundaries at home as necessary.
• Maintain positive communications.
• Be aware of the possibility of recovery backsliding and relapse to prior distorted eating.

6) The Termination Stage & Relapse Prevention. Relapse is sometimes grouped with the maintenance stage since recovery doesn’t occur all at once, and it’s normal for some relapsing behaviors.

So, how do you know when it is time to discontinue treatment? With the understanding that this decision is best made in consultation with your treatment team, ask yourself the following questions:

• Have I mastered the Stages of Change in the major areas of my eating disorder?
• Do I have the coping skills necessary to maintain these changes?
• Do I have a relapse prevention plan in place?
• Am I willing to resume treatment in the future if necessary?

To prevent relapsing ask for help, communicate your thoughts and feelings, address and resolve problems as they arise, live a healthful and balanced life, and remember that you would not have made it this far if it were not for your strong determination and dedication toward recovery.