Understanding the Neurobiological Impact of Trauma

1. Understanding the Neurobiological Impact of Trauma Gives us clues how to heal from the effects of trauma

2. Forgiveness, Khamisa likes to say, is a process, not a destination, and it doesn’t mean skipping grief. As the poet Rumi wrote, “The cure for the pain is in the pain”

3. We do not see things as they are...we see things as we are.

4. What is Trauma? • Any event that overwhelms a person's capacity to cope can be traumatic and have lasting impact

6. It is the individual’s personal experienceof the event that determines whether it is traumatic

7. An event is traumatic… • When the person experiences a real or perceived threatto life, bodily integrity, or sanity; • Circumstances of the event or feeling memory include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss, and • Ability to cope is overwhelmed. (Pearlman & Saakvitne, 1995; Giller, 2003) “A profound and meaningful loss of control”

8. Risk & Resilience What are likely determinants of post traumatic stress? • Biology • Trauma History • Protective Factors Being left alone alone in a cold room can be totally overwhelming to an infant, frightening to a toddler, distressing to a ten year old and only mildly uncomfortable to an adolescent or adult (Levine, 1997).

9. Types of Trauma • Pre and Perinatal ~ birth trauma • Single Episode ~ car accident • Complex / Developmental ~ abuse &/or neglect • Intergenerational • Historical ~ genocide • Institutional ~ prisons, hospitals, schools

10. Beyond & Informed by Culture Violence and trauma know no class, racial, economic or geographical boundaries Understanding cultural context is key to healing trauma

11. Trauma Prevalence

12. Individuals with histories of violence, abuse, and neglect from childhood onward make up the majority of clients served by public mental health and substance abuse service systems (Jennings, 2004).

13. Prevalence of TraumaMental Health/ Substance Abuse Population • 75%of women and men in substance abuse treatment report abuse and trauma histories (SAMHSA/CSAT,2000) • 97%of homeless women with mental illness experienced severe physical &/or sexual abuse, 87 % experiencedthis abuse both as children and asadults (Goodman, Dutton et al.,1997) • 90% of public mental health clients have been exposed to trauma (Mueser et al.,2004) Most have multiple experiences of trauma

14. Prevalence of TraumaMental Health/ Substance Abuse Population • 82% ofchildren and adolescents inpatient and intensive residential treatment programs in Massachusetts have histories of trauma(LeBel J, Stromberg, N,2004) • 55% of consumers with a dual diagnosis of both mental illness and substance abuse report histories of physical &/or sexual abuse (Maine Department of Behavioral and Development Services,1998) • Nearly 8 out of 10 female offenders with a mental illnessreports having been physically or sexually abused(Smith,1998)

15. National Survey Children’s Health (2011-2012) • In a nationally representative sample of 34,000, nearly one third (30.5%) of US youth and adolescents aged 12-17 experienced two or more adverse family experiences. .

16. National Comorbidity Survey (2001–2003) • 34 million American adults, or 17 % of the adult population, have comorbid mental-medical conditions (Kessler, 1995).

17. Trauma Sequelae Isolation Mental Illness/ Addiction Physical Illness Elsey, Jones, Rhonda. Social Inclusion and Trauma-Informed Care: A Personal Perspective. Power Point. promoteacceptance.samhsa.gov/teleconferences/archive/training/teleconference09102009.aspx

18. Trauma and PTSD are common in Primary Care • 50% of primary care visits are for symptoms without identifiable pathology such as headaches, fatigue and abdominal pain (Katon, W., 2001).

19. Trauma and PTSD are expensive to the Health Care System • Multiple and excessive costly tests are performed routinely, yet often there is no identifiable cause for a person’s disease (Katon, 1990).

20. Primary Care Challenges • Primary care providers (PCPs) are reluctant to discuss trauma • Providers do not feel prepared to work with trauma/mental health patients • PCPs have low exposure to trauma-informed care in medical schools and residencies (Chung, J., 2012).

21. Unrecognized Trauma • PTSD symptoms are often not evaluated and therefore go unrecognized and untreated • Routine assessment of trauma is often “overlooked”in the absence of typical PTSD symptoms as the presenting complaint • Most providers underestimate the prevalenceof trauma (Frueh, 2002).

22. Understanding Trauma Impact Adverse Childhood Experiences (ACEs) Study

23. ACEstudy.org Studied: • Association of childhood maltreatment & family dysfunction with current health status & health-risk behaviors (Felitti, V., 1998).

24. Demographics Drs. Vincent Felitti & Charles Anda (1994 – 1998) • 75% - White • 46% - 60 and over • 39% - College graduated (Felitti, V., 1998).

25. ACEs (prior to 18 years of age ) Abuse • Physical • Emotional • Sexual Neglect • Physical • Emotional Household Dysfunction • Divorce or loss of parent • Domestic Violence • Chronic mental illness • Substance use • Incarceration

26. ACE study

27. Seminal Findings • 2/3 of over 17,000 participants reported at least one ACE, and 1 in 5reported 3 or more (common) • Behaviorstraditionally viewed as public health or mental health problems - “adaptive coping”for people who have had Adverse Childhood Experiences   • ACEs are associated with chronic health conditions that are the leading causes of death such as diabetes, cancer, and heart disease

28. Cumulative Impact • A person with one ACE has an 80% likelihood of exposure to an additional ACE category. • People with six or more ACEs on average die 20 years earlier than those with no ACEs.

29. ACE Scores ACE Score >3 • 2x as likely – Smoke, dx with Cancer or Heart Disease • 4x as likely – Emphysema or chronic bronchitis • 6x as likely – Sex before 15 y/o • 7x as likely – Alcoholism • 12x as likely – Attempted suicide ACE Score >5 • 46 x as likely – Injected drug use hx(Males)

30. Health-Risk Behaviors • Over or under - eating • Unintended pregnancy • More sexual partners • Lack of use of safe-sex techniques • Smoking • Alcoholism and alcohol abuse • Illicit & prescription drug abuse • Self-injury • Suicide attempts

31. Calculate Your ACE Score http://www.acestudy.org/

32. “The prevalence of child trauma is high enough that every child should be screened. What looks like a social situation is actually a neurochemical situation” (Burke, 2011). Routine Trauma Screening

33. Asking about Trauma Asking about what happened and seeking to understand rather than focusing solely on symptoms and diagnosing what is wrong: • 35% decrease in doctor office visits • 11% decrease in ER visits (Felitti, V., 2010).

34. Routine Screening Asking every one about trauma can help to: • Determine appropriate referrals • Increaseawareness of imminent danger • Identify need for trauma-specific services • Validateexperience • Demonstraterecognition of past trauma and its impact on the present • Empowerpeople to talk about traumatic experiences

35. Universal Precautions • Presume that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences National Association Mental Health State Program Directors (NASMHPD)

36. Recognizing & Reframing Trauma Symptoms

38. There is No Single Diagnosis People with abuse and trauma histories face a range of mental health issues including; • Anxiety • Panic attacks • Depression • Substance abuse and dependence • Personality disorders (especially borderline personality disorder) • Dissociative identity disorders • Psychotic disorders • Somatization • Eating disorders • Post-traumatic stress disorders

40. Co-occurring Disorders • Survivors of early sexual abuse may use drugs and alcohol to cope with abuse-related memories. • Substance abuse may not be effectively managed until the trauma-based memories have been addressed and alternative means of coping with the pain are provided. • PTSD symptoms are widely reported to become worse with initial abstinence. (Jennings, 2004)

41. Trauma-Informed Lens “How do I understand this person?” rather than “How do I understand this problem or symptom?”

42. Think of one or more complex clients/patients and their symptoms / behavior. • What is the adaptive intentfor each symptom / behavior?

43. Trauma Affects All Aspects of the Self *Cognitive *Emotional *Physical *Social*Cultural *Spiritual

44. Neuroscience Brain and trauma

50. Survival responses