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THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M.D. scaermdpc@msn.com www.traumasoma.com. THE ROOTS OF TRAUMA. A THREAT TO LIFE IN THE FACE OF HELPLESSNESS THE FIGHT /FLIGHT / FREEZE RESPONSE. THE FREEZE RESPONSE. NUMBING THROUGH ENDORPHINS VAGAL (PARASYMPATHETIC) TONE
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THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONSROBERT SCAER, M.D.scaermdpc@msn.comwww.traumasoma.com
THE ROOTS OF TRAUMA A THREAT TO LIFE IN THE FACE OF HELPLESSNESS THE FIGHT /FLIGHT / FREEZE RESPONSE
THE FREEZE RESPONSE • NUMBING THROUGH ENDORPHINS • VAGAL (PARASYMPATHETIC) TONE • BIMODAL SYMPATHETIC / PARASYMPATHETIC CYCLING (ACCELERATOR / BRAKE ANALOGY)
LESSONS FROM THE WILD:THE CRITICAL IMPORTANCEOF DISCHARGINGTHE FREEZE RESPONSE
FREEZE/IMMOBILIZATIONAND SURVIVAL BABY CHICKS NOT IMMOBILIZED IMMOBILIZED IMMOBILIZED SPONTANEOUS FORCED RECOVERY RECOVERY BEST INTERMEDIATE WORST DROWNING DROWNING DROWNING SURVIVAL SURVIVAL SURVIVAL
ANIMALS THAT DO NOT DISCHARGE THE FREEZE • ZOO ANIMALS • LABORATORY ANIMALS • DOMESTIC ANIMALS • HUMAN ANIMALS Q: WHAT DO THESE ANIMALS HAVE IN COMMON? A: THEY ALL LIVE IN A CAGE!
CEREBRAL CORTEX HYPOTHALAMUS HPA AXIS ORBITOFRONTAL CORTEX ORGANIZES RESPONSE TO THREAT SENSORY INPUT – HEAD AND NECK ANTERIOR CINGULATE GYRUS MODULATES AMYGDALA HIPPOCAMPUS DECLARATIVE MEMORY COGNITIVE MEANING AMYGDALA EMOTIONAL CONTENT LOCUS CERULEUS EARLY WARNING
ENDORPHINS IN TRAUMA • RELEASED IN AROUSAL: STRESS INDUCED ANALGESIA (S.I.A.) - INHIBITS MINISTERING TO WOUND, SELF-CARE, - ALLOWS CONTINUED FIGHT / FLIGHT BEHAVIOR • MEDIATES FREEZE RESPONSE - ANALGESIA INHIBITS PAIN BEHAVIOR - IMMOBILITY PROMOTES SURVIVAL
MEMORY MECHANISMS IN TRAUMA • DECLARATIVE (EXPLICIT) MEM0RY - FACTS AND EVENTS • NON-DECLARATIVE (IMPLICIT)MEMORY - EMOTIONAL ASSOCIATIONS - PROCEDURAL MEMORY -SKILLS AND HABITS - CONDITIONED SENSORIMOTOR RESPONSES
MEMORY IN TRAUMA • TRAUMATIC STRESS: A LIFE THREAT WHILE IN A STATE OF HELPLESSNESS • THIS LEADS TO THE FREEZE RESPONSE • DISCHARGE OF THE FREEZE RESPONSE ALLOWS “COMPLETION” OF ESCAPE OR DEFENSE IN PROCEDURAL MEMORY, EXTINGUISHES CONDITIONED SOMATIC CUES
TRAUMA AS A MODEL OF CONDITIONING ANDPROCEDURAL MEMORY A “CAPSULE” OF PROCEDURAL MEMORY CUES FOR: - SOMATOSENSORY, - EMOTIONAL, - AND AUTONOMIC “FEELINGS” - AND EMOTION-LINKED DECLARATIVE MEMORY ALL PERCEIVED AS BEING IN THE PRESENT!
KINDLING / NEUROSENSITIZATION THE DEVELOPMENT OF SELF-PERPETUATING NEURAL CIRCUITS THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF A TRAUMA
DISSOCIATION :THE PERCEPTUAL EXPERIENCE OF THE FREEZE RESPONSE?
PERSONAL EXPERIENCE • MILITARY COMBAT • VIOLENT PERSONAL ATTACK • KIDNAPPING • HOSTAGE TAKING • TERRORIST ATTACK • INCARCERATION AS A POW • TORTURE • NATURAL OR MAN-MADE DISASTERS • SEVERE MOTOR VEHICLE ACCIDENTS • CHILDHOOD SEXUAL TRAUMA
WHY DO THE MAJORITY OF TRAUMA VICTIMS EXPOSED TO TRAUMA NOT DEVELOP PTSD?WHY DO SOME VICTIMS EXPOSED TO MINOR TRAUMATIC EVENTSDEVELOP PTSD?
RESILIENCY VS.VULNERABILITY TO TRAUMA OUR PRIOR BURDEN OF LIFE TRAUMA CREATES AN ENVIRONMENT OF VULNERABILITY TO FURTHER TRAUMATIC EVENTS
THOSE LIFE EXPERIENCES MOST LIKELY TO REPRESENT TRAUMAHAVE MEANINGFOR SURVIVAL BASED ON PAST EXPERIENCE
THE EXPERIENCE-BASED DEVELOPMENT OF THE BRAIN • ALLAN SCHORE, 1996: AFFECT REGULATION AND THE ORIGIN OF THE SELF * THE MATERNAL / INFANT DYAD: FACE-TO-FACE ATTUNEMENT FACILITATES DEVELOPMENT OF THE RIGHT ORBITO-FRONTAL CORTEX, WHICH PROMOTES AUTONOMIC REGULATION, AND RESILIENCY TO SUBSEQUENT STRESS/TRAUMA
LEARNED HELPLESSNESS ONCE YOU FREEZE YOU TEND TO FREEZE / DISSOCIATE AGAIN!
THE LEGACY OFIMPAIRED ATTACHMENT AND DEVELOPMENTAL TRAUMA: A LIFETIME OF AUTONOMIC AND EMOTIONAL DYSREGULATION
IF THE ABSENCE OFNURTURING IS TRAUMATIC STRESS,WHAT ARE WE MISSING HERE?THE UNRECOGNIZEDSOURCESOF TRAUMA
UNRECOGNIZED SOURCESOF TRAUMA • PREVERBAL TRAUMA • PEDIATRIC AND ADULT MEDICAL TRAUMA • CULTURALLY ENDORSED TRAUMA • “LITTLE TRAUMAS”
FETAL SENTIENCE • CAPABLE OF CLASSICAL HABITUATION AND CONDITIONING • TACTILE, AUDITORY, OLFACTORY LEARNING • RECOGNITION LEARNING OF MUSIC/SOUNDS/VOICES/RHYMES • PLAY/AGGRESSION BEHAVIOR OF FETAL TWINS
INTRAUTERINE TRAUMA • INCREASED FETAL PULSE / BP WITH MATERNAL AROUSAL • DEFENSIVE FETAL REACTIONS TO AMNIOCENTESIS • INCREASED FETAL ENDORPHINS AND CORTISOL WITH FETAL NEEDLING • LOW BIRTH WEIGHT WITH FREQUENT PRENATAL ULTRASOUND AND THIRD TRIMESTER MEDICATIONS • LOW BIRTH RATE WITH MATERNAL DISTRESS
THE NEONATAL ICU • TUBES: BREATHING, SUCTIONING, FEEDING • NOISE, BRIGHT LIGHTS, ISOLATION • PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / VENOUS PUNCTURES / CUTDOWNS
NEONATAL ICU OUTCOMES • 283 PREMIES ASSESSED AT 30 MONTHS * 19% SEVERELY DELAYED DEVELOPMENT * 11% MODERATELY DELAYED DEVELOPMENT * 10 % SEVERE NEUROMOTOR DISABILITY * 7 % BLIND * 8 % SEVERE HEARING LOSS * OVERALL, 49% WITH DISABILITY, 23% WITH SEVERE DISABILITY
THE AMERICAN WAY OF BIRTHING • THE OBSTETRICALDELIVERY ROOM * INDUCTION * FETAL MONITORING * FORCEPS * SUCTION DELIVERY * C-SECTIONS * NEONATAL SUCTIONING * HEEL STICKS, EYE MEDS * COLD, BRIGHT, NOISY ENVIRONMENT * SEPARATION / ISOLATION
THE AMERICAN WAY OF BIRTHING • MATERNAL ANESTHESIA AND SLOW INFANT DEVELOPMENT • INCREASED RATE OF JUVENILE BEHAVIORAL PROBLEMS AND CRIMINAL VIOLENCE IN MALES WITH NON-BRAIN INJURY RELATED BIRTH COMPLICATIONS
PEDIATRIC MEDICAL TRAUMA • 1986 - PATENT DUCTUS SURGERY WITHOUT ANESTHESIA DISCONTINUED • 1988 - AMA : INFANTS CAN FEEL PAIN - RECOMMENDS SURGICAL ANESTHESIA • 1990’s - FIRST ANESTHESIA USED IN PEDIATRIC ICU’S • 1997 – AMA: RECOMMENDS ANALGESIA FOR CIRCUMCISION • PRESENT: ANALGESIA NEEDS OF PREMIES, NEONATES AND INFANTS ADDRESSED
PEDIATRIC MEDICAL TRAUMA • PEDIATRIC E.R., ANESTHESIA, SURGERY AND HOSPITALIZATION * ISOLATION AND PHYSICAL RESTRAINTS * INADEQUATE PAIN MANAGEMENT * ETHER ANESTHESIA * IGNORAL AND ISOLATION FROM CARE-GIVERS * THE FEAR INSTILLED BY ISOLATION IN A TERRIFYING ENVIRONMENT
PEDIATRIC MEDICAL TRAUMA • CIRCUMCISION * CIRCUMCIZED MALES HAVE A GREATER PAIN RESPONSE TO SUBSEQUENT IMMUNIZATION SHOTS THAN NON-CIRCUMCIZED MALES * USE OF EMLA CREAM EFFECTIVE
ADULT MEDICAL TRAUMA • THE SURGICAL THEATER - SMELLS, SOUNDS, MASKED FACES, IGNORAL OF THE PATIENT, A STATE OF NAKED HELPLESSNESS - PRE-OP ANXIETY AND POST-OP COMPLICATIONS * INCREASED THIOPENTAL AND CIRCULATORY COLLAPSE * POST-OP AGITATION * POST-OP SOMATIC SX: SLEEP DISTURBANCE, PERSISTENT PAIN, BOWEL COMPLAINTS
ADULT MEDICAL TRAUMA • AWAKENING UNDER ANESTHESIA * 30-35,000 CASES / YEAR IN U.S. * USUALLY UNDETECTED * OVERWHELMING HELPLESSNESS * PTSD: MAJOR NIGHTMARES, FLASHBACKS, AROUSAL, PHOBIAS. VIVID DECLARATIVE MEMORY * SOMATIC SX.: COMPARABLE TO WHIPLASH * PARTIAL AWAKENING WITHOUT MEMORY MAY EXPLAIN POST-OP AGITATION AND UNEXPLAINED CHRONIC PAIN BASED ON PROCEDURAL MEMORY
“I CAN’T FIND ANYTHING WRONG, BUT WE’D PROBABLY BETTER GET AN MRI”
NEW TECHNOLOGY AND THE TRAP OF THE “UNEXPLAINED” ABNORMALITY
REJECTION OF THE PATIENT IF THE TESTS ARE NORMAL:“IT MUST BE PSYCHOLOGICAL”
THE INSIDIOUS REINFORCEMENT OF THE FEAR OF ILLNESS BY THE MEDIA AND PHARMACEUTICAL INDUSTRY
GOVERNMENT ANDTHE MEDIA • THE POLITICS OF FEAR: THE COLD WAR AND THE WAR ON TERROR • LESSONS FROM VIETNAM: IMAGES OF WARFARE • THE VISUAL MEDIA: IMAGES OF HORROR AND THE POWER OF TRAUMATIC REENACTMENT - THE APPEAL OF C.S.I.
“LITTLE TRAUMAS” • MOTOR VEHICLE ACCIDENTS • PARENTAL ALCOHOLISM AND MENTAL ILLNESS • RACIAL, GENDER AND JOB DISCRIMINATION • VIOLENCE IN THE MEDIA AND ENTERTAINMENT • BULLYING IN SCHOOLS • PERSONAL DEBT • THE INSURANCE INDUSTRY • THE LEGAL SYSTEM
TRAUMATIC REENACTMENT • SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE, VIOLENCE AND CRIMINAL BEHAVIOR • 14 JUVENILES CONDEMNED TO DEATH: 12 PHYSICALLY ABUSED, 5 SODOMIZED
TRAUMATIC REENACTMENT • CHILDHOOD SEXUAL ABUSE: HIGHER ADULT INCIDENCE OF RAPE, SPOUSAL ABUSE, PROSTITUTION, POSING FOR PORNOGRAPHY • SELF MUTILATION: CHILDHOOD HISTORY OF PHYSICAL AND SEXUAL ABUSE, MULTIPLE SURGICAL PROCEDURES