Understanding the role of trauma in patient care

1. Understanding the role of trauma in patient care Darryl Tonemah PhD

2. Who? What? Where? When? Why? How?

3. Gracie

4. MWB https://www.youtube.com/watch?v=Ahg6qcgoay4

5. From Biology to Sociology

6. High 5’s

7. When the midbrain is activated a non-traumatized patient reacts in elevated arousal-with several possible self-regulatory responses, based on resources. Signals are sent simultaneously to the frontal brain and lower brain for appropriate responses MRI’s show that for a patient who has been traumatized the perceived threat is NOT processed through dual signals. Instead ONLY the lower brain –amygdala-survival instincts is activated. (Levine, Kline, et. Al)

8. Trauma is the unfinished cycle of energy, it is stored in our nervous system. We’ve learned a lot from animal research on why Zebras don’t get ulcers. (Sapolsky, 1994) Trauma is in the constriction (lack of options) and incompletion of the cycle We think too much! Don’t rationalize fear, shame, blame

9. The baby brain (Stiles, 2008) 500,000 cells per minute-Neurogenesis 8000 cells per second Synaptogenesis-1.8 million connections per second to make a complete brain Even at this rate baby brains never make the birth deadline. About 83% of synaptogenesis continues after birth. Wiring isn’t complete until the early 20’s

10. Stress In Utero (Beydoun, 2008), (Lou, 1994) -Lower baby IQ, averaging around 8 points lower in the babies first year of life -Inhibit babys future motor skills, attentional states, ability to concentrate, difference still observable into school years, if chronic stress is not alleviated

11. Stressed cont. Damage the babys stress response system, epigenetics Shrink the size of the babys brain

12. Types of Toxic Stress (Guttelning, 2006) Too Frequent- no break Too Chronic- Break up, divorce, death of loved one Too much for you- If you are stressed all the time, so is the baby

13. “I need to be safe” (Gopnik, 2000), (Wilson, 1998) During the attachment process the brain is seeking “Am I being touched?” “Am I being Fed?” “Who is safe?” If the brains requirements are being fulfilled the baby develops healthy bonds and healthier behaviors If they are not being fulfilled and the baby regularly experiences angry or hostile environments the babys stress responders become hyperactive

14. Safety cont. If the brains requirements are being fulfilled the baby develops healthy bonds and healthier behaviors -If they are not being fulfilled and the baby regularly experiences angry or hostile environments the babys stress responders become hyperactive. -If they are exposed to silence and neglect- hyPOcorticalism- Unplugging, blank stares

15. The brain itself is changed by stress • “What fires together, wires together” • Complex process of “sculpting” the brain, converting experience into neuronal changes • Cortisol, Brain-Derived Neurotrophic Factor (BDNF) • Chronic stress and depression: • shrink the hippocampus and prefrontal cortex • ↓ Memory, selective attention, executive function/decision making • potentiate growth of the amygdala • ↑ Fear/hypervigilience, anxiety, aggression McEwen, Physiol Rev 2007;87:873-904

16. Original Trauma Any input which amygdala interprets as like original trauma Amygdala Recreates body state at time of original trauma Cortisol Adrenaline Original emotion re-experienced: fear, rage, sadnessAdapted from LeDoux, The Emotional Brain, 1996

17. Big feeling are confusing to little kids. (Lebrach, 2008) (Tucker, 1995) Ability to verbally label an emotion is an important self regulation strategy. If a young person is not aware of the emotion they are experiencing, they may not understand how to react to it socially

18. We are born with survival mechanisms (Levine 2001) The basis of trauma is physiological Often there is no time to THINK when facing a threat, our primary response is instinctive, in the midbrain, not the frontal cortex It is difficult to THINK our way to healing Cognitive behaviorism is more effective with stress and cognitive self calming methods

19. Stress in Children Positive Normal/necessary part of healthy development First day with new caregiver; immunization Brief increases in heart rate and stress hormones Tolerable More severe, longer lasting stressor Loss of a loved one, natural disaster, injury If buffered by relationship with supportive adult(s), brain and body can recover Toxic Strong, frequent, prolonged adversity Abuse, neglect, caregiver mental illness, poverty If no adult support, can disrupt brain and organ development long-term Center on the Developing Child at Harvard Univ.

20. Stress and Trauma • Stress: anything that requires a response, can be “good” or “bad” • Trauma: anything that overwhelms our ability to respond, especially if we perceive that our life or our connection to things that support us physically or emotionally is threatened So what factors make it more likely that a stressful situation will become traumatizing?

21. Posttraumatic Stress Responses “the long-term consequences of trauma are far-reaching…” Context of the trauma Age/stage of life Loss of family/cultural coherence Pre-trauma characteristics Life conditions post-trauma

22. Trauma is in the nervous system, not the event -M. Kline Fight-Flight-Freeze Because of their limited capacity to defend themselves children are particularly susceptible to Freezing and therefore are very vulnerable to being traumatized

23. How does the jolt of energy in trauma affect us in the long run? Depends on what happens during and after the overwhelming event The excess “Jolt” of energy, must be used up The younger the child the few resources he/she has to protect him/herself When a traumatic event occurs, the imprinting of neurological patterns is dramatically heightened. Remember why are brain is put in our noodle? (Sapolsky, Kline, Levine 2007)

24. Developing Trauma Symptoms Related to the level of shutdown as well as the undischarged survival energy that was originally mobilized for flight or flee When the brain sets a sensory motor impulse into action but the limbs cannot move (or if the movement itself could be dangerous e.g. Molestation, surgery) symptoms are likely to develop Although the event may have lessened in conscious memory, the body doesn’t forget (Levine, Van Der Kolk)

25. Learning to “befriend” the feeling in small increments, we can make the connection to the past and discharged the paralyzing sensations we experience. The heightened arousal state should be time sensitive, not constant

26. Universal Symptoms of Trauma 1. Hyperarousal 2. Constriction 3. Dissociation 4. Feelings of numbness or shutdown (or “freeze”) (Levine Et al)

27. Hyperarousal Revved up internal state. The stimulation is coming from within the child, from the nervous system that they cannot turn down. When there is perceived stress, the sympathetic nervous system acts to engage the child. The child who cannot pendulate gets stuck in this mode. Hyperactivity, can’t sleep, cannot deeply relax, hypervigilance, difficulty falling and staying asleep, exaggerated startle response. Often resembles ADHD

28. Constriction Once the bodys CNS has been hyperaroused, adrenaline is released into the blood stream to preapre the large motor muscles for moveent. Certain muscles, by their nature, must tense or constrict in order to perform. But with trauma, the whole body braces. This includes tightening of the mucles, joints, and internal organizes, as well as the sensory and respiratory systems. The primary symptom is shutdown.

29. Constriction cont. Child more withdrawn, shy, more dependent than before, lethargy, fatigue, stiff awkward appearance, rigid gait, poor coordination. Ability to see hear, smell feel, taste decreases-food may be less interesting to them. Relaxing would mean letting down the guard of protection Digestion problems, tummy aches, diarrhea and constipation. Shallow breathing, hyperventilation can limit oxygen flow to the brain and body, causing fatigue and lethargic behavior, often mistaken for laziness

30. Freeze/Dissociation A child experience freeze will often be spared the initial impact of the incident thorugh the mechanism of physiological shock and dissociation. This numbing (mediated by internal secretions of endorphins) serves to stamp down the physical and emotional pain of the event Unable to cry Dazed

31. Freeze cont. Sometimes we say “They are tough” Shock Too numb to feel pain or emotions due to endorphins and epinephrine boost Can last decades

32. Recognizing Symptoms Physical: Loss of appetite, sleep disturbance Emotional: Anger, shame, irritability Spiritual: Feeling, alone, isolation, shame Cognitive: Confusion shortened attention span Behavioral: Repetitive play, aggression

33. Posttraumatic Stress Responses • PTSD • Depression • Anxiety • Demoralization-To undermine the confidence or morale of; dishearten: Kroll, JAMA 2003;290:667-670

34. Adverse Childhood Experiences (ACE) • Physical, emotional, sexual abuse; mentally ill, substance abusing, incarcerated family member; seeing mother beaten; parents divorced/separated --Overall Exposure: 86% (among 7 tribes) Non-Native Native Physical Abuse-M 30% 40% Physical Abuse-F 27 42 Sexual Abuse-M 16 24 Sexual Abuse-F 25 31 Emotional Abuse 11 30 Household alcohol 27 65 Four or More ACEs 6 33 Am J Prev Med 2003;25:238-244

35. ACEs and Adult Health • ACE Score ≥4 • 4-12 x risk for alcoholism, drug abuse, depression and suicide attempt • 2-4 x risk for smoking, teen pregnancy, STDs, multiple sexual partners • 1.4-1.6 x risk for severe obesity • Strong graded relationship at all levels of ACEs for almost all outcomes, including heart disease Am J Prev Med 1998;14:245-258 and Circulation 2004;110:1761-6 • Across 10 countries, adults who experienced ≥3 childhood adversities • Hazard ratios 1.59 for diabetes, 2.19 for heart disease • Risk similar to the association between cholesterol and heart disease • Both in magnitude as well as population prevalence Arch Gen Psychiatry 2011;68:838-844

36. --What is your ace score?

37. Cook, et al. 2005. Psychiatric Annals 35(5) p. 392

38. Goldilocks

39. Historical Trauma-Colonization, Residential Schools Trauma is in the freeze-Lack of Options Squeeze Imagine your home, your neighborhood, your community, without the sound of childrens laughter

45. What is multigenerational/historic trauma? • Cultural trauma: –is an attack on the fabric of a society, affecting the essence of the community and its members • Historical trauma: –cumulative exposure of traumatic events that affect an individual and continues to affect subsequent generations. “The collective emotional and psychological injury both over the life span and across generations, resulting from a cataclysmic history of genocide.” • Multigenerational trauma: –occurs when trauma is not resolved, subsequently internalized, and passed from one generation to the next. Maria Yellow Horse Brave Heart

46. Historical Trauma Trauma(s) that are often intentionally inflicted and occur at more or less the same time to a defined group of people—these traumas: Have effects like individual traumas, plus Because the traumas are so pervasive, affect caregivers and elders, affect community and cultural infrastructures and are targeted at a specific group—they have huge effects on: People’s/communities’ abilities to cope with and adapt to traumatic event and aftermath Abilities to interpret the meaning/psychologically incorporate the trauma Patterns of trauma transmission to subsequent generations

47. Some Behaviors/Beliefs We Can Have as the Result of Trauma • Distrust—of the government, institutions, our own leaders, supervisors, etc. even to our own detriment--“they” are out to get us • Sense of never having “enough” • Spend/eat/use what you have now as it may be taken from you • We will not live to be old, so it doesn’t matter what we do now. • “Love” is not to be trusted and is often linked with emotional/physical/sexual abuse

48. Behaviors cont. • Different threshold for “normal” behaviors (That’s just the way it is) • Anger, rage “out of proportion” to situation • Escalation of emotions/voice if demands aren’t met • Dissociation: can look like disinterest, “spaciness” • Desensitized to loss • Distrust of providers • Overly dependent on providers • Its genesis was relatively recent and its transmission is consistent

49. Intergenerational Transmission of HTR: Research Findings • No clinically significant difference between children of holocaust survivors and Jewish non-survivor controls in terms of PTSD; however, when the survivor children were exposed to stressful events, they were significantly more likely to develop PTSD or sub-threshold PTSD symptoms than controls (Danieli, 1998). • Similar multigenerational effects have been documented among Japanese internment survivors and offspring. • For AIAN offspring, increased sensitivity or hyperarousal to stressful events, in particular to events that act as reminders of their colonized status may predispose AIANs to trauma responses and corresponding symptoms.

50. Promoting Resilience Heavy Runner and Marshall (2003) • Spirituality • Family Strength • Elders • Ceremonial Rituals • Oral Traditions • Tribal Identity • Support Networks