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The Trauma Spectrum and Its Clinical Implications

This article explores the roots of trauma, the freeze response, and the importance of discharging the freeze response for survival. It discusses the impact of trauma on memory mechanisms and the development of self-perpetuating neural circuits. The role of developmental neurobiology in resilience to trauma is also examined. The article highlights the unrecognized sources of trauma and the long-term effects of impaired attachment and developmental trauma. Lastly, it explores the impact of prenatal and neonatal trauma on long-term outcomes.

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The Trauma Spectrum and Its Clinical Implications

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  1. THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONSROBERT SCAER, M.D.scaermdpc@msn.comwww.traumasoma.com

  2. THE ROOTS OF TRAUMA A THREAT TO LIFE IN THE FACE OF HELPLESSNESS THE FIGHT /FLIGHT / FREEZE RESPONSE

  3. THE FREEZE RESPONSE • NUMBING THROUGH ENDORPHINS • VAGAL (PARASYMPATHETIC) TONE • BIMODAL SYMPATHETIC / PARASYMPATHETIC CYCLING (ACCELERATOR / BRAKE ANALOGY)

  4. LESSONS FROM THE WILD:THE CRITICAL IMPORTANCEOF DISCHARGINGTHE FREEZE RESPONSE

  5. FREEZE/IMMOBILIZATIONAND SURVIVAL BABY CHICKS NOT IMMOBILIZED IMMOBILIZED IMMOBILIZED SPONTANEOUS FORCED RECOVERY RECOVERY BEST INTERMEDIATE WORST DROWNING DROWNING DROWNING SURVIVAL SURVIVAL SURVIVAL

  6. 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!

  7. 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

  8. 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

  9. MEMORY MECHANISMS IN TRAUMA • DECLARATIVE (EXPLICIT) MEM0RY - FACTS AND EVENTS • NON-DECLARATIVE (IMPLICIT)MEMORY - EMOTIONAL ASSOCIATIONS - PROCEDURAL MEMORY -SKILLS AND HABITS - CONDITIONED SENSORIMOTOR RESPONSES

  10. 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

  11. 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!

  12. KINDLING / NEUROSENSITIZATION THE DEVELOPMENT OF SELF-PERPETUATING NEURAL CIRCUITS THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF A TRAUMA

  13. DISSOCIATION :THE PERCEPTUAL EXPERIENCE OF THE FREEZE RESPONSE?

  14. WHAT LIFE EVENTSCONSTITUTEA TRAUMATIC EXPERIENCE?

  15. 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

  16. WHY DO THE MAJORITY OF TRAUMA VICTIMS EXPOSED TO TRAUMA NOT DEVELOP PTSD?WHY DO SOME VICTIMS EXPOSED TO MINOR TRAUMATIC EVENTSDEVELOP PTSD?

  17. RESILIENCY VS.VULNERABILITY TO TRAUMA OUR PRIOR BURDEN OF LIFE TRAUMA CREATES AN ENVIRONMENT OF VULNERABILITY TO FURTHER TRAUMATIC EVENTS

  18. THOSE LIFE EXPERIENCES MOST LIKELY TO REPRESENT TRAUMAHAVE MEANINGFOR SURVIVAL BASED ON PAST EXPERIENCE

  19. THE ROLE OFDEVELOPMENTALNEUROBIOLOGYIN RESILIENCE TOTRAUMA

  20. 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

  21. LEARNED HELPLESSNESS ONCE YOU FREEZE YOU TEND TO FREEZE / DISSOCIATE AGAIN!

  22. THE LEGACY OFIMPAIRED ATTACHMENT AND DEVELOPMENTAL TRAUMA: A LIFETIME OF AUTONOMIC AND EMOTIONAL DYSREGULATION

  23. IF THE ABSENCE OFNURTURING IS TRAUMATIC STRESS,WHAT ARE WE MISSING HERE?THE UNRECOGNIZEDSOURCESOF TRAUMA

  24. UNRECOGNIZED SOURCESOF TRAUMA • PREVERBAL TRAUMA • PEDIATRIC AND ADULT MEDICAL TRAUMA • CULTURALLY ENDORSED TRAUMA • “LITTLE TRAUMAS”

  25. 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

  26. 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

  27. THE NEONATAL ICU • TUBES: BREATHING, SUCTIONING, FEEDING • NOISE, BRIGHT LIGHTS, ISOLATION • PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / VENOUS PUNCTURES / CUTDOWNS

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. PEDIATRIC MEDICAL TRAUMA • CIRCUMCISION * CIRCUMCIZED MALES HAVE A GREATER PAIN RESPONSE TO SUBSEQUENT IMMUNIZATION SHOTS THAN NON-CIRCUMCIZED MALES * USE OF EMLA CREAM EFFECTIVE

  34. 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

  35. 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

  36. MEDICAL TECHNOLOGY:TRAUMA BY THE CAREGIVER

  37. “I CAN’T FIND ANYTHING WRONG, BUT WE’D PROBABLY BETTER GET AN MRI”

  38. ORDERING TESTS TO AVOID MEDICAL / LEGAL LIABILITY

  39. NEW TECHNOLOGY AND THE TRAP OF THE “UNEXPLAINED” ABNORMALITY

  40. THE INFALLIBILITY OF TECHNOLOGY AND “EFFORT AFTER MEANING”

  41. REJECTION OF THE PATIENT IF THE TESTS ARE NORMAL:“IT MUST BE PSYCHOLOGICAL”

  42. THE DILEMMA OF AN IMPERFECT SCIENCE

  43. THE INSIDIOUS REINFORCEMENT OF THE FEAR OF ILLNESS BY THE MEDIA AND PHARMACEUTICAL INDUSTRY

  44. 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.

  45. “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

  46. TRAUMATIC REENACTMENT • SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE, VIOLENCE AND CRIMINAL BEHAVIOR • 14 JUVENILES CONDEMNED TO DEATH: 12 PHYSICALLY ABUSED, 5 SODOMIZED

  47. 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

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