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Why Survivors of Trauma Feel and Act the Way They Do: Understanding the Neurobiology of Trauma

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Title: Why Survivors of Trauma Feel and Act the Way They Do: Understanding the Neurobiology of Trauma


1
Why Survivors of Trauma Feel and Act the Way They
Do Understanding the Neurobiology of Trauma
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  • Janine M. DAnniballe, Ph.D.
  • Childrens Roundtable Summit
  • Seven Springs, PA

2
The Stress-Trauma Continuum
  • Normal
  • Situational
  • Traumatic

3
What is Trauma?
  • Physical, sexual abuse, neglect
  • Domestic violence
  • Stalking
  • School or gang violence
  • Divorce/custody battle
  • Kidnapping
  • War
  • Natural Disasters
  • Severe motor vehicle accidents
  • Witnessing or hearing about any of the above

4
Trauma and Culture
  • Cultural/Gender differences in the perception and
    expression of trauma
  • Historical trauma
  • Forms of traumatic injury
  • Psychological
  • Spiritual
  • Brain/Body

5
Trauma Symptoms as Adaptations
  • Substance abuse
  • Indiscriminant sexual behavior
  • Self-harm and suicidal gestures
  • Dissociation
  • Continued contact with the abuser
  • The freeze response
  • Avoidance or withdrawal
  • Eating disorders
  • Engaging in high risk behaviors

6
The Neurobiology of Trauma
  • Trauma is not purely a psychological issue
  • The past becomes present because of the way that
    the brain dysregulates and changes after
    traumatic events
  • What fires together wires together
  • Trauma echoes in the brain and treatment
    needs to quiet the reverberations of the echo

7
Neurobiology of Trauma
Dendrites
Nucleus
Axon
8
Synaptic Activity
9
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10
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13
More on the Sympathic Nervous System Response
  • HPA axis hypothalamic-pituitary-adrenal
  • This system is responsible for bringing the body
    back into balance
  • The following chemicals/hormones are released
  • Catecholamines (epinephrine and norepinephrine)
    responsible for fight or flight
  • Corticosteroids (glucocorticoids, cortisol)
    control energy and bodys immune functioning
  • Opiods prevent pain, inhibit memory
    consolidation
  • Oxytocin inhibits memory consolidation,
    promotes good feelings
  • These chemicals are POWERFUL substances .

14
Sympathic Nervous System Response
  • If trauma is too severe, too long, triggered
    often then
  • Catecholamines are chronically increased damage
    to memory, rational thought, hypervigilance,
    inability to distinguish danger signals
  • Corticosteroids are chronically low reduced
    immune functioning (lupus, Graves disease, RA,
    fibromyalgia), catecholamines arent regulated
  • Opiod levels increase (equivalent to 8 mg of
    morphine) flat affect
  • Oxytocin increased memory impaired bonding to
    perp

15
Other Neurotransmitters of Importance
  • Serotonin inhibitory involved in emotion and
    mood.  Too little serotonin has been shown to
    lead to depression, problems with anger control,
    obsessive-compulsive disorder, and suicide.
  • Dopamine inhibitory (meaning when it finds
    receptor sites, it blocks the firing of the
    neuron) controls arousal, alertness, attention
    vital for giving motivation Drugs like cocaine,
    opium, heroin, and alcohol increase the levels of
    dopamine, as does nicotine.
  • GABA inhibitory acts like a brake to the
    excitatory neurotransmitters that lead to anxiety.

16
Structures of the Brain The Limbic System
17
The Amygdala
  • an almond-sized structure that stores memories of
    fearful experiences
  • responsible for regulating safety, and regulates
    heart rate and blood pressure, via the
    parasympathetic /sympathetic nervous system.
  • monitors incoming stimuli for anything
    threatening
  • activates the fight-flight-freeze stress response
    when danger is detected
  • imaging studies reveal hyper-responsivity here
    during the presentation of traumatic scripts,
    cues, reminders
  • increased amygdala reactivity is genetic

18
The Hippocampus
  • a finger-sized cluster of neurons, is the hub of
    memory and learning because all conscious memory
    must be processed through this structure of the
    brain.
  • functions like a memory chip in a computer. It is
    involved in verbal and emotional memory.
  • highly sensitive to stress hormones (e.g.,
    cortisol).

19
The Adolescent Brain and Trauma
  • Cortex still developing until mid-20s
  • Not able to execute cause and effect thinking
    consistently even without trauma
  • Dopamine is helpful to increase judgment and
    impulse control trauma disrupts dopamine
  • Brain hemisphere integration (via the corpus
    callosum) is effected rational thought vs.
    overwhelming emotion

20
Neurobiological Changes in Children with PTSD
(DeBellis et al., 1999)
  • Study University of Pittsburgh, took MRI scans
    of the brains of 44 children with histories of
    abuse and diagnoses of PTSD and compared them
    with 61 healthy controls who had not experienced
    abuse. The average age of the subjects was 12
    years

21
More details from DeBellis, et al
  • Abused children excreted greater amounts of
    cortisol and catecholamines than non-abused kids
  • Abused children had 7-8 less cerebral volumes
    (impairing memory, dysregulating arousal)
  • Neurons enlarge with age and axons thicken.
    Between the ages of 5 and 18 years, the process
    of coating the neurons in the central nervous
    system with a myelin sheath is most influential
    in determining brain size
  • In the PTSD children, the corpus callosum did not
    grow with age compared with controls, which may
    be due to a failure of myelination.

22
The Adverse Childhood Experiences (ACE) Study
(Robert Anda, MD Co-Principal Investigator)
  • www.acestudy.org
  • Examined the health and social effects of ACEs
    throughout the lifespan of 17,421 Kaiser members
    in San Diego county
  • ACEs children exposed to household substance
    abuse, separation/divorce, mental illness,
    battered parent, criminal behavior abuse or
    neglect

23
ACE findings
  • The higher the ACE score, the higher the
    incidence of
  • Intercourse by age 15
  • Teen pregnancy
  • Teen paternity
  • Obesity
  • Depression/suicide attempts
  • Rick of being victimized as an adult
  • Substance abuse
  • HIV risk
  • Smoking

24
Hippocampal Volume Reduction in PTSD
  • NORMAL PTSD
  • MRI scan of the hippocampus in a normal control
    and patient with PTSD secondary to childhood
    abuse. The hippocampus, outlined in red, is
    visibly smaller in PTSD. Overall there was a 12
    reduction in volume in PTSD.

Bremner et al., Am. J. Psychiatry 1995
152973-981 Bremner et al., Biol. Psychiatry
1997 4123-32
25
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26
The Prefrontal Cortex
  • Highly developed in primates and humans
  • Allows executive control or at least guidance
    over more primitive brain structures
  • Middle region is critical to relational
    functioning, empathy, connecting
  • Helps us with
  • Being able to focus
  • Memory and reason
  • Self-awareness, reflection, emotions, impulses

27
The Prefrontal Cortex (PFC)
  • Connected with the amygdala and
  • exerts inhibitory control over stress responses
    and emotional reactivity goals, reason, controls
    habits
  • Prefrontal cortex actually shrinks with PTSD
    children/adolescents/young adults dont have
    developed PFC
  • Successful SSRI treatment restored PFC activation
    patterns

28
High Arousal (Fear) Impaired Prefrontal Cortex
  • Stress chemicals disable the mid cortex and
    limbic brain takes over
  • So what activates the Prefrontal and Medial
    Cortex?
  • - Meditation and mindfulness practices
  • - these kick-in top-down brain functioning
    versus bottom-up

29
The Insular Cortex and the Embodied Self
  • Trauma disembodiment
  • Mindfulness embodiment
  • Research
  • (Lazar, 2005) 20 people with extensive
    meditation experience vs. 15 controls in
    meditators, no age-related thinning of PFC area
    associated with emotion and thoughts
  • (Britta, 2008) Significant thickness in PFC in
    meditators

30
Traumatic Memory
31
Factors that Influence Traumatic Memory
  • Continuous Memory
  • Single traumatic event
  • Natural or accidental cause
  • Adult victim
  • Validation and support present
  • Dissociative/Incomplete Memory
  • Repeated events
  • Deliberately human caused
  • Child victim
  • Denial and secrecy

32
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33
When Amygdala is highly activated, it interferes
with Hippocampus functioning
Sensory Thalamus
34
Self-Harming Behavior
  • Deliberate destruction or alteration of body
    tissue without suicidal intent
  • Prevalence
  • 13 to 25 in adolescents (Rodham Hawton, 2009)
  • 11 of college-aged students
  • middle school populations have higher prevalence
    since that is the age at which most individuals
    initiate self-injury. (Whitlock, Eckenrode, et
    al., 2006 Gollust, Eisenberg, Golberstein,
    2008).

35
Self-Harming Behavior
Why do people self-injure?
  • Psychological Reasons
  • to exert self-control or punishment
  • as a distraction
  • to get attention
  • to attain group membership
  • Neurobiological Reasons
  • to unconsciously rebalance brain chemistry
  • to evoke emotion when feeling numb (up
    regulation)
  • to stimulate a high

36
Neurobiological explanations for Self-Harming
Behavior EOS and Serotonin
  • Self-harm activates the endogenous opiod system
    (EOS)
  • The EOS system regulates pain releases
    endorphins, adrenaline and dopamine promotes
    calm, well-being
  • Low serotonin is correlated with suicide
    attempts, aggression, and impulsivity
  • Impact of an adverse rearing environment
    Peer-reared monkeys have lower seratonin activity
    in comparison to maternally raised monkey (Higley
    et al., 1993)

37
Fight, Flight, or Freeze
  • A lesson from Jakey Cat

38
Jakey Cat (RIP)
39
The Freeze Response Tonic Immobility
  • Autonomic Nervous System sympathetic and
    parasympathetic nervous system
  • Both systems heightened simultaneously under
    extreme stress
  • Tonic immobility as an adaptive survival
    response if you move in the animal world the
    predator will chase and kill

40
If you dont remember anything from this
presentation, remember .
  • The more the neural system is activated, the more
    it will change
  • What fires together, wires together
  • Trauma leads to dysregulation of the autonomic
    nervous system and the limbic system
  • Memory is often corrupted by trauma recall
    impaired the past is present

41
Neurobiological Conclusions
  • Any trauma during birth to 25 has the potential
    to disrupt typical neurodevelopmental processes
    and contribute to long-term consequences
  • Chronic abuse and multiple traumas have a greater
    neurobiological impact
  • Permanence/impermanence of the damage is
    debatable. Teicher (2002) suggests effects are
    irreversible BUT some evidence suggests that
    neurogenesis is possible
  • Prolonged stress leads to exposure to
    glucocorticoids (adrenal steroids) and elevated
    levels of catecholamines (adrenaline, serotonin,
    dopamine)
  • Result impaired cognition, emotional/behavioral
    regulation, potential autoimmune disorders

42
The Insidious Nature of the Vicarious Trauma
  • Brainstorm how does this work impact us?
  • What are the signs that let us know we are not
    being effective?
  • What are you and your agency doing to address
    vicarious trauma?

43
Symptoms of Vicarious Trauma
  • Feel very emotional during/after a session or
    meeting
  • Difficulty sleeping
  • Nightmares
  • Vivid mental replaying of clients trauma
  • Revenge fantasies
  • Lack of interest in sex or romance
  • Numbing, flat affect, loss of humor or warmth

44
Symptoms of Vicarious Trauma
  • Generalized anxiety, worry
  • Feelings of being overwhelmed
  • Feelings of incompetence
  • Low grade depression, listlessness, the blahs
  • Pervasive cynicism (in self or in the work
    culture)
  • Tendency to talk more about our own trauma
    histories
  • Seeing others as potential victims or abusers

45
Assess and Address Vicarious Trauma
  • How do we cope with hearing horrible stories and
    dealing with difficult cases?
  • Caseworkers may feel more helpless to help a
    trauma survivor particularly when there are
    multiple traumas
  • Perhaps not as many concrete things to do (e.g.,
    help with reporting, advocacy, restraining
    orders, etc.)
  • One sign of vicarious trauma and/or burnout OUR
    LANGUAGE

46
Common Pejorative Language Used When Working with
Trauma Survivors
  • Shes manipulative.
  • Shes a multiple.
  • Hes crazy.
  • Shes a cutter.
  • Hes a train wreck.
  • Shes Borderline.
  • Implications, Reactions, Alternatives

47
Suggestions
  • Describe difficult things that we experience with
    clients in behavioral terms
  • Reframe symptoms as adaptations e.g.,
    manipulation communicating indirectly
    resistance clients protecting themselves from
    further harm they expect from the relationship

48
Strategies that Address Neurobiological Issues
  • The helping relationship (can be therapeutic,
    first responder, any system response)
  • "There is no more effective neurobiological
    intervention than a safe relationship"
  • -- Bruce Perry

49
The Importance of Relationship
  • Oxytocin and vasopressin are linked to bonding
    and relationships characterized by strong
    attachments.
  • Positive attachments directly
  • rewire the wiring of the orbito-
  • frontal cortex to the Limbic
  • system to mediate emotional
  • response balance sympathetic
  • and parasympathetic systems

50
Importance of Empowerment
  • Making decisions develops the cortex
  • Involved clients in treatment decisions (e.g.,
    court, child welfare)
  • Avoid using relationships as consequences (e.g.,
    restricting family visits, peer connections)
  • Avoid pathologizing behaviors

51
Psychotropic Medication for Adolescents and Adults
  • A comprehensive review of pediatric trials
    conducted between 1988 and 2006 suggested that
    the benefits of antidepressant medications likely
    outweigh their risks to children and adolescents
    with major depression and anxiety disorders.

52
Increased Hippocampal Volume With Paxil in PTSD
Effects of 9-12 months of treatment with 10-40 mg
paroxetine. (Vermetten et al. Biol Psychiatry,
2003)
53
ADHD and PTSD The importance of accurate
diagnosis
  • Richard Friedman, NYT, April, 2012 Are We
    Drugging our Soldiers
  • Since PTSD is basically a pathological form of
    learning known as fear conditioning, (ADHD)
    stimulants could plausibly increase the risk of
    getting the disorder.
  • Because norepinephrine enhances emotional
    memory, a soldier taking a stimulant medication,
    which releases norepinephrine in the brain, could
    be at higher risk of becoming fear-conditioned
    and getting PTSD in the setting of trauma.

54
  • Engaging and Exercising the Brain Neurobics It
    is important to challenge the brain to learn new
    tasks
  • Learn new content/skills
  • Drive home from work a different way
  • Operate mouse with non-dominant hand

55
More Neurobics
  • Try to include one or more of your senses in an
    everyday task Get dressed with your eyes closed,
    wash your hair with your eyes closed, close your
    eyes and eat identifying food by taste
  • Combine two senses Listen to music and smell
    flowers, listen to the rain and tap your fingers,
    watch clouds and play with modeling clay at the
    same time  
  • Break routines Go to work on a new route, eat
    with your opposite hand, shop at new grocery
    store, switch places at the meeting table

56
Transforming from the Sympathetic to the
Parasympathic System
  • The more anxiety we have, the less optimally our
    brains function
  • Sympathetic System -
  • Ready to react, on alert, high arousal
  • Parasympathic System -
  • Relaxed, comfortable, intentional, optimal
    functioning

57
Three Quick Ways to Activate the Parasympathic
System
  • Breathing particularly the exhale
  • Mindfulness practice
  • Relaxing the pelvic muscles
  • While sitting, put hands under the buttocks and
    find the sits bones
  • Touch the two bony points just below the waist on
    your right and left side
  • Visualize a square breathe into the square to
    expand that area release and relax all muscles
    there

58
Safe Physical Contact (with humans or animals)
  • Touch lowers cortisol, increases limbic bonding
  • Massage
  • Contact with animals lowers cholesterol, blood
    pressure, and triglyceride levels

Scout in Crested Butte, CO
59
Meditation/Mindfulness Psychosomatic State Shift
  • Thickens the cerebral cortex (due to trauma, age)
  • Increases attention span, sharpens focus,
    improves memory
  • Restores synapses, similar to sleep

Study Boston-area workers who meditated for 40
minutes a day had significantly thicker cortexes
than controls (Lazar et al, 2005)
60
More Research on Meditation Outcomes
  • (Grant et al., 2011) 13 meditators, 13
    non-meditators. Gave thermal stimulation to
    calf. The more meditation experience, the lower
    the pain ratings. Amygdala was less active!
  • (Kimbrough, 2009) Modified Mindfulness Based
    Stress Reduction (MBSR) for Adults with PTSD and
    Histories of Childhood Sexual Abuse depression,
    anxiety, and PTSD symptoms decreased

61
YogaTrauma split between mind and bodyYoga
unifying mind and body
  • Yoga increases heart rate variability (HRV) an
    indicator of the bodys ability to respond more
    flexibly to stress
  • Benefits of controlled breathing activates
    parasympathetic system similar to those receiving
    ECT, and taking an antidepressant
  • 2010 study from Boston U. School of Medicine
    yoga increasing GABA levels (GABA involved in
    alcohol use)

62
More Benefits of Yoga to Mitigate Effects of
Trauma
  • Research shows that yoga decreases oxidative
    stress in the cells after an eight week practice.
    Less inflammation, less cell damage, less acidity
    in the body health

Janine and Scout Practicing
63
Exercise
  • Rebalances melatonin enhances sleep cycle
  • Releases endorphins (endogenous opioids)
  • Promotes tryptophan which enhances mood
    precursor to serotonin

64
Sleep, Rest, and Relaxation
  • Sleep deprivation keeps nervous system on
    high-alert cortisol is elevated
  • Serotonin and dopamine rise when sleeping,
    resting

65
Diet
  • The brain reads a drop in blood sugar as danger
    and begins to produce adrenaline. Adrenaline can
    be produced in a split second, leaving one
    feeling tense, jittery, weak, and dizzy. With
    someone who suffers from PTSD, these constant
    drops in blood sugar can cause mood swings into
    panic, anger or desperation
  • Avoid stimulants (sugars, caffeine, non-herbal
    tea, nicotine, and simple carbohydrates such as
    white bread, white rice, cakes, cookies, candy
    bars, soda and ice cream)
  • Avoid some fruit like bananas, grapefruit,
    melons, honey, and dates because they are high in
    sugar content

66
Eating to Manage PTSD
  • Eat berries such as strawberries, raspberries,
    blackberries and wild blue berries. These are
    high in fiber, lower in sugar .
  • Eat a combination of lean protein and complex
    carbohydrates every two to three hours, this
    prevents the sugar spike and crash. Good sources
    of proteins are eggs, white meat from chicken or
    turkey and fish.
  • TIP eat an egg before bed! It helps keep blood
    sugar even throughout the night and decreases the
    likelihood of waking shaky or in a panic.

67
Strategies to Reduce Trauma in the Courtroom
  • Physical Environment
  • Be child and family friendly

Allegheny County Courtroom
Chester County Courtroom
68
Strategies to Reduce Trauma in the Courtroom
  • Physical Environment
  • Be creative

Dogs in Court, Bucks County Pennsylvania
69
Strategies to Reduce Trauma in the Courtroom
  • Physical Environment
  • Decrease fear of the unknown
  • Maintain existing healthy
    connections
  • Start and end with strengths
  • Be aware of proxemics and
    boundaries in the courtroom

70
System Strategies
  • Assure that all professionals are trained in
    trauma and understand it
  • Lead the development of trauma informed/focused
    community resources
  • Recognize gaps and services and encourage
    resource development

71
Strategies for Reducing Trauma for Children
Youth
  • Ensure child/youth is prepared for court
  • Give child/youth a voice in court
  • Focus on what is going well for the child

72
Strategies for Reducing Trauma for Parents
  • Set the tone
  • Encourage parents to bring a support person
  • Reduce anxiety by reducing fear of the unknown
  • Address trauma

73
Strategies for Reducing Trauma for Professionals
  • Reduce fear of the unknown
  • End the week on a positive note
  • Find support from colleagues
  • Keep perspective

74
Thank you for all that you do for your community!
75
Contact Information
  • Janine M. DAnniballe, Ph.D.
  • jdanniballe_at_gmail.com
  • www.janinedanniballe.com
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