JESUS SALVADOR A. LIGOT, JR., M.D. Clinical Assistant ... Post Trauma… · President Elpidio Quirino Foundation. Vigan, Ilocos Sur UNESCO World Heritage Site

JESUS SALVADOR A. LIGOT, JR., M.D.Clinical Assistant Professor of PsychiatryState University of New York at Buffalo

POST-TRAUMATIC GROWTH NO FINANCIAL DISCLOSURES.

POST-TRAUMATIC STRESS DISORDER Exposure to actual or threatened death, serious injury,

physical and sexual violence

Intrusive symptoms: Nightmares, flashbacks, intense psychological distress

Avoidance of stimuli

Negative alterations in cognition and mood (detachment and isolation)

Hyperarousal and hypervigilance

Self destructive behaviors > alcohol & substance abuse

Negative sequelae: Depression, suicidal ideations and attempts, homicidal ideations, attempts and aggression

Source: DSM V, American Psychiatric Association

NEURAL CIRCUITRY OF FEAR

NEURAL CIRCUITRY OF FEARThreat Thalamus Amygdala & visual cortex

Amygdala receives threat; initiates the fight or flight

response, sends signals to the hypothalamus

and activates the sympathetic nervous

system releasing adrenaline, cortisol and NE

causing increased HR, RR, increased blood

flow to muscles, pupils dilate, fat mobilized

Concurrently, detailed information sent to the

visual cortex -> contextual info to hippocampus

NEURAL CIRCUITRY OF FEAR Hippocampus relays info back to amygdala and the

amygdala determines whether there is an actual threat or not fight or flight response gets turned off if no threat.

PTSD > overactive amygdala > impaired hippocampus (helps in the contextual

understanding of fear). > decreased volumes of the frontal cortex impairs

the extinction of fear responses The brain enters a vicious cycle of emotional and cognitive excitement, and like a runaway train just keeps on picking up speed. (Le Doux, 1996)

NEURAL CIRCUITRY OF FEAR PTSD

State of high alert

Systems are still responding to a trauma that happened months or years ago.

Amygdala is overactive sympathetic overdrive

> CRH & NE increase fear conditioning, enhance

arousal and vigilance.

Parts of the brain that should be overriding amygdalahippocampus and frontal cortex are dysfunctional

Brain unable to differentiate things that should trigger a fear response and things that should not.

Nemeroff, Post-traumatic stress disorder: the neurobiological impact of psychological trauma, Dialogues in Clinical Neurosccienses, 2011

FOUR OUTCOMES OF PTSD Actively symptomatic , at times with self-medication

with drugs and/or alcohol

Recovery with some residual impairment

Full Recovery /Resilience

Post-traumatic growth - positive psychological

change resulting in above baseline functioning

(Tedeschi, 2011). Trauma becomes the catalyst

for positive change

Warner, 2013, Promoting Post-traumatic growth

RESILIENCE Ability to adapt successfully to acute stress, trauma or

more chronic forms of adversity

Psychosocial factors:

Optimism and positive emotionality

Ability to harness social support

Spirituality : ability to find meaning

Use of active coping strategies such as problem

solving and planning

Lower levels of denial and avoidant coping behaviorNestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009

NEUROBIOLOGY OF RESILIENCE The H-P-A Axis: Resilience associated with less

stress induced increase in CRH (corticotropin-

releasing hormone) and cortisol.

Neuropeptide Y counteracts anxiogenic effects of

CRH in amygdala, hippocampus, hypothalamus.

In people who are resilient, NPY balances out CRH

BDNF (brain-derived neurotrophic factor)

> promotes functioning of the hippocampus

Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009

H-P-A Axis

NEUROBIOLOGY OF RESILIENCE BDNF (brain-derived neurotrophic factor)

> promotes functioning of the hippocampus

GENETICS:

1.) CHR1 receptor gene regulation of H-P-A axis.

2.) Serotonin transporter gene short allele (5 HTTLPR)

3.) COMT gene low functioning allele increases NE

and dopamine increases anxiety

4.) NPY gene

5.) SNP in gene encoding BDNF reduced hippocampal

Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009

NEUROBIOLOGY OF RESILIENCE EPIGENETICS :

Meaney and colleagues

Compared offspring of high nurturing and low

nurturing maternal rats (i.e. licking)

Offspring of high nurturing rats less anxious, attenuated responses to stress

Offspring of less nurturing rats - epigenetic changes

affecting the hippocampus resulting in behavioral

deficits Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009

POST-TRAUMATIC GROWTH Change beyond the ability to resist and not be

damaged by stressful events

Seismic shaking ones foundation to the core

Beyond pre-trauma levels of adaptation

Ironically, those who score highest on dimensions

of coping will report relatively little growth

Struggle with trauma is crucial for post-traumatic growth but PTSD is not a pre-requisite

Tedeschi, Interview, November 2016

POST-TRAUMATIC GROWTH Positive psychological change (Tedeschi, 2004)

Attempt to find meaning and resolve (Morris, 2007)

Human capacity for resilience & potential growth

Recovery from trauma is not about putting

the shattered world back together as it was but

rebuilding the shattered world in a way that is

better(Dorotik-Nana, 2016)

Tedeschi and Calhoun, 2004. Psychiatric Times

POST-TRAUMATIC GROWTH Implication: We are capable of growth experiences in the

context of suffering and struggle as well in the aftermath of traumatic events, losses, abuse and betrayal. (Ferentz, 2016)

Not everybody ends up with learned helplessness but some come out of it with learned optimism. (Seligman, Positive Psychology, 1998)

In order to reach a place of transformation, there has to be a place of struggle (Ferentz, 2016. Helping people move from heartache to healing.)

POST-TRAUMATIC GROWTH

HISTORICAL CONTEXT

Victor Frankl: Mans Search for Meaning

William Sledge: Study of POWs by Vietnamese

> showed that the POWS who were held captive

longest and had been subjected to harshest

treatment reported most positive changes

Richard Tedeschi, Ph.D. and Lawrence Calhoun, Ph.D.

of UNCC (University of North Carolina at Charlotte)

> pioneers in the field of post-traumatic growth

Upside, Rendon, 2015

POST-TRAUMATIC GROWTH5 Dimensions of Posttraumatic growth

(Tedeschi and Calhoun)

1.) Rediscovering personal strengths

2.) Belief in new possibilities

3.) Improvement in relationship with others

4.) Spiritual growth

5.) A newfound appreciation of life

Post Traumatic Growth Inventory: tool to measure PTG

Tedeschi and Calhoun, 1996

PTG Inventory (Tedeschi & Calhoun)21-item standardized questionnaire

5 Research Validated PTG Factors

Relating to Others

New Possibilities

New Personal Strengths

Newfound appreciation of life

Spiritual ChangeTedeschi and Calhoun, 1996,

PTG Inventory (Tedeschi & Calhoun)

POST-TRAUMATIC GROWTH

,

Writing a new life narrative

Challenging ones assumptive world-view

i.e.

Good things happen to good people and bad things

happen only to bad people. (Why me ?)

Assimilation: Person wishes to maintain or retain pre-existing assumptions. Person fits the new trauma related

information into his world view (maladaptive)

Accomodation: Reconstructing world view to achieve congruence with the new trauma-related information

POST-TRAUMATIC GROWTH Deliberative rumination/Reflective pondering :

Intrusive thoughts must not be avoided. It is the

catalayst to rethinking the meaning attached to

event. This will allow survivors to construct a new

view of themselves.

Cognitive reframing of ones story from that of mental defeat and hopelessness to one that is hopeful and

optimistic (Narrative reframing)

Upside, Rendon, 2015.

FACILITATING PTG Cognitive Behavioral Therapy CPT (Cognitive

Processing Therapy)- reappraisal, reviewing of cognitive styles, assumptions

Mindfulness-based therapy promotes direct reduction of intense and inappropriate emotional states , e.g. relaxation training


FACILITATING PTG Expressive writing : writing forces people to break

ideas and events into smaller units; also facilitates deliberative rumination

Study of Smyth (2008) comparing group of veterans with PTSD who wrote about time management vs trauma the ones who wrote and reflected about their trauma showed improvement in severity and

decrease in stress indicators (cortisol).


FACILITATING PTG Art therapy : including music and dance

>Process of deliberate rumination creative process

> Subjects who scored high in openness to new

possibilities have usually high creativity.

Spirituality /Spiritual counseling

In 103 studies of PTG, religious coping often correlated

with growth more than community support and

enthusiasm

His ExcellencyPresident Elpidio Quirino

Birth: Vigan, Ilocos Sur 2nd child among 8 Father: jail warden Mother: school teacher Modest and humble beginnings

President Elpidio Quirino Foundation

Vigan, Ilocos Sur

UNESCO World Heritage Site

Taught grade school students in a village/barrio school while in high school

Walked 10 kilometers everyday to earn money Made sketches of Filipino heroes and won

prizes for them Saved up money to be able to transfer to

Manila High School

Supported himself to go to school by working as a clerk in the Manila Police Department

He did sketches and illustrations for some publications


Captain of the debating team in Manila High School and debated with another future president

University of the Philippines College of Law

Topnotcher in the 1915 Bar Examinations

Dean, Adamson University Law School

The President Elpidio Quirino Foundation

Congressman at the age of 29

Senator at the age of 35

Secretary of Finance

Secretary of Interior

Secretary of Foreign Affairs

Senate President Pro-Tempore

Vice President


Married Alicia Syquia, scion and heiress of the

Syquia clan in 1921

5 Children: Tomas, Armando,

Norma, Victoria and Fe Angela


Quirino Family Portrait

Armando,

Dona Alicia Syquia Quirino

Norma

Victoria

Tomas

Fe Angela (not yet born)


THE SYQUIA MANSION

Japanese occupation of the Philippines

General McArthur and the US government had to leave the Philippines

President Quezon in exile in Saranac Lake, New York

Senator Quirino imprisoned for two weeks in Fort Santiago for refusing to collaborate with the Japanese

,

One of the most devastating events that happened to a country in World War II

Whole city of Manila torn down to pieces and burned

Gruesome death of 100,000 Filipinos

C,

THE BATTLE OF MANILA

Credit: The Shambles that was Manila, Daily Mail.co.uk


Credit: The Shambles that was Manila, Daily Mail.Co.UK


Credit: The Shambles that was Manila, Daily Mail.co.UK

QUIRINO FAMILY TRAGEDY

Credit: The Shambles that was Manila,

TRAGEDY OF ELPIDIO QUIRINO

Family caught between American shells and Japanese machine guns

Mrs. Quirino and three children were killed daughter bayoneted

Mother-in-law and brother killed as well

Carried the dead bodies of his family to cemetery

Single-handedly dug a grave for each of them

Never spoke about this again.

Laya, 2015. The Calvary of Elpidio Quirino

POST WORLD WAR Won the elections as Vice President of President

Manuel Roxas

Premier post of Secretary of Foreign Affairs

First Filipino Diplomat established requisite embassies and consulates abroad

President Roxas died of heart attack and he assumed presidency in 1948

Won the succeeding election in 1949


MALACANANG PALACE

THE QUIRINO ROOM

MALACANANG PALACE

With daughter Victoria who became the First Lady at 16 years old.


THE FIRST FAMILY

Victoria, Elpidio, Conchita, and Tomas


PERSONAL STRENGTHS Resilience and fortitude

Born in provincial jail Ilocos Sur

Humble beginnings barrio school teacher

Walked 10 kms each day to teach children

Hardship and adversity > burning desire and

firm determination to succeed

SPIRITUAL GROWTH Man of unwavering faith

Speech to the Catholic Womens League in 1948:

There is an Unseen Hand that subtly guides and directs our national conscience in moments of peril and adversity. What we need to rebuild is our spirit and soul, our morale as a people. The tenets and teachings of Christ must be revived and revitalized or society will perish. The rock of ages should still be our rock of strength.

SPIRITUAL GROWTH Japanese occupation: Imprisoned for several months

at Fort Santiago for refusing to collaborate with the Japanese.

Man of integrity and uncompromising principles

Exemplified the adage , courage is fear conquered by faith and love.

DEFENSE MECHANISMS People when faced with difficult and challenging

circumstances regress to more primitive defense

mechanisms such as denial, repression, splitting

President Quirino > Mature & advanced defense

defense mechanisms

Altruism: When faced with an emotional conflict,

an individual deals with it by dedicating

himself to the needs of others

IMPROVEMENT INRELATIONSHIP WITH OTHERS President Quirino looked beyond himself and

empathized with the rest of the Filipino nation

Showed compassion and initiative in accepting

the White Russian refugees fleeing communism

from China

Provided a beacon of hope to the White Russian

refugees

Establishing diplomatic ties with other countries and fostering goodwill

BELIEF IN NEW POSSIBILITIES President Quirino was a teacher, painter and orator.

Reinvented himself as a statesman and diplomat.

Achieved economic growth of GDP of 9 percent

Mass housing for low and middle income families

Initiated the creation of the Social Security System

Initiated serious land reform

Minimum wage act

,

NEWFOUND APPRECIATION OF LIFE Sublimation Channeling negative and unacceptable

impulses into more positive outcomes

Pardoned and repatriated the Japanese prisoners of

war in an unprecedented act of compassion and

reconciliation

Benevolent gesture received initially

with criticism and anger

He did not want his people and his children and grandchildren to inherit hatred and anger

C

CLEMENCYSTATEMENT

PRINCIPLES AND VALUES Forgiveness and compassion

Benevolence and magnanimity

Tolerance, good will and love

With the passage of time, Elpidio Quirino stands still in the Pantheon of Philippine presidents. He deserves to be enshrined in the hearts of the Filipino people not only as the First Diplomat and eminent president of the Republic of the Philippines, but in the sober judgment of many as the greatest and the best.

UP President Salvador Lopez

Reburial (February 29,2016)

Credit: The President Elpidio Quirino Foundation

Reburial (February 29,2016)

The tomb of President Quirino

,

The grandchildren of PEQ

Mrs. Ruby Quirino Gonzalez-Meyer, Ms. Cory Quirino and Mr.Elpidio Butch Quirino

Documents

JESUS SALVADOR A. LIGOT, JR., M.D. Clinical Assistant ... Post Trauma… · President Elpidio Quirino Foundation. Vigan, Ilocos Sur UNESCO World Heritage Site