Understanding the Biopsychosocial Impact of Trauma Module created by Saxe, 2002

Understanding the Biopsychosocial Understanding the Biopsychosocial Impact of TraumaImpact of Trauma

Module created by Saxe, 2002Module created by Saxe, 2002

Time Period

PT

SD

-RI

Sco

re

Acute Assessment 3 Month Assessment 0

Longitudinal Course of PTSD Symptoms Longitudinal Course of PTSD Symptoms in Children with Burnsin Children with Burns

5

10

15

20

25

30

35

40

45

50

Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a

Healthy, Non-Maltreated Matched Control

(De Bellis et al., 1999)

From Neurons to Neighborhoods: The Science of Early Child Development

Report from the Institute of Medicine/National Academies National Research Council

Trauma in American ChildrenTrauma in American Children

• 3 million children were suspected of being victims of abuse 3 million children were suspected of being victims of abuse and/or neglect in 1998 (and/or neglect in 1998 (Mazelis, 1999Mazelis, 1999) )

• 3.9 million adolescents have been victims of serious 3.9 million adolescents have been victims of serious physical assault, and almost 9 million have witnessed an act physical assault, and almost 9 million have witnessed an act of serious violence (of serious violence (Kilpatrick et al., 2001Kilpatrick et al., 2001))

• In 1998, 92% of incarcerated girls reported sexual, physical In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood or severe emotional abuse in childhood

((Acoca & Dedel,, 1998Acoca & Dedel,, 1998))

• Each year between 3.5 and 10 million children witness the Each year between 3.5 and 10 million children witness the abuse of their mother – up to half are victims of abuse abuse of their mother – up to half are victims of abuse themselves themselves ((Edelson, 1999Edelson, 1999))

PTSD Rates

• 8-14% of PTSD rates in the general population and among certain disadvantaged groups may even be higher.

(Kaplan et al., 1994; Kessler et al., 1995)

• Trauma victimizations studies show prevalence between 51-98% among persons with serious mental illness (SMI) in the public sector.

(Goodman et al., 1997; Muesar et al., 1998))

Effective Treatment Must Account For:Effective Treatment Must Account For:

1) A dysregulated nervous system1) A dysregulated nervous system

2) A social-environment that cannot 2) A social-environment that cannot contain this dysregulationcontain this dysregulation

Core Concepts of DevelopmentCore Concepts of Development

1) The development of children unfolds 1) The development of children unfolds along individual pathways whose along individual pathways whose trajectories are characterized by trajectories are characterized by continuities and discontinuities, as well continuities and discontinuities, as well as by a series of significant transitions.as by a series of significant transitions.

(Shonkoff & Phillips, 2000)

309.81 PTSD Definition

The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of:

– Actual or threatened death– Actual or threatened serious injury– Threat to physical integrity

Post Traumatic Stress Disorder• Characterized by:

– Re-experiencing the event• Intrusive thoughts, nightmares, or flashbacks that

recollect traumatic images and memories

– Avoidance and emotional numbing• Flattening of affect, detachment from others, loss of

interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience


2) The growth of self regulation is a 2) The growth of self regulation is a cornerstone of early development that cornerstone of early development that cuts across all behavioral domains.cuts across all behavioral domains.


State ChangeState Change22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained.

Calm/Continuous/

Engaged

Aggression

Fear

Dissociation

State ChangeState Change12 year-old sexually abused girl in school when provoked by older male peer.

Calm/Continuous/

Engaged

Shame

Fear

Dissociation Self Mutilation

Parameters that change between stateParameters that change between state

•AffectAffect•ThoughtThought•BehaviorBehavior•Sense-of-selfSense-of-self•ConsciousnessConsciousness

Emotional States and Child DevelopmentEmotional States and Child Development

• Discrete behavioral states are a central organizing experience of infancy

• Infants experiential world is divided into separate and definable emotional/behavioral states

• Critical task of early child development is to build smooth transitions/bridges between states

• Regulation of emotion is initially contingent on caregivers facilitating these transitions.

(Wolff, 1987)

Goal of TreatmentGoal of Treatment• Maintain Calm/Continuous/Maintain Calm/Continuous/

Engaged StateEngaged State

• Prevent Discontinuous StatesPrevent Discontinuous States

• Build Cognitive Structures Build Cognitive Structures that allow choicesthat allow choices

Between Stimulus and ResponseBetween Stimulus and Response

ResponseResponseStimulusStimulus


Traumatic Reminder

Traumatic State

Social-Environmental

intervention

Intervention

ResponseStimulus

Neuro-regulatory

intervention


ResponseResponse

StimulusStimulus

Traumatic Reminder

Traumatic State

InterventionIntervention

Social-environmental Intervention

Neuro-regulatory

Intervention

COGNITION!!!COGNITION!!!


3) Human development is shaped by a 3) Human development is shaped by a dynamic and continuous interplay dynamic and continuous interplay between biology and experience.between biology and experience.


Emotional BrainEmotional Brain

(Restak, 1988)


(LeDoux, 1996)

Stimulus


(LeDoux, 1996)

Stimulus

Sensory Thalamus


Very Fast

(LeDoux, 1996)

Stimulus

Sensory Thalamus Amygdala


Cortex

Very Fast

SlowerHippocampus

(LeDoux, 1996)

Stimulus



Cortex

Very Fast

SlowerHippocampus

(LeDoux, 1996)

Stimulus


Response


Cortex

Very Fast

SlowerHippocampus

(LeDoux, 1996)

ResponseStimulus



Cortex

Very Fast

SlowerHippocampus

(LeDoux, 1996)

Stimulus


Response


Very Fast

SlowerHippocampus

Cortex

(LeDoux, 1996)

Stimulus


Response


Very Fast

Slower

Cortex

Hippocampus

(LeDoux, 1996)

Stimulus


Response


Very Fast

Slower

Cortex

Hippocampus

Neuroregulatory InterventionPsychotherapy

Psychopharmacology

Social Environmental Intervention

(LeDoux, 1996)

Stimulus


Response

Rauch Brain scans

Play

(Panksepp, 1998)

Play and FearPlay and Fear

(Panksepp, 1998)


4) Human relationships, and the 4) Human relationships, and the effects of relationships on effects of relationships on relationships, are the building blocks relationships, are the building blocks of healthy development.of healthy development.

((Shonkoff & Phillips, 2000Shonkoff & Phillips, 2000))

AttachmentAttachment• Earliest relationships critical for capacity to regulate state

• Neglectful and traumatic early relationships set up person to respond with state dysregulation to interpersonal cues in subsequent relationships.

Attachment & Relational DeficitsAttachment & Relational Deficits

• Appear guarded & anxious• Difficult to re-direct, reject support• Highly emotionally reactive• Hold on to grievances• Do not take responsibility for behavior• Make the same mistakes over and over• Repetition compulsion / traumatic re-

enactment(Hodas, 2004)(Hodas, 2004)

Traumatic RelationshipsTraumatic Relationships

• Emotions expressed in interpersonal relationshipsEmotions expressed in interpersonal relationshipscan be extremely painful and can be related to can be extremely painful and can be related to trauma experiencetrauma experience

• These trauma-based emotions (e.g. anger, fear, These trauma-based emotions (e.g. anger, fear, hopelessness, sexual arousal) can be very hard for hopelessness, sexual arousal) can be very hard for clinicians to tolerateclinicians to tolerate

• Clinicians must be mindful about their experience Clinicians must be mindful about their experience of trauma-based emotion so that this emotion is not of trauma-based emotion so that this emotion is not enacted in the clinical relationship. enacted in the clinical relationship.


5) Children are active participants in 5) Children are active participants in their own development, reflecting the their own development, reflecting the intrinsic human drive to explore and intrinsic human drive to explore and master one’s environment.master one’s environment.

((Shonkoff & Phillips, 2000Shonkoff & Phillips, 2000))

Australian Defence Force

• BattleSMART

SMART: Self-Management and Resilience Training

Based on Cognitive-Behavioral theory

Encourages optimal emotional and behavioral outcomes in response to adverse events

4 response areas: physical, thoughts, emotions and behaviors

Participants are asked to “test” their initial response to a situation in each of the 4 areas, then adjust their response to achieve optimal performance

Australian Defence ForceBattleSMART Overview

• Introduce concept of resilience

• Flight/fight response

• Arousal reduction skills

• Coping strategies taught in 4 domains:– Adaptive physiological response

– Adaptive ways to think about stressful event.

– Adaptive behavioral response

– Adaptive Emotional Management

Traumatic MasteryTraumatic Mastery• Many children have primarily experienced abusive and neglectful relationships

• Extreme behaviors within relationshipscan be seen as defensive or self-protective

• Traumatized children respond to their trauma history in the present. They are not able to discern that the context has changed

• This behavior must be seen as an attempt to master extremely difficult environments

• In this way, traumatized children are “doing the best that they can”


6) The course of development can be 6) The course of development can be altered…by effective interventions that altered…by effective interventions that change the balance between risk and change the balance between risk and protection, thereby shifting the odds in protection, thereby shifting the odds in favor of more adaptive outcomes.favor of more adaptive outcomes.

(Shonkoff & Phillips, 2000)(Shonkoff & Phillips, 2000)

TAKE HOME IDEAS• Set up calm and nurturing environments • Teach staff to meticulously observe for ‘triggers’ – when

someone is beginning to move from a calm, continuous state to a discreet state of emergency

• Train to caring and compassion • Meticulously interview for triggers• Adjust the environment• Adjust what we do (i.e., look at ourselves and our

behaviors and actions as the key for success)

CONCLUSIONS

• Response to traumatic stress is learned behavior, mediated by the brain & the social environment

• Traumatic stress brings the past to the present• The survival response impacts the mind, body,

behavior & speech “… the amygdala leads a hostile takeover of consciousness by emotion.” (LeDoux, 2002 )

• To change the response, create new learning & skills: – Analyze & adapt– Buffer & bolster– Teach, support, & build that “cognitive wedge”

Documents

Understanding the Biopsychosocial Impact of Trauma Module created by Saxe, 2002