DE- ESCALATING AGITATED AND VIOLENT PATIENTS WHY IT SHOULD MATTER TO ME? 35% TO 80% OF HOSPITAL STAFF HAVE BEEN

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1 DE- ESCALATING AGITATED AND VIOLENT PATIENTS ERIC ARAUZ MLER TRAUMA INSTITUTE OF NEW JERSEY ADJUNCT FACULTY INSTRUCTOR: RUTGERS ROBERT WOOD JOHNSON MEDICAL SCHOOL PSYCHIATRY WHY IT SHOULD MATTER TO ME? 35% TO 80% OF HOSPITAL STAFF HAVE BEEN PHYSICALLY ASSAULTED AT LEAST ONCE IN THEIR CAREERS. Clements PT, et al. Nurse Econ. 2005;23(3): SECONDARY TRAUMATIC STRESS THERAPEUTIC WORKERS A PERSISTENT RAISED STRESS RESPONSE META- ANALYSIS OF RISK FACTORS FOR SECONDARY TRAUMATIC STRESS IN THERAPEUTIC WORK WITH TRAUMA VICTIMS. Jennifer M. Hensel, Carlos Ruiz, Caitlin Finney, and Carolyn S. Dewa. All out of Toronto, Ontario, Canada. Volume 28, Number 2, April 2015 of the Journal of Trauma[c Stress. Published by the Interna[onal Society for Trauma[c Stress Studies.

2 TRAUMA OF PSYCHOSIS MORE THAN ONE- HALF OF THE PARTICIPANTS REPORTED INTENSE DISTRESS RELATED TO PSYCHOTIC SYMPTOMS OR TREATMENT EXPERIENCES, WITH 66% MEETING SYMPTOM CRITERIA FOR THE PTSD SYNDROME (REGARDLESS OF A1/A2), AND 39% MEETING FULL DIAGNOSTIC CRITERIA FOR PTSD (INCLUDING A1/A2). MUESER KT, LU W, ROSENBERG SD, WOLFE R. THE TRAUMA OF PSYCHOSIS: POSTTRAUMATIC STRESS DISORDER AND RECENT ONSET PSYCHOSIS. SCHIZOPHRENIA RESEARCH. 2010;116(2-3): REACTIVE PARTNERS IN RELATIONAL DYAD RECIPROCAL NEURAL INTERACTION ACROSS AFFERENT CIRCUITS Jensen KB, et al. Mol Psychiatry. 2014;19(3): ETYMOLOGY DOES NOT MATTER 7% VERBAL Richmond JS, et al. West J Emerg Med. 2012;13(1): Porges SW. Clev Clin J Med. 2009;76(3):S86-S90.

3 PHYSIOLOGICAL STATE DETERMINES PSYCHOLOGICAL EXPERIENCE SAFETY: PRO SOCIAL SAFETY (Certainty/Efficacy) DANGER: MOBILIZE LIFE THREAT: SHUTDOWN DANGER (UNCERTAINTY/HELPLESSNESS) Porges SW. Int J Psychophysiol. 2001;42(2): Porges SW. Clev Clin J Med. 2009;76(3):S86-S90. STATE DEPENDENT FUNCTIONING OF THE BRAIN Neocortex Limbic Diencephalon Brainstem Abstract Thought Concrete Thought Affilia[on Ahachment Sexual Behavior Emo[onal Reac[vity Motor Regula[on Arousal Appe[te/Sa[ety Sleep Blood Pressure Heart Rate Body Temperature C O M P L E X I T Y Perry BD. In: Murberg MM (Ed.) Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts. Washington, DC: American Psychiatric Press; 1994: Perry BD. In: Coffey CE, et al (Eds). Textbook of Pediatric Neuropsychiatry. Washington, DC: American Psychiatric Press; ABSTRACT SAFETY (CERTAINTY/EFFICACY) CONCRETE/ EMOTIONAL REACTIVE REFLEXIVE DANGER (UNCERTAINTY/HELPLESSNESS) Perry BD. In: Murberg MM (Ed.) Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts. Washington, DC: American Psychiatric Press; 1994: Perry BD. In: Coffey CE, et al (Eds). Textbook of Pediatric Neuropsychiatry. Washington, DC: American Psychiatric Press; 1998.

4 THE VAGUS NERVE: 10 TH CRANIAL NERVE THE POLYVAGAL THEORY 80% AFFERENT 1. PHYSIOLOGICAL STATE CHARACTERIZED BY VAGAL INFLUENCE ON HRV SUPPORTS SOCIAL ENGAGEMENT & BONDING 2. ANY STIMULUS THAT S FEELING OF SAFETY CAN RECRUIT NEURAL CIRCUITS THAT SUPPORT SOCIAL ENGAGEMENT SYSTEM AND INHIBIT DEFENSIVE LIMBIC STRUCTURES 3. NEUROCEPTION ENABLES SOCIAL BEHAVIOR BY DISTINGUISHING SAFE FROM DANGEROUS HRV = heart rate variability. Porges SW. Int J Psychophysiol. 2001;42(2): Levine P. An Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books; 2010:71. Porges SW. Clev Clin J Med. 2009;76(3):S86-S90. POLYVAGAL THEORY: MUTUALLY THERAPEUTIC DYADIC ATTUNEMENT SOCIAL ENGAGEMENT SYSTEM HEART TO FACE, HEART TO VOICE, HEART TO EYES DVC: DORSAL MOTOR NUCLEUS VVC: NUCLEUS AMBIGUUS POSTURE: FACE, GESTURES, BARORECEPTOR CELLS BREATHE: LENGTHEN EXHALE VOICE: PROSODY, VOCALIZATION NOT SYNTAX (PORGES SW. THE POLYVAGAL THEORY: PHYLOGENETIC SUBSTRATES OF A SOCIAL NERVOUS SYSTEM. INTERNATIONAL JOURNAL OF PSYCHOPHYSIOLOGY 42 (2001) )

5 SPECIAL VISCERAL EFFERENTS Still Face Experiment: Dr. Edward Tronick. Accessed January 24, PS NONVERBAL COMMUNICATION 93% 1. PLAN 2. PAUSE: PREFRONTAL CORTEX ONLINE REDUCE REACTIVITY 3. PROCEED 4. PARALLELING: STAND AT ANGLES, NOT DIRECTLY IN FRONT OR BEHIND (PERRY) 5. PROXIMITY: PHYSICAL DISTANCE IN THE DYAD (PORGES) 6. POSTURE: ERECT SPINE; SHOULDERS RELAXED (WONDER WOMAN; CUDDY) 7. PACE OF RESPONSE: PAUSING TO REFLECT (PORGES) 8. PACE OF BODILY MOVEMENT: CONTROLLED, NOT SUDDEN (PORGES; SIEGEL) State of New Jersey Department of Children and Families. Taming Trauma New Jersey Statewide Training. Accessed February 15, 2017.

6 BEE BREATH EXERCISE LONG SLOW COMPLETE SENTENCES LONG SLOW BUZZING AS EXHALE (PARASYMPATHEIC NERVOUS SYSTEM, VAGAL TONE TO HEART) VIBRATIONS ALONG THE RECURRENT LARYNGEAL NERVE BRANCH OF THE 10 TH CRANIAL NERVE THE VAGUS. SELF OVERHEARING ATTENUATES THE VAGUS NERVE IN THE MIDDLE EAR MUSCLE. FEEL THE UNTANGLING, DE- CONSTRICTION ALONG THE VAGUS NERVE. FEELING OF SAFETY AND EASE.

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