Understandin g the Biopsychosocial Impact of Trauma Brian Sims, M.D., NASMHPD Consultant Module created by Saxe, 2002
Longitudinal Course of PTSD Symptoms in Children with Bur ns 50 45 40 35 PTSD- -RI Score 30 25 20 15 10 5 0 Acute Assessment 3 Month Assessment Time Period
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 Institut te of fmedicine/national i i Academies National Research Council
Trauma in Ame erican Children 3 million children were suspec cted of being victims of abuse and/or neglect in 1998 (Mazelis, 1999) 3.9 million adolescents have be een victims of serious physical assault, and almost 9 million have witnessed an act of serious violence (Kilpatrick et al., 2001) In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood Each year between 3.5 and 10 million children witness the abuse of their mother up to hal lf are victims of abuse themselves (Edelson, 1999) (Acoca & Dedel,, 1998)
PTSD Rates 8 14% of PTSD rates in the general population and among certain disadvantaged groups may even be higher. (K Trauma victimizations studies show prevalence between 51 98% among persons with serious mental il lness (SMI) in the public sector. (Goodman et al., 1997; Muesar et al., 1998)) Kaplan et al., 1994; Kessler et al., 1995)
Effective Treatment t Must Account For: 1) A dysregulated nervous system 2) A social-environm ment that cannot contain this dysregul lation
Core Concepts of Development 1) The development of children unfolds along individual dvdu pat thways wyswose whose trajectories are characterized by continuities i i and disc continuities, i i as well as by a series of sign nificant 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 pers sons 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, nig ghtmares, or flashbacks that recollect traumatic images and memories Avoidance and emotional numbing Flattening of affect, de etachment fromothers, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience
Core Concepts of Development 2) The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains. (Shonkoff & Phillips, 2000)
22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained. State Change
State Change 12 year-old sexually abused girl in school when provoked by older male peer.
Parameters that ch hange between state Affect Thought Behavior Sense-o of-self Conscio ousness
Emotional States and Child Development Discrete behavioral states are a central organizing gexperience 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 t s/b between states Regulation of emotion is initially contingent on caregivers facilitating these transitions. (Wolff, 1987)
Goal of Treatment Maintain Calm/ /Continuous/ Engaged State Prevent Discontinuous States Build Cognitive Structures that allow choices
Between Stimulu us and Response Stimulus Response
Between Stimulu us and Response Traumatic Reminder Stimulus Response Socialenvironmental intervention Neuro- regulatory Intervention Traumatic State Interv vention
Between Stimulu us and Response Stimulus Traumatic Reminder COG GNITION!!! Response Traumatic State Socialenvironmental Intervention Neuro- regulatory Intervention Interv vention
Core Concepts of Development 3) Human development is shaped by a dynamic and continu uous interplay between biology and experience. (Shonkoff & Phillips, 2000)
Emotional Brain (Restak, 1988)
Between Stimulu us and Response S Stimulus (LeDoux, 1996)
Between Stimulu us and Response Sensory Thalamus S Stimulus (LeDoux, 1996)
Between Stimulu us and Response Very Fast Sensory Thalamus Amygdala S Stimulus (LeDoux, 1996)
Between Stimulu us and Response Corte ex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus (LeDoux, 1996)
Between Stimulu us and Response Corte ex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Between Stimulu us and Response Corte ex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Between Stimulu us and Response Corte ex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Between Stimulu us and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Between Stimulu us and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Between Stimulu us and Response Social Environmental Intervention Cortex Psychotherapy Neuroregulatory Intervention Hippocampus Slower Psychopharmacology Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)
Rauch Brain scans
Play (Panksepp, 1998)
Play and Fear (Panksepp, 1998)
Core Concepts of Development 4) Human relationships, and the effects of relationsh hips on relationships, are the building blocks of healthy development. (Shonkoff & Phillips, 2000)
Attach hment Earliest relationships critical ii lfor capacity to regulate state Neglectful and traumatic early relationships set up person to respond with state dysregulation to interper rsonal cues in subsequent relationships.
Attachment & Relational Deficits Appear guarded dd& anxious Difficult to re direct, reject support Highly emotionally reactive Hold on to grievances Do not take responsibility for behavior Make the same mista kes over and over Repetition compulsion / traumatic re enactment (Hodas, 2004)
Traumatic Relationships Emotions expressed in inte rpersonal relationships can be extremely painful and can be related to trauma experience These trauma-based emotions (e.g. anger, fear, hopelessness, sexual arousal) can be very hard for clinicians to tolerate Clinicians must be mindful about their experience of trauma-based emotion so that this emotion is not enacted in the clinical relationship.
Core Concepts of Development 5) Children are active participants in their own developme ent, reflecting the intrinsic human drive to explore and master one s environment. (Shonkoff & Phillips, 2000)
Traumatic Mastery Many children have primarily experien nced abusive and neglectful relationships Extreme behaviors within relationship ps can 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
Core Concepts of Development 6) The course of dev velopment can be altered by ed by effectiv ec einterventions that change the balance between risk and protection, thereby shifting i the odds in favor of more adapti ive outcomes. (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 e emotion. (LeDoux, 2002 ) To change the response, create new learning & skills: Analyze & adapt Buffer & bolster Teach, support, & build that cognitive wedge