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

Trauma

Janine M. D’Anniballe, Ph.D. Children’s Roundtable Summit Seven Springs, PA

The Stress-Trauma Continuum

Normal Situational Traumatic

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

Trauma and Culture

Cultural/Gender differences in the perception and expression of trauma

Historical trauma Forms of traumatic injury

Psychological Spiritual Brain/Body

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

The Neurobiology of Trauma

Trauma is not purely a psychological issueThe past becomes present because of the way that the brain dysregulates and changes after traumatic eventsWhat fires together wires togetherTrauma “echoes” in the brain – and treatment needs to quiet the reverberations of the echo

Nucleus

Dendrites

Axon

Neurobiology of Trauma

Synaptic Activity

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 body’s immune functioning

Opiods – prevent pain, inhibit memory consolidation Oxytocin – inhibits memory consolidation, promotes good

feelings These chemicals are POWERFUL substances ….

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 aren’t regulated

Opiod levels increase (equivalent to 8 mg of morphine); flat affect

Oxytocin increased– memory impaired; bonding to perp

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.

Structures of the Brain: The Limbic System

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

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).

The Adolescent Brain and Trauma

Cortex still developing until mid-20’s 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

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

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.

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

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

Hippocampal Volume Reduction in PTSD

NORMAL PTSDMRI 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; 152:973-981; Bremner et al., Biol. Psychiatry 1997; 41:23-32;

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

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 don’t have developed PFC

Successful SSRI treatment restored PFC activation patterns

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”

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

Traumatic Memory

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

Sensory Thalamus

When Amygdala is highly activated, it interferes with Hippocampus functioning

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).

Self-Harming Behavior

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

Why do people self-injure?

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)

Fight, Flight, or Freeze

A lesson from Jakey Cat

Jakey Cat (RIP)

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

If you don’t 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

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

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?

Symptoms of Vicarious Trauma

Feel very emotional during/after a session or meeting

Difficulty sleeping Nightmares Vivid mental replaying of client’s trauma Revenge fantasies Lack of interest in sex or romance Numbing, flat affect, loss of humor or warmth

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

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

Common Pejorative Language Used When Working with Trauma Survivors

“She’s manipulative.”

“She’s a multiple.”

“He’s crazy.”

“She’s a cutter.”

“He’s a train wreck.”

“She’s Borderline.”

Implications, Reactions, Alternatives

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

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

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

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

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.

Increased Hippocampal Volume With Paxil in PTSD

1180

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Left Hippocampus Right Hippocampus

Hip

poca

mpa

l Vol

ume

(mm

-3) Baseline

Post-treatment

Effects of 9-12 months of treatment with 10-40 mg paroxetine.(Vermetten et al. Biol Psychiatry, 2003)

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. “

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

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

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

Three Quick Ways to Activate the Parasympathic System

Breathing – particularly the exhale Mindfulness practice Relaxing the pelvic muscles:

1) While sitting, put hands under the buttocks and find the sits bones

2) Touch the two bony points just below the waist on your right and left side

3) Visualize a square; breathe into the square to expand that area; release and relax all muscles there

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

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)

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

YogaTrauma = split between mind and body

Yoga = unifying mind and body Yoga increases heart rate

variability (HRV); an indicator of the body’s 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)

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

Exercise:

Rebalances melatonin; enhances sleep cycle Releases endorphins (endogenous opioids) Promotes tryptophan which enhances mood;

precursor to serotonin

Sleep, Rest, and Relaxation

Sleep deprivation keeps nervous system on high-alert; cortisol is elevated

Serotonin and dopamine rise when sleeping, resting

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

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.

Strategies to Reduce Trauma in the Courtroom

Physical Environment

Be child and family friendly

Allegheny County CourtroomChester County Courtroom

Strategies to Reduce Trauma in the Courtroom

Physical Environment

Be creative

Dogs in Court, Bucks County Pennsylvania

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

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

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

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

Strategies for Reducing Trauma for Professionals

Reduce fear of the unknown End the week on a positive

note Find support from colleagues Keep perspective

Thank you for all that you do for your

community!

Contact Information:

Janine M. D’Anniballe, Ph.D.jdanniballe@gmail.com

www.janinedanniballe.com