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THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M.D. scaermdpc@msn.com www.traumasoma.com. THE ROOTS OF TRAUMA. A THREAT TO LIFE IN THE FACE OF HELPLESSNESS THE FIGHT /FLIGHT / FREEZE RESPONSE. THE FREEZE RESPONSE. NUMBING THROUGH ENDORPHINS VAGAL (PARASYMPATHETIC) TONE

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slide1
THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONSROBERT SCAER, M.D.scaermdpc@msn.comwww.traumasoma.com
the roots of trauma

THE ROOTS OF TRAUMA

A THREAT TO LIFE

IN THE FACE OF HELPLESSNESS

THE FIGHT /FLIGHT / FREEZE RESPONSE

the freeze response
THE FREEZE RESPONSE
  • NUMBING THROUGH ENDORPHINS
  • VAGAL (PARASYMPATHETIC) TONE
  • BIMODAL SYMPATHETIC /

PARASYMPATHETIC CYCLING

(ACCELERATOR / BRAKE

ANALOGY)

freeze immobilization and survival
FREEZE/IMMOBILIZATIONAND SURVIVAL

BABY CHICKS

NOT

IMMOBILIZED IMMOBILIZED IMMOBILIZED

SPONTANEOUS FORCED

RECOVERY RECOVERY

BEST INTERMEDIATE WORST

DROWNING DROWNING DROWNING

SURVIVAL SURVIVAL SURVIVAL

animals that do not discharge the freeze
ANIMALS THAT DO NOT DISCHARGE THE FREEZE
  • ZOO ANIMALS
  • LABORATORY ANIMALS
  • DOMESTIC ANIMALS
  • HUMAN ANIMALS

Q: WHAT DO THESE ANIMALS HAVE

IN COMMON?

A: THEY ALL LIVE IN A CAGE!

slide8

CEREBRAL CORTEX

HYPOTHALAMUS

HPA AXIS

ORBITOFRONTAL

CORTEX

ORGANIZES RESPONSE

TO THREAT

SENSORY

INPUT –

HEAD AND NECK

ANTERIOR

CINGULATE GYRUS

MODULATES

AMYGDALA

HIPPOCAMPUS

DECLARATIVE MEMORY

COGNITIVE MEANING

AMYGDALA

EMOTIONAL

CONTENT

LOCUS

CERULEUS

EARLY WARNING

endorphins in trauma
ENDORPHINS IN TRAUMA
  • RELEASED IN AROUSAL: STRESS INDUCED ANALGESIA (S.I.A.)

- INHIBITS MINISTERING TO WOUND, SELF-CARE, - ALLOWS CONTINUED FIGHT / FLIGHT BEHAVIOR

  • MEDIATES FREEZE RESPONSE

- ANALGESIA INHIBITS PAIN BEHAVIOR

- IMMOBILITY PROMOTES SURVIVAL

memory mechanisms in trauma
MEMORY MECHANISMS IN TRAUMA
  • DECLARATIVE (EXPLICIT) MEM0RY

- FACTS AND EVENTS

  • NON-DECLARATIVE (IMPLICIT)MEMORY

- EMOTIONAL ASSOCIATIONS

- PROCEDURAL MEMORY

-SKILLS AND HABITS

- CONDITIONED SENSORIMOTOR

RESPONSES

memory in trauma
MEMORY IN TRAUMA
  • TRAUMATIC STRESS: A LIFE THREAT WHILE IN A STATE OF HELPLESSNESS
  • THIS LEADS TO THE FREEZE RESPONSE
  • DISCHARGE OF THE FREEZE RESPONSE ALLOWS “COMPLETION” OF ESCAPE OR DEFENSE IN PROCEDURAL MEMORY, EXTINGUISHES CONDITIONED SOMATIC CUES
trauma as a model of conditioning and procedural memory
TRAUMA AS A MODEL OF CONDITIONING ANDPROCEDURAL MEMORY

A “CAPSULE” OF PROCEDURAL MEMORY CUES FOR:

- SOMATOSENSORY,

- EMOTIONAL,

- AND AUTONOMIC “FEELINGS”

- AND EMOTION-LINKED

DECLARATIVE MEMORY

ALL PERCEIVED AS BEING

IN THE PRESENT!

kindling neurosensitization

KINDLING / NEUROSENSITIZATION

THE DEVELOPMENT OF

SELF-PERPETUATING

NEURAL CIRCUITS

THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF A TRAUMA

personal experience
PERSONAL EXPERIENCE
  • MILITARY COMBAT
  • VIOLENT PERSONAL ATTACK
  • KIDNAPPING
  • HOSTAGE TAKING
  • TERRORIST ATTACK
  • INCARCERATION AS A POW
  • TORTURE
  • NATURAL OR MAN-MADE DISASTERS
  • SEVERE MOTOR VEHICLE ACCIDENTS
  • CHILDHOOD SEXUAL TRAUMA
slide17

WHY DO THE MAJORITY OF TRAUMA VICTIMS EXPOSED TO TRAUMA NOT DEVELOP PTSD?WHY DO SOME VICTIMS EXPOSED TO MINOR TRAUMATIC EVENTSDEVELOP PTSD?

resiliency vs vulnerability to trauma

RESILIENCY VS.VULNERABILITY TO TRAUMA

OUR PRIOR BURDEN

OF LIFE TRAUMA

CREATES AN ENVIRONMENT

OF VULNERABILITY TO

FURTHER TRAUMATIC EVENTS

slide19
THOSE LIFE EXPERIENCES MOST LIKELY TO REPRESENT TRAUMAHAVE MEANINGFOR SURVIVAL BASED ON PAST EXPERIENCE
the experience based development of the brain
THE EXPERIENCE-BASED DEVELOPMENT OF THE BRAIN
  • ALLAN SCHORE, 1996: AFFECT REGULATION AND THE ORIGIN OF THE SELF

* THE MATERNAL / INFANT DYAD:

FACE-TO-FACE ATTUNEMENT FACILITATES DEVELOPMENT OF THE RIGHT ORBITO-FRONTAL CORTEX, WHICH PROMOTES AUTONOMIC REGULATION, AND RESILIENCY TO SUBSEQUENT STRESS/TRAUMA

learned helplessness

LEARNED HELPLESSNESS

ONCE YOU FREEZE

YOU TEND TO

FREEZE / DISSOCIATE AGAIN!

the legacy of impaired attachment and developmental trauma

THE LEGACY OFIMPAIRED ATTACHMENT AND DEVELOPMENTAL TRAUMA:

A LIFETIME OF

AUTONOMIC

AND EMOTIONAL

DYSREGULATION

slide26
IF THE ABSENCE OFNURTURING IS TRAUMATIC STRESS,WHAT ARE WE MISSING HERE?THE UNRECOGNIZEDSOURCESOF TRAUMA
unrecognized sources of trauma
UNRECOGNIZED SOURCESOF TRAUMA
  • PREVERBAL TRAUMA
  • PEDIATRIC AND ADULT MEDICAL TRAUMA
  • CULTURALLY ENDORSED TRAUMA
  • “LITTLE TRAUMAS”
fetal sentience
FETAL SENTIENCE
  • CAPABLE OF CLASSICAL HABITUATION AND CONDITIONING
  • TACTILE, AUDITORY, OLFACTORY LEARNING
  • RECOGNITION LEARNING OF MUSIC/SOUNDS/VOICES/RHYMES
  • PLAY/AGGRESSION BEHAVIOR OF FETAL TWINS
intrauterine trauma
INTRAUTERINE TRAUMA
  • INCREASED FETAL PULSE / BP WITH MATERNAL AROUSAL
  • DEFENSIVE FETAL REACTIONS TO AMNIOCENTESIS
  • INCREASED FETAL ENDORPHINS AND CORTISOL WITH FETAL NEEDLING
  • LOW BIRTH WEIGHT WITH FREQUENT PRENATAL ULTRASOUND AND THIRD TRIMESTER MEDICATIONS
  • LOW BIRTH RATE WITH MATERNAL DISTRESS
the neonatal icu
THE NEONATAL ICU
  • TUBES: BREATHING, SUCTIONING, FEEDING
  • NOISE, BRIGHT LIGHTS, ISOLATION
  • PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / VENOUS PUNCTURES / CUTDOWNS
neonatal icu outcomes
NEONATAL ICU OUTCOMES
  • 283 PREMIES ASSESSED AT 30 MONTHS

* 19% SEVERELY DELAYED DEVELOPMENT

* 11% MODERATELY DELAYED

DEVELOPMENT

* 10 % SEVERE NEUROMOTOR DISABILITY

* 7 % BLIND

* 8 % SEVERE HEARING LOSS

* OVERALL, 49% WITH DISABILITY,

23% WITH SEVERE DISABILITY

the american way of birthing
THE AMERICAN WAY OF BIRTHING
  • THE OBSTETRICALDELIVERY ROOM

* INDUCTION

* FETAL MONITORING

* FORCEPS

* SUCTION DELIVERY

* C-SECTIONS

* NEONATAL SUCTIONING

* HEEL STICKS, EYE MEDS

* COLD, BRIGHT, NOISY ENVIRONMENT * SEPARATION / ISOLATION

the american way of birthing33
THE AMERICAN WAY OF BIRTHING
  • MATERNAL ANESTHESIA AND SLOW INFANT DEVELOPMENT
  • INCREASED RATE OF JUVENILE BEHAVIORAL PROBLEMS AND CRIMINAL VIOLENCE IN MALES WITH NON-BRAIN INJURY RELATED BIRTH COMPLICATIONS
pediatric medical trauma
PEDIATRIC MEDICAL TRAUMA
  • 1986 - PATENT DUCTUS SURGERY WITHOUT ANESTHESIA DISCONTINUED
  • 1988 - AMA : INFANTS CAN FEEL PAIN - RECOMMENDS SURGICAL ANESTHESIA
  • 1990’s - FIRST ANESTHESIA USED IN

PEDIATRIC ICU’S

  • 1997 – AMA: RECOMMENDS ANALGESIA

FOR CIRCUMCISION

  • PRESENT: ANALGESIA NEEDS OF PREMIES, NEONATES AND INFANTS ADDRESSED
pediatric medical trauma35
PEDIATRIC MEDICAL TRAUMA
  • PEDIATRIC E.R., ANESTHESIA, SURGERY AND HOSPITALIZATION

* ISOLATION AND PHYSICAL RESTRAINTS

* INADEQUATE PAIN MANAGEMENT

* ETHER ANESTHESIA

* IGNORAL AND ISOLATION FROM

CARE-GIVERS

* THE FEAR INSTILLED BY ISOLATION IN A TERRIFYING ENVIRONMENT

pediatric medical trauma36
PEDIATRIC MEDICAL TRAUMA
  • CIRCUMCISION

* CIRCUMCIZED MALES HAVE A GREATER PAIN RESPONSE TO SUBSEQUENT IMMUNIZATION SHOTS THAN NON-CIRCUMCIZED MALES

* USE OF EMLA CREAM EFFECTIVE

adult medical trauma
ADULT MEDICAL TRAUMA
  • THE SURGICAL THEATER

- SMELLS, SOUNDS, MASKED FACES, IGNORAL OF THE PATIENT, A STATE OF NAKED HELPLESSNESS

- PRE-OP ANXIETY AND POST-OP COMPLICATIONS

* INCREASED THIOPENTAL AND CIRCULATORY COLLAPSE

* POST-OP AGITATION

* POST-OP SOMATIC SX: SLEEP DISTURBANCE,

PERSISTENT PAIN, BOWEL COMPLAINTS

adult medical trauma38
ADULT MEDICAL TRAUMA
  • AWAKENING UNDER ANESTHESIA

* 30-35,000 CASES / YEAR IN U.S.

* USUALLY UNDETECTED

* OVERWHELMING HELPLESSNESS

* PTSD: MAJOR NIGHTMARES, FLASHBACKS, AROUSAL, PHOBIAS. VIVID DECLARATIVE MEMORY

* SOMATIC SX.: COMPARABLE TO WHIPLASH

* PARTIAL AWAKENING WITHOUT MEMORY MAY EXPLAIN POST-OP AGITATION AND UNEXPLAINED CHRONIC PAIN BASED ON PROCEDURAL MEMORY

government and the media
GOVERNMENT ANDTHE MEDIA
  • THE POLITICS OF FEAR: THE COLD WAR AND THE WAR ON TERROR
  • LESSONS FROM VIETNAM: IMAGES OF WARFARE
  • THE VISUAL MEDIA: IMAGES OF HORROR AND THE POWER OF TRAUMATIC REENACTMENT

- THE APPEAL OF C.S.I.

little traumas
“LITTLE TRAUMAS”
  • MOTOR VEHICLE ACCIDENTS
  • PARENTAL ALCOHOLISM AND MENTAL ILLNESS
  • RACIAL, GENDER AND JOB DISCRIMINATION
  • VIOLENCE IN THE MEDIA AND ENTERTAINMENT
  • BULLYING IN SCHOOLS
  • PERSONAL DEBT
  • THE INSURANCE INDUSTRY
  • THE LEGAL SYSTEM
traumatic reenactment
TRAUMATIC REENACTMENT
  • SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE,

VIOLENCE AND CRIMINAL

BEHAVIOR

  • 14 JUVENILES CONDEMNED TO DEATH:

12 PHYSICALLY ABUSED, 5 SODOMIZED

traumatic reenactment50
TRAUMATIC REENACTMENT
  • CHILDHOOD SEXUAL ABUSE: HIGHER ADULT INCIDENCE OF RAPE, SPOUSAL ABUSE, PROSTITUTION, POSING FOR PORNOGRAPHY
  • SELF MUTILATION: CHILDHOOD HISTORY OF PHYSICAL AND SEXUAL ABUSE, MULTIPLE

SURGICAL PROCEDURES

traumatic attachment
TRAUMATIC ATTACHMENT
  • ABUSIVE PARENT / CHILD BONDING
  • ABUSIVE SPOUSE / VICTIM BONDING
  • KIDNAPPED VICTIM / CAPTOR BONDING
  • WE SEEK THE NEGATIVE CHARACTERISTICS OF OUR CAREGIVERS IN OUR MATES
endorphins and traumatic reenactment
ENDORPHINS AND TRAUMATIC REENACTMENT
  • VICTIMS OF TRAUMA SEEK REEXPOSURE TO SITUATIONS SIMILAR TO OLD TRAUMA TO ACHIEVE ENDORPHIN RELEASE, AS WELL AS “COMPLETION”

“THE COMPULSION TO REPEAT THE TRAUMA”

enorphins and traumatic reenactment
ENORPHINS AND TRAUMATIC REENACTMENT
  • ENDORPHINS MEDIATE HUMAN ATTACHMENT AND BONDING
  • LOSS OF MATERNAL BONDING AND SOCIAL SUPPORT:

* DECREASED ANTERIOR CINGULATE OPIATE RECEPTORS (THE CINGULATE INHIBITS FEAR CONDITIONING)

* SEEKING ENDORPHINS THROUGH

TRAUMATIC REENACTMENT

endorphins and traumatic reenactment55
ENDORPHINS AND TRAUMATIC REENACTMENT
  • SELF-MUTILATION, SELF-STARVING: INCREASED OPOIDS, WITH

RELIEF FROM AROUSAL

  • REWARDS OF POST-TRAUMATIC REUNION AFTER ABUSE
  • REWARD SYSTEMS IN EXTREME SPORTS AND ENDURANCE ATHLETICS
endurance and extreme sports
ENDURANCE AND EXTREME SPORTS
  • ? HIGHER INCIDENCE OF CHILDHOOD TRAUMA IN HIGH ENDURANCE SPORTS ATHLETES
  • RESTORATION OF DEPRESSED ENDORPHIN LEVELS THROUGH EXTREME EFFORT
  • “FEARLESS”: TRAUMATIC REENACTMENT THROUGH

RISK-TAKING

gender issues in trauma
GENDER ISSUES IN TRAUMA
  • DISSOCIATION AT THE TIME OF TRAUMA A MAJOR PREDICTOR OF PTSD
  • INCIDENCE OF DISSOCIATION AND PTSD MUCH HIGHER IN WOMEN (3:1)
  • PERRY: ANTHROPOLOGICAL IMPLICATIONS OF THE FREEZE RESPONSE
  • A MODEL FOR VIOLENCE IN MALES
  • ENDORPHIN HABITUATION AND KINDLING
reenactment in daily life
REENACTMENTIN DAILY LIFE
  • MATURATIONAL ARREST IN TRAUMA
  • OUR CHOICE OF MATES
  • OUR CHOICE OF CAREERS
  • OUR CHOICE OF RECREATION
  • OUR CHOICE OF SUBSTANCES
conclusions

CONCLUSIONS

MANY NEGATIVE LIFE EVENTS, IF EXPERIENCED IN A STATE OF HELPLESSNESS ASSUME THE DEFINITION OF TRAUMA

SUCH EXPERIENCES MAY BE CULTURALLY DETERMINED, AND CONSIDERED TO BE “NORMAL”

INEXPLICABLE BEHAVIOR MAY REFLECT UNCONSCIOUS RECAPITULATION OF PRIOR TRAUMA