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THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M.D.

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Presentation on theme: "THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M.D."— Presentation transcript:

1 THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M.D.

2 THE ROOTS OF TRAUMA A THREAT TO LIFE IN THE FACE OF HELPLESSNESS THE FIGHT /FLIGHT / FREEZE RESPONSE

3 THE FREEZE RESPONSE NUMBING THROUGH ENDORPHINSNUMBING THROUGH ENDORPHINS VAGAL (PARASYMPATHETIC) TONEVAGAL (PARASYMPATHETIC) TONE BIMODAL SYMPATHETIC /BIMODAL SYMPATHETIC / PARASYMPATHETIC CYCLING (ACCELERATOR / BRAKE ANALOGY)

4 LESSONS FROM THE WILD: THE CRITICAL IMPORTANCE OF DISCHARGING THE FREEZE RESPONSE

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6 FREEZE/IMMOBILIZATION AND SURVIVAL BABY CHICKS BABY CHICKS NOT NOT IMMOBILIZED IMMOBILIZED IMMOBILIZED SPONTANEOUS FORCED RECOVERY RECOVERY RECOVERY RECOVERY BEST INTERMEDIATE WORST BEST INTERMEDIATE WORST DROWNING DROWNING DROWNING SURVIVAL SURVIVAL SURVIVAL SURVIVAL SURVIVAL SURVIVAL

7 ANIMALS THAT DO NOT DISCHARGE THE FREEZE ZOO ANIMALSZOO ANIMALS LABORATORY ANIMALSLABORATORY ANIMALS DOMESTIC ANIMALSDOMESTIC ANIMALS HUMAN ANIMALSHUMAN ANIMALS Q: WHAT DO THESE ANIMALS HAVE IN COMMON? A: THEY ALL LIVE IN A CAGE!

8 SENSORY INPUT – HEAD AND NECK AMYGDALA EMOTIONAL CONTENT ANTERIOR CINGULATE GYRUS MODULATES AMYGDALA CEREBRAL CORTEX HYPOTHALAMUS HPA AXIS HIPPOCAMPUS DECLARATIVE MEMORY COGNITIVE MEANING ORBITOFRONTAL CORTEX ORGANIZES RESPONSE TO THREAT LOCUS CERULEUS EARLY WARNING

9 ENDORPHINS IN TRAUMA RELEASED IN AROUSAL: STRESS INDUCED ANALGESIA (S.I.A.)RELEASED IN AROUSAL: STRESS INDUCED ANALGESIA (S.I.A.) - INHIBITS MINISTERING TO WOUND, SELF-CARE, - ALLOWS CONTINUED FIGHT / FLIGHT BEHAVIOR MEDIATES FREEZE RESPONSEMEDIATES FREEZE RESPONSE - ANALGESIA INHIBITS PAIN BEHAVIOR - IMMOBILITY PROMOTES SURVIVAL

10 MEMORY MECHANISMS IN TRAUMA DECLARATIVE (EXPLICIT) MEM0RYDECLARATIVE (EXPLICIT) MEM0RY - FACTS AND EVENTS NON-DECLARATIVE (IMPLICIT) MEMORYNON-DECLARATIVE (IMPLICIT) MEMORY - EMOTIONAL ASSOCIATIONS - PROCEDURAL MEMORY -SKILLS AND HABITS - CONDITIONED SENSORIMOTOR RESPONSES

11 MEMORY IN TRAUMA TRAUMATIC STRESS: A LIFE THREAT WHILE IN A STATE OF HELPLESSNESSTRAUMATIC STRESS: A LIFE THREAT WHILE IN A STATE OF HELPLESSNESS THIS LEADS TO THE FREEZE RESPONSETHIS LEADS TO THE FREEZE RESPONSE DISCHARGE OF THE FREEZE RESPONSE ALLOWS “COMPLETION” OF ESCAPE OR DEFENSE IN PROCEDURAL MEMORY, EXTINGUISHES CONDITIONED SOMATIC CUESDISCHARGE OF THE FREEZE RESPONSE ALLOWS “COMPLETION” OF ESCAPE OR DEFENSE IN PROCEDURAL MEMORY, EXTINGUISHES CONDITIONED SOMATIC CUES

12 TRAUMA AS A MODEL OF CONDITIONING AND PROCEDURAL MEMORY A “CAPSULE” OF PROCEDURAL MEMORY CUES FOR: - SOMATOSENSORY, - EMOTIONAL, - EMOTIONAL, - AND AUTONOMIC “FEELINGS” - AND EMOTION-LINKED DECLARATIVE MEMORY DECLARATIVE MEMORY ALL PERCEIVED AS BEING IN THE PRESENT!

13 KINDLING / NEUROSENSITIZATION THE DEVELOPMENT OF SELF-PERPETUATING SELF-PERPETUATING NEURAL CIRCUITS THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF A TRAUMA

14 DISSOCIATION : THE PERCEPTUAL EXPERIENCE OF THE FREEZE RESPONSE?

15 WHAT LIFE EVENTS CONSTITUTE A TRAUMATIC EXPERIENCE?

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

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

18 RESILIENCY VS. VULNERABILITY TO TRAUMA OUR PRIOR BURDEN OF LIFE TRAUMA CREATES AN ENVIRONMENT OF VULNERABILITY TO FURTHER TRAUMATIC EVENTS

19 THOSE LIFE EXPERIENCES MOST LIKELY TO REPRESENT TRAUMA HAVE MEANING FOR SURVIVAL BASED ON PAST EXPERIENCE

20 THE ROLE OF DEVELOPMENTAL NEUROBIOLOGY IN RESILIENCE TO TRAUMA

21 THE EXPERIENCE-BASED DEVELOPMENT OF THE BRAIN ALLAN SCHORE, 1996: AFFECT REGULATION AND THE ORIGIN OF THE SELF 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

22 LEARNED HELPLESSNESS ONCE YOU FREEZE YOU TEND TO FREEZE / DISSOCIATE AGAIN!

23 THE LEGACY OF IMPAIRED ATTACHMENT AND DEVELOPMENTAL TRAUMA: A LIFETIME OF AUTONOMIC AND EMOTIONAL DYSREGULATION

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26 IF THE ABSENCE OFNURTURING IS TRAUMATIC STRESS, WHAT ARE WE MISSING HERE? THE UNRECOGNIZED SOURCES OF TRAUMA

27 UNRECOGNIZED SOURCES OF TRAUMA PREVERBAL TRAUMA PREVERBAL TRAUMA PEDIATRIC AND ADULT MEDICAL TRAUMA PEDIATRIC AND ADULT MEDICAL TRAUMA CULTURALLY ENDORSED TRAUMA CULTURALLY ENDORSED TRAUMA “LITTLE TRAUMAS” “LITTLE TRAUMAS”

28 FETAL SENTIENCE CAPABLE OF CLASSICAL HABITUATION AND CONDITIONING CAPABLE OF CLASSICAL HABITUATION AND CONDITIONING TACTILE, AUDITORY, OLFACTORY LEARNING TACTILE, AUDITORY, OLFACTORY LEARNING RECOGNITION LEARNING OF MUSIC/SOUNDS/VOICES/RHYMES RECOGNITION LEARNING OF MUSIC/SOUNDS/VOICES/RHYMES PLAY/AGGRESSION BEHAVIOR OF FETAL TWINS PLAY/AGGRESSION BEHAVIOR OF FETAL TWINS

29 INTRAUTERINE TRAUMA INCREASED FETAL PULSE / BP WITH MATERNAL AROUSAL INCREASED FETAL PULSE / BP WITH MATERNAL AROUSAL DEFENSIVE FETAL REACTIONS TO AMNIOCENTESIS DEFENSIVE FETAL REACTIONS TO AMNIOCENTESIS INCREASED FETAL ENDORPHINS AND CORTISOL WITH FETAL NEEDLING INCREASED FETAL ENDORPHINS AND CORTISOL WITH FETAL NEEDLING LOW BIRTH WEIGHT WITH FREQUENT PRENATAL ULTRASOUND AND THIRD TRIMESTER MEDICATIONS LOW BIRTH WEIGHT WITH FREQUENT PRENATAL ULTRASOUND AND THIRD TRIMESTER MEDICATIONS LOW BIRTH RATE WITH MATERNAL DISTRESS LOW BIRTH RATE WITH MATERNAL DISTRESS

30 THE NEONATAL ICU TUBES: BREATHING, SUCTIONING, FEEDING TUBES: BREATHING, SUCTIONING, FEEDING NOISE, BRIGHT LIGHTS, ISOLATION NOISE, BRIGHT LIGHTS, ISOLATION PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / VENOUS PUNCTURES / CUTDOWNS PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / VENOUS PUNCTURES / CUTDOWNS

31 NEONATAL ICU OUTCOMES 283 PREMIES ASSESSED AT 30 MONTHS 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

32 THE AMERICAN WAY OF BIRTHING THE OBSTETRICAL DELIVERY ROOM THE OBSTETRICAL DELIVERY ROOM * INDUCTION * FETAL MONITORING * FORCEPS * SUCTION DELIVERY * C-SECTIONS * NEONATAL SUCTIONING * HEEL STICKS, EYE MEDS * COLD, BRIGHT, NOISY ENVIRONMENT * SEPARATION / ISOLATION

33 THE AMERICAN WAY OF BIRTHING MATERNAL ANESTHESIA AND SLOW INFANT DEVELOPMENT MATERNAL ANESTHESIA AND SLOW INFANT DEVELOPMENT INCREASED RATE OF JUVENILE BEHAVIORAL PROBLEMS AND CRIMINAL VIOLENCE IN MALES WITH NON-BRAIN INJURY RELATED BIRTH COMPLICATIONS INCREASED RATE OF JUVENILE BEHAVIORAL PROBLEMS AND CRIMINAL VIOLENCE IN MALES WITH NON-BRAIN INJURY RELATED BIRTH COMPLICATIONS

34 PEDIATRIC MEDICAL TRAUMA PATENT DUCTUS SURGERY WITHOUT ANESTHESIA DISCONTINUED PATENT DUCTUS SURGERY WITHOUT ANESTHESIA DISCONTINUED AMA : INFANTS CAN FEEL PAIN - RECOMMENDS SURGICAL ANESTHESIA AMA : INFANTS CAN FEEL PAIN - RECOMMENDS SURGICAL ANESTHESIA 1990’s - FIRST ANESTHESIA USED IN 1990’s - FIRST ANESTHESIA USED IN PEDIATRIC ICU’S 1997 – AMA: RECOMMENDS ANALGESIA 1997 – AMA: RECOMMENDS ANALGESIA FOR CIRCUMCISION PRESENT: ANALGESIA NEEDS OF PREMIES, NEONATES AND INFANTS ADDRESSED PRESENT: ANALGESIA NEEDS OF PREMIES, NEONATES AND INFANTS ADDRESSED

35 PEDIATRIC MEDICAL TRAUMA PEDIATRIC MEDICAL TRAUMA PEDIATRIC E.R., ANESTHESIA, SURGERY AND HOSPITALIZATION 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

36 PEDIATRIC MEDICAL TRAUMA PEDIATRIC MEDICAL TRAUMA CIRCUMCISION CIRCUMCISION * CIRCUMCIZED MALES HAVE A GREATER PAIN RESPONSE TO SUBSEQUENT IMMUNIZATION SHOTS THAN NON-CIRCUMCIZED MALES * USE OF EMLA CREAM EFFECTIVE

37 ADULT MEDICAL TRAUMA THE SURGICAL THEATER 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 * INCREASED THIOPENTAL AND CIRCULATORY COLLAPSE * POST-OP AGITATION * POST-OP SOMATIC SX: SLEEP DISTURBANCE, PERSISTENT PAIN, BOWEL COMPLAINTS

38 ADULT MEDICAL TRAUMA AWAKENING UNDER ANESTHESIA 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

39 MEDICAL TECHNOLOGY: TRAUMA BY THE CAREGIVER

40 “I CAN’T FIND ANYTHING WRONG, BUT WE’D PROBABLY BETTER GET AN MRI”

41 ORDERING TESTS TO AVOID MEDICAL / LEGAL LIABILITY

42 NEW TECHNOLOGY AND THE TRAP OF THE “UNEXPLAINED” ABNORMALITY

43 THE INFALLIBILITY OF TECHNOLOGY AND “EFFORT AFTER MEANING”

44 REJECTION OF THE PATIENT IF THE TESTS ARE NORMAL: “ IT MUST BE PSYCHOLOGICAL”

45 THE DILEMMA OF AN IMPERFECT SCIENCE

46 THE INSIDIOUS REINFORCEMENT OF THE FEAR OF ILLNESS BY THE MEDIA AND PHARMACEUTICAL INDUSTRY

47 GOVERNMENT AND THE MEDIA THE POLITICS OF FEAR: THE COLD WAR AND THE WAR ON TERRORTHE POLITICS OF FEAR: THE COLD WAR AND THE WAR ON TERROR LESSONS FROM VIETNAM: IMAGES OF WARFARELESSONS FROM VIETNAM: IMAGES OF WARFARE THE VISUAL MEDIA: IMAGES OF HORROR AND THE POWER OF TRAUMATIC REENACTMENTTHE VISUAL MEDIA: IMAGES OF HORROR AND THE POWER OF TRAUMATIC REENACTMENT - THE APPEAL OF C.S.I. - THE APPEAL OF C.S.I.

48 “LITTLE TRAUMAS” MOTOR VEHICLE ACCIDENTS MOTOR VEHICLE ACCIDENTS PARENTAL ALCOHOLISM AND MENTAL ILLNESS PARENTAL ALCOHOLISM AND MENTAL ILLNESS RACIAL, GENDER AND JOB DISCRIMINATION RACIAL, GENDER AND JOB DISCRIMINATION VIOLENCE IN THE MEDIA AND ENTERTAINMENT VIOLENCE IN THE MEDIA AND ENTERTAINMENT BULLYING IN SCHOOLS BULLYING IN SCHOOLS PERSONAL DEBT PERSONAL DEBT THE INSURANCE INDUSTRY THE INSURANCE INDUSTRY THE LEGAL SYSTEM THE LEGAL SYSTEM

49 TRAUMATIC REENACTMENT SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE, SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE, VIOLENCE AND CRIMINAL BEHAVIOR 14 JUVENILES CONDEMNED TO DEATH: 14 JUVENILES CONDEMNED TO DEATH: 12 PHYSICALLY ABUSED, 5 SODOMIZED

50 TRAUMATIC REENACTMENT CHILDHOOD SEXUAL ABUSE: HIGHER ADULT INCIDENCE OF RAPE, SPOUSAL ABUSE, PROSTITUTION, POSING FOR PORNOGRAPHY CHILDHOOD SEXUAL ABUSE: HIGHER ADULT INCIDENCE OF RAPE, SPOUSAL ABUSE, PROSTITUTION, POSING FOR PORNOGRAPHY SELF MUTILATION: CHILDHOOD HISTORY OF PHYSICAL AND SEXUAL ABUSE, MULTIPLE SELF MUTILATION: CHILDHOOD HISTORY OF PHYSICAL AND SEXUAL ABUSE, MULTIPLE SURGICAL PROCEDURES

51 REEXPERIENCING AND THE ANNIVERSARY SYNDROME

52 TRAUMATIC ATTACHMENT ABUSIVE PARENT / CHILD BONDING ABUSIVE PARENT / CHILD BONDING ABUSIVE SPOUSE / VICTIM BONDING ABUSIVE SPOUSE / VICTIM BONDING KIDNAPPED VICTIM / CAPTOR BONDING KIDNAPPED VICTIM / CAPTOR BONDING WE SEEK THE NEGATIVE CHARACTERISTICS OF OUR CAREGIVERS IN OUR MATES WE SEEK THE NEGATIVE CHARACTERISTICS OF OUR CAREGIVERS IN OUR MATES

53 ENDORPHINS AND TRAUMATIC REENACTMENT VICTIMS OF TRAUMA SEEK REEXPOSURE TO SITUATIONS SIMILAR TO OLD TRAUMA TO ACHIEVE ENDORPHIN RELEASE, AS WELL AS “COMPLETION” 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”

54 ENORPHINS AND TRAUMATIC REENACTMENT ENDORPHINS MEDIATE HUMAN ATTACHMENT AND BONDING ENDORPHINS MEDIATE HUMAN ATTACHMENT AND BONDING LOSS OF MATERNAL BONDING AND SOCIAL SUPPORT: LOSS OF MATERNAL BONDING AND SOCIAL SUPPORT: * DECREASED ANTERIOR CINGULATE OPIATE RECEPTORS (THE CINGULATE INHIBITS FEAR CONDITIONING) * SEEKING ENDORPHINS THROUGH TRAUMATIC REENACTMENT

55 ENDORPHINS AND TRAUMATIC REENACTMENT SELF-MUTILATION, SELF-STARVING: INCREASED OPOIDS, WITH SELF-MUTILATION, SELF-STARVING: INCREASED OPOIDS, WITH RELIEF FROM AROUSAL RELIEF FROM AROUSAL REWARDS OF POST-TRAUMATIC REUNION AFTER ABUSE REWARDS OF POST-TRAUMATIC REUNION AFTER ABUSE REWARD SYSTEMS IN EXTREME SPORTS AND ENDURANCE ATHLETICS REWARD SYSTEMS IN EXTREME SPORTS AND ENDURANCE ATHLETICS

56 ENDURANCE AND EXTREME SPORTS ? HIGHER INCIDENCE OF CHILDHOOD TRAUMA IN HIGH ENDURANCE SPORTS ATHLETES? HIGHER INCIDENCE OF CHILDHOOD TRAUMA IN HIGH ENDURANCE SPORTS ATHLETES RESTORATION OF DEPRESSED ENDORPHIN LEVELS THROUGH EXTREME EFFORTRESTORATION OF DEPRESSED ENDORPHIN LEVELS THROUGH EXTREME EFFORT “FEARLESS”: TRAUMATIC REENACTMENT THROUGH“FEARLESS”: TRAUMATIC REENACTMENT THROUGHRISK-TAKING

57 GENDER ISSUES IN TRAUMA DISSOCIATION AT THE TIME OF TRAUMA A MAJOR PREDICTOR OF PTSD DISSOCIATION AT THE TIME OF TRAUMA A MAJOR PREDICTOR OF PTSD INCIDENCE OF DISSOCIATION AND PTSD MUCH HIGHER IN WOMEN (3:1) INCIDENCE OF DISSOCIATION AND PTSD MUCH HIGHER IN WOMEN (3:1) PERRY: ANTHROPOLOGICAL IMPLICATIONS OF THE FREEZE RESPONSE PERRY: ANTHROPOLOGICAL IMPLICATIONS OF THE FREEZE RESPONSE A MODEL FOR VIOLENCE IN MALES A MODEL FOR VIOLENCE IN MALES ENDORPHIN HABITUATION AND KINDLING ENDORPHIN HABITUATION AND KINDLING

58 REENACTMENT IN DAILY LIFE MATURATIONAL ARREST IN TRAUMA MATURATIONAL ARREST IN TRAUMA OUR CHOICE OF MATES OUR CHOICE OF MATES OUR CHOICE OF CAREERS OUR CHOICE OF CAREERS OUR CHOICE OF RECREATION OUR CHOICE OF RECREATION OUR CHOICE OF SUBSTANCES OUR CHOICE OF SUBSTANCES

59 CONCLUSIONS MANY NEGATIVE LIFE EVENTS, IF EXPERIENCED IN A STATE OF HELPLESSNESS ASSUME THE DEFINITION OF TRAUMA 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” SUCH EXPERIENCES MAY BE CULTURALLY DETERMINED, AND CONSIDERED TO BE “NORMAL” INEXPLICABLE BEHAVIOR MAY REFLECT UNCONSCIOUS RECAPITULATION OF PRIOR TRAUMA INEXPLICABLE BEHAVIOR MAY REFLECT UNCONSCIOUS RECAPITULATION OF PRIOR TRAUMA


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