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

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1 THE TRAUMA SPECTRUM AND ITS CLINICAL IMPLICATIONS ROBERT SCAER, M. D
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 ENDORPHINS
VAGAL (PARASYMPATHETIC) TONE BIMODAL SYMPATHETIC / PARASYMPATHETIC CYCLING (ACCELERATOR / BRAKE ANALOGY)

4 LESSONS FROM THE WILD: THE CRITICAL IMPORTANCE OF DISCHARGING THE FREEZE RESPONSE
Gamekeeper’s story

5

6 FREEZE/IMMOBILIZATION AND SURVIVAL
BABY CHICKS NOT IMMOBILIZED IMMOBILIZED IMMOBILIZED SPONTANEOUS FORCED RECOVERY RECOVERY BEST INTERMEDIATE WORST DROWNING DROWNING DROWNING SURVIVAL SURVIVAL SURVIVAL Rats: swim for hours without drowning. Lab rats do better than wild. Wild rats may die during immobilization.

7 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!

8 CEREBRAL CORTEX HYPOTHALAMUS HPA AXIS ORBITOFRONTAL CORTEX SENSORY
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

9 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

10 MEMORY MECHANISMS IN TRAUMA
DECLARATIVE (EXPLICIT) MEM0RY - FACTS AND EVENTS NON-DECLARATIVE (IMPLICIT) MEMORY - EMOTIONAL ASSOCIATIONS - PROCEDURAL MEMORY -SKILLS AND HABITS - CONDITIONED SENSORIMOTOR RESPONSES Traumatic event/helplessness leads to freeze. Lack of freeze discharge implies lack of completion, events stored in procedural memory, link made between arousal, declarative and procedural memory through conditioned association.

11 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

12 TRAUMA AS A MODEL OF CONDITIONING AND PROCEDURAL 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!

13 KINDLING / NEUROSENSITIZATION
THE DEVELOPMENT OF 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?
DSM-III: “.. Outside the range of normal human experience, distressing to anyone.” DSM-IV: “Threat to life or physical integrity of self or others. Response: fear, helplessness or horror.” Therefore, a threat to life in the face of helplessness, and freeze/dissociation likely (helplessness, horror). What therefore constitutes a traumatic experience?

16 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 DSM-IV examples

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
Allen Schore: Affect Development and the Origin of the Self Maternal/infant dyad facilitates neuronal origin and development of the orbitofrontal cortex, the master regulator of the autonomic n.s. and the brain’s response to threat. Correlates with subsequent resiliency to stress/trauma Jim Grigsby: Neurodynamics of Personality Phenotypic (genetic) expression of neural inheritance relatively hard-wired, forms a template on which experience shapes neural networks. Experience creates behavioral attributes/personality/character. Procedural memory involved. Pathways mediating declarative learning & memory (hippocampus) not myelinated until months of life. Therefore, early resiliency to fear conditioning in trauma may be established through procedural learning in the first 6-12 months of life. WE need to explore concepts of unrecognized trauma.

21 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

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

24

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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 PEDIATRIC AND ADULT MEDICAL TRAUMA CULTURALLY ENDORSED TRAUMA “LITTLE TRAUMAS”

28 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

29 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

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

31 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

32 THE AMERICAN WAY OF BIRTHING
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 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 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

35 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

36 PEDIATRIC MEDICAL TRAUMA
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
- 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

38 ADULT MEDICAL TRAUMA AWAKENING UNDER ANESTHESIA * USUALLY UNDETECTED
* 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 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.

48 “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

49 TRAUMATIC REENACTMENT
SEXUALLY MOLESTED BOYS: INCREASED DRUG ABUSE, VIOLENCE AND CRIMINAL BEHAVIOR 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 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 SPOUSE / VICTIM BONDING KIDNAPPED VICTIM / CAPTOR BONDING 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” “THE COMPULSION TO REPEAT THE TRAUMA”

54 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

55 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

56 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

57 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

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

59 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


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