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Treating Traumatized Individuals: Neurobiological & Psychological Effects of Trauma Module created by Glenn Saxe, MD Module created by Glenn Saxe, MD.

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Presentation on theme: "Treating Traumatized Individuals: Neurobiological & Psychological Effects of Trauma Module created by Glenn Saxe, MD Module created by Glenn Saxe, MD."— Presentation transcript:

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2 Treating Traumatized Individuals: Neurobiological & Psychological Effects of Trauma Module created by Glenn Saxe, MD Module created by Glenn Saxe, MD Adapted by the NYS Office of Mental Health

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4 Time Period PTSD-RI Score Acute Assessment 3 Month Assessment 0 Longitudinal Course of PTSD Symptoms in Children with Burns Got Better Got Worse

5 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)

6 From Neurons to Neighborhoods: The Science of Early Child Development Report from the Institute of Medicine/National Academies National Research Council

7 Trauma in U.S.A. 3 million children were suspected of being victims of abuse and/or neglect (Mazelis, 1999) 3.9 million adolescents have been 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 (Acoca & Dedel, 1998)

8 PTSD in U.S.A. Over 50% of U.S. women & 60% of men report experiencing at least 1 traumatic event at some point in their lives. But only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events. (Koenen, 2005; Kessler et al, 1995) More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders. (Solomon & Davidson, 1997) For more than 1/3 with PTSD, it will be a persistent condition and experienced for several years (Solomon & Davidson, 1997) Over 50% of U.S. women & 60% of men report experiencing at least 1 traumatic event at some point in their lives. But only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events. (Koenen, 2005; Kessler et al, 1995) More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders. (Solomon & Davidson, 1997) For more than 1/3 with PTSD, it will be a persistent condition and experienced for several years (Solomon & Davidson, 1997)

9 Effective Treatment Must Account For: 1) A dysregulated nervous system 2) A social environment that cannot contain this dysregulation

10 Core Concepts of Development Developmental Principle 1: The development of children unfolds along individual pathways whose trajectories are characterized by continuities and discontinuities, as well as by a series of significant transitions. (Shonkoff & Phillips, 2000)

11 Time Period PTSD-RI Score Acute Assessment 3 Month Assessment 0 Longitudinal Course of PTSD Symptoms in Children with Burns

12 PTSD Definition The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another person’s experience of: Actual or threatened death Actual or threatened death Actual or threatened serious injury Actual or threatened serious injury Threat to physical integrity Threat to physical integrity

13 Post Traumatic Stress Disorder Characterized by: Re-experiencing the event Re-experiencing the event Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories Avoidance and emotional numbing Avoidance and emotional numbing Flattening of affect, detachment from others, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience Flattening of affect, detachment from others, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience

14 Core Concepts of Development Developmental Principle 2: The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains. (Shonkoff & Phillips, 2000)

15 State Change 22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained.

16 State Change 12 year-old sexually abused girl in school when provoked by older male peer.

17 Parameters that change between states AffectAffect ThoughtThought BehaviorBehavior Sense-of-selfSense-of-self ConsciousnessConsciousness

18 Emotional States and Child Development Discrete behavioral states are a central organizing experience of infancy Infants’ experiential world is divided into separate and definable emotional/behavioral states A c ritical task of early child development is to build smooth transitions/bridges between states Regulation of emotion is initially contingent on caregivers facilitating these transitions. (Wolff, 1987) Discrete behavioral states are a central organizing experience of infancy Infants’ experiential world is divided into separate and definable emotional/behavioral states A c ritical task of early child development is to build smooth transitions/bridges between states Regulation of emotion is initially contingent on caregivers facilitating these transitions. (Wolff, 1987)

19 Goal of Treatment Maintain Calm/Continuous/ Maintain Calm/Continuous/ Engaged State Prevent Discontinuous States Prevent Discontinuous States Build Cognitive Structures Build Cognitive Structures that allow Choices

20 Between Stimulus and Response Response Stimulus

21 Response Stimulus Traumatic Reminder Traumatic State Intervention Social- environmental intervention Neuro- regulatory Intervention

22 Between Stimulus and Response Response Stimulus Traumatic Reminder Traumatic State Intervention Social- environmental Intervention Neuro- regulatory Intervention COGNITION!!!

23 Core Concepts of Development Developmental Principle 3: Human development is shaped by a dynamic and continuous interplay between biology and experience. (Shonkoff & Phillips, 2000)

24 Emotional Brain (Restak, 1988)

25 Between Stimulus and Response Stimulus (LeDoux, 1996)

26 Between Stimulus and Response Stimulus Sensory Thalamus (LeDoux, 1996)

27 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast (LeDoux, 1996 (LeDoux, 1996)

28 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Cortex Very Fast Slower Hippocampus (LeDoux, 1996)

29 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Cortex Very Fast Slower Hippocampus Response (LeDoux, 1996)

30 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Cortex Very Fast Slower Hippocampus Response (LeDoux, 1996)

31 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Cortex Very Fast Slower Hippocampus Response (LeDoux, 1996)

32 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast Slower Hippocampus Response Cortex (LeDoux, 1996 (LeDoux, 1996)

33 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast Slower Response Cortex Hippocampus (LeDoux, 1996)

34 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast Slower Response Cortex Hippocampus Neuroregulatory Intervention Psychotherapy Psychopharmacology Social Environmental Intervention (LeDoux, 1996)

35 Rauch Brain scans

36 Play (Panksepp, 1998)

37 Play and Fear (Panksepp, 1998)

38 Social-Ecological Model Peer Group School Neighborhood Culture Family Individual

39 Core Concepts of Development 4) Human relationships, and the effects of relationships on relationships, are the building blocks of healthy development. (Shonkoff & Phillips, 2000)

40 ShapingShaping Over time consistently working with the recipient to understand what needs to be learned. Over time consistently working with the recipient to understand what needs to be learned. Giving frequent positive feedback as to how the recipient is doing. Giving frequent positive feedback as to how the recipient is doing. Praising the recipient for successes. Praising the recipient for successes.

41 Shaping Exercise

42 Attachment Earliest relationships are critical for the capacity to regulate one’s state Early traumatic relationships set up the person to respond with a state of dysregulation to interpersonal cues in subsequent relationships Earliest relationships are critical for the capacity to regulate one’s state Early traumatic relationships set up the person to respond with a state of dysregulation to interpersonal cues in subsequent relationships

43 Attachment & Relational Deficits Appears guarded & anxious Is difficult to re-direct, rejects support Highly emotionally reactive Holds on to grievances Does not take responsibility for behavior Makes the same mistakes over and over Demonstrates repetition compulsion / traumatic re- enactment (Hodas, 2004) Appears guarded & anxious Is difficult to re-direct, rejects support Highly emotionally reactive Holds on to grievances Does not take responsibility for behavior Makes the same mistakes over and over Demonstrates repetition compulsion / traumatic re- enactment (Hodas, 2004)

44 Traumatic Relationships Emotions expressed in interpersonal relationships Emotions expressed in interpersonal relationships can be extremely painful and can be related to trauma experience These trauma-based emotions (e.g. anger, fear, 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 Clinicians must be mindful about their experience of trauma-based emotion so that this emotion is not enacted in the clinical relationship

45 Core Concepts of Development 5) Children are active participants in their own development, reflecting the intrinsic human drive to explore and master one’s environment. (Shonkoff & Phillips, 2000)

46 Traumatic Mastery Many children have primarily experienced abusive and neglectful relationships Extreme behaviors within relationships 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” Many children have primarily experienced abusive and neglectful relationships Extreme behaviors within relationships 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”

47 Core Concepts of Development 6) The course of development can be altered…by effective interventions that change the balance between risk and protection, thereby shifting the odds in favor of more adaptive outcomes. (Shonkoff & Phillips, 2000)

48 CONCLUSIONS Response to traumatic stress is learned behavior, mediated by the brain & the social environment Response to traumatic stress is learned behavior, mediated by the brain & the social environment Traumatic stress brings the past to the present 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 emotion.” (LeDoux, 2002 ) The survival response impacts the mind, body, behavior & speech “… the amygdala leads a hostile takeover of consciousness by emotion.” (LeDoux, 2002 ) To change the response, create new learning & skills: To change the response, create new learning & skills: Analyze & adapt Analyze & adapt Buffer & bolster Buffer & bolster Teach, support, & build that “cognitive wedge” Teach, support, & build that “cognitive wedge”

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