1. Janine M. D’Anniballe, Ph.D. Children’s Roundtable Summit
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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

2. The Stress-Trauma Continuum
Normal
Situational
Traumatic

3. 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

4. Trauma and Culture
Cultural/Gender differences in the perception and expression of trauma
Historical trauma
Forms of traumatic injury
Psychological
Spiritual
Brain/Body

5. 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

6. The Neurobiology of Trauma
Trauma is not purely a psychological issue
The past becomes present because of the way that the brain dysregulates and changes after traumatic events
What fires together wires together
Trauma “echoes” in the brain – and treatment needs to quiet the reverberations of the echo

7. Neurobiology of Trauma
Dendrites
Nucleus
Axon

8. Synaptic Activity

13. 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 ….

14. 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

15. 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.

16. Structures of the Brain: The Limbic System

17. 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

18. 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).

19. 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

20. 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

21. 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.

22. The Adverse Childhood Experiences (ACE) Study (Robert Anda, MD Co-Principal Investigator)
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

23. 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

24. Hippocampal Volume Reduction in PTSD
NORMAL PTSD
MRI 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: ; Bremner et al., Biol. Psychiatry 1997; 41:23-32;

26. 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

27. 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

28. 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”

29. 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

30. Traumatic Memory

31. 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

33. When Amygdala is highly activated, it interferes with Hippocampus functioning
Sensory Thalamus

34. 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).

35. Self-Harming Behavior
Why do people self-injure?
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

36. 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)

37. Fight, Flight, or Freeze
A lesson from Jakey Cat

38. Jakey Cat (RIP)

39. 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

40. 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

41. 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

42. 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?

43. 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

44. 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

45. 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

46. 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 46

47. 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

48. 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

49. 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

50. 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

51. 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.

52. Increased Hippocampal Volume With Paxil in PTSD
Effects of 9-12 months of treatment with mg paroxetine.
(Vermetten et al. Biol Psychiatry, 2003)

53. 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. “

54. 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

55. 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

56. 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

57. Three Quick Ways to Activate the Parasympathic System
Breathing – particularly the exhale
Mindfulness practice
Relaxing the pelvic muscles:
While sitting, put hands under the buttocks and find the sits bones
Touch the two bony points just below the waist on your right and left side
Visualize a square; breathe into the square to expand that area; release and relax all muscles there

58. 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

59. 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)

60. 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

61. Yoga Trauma = 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)

62. 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

63. Exercise: Rebalances melatonin; enhances sleep cycle
Releases endorphins (endogenous opioids)
Promotes tryptophan which enhances mood; precursor to serotonin

64. Sleep, Rest, and Relaxation
Sleep deprivation keeps nervous system on high-alert; cortisol is elevated
Serotonin and dopamine rise when sleeping, resting

65. 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

66. 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.

67. Strategies to Reduce Trauma in the Courtroom
Physical Environment
Be child and family friendly
Group issues for preliminary hearings so that those requiring the complainant to be present are held all at once
Use the same standards in setting bail for defendants in stranger and non-stranger cases
Establish and adhere to deadlines for filing motions
Enforce rape shield statute consistently; set a schedule for early determination of rape shield issues
Chester County Courtroom
Allegheny County Courtroom

68. Strategies to Reduce Trauma in the Courtroom
Physical Environment
Be creative
Group issues for preliminary hearings so that those requiring the complainant to be present are held all at once
Use the same standards in setting bail for defendants in stranger and non-stranger cases
Establish and adhere to deadlines for filing motions
Enforce rape shield statute consistently; set a schedule for early determination of rape shield issues
Dogs in Court, Bucks County Pennsylvania

69. 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
Group issues for preliminary hearings so that those requiring the complainant to be present are held all at once
Use the same standards in setting bail for defendants in stranger and non-stranger cases
Establish and adhere to deadlines for filing motions
Enforce rape shield statute consistently; set a schedule for early determination of rape shield issues

70. 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
Have a conference with attorneys before trial to review voir dire
Ask thorough questions in voir dire
Use a questionnaire to elicit sensitive information about potential jurors’ sexual assault experience, whether as victims or defendants
Complainants should not be asked to show on their own bodies how they were touched or to demonstrate the position in which they were sexually assaulted. Use diagrams, dolls, or expert testimony

71. 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

72. 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

73. Strategies for Reducing Trauma for Professionals
Reduce fear of the unknown
End the week on a positive note
Find support from colleagues
Keep perspective

74. Thank you for all that you do for your community!

75. Janine M. D’Anniballe, Ph.D.
Contact Information:
Janine M. D’Anniballe, Ph.D.