The Neurobiology of Trauma and Approaches for Healing Presenter: Ryan C. Van Wyk, PsyD, LP
OBJECTIVES • Attendees will understand the neurobiology of trauma • Attendees will understand the importance of identifying and treating trauma related symptoms • Attendees will be identify approaches to treating PTSD and helping people heal from trauma
“ Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, ” social, emotional, or spiritual well-being. SAMHSA Trauma and Justice Strategic Initiative Definition
DEFINING TRAUMA… • A wide array of experiences can be experienced as traumatic • {Potentially Traumatic Event} • It is the intersection of the event and the person’s capacity to integrate (internal and external resources) their experience that results in a lingering trauma response
DEFINING TRAUMA… • Considerations: • Acute vs. Chronic • Degree of Intensity • Resources at the time of event • Experienced alone or with others
PTSD in Veterans • Hysteria (Freud, Breuer, and Janet) • Combat survivors (Nostalgia, Shell Shock) • Thought to be the result of damage to the brain resulting from explosions Treatment focused on rest and physical recovery • • By WWII – understanding had shifted to Combat Stress Reaction (battle fatigue) • This remains a relevant consideration, but is considered a normative response that diminishes after 72 hours. DSM I – Gross Stress Reaction • • Expected to resolve after experiences of disaster or combat
PTSD in Veterans PTSD was not added as a diagnosis until DSM III (1980) • • Understanding broadened as it was observed that civilians who had never experienced combat displayed similar symptoms after traumatic experiences Continued research has resulted in a refining of the diagnosis • and its symptoms • Recently reported PTSD lifetime prevalence rates: • 3.6% of American men and 9.6% of American women With DSM V, PTSD has been removed from the Anxiety • Disorders Category and placed in its own category – Trauma and Stressor-Related Disorders • Recognition that PTSD is not necessarily just an anxiety disorder, it can also present with depression, anger, acting behaviors, dissociation
PTSD in Veterans • 5-20 percent of veterans who served in Afghanistan and Iraq meet criteria for PTSD after returning home • Higher rates in personnel who experienced direct combat (those in brigade or regimental combat teams) • Lower rates in population samples that include support personnel. • These figures are comparable to those observed in Vietnam veterans.
PTSD in Veterans Important to see the normalcy of • symptoms as a response to the combat environment • Hypervigilance as protective in a high threat environment Obsessive thinking as proactive in mission planning and • execution • Emotional numbing in order to sustain a focus on the mission • Disruptions to sleep cycle and reduced deep wave sleep as mission normative experiences
So What Happens in Trauma??
NEUROBIOLOGY BASICS
NEUROBIOLOGY BASICS
NEUROBIOLOGY BASICS
NEUROBIOLOGY BASICS
NEUROBIOLOGY BASICS The role of the orbital Prefrontal cortex (OPFC) • Allows us to register sensations • Stay attuned to others through non-verbal communication • Regulate Emotions and extinguish irrational fear Be reflective, to think about and choose the • most appropriate action or reaction • Have empathy for others and treat them kindly • Make decisions to act morally and ethically • Becomes disordered with the experience of trauma
NEUROBIOLOGY BASICS We remember trauma less in words and more with our feelings and our bodies (van der Kolk & Fisler, 1995) Limbic System registers presence of threat Thinking brain goes offline Alert center activates the… survival system response
NEUROBIOLOGY BASICS
THE WINDOW OF TOLERANCE
TRAUMATIC DYSREGULATION • Disrupted Concentration • Shutting Down • Disturbed Executive • Overreacting Functioning • Decreased Patience • Trust • Helplessness • Shame • Emotional detachment • Social Difficulties • Hyper-alert (orienting) • Hypervigilance • Aggressive • Impulsivity • Avoidance • Disrupted Sleep
NEUROBIOLOGY BASICS • The role of implicit memory (procedural learning) • Knowing without knowing • Automated response patterns • Association driven • Not tagged as from the past (Siegel)
NEUROBIOLOGY BASICS When we experience trauma, our sensory system encodes the threat to anticipate future threats to safety Our implicit memory system looks for similarities and familiarities to predict what is going to happen next
NEUROBIOLOGY BASICS If a traumatized person encounters this:
NEUROBIOLOGY BASICS The traumatized brain may see this:
Our Level of Resilience depends upon our capacity to integrate
An inability to effectively integrate traumatic experiences can result in PTSD
“ When neither resistance [fight] nor escape [flight] is possible, the human system of self-defense becomes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated way long after the actual danger is ” over. Judith Herman, 1992
What to Look for • Re-enactment (Self-destructive behavior) • Re-experiencing (Nightmares, flashbacks) • Hypervigilance – Mistrust, hypersensitivity • Feeling Unsafe • Hyper-arousal • Hypo-arousal • Avoidance Strategies – Eating Disorders, Substance Use, Self- injury • Irritability, Depression, Anxiety, Numbness, Anhedonia, Shame, Worthlessness, Hopelessness • Disrupted sleep, insomnia • Chronic pain, headaches • Self-neglect, no awareness of own needs
The Pervasive Effects of Trauma • Our ability to make sense of our environment or experiences is affected and often derailed • The part of the brain responsible for insight and self- awareness (orbitofrontal cortex) remains more often offline • Avoidance becomes normative (situations, people, sensations, emotions, thoughts) People are affected globally (physical, affective, • cognitive, spiritual, relational) Our beliefs about self, others, world change • • Body is often experienced as out of control – physical responses are driven by chronic hyperarousal or hypoarousal (dissociation) • In remembering and re-experiencing, the past is often experienced as more real than the present, chronology is disrupted
The Challenge of Working with Veterans • Half of veterans in need of mental health care still don’t receive services. • High percentage dropout of treatment before experiencing benefits. • Estimated only 20 percent of veterans in need of care receive adequate mental health treatment.
TREATING TRAUMA PHASE ORIENTED • Establish Safety, Stabilize symptoms, improve ability to self-regulate • Process trauma memories • Integration
TREATING TRAUMA PHASE ORIENTED • Establish Safety, Stabilize symptoms, improve ability to self-regulate (Present Focused) • Process trauma memories (Past Focused) • Integration (Future Focused)
PRESENT FOCUSED TREATMENT SPECIFIC MODELS • Seeking Safety • Trauma Recovery and Empowerment Model (TREM) • Addictions and Trauma Recovery Integrated Model (ATRIUM) • TRIAD Women’s Group
PRESENT FOCUSED TREATMENT Other Approaches that can be helpful • Dialectical Behavior Therapy (DBT) • Yoga • Mindfulness Practices
“ To be safe in the here and now you have to give people what they needed in ” the there and then. van der Kolk
TRAUMA INFORMED CARE • Psycho-educational • Normalizing (Avoid Pathologizing symptoms) • Directive • Validating Attuning • Collaborative • Non-Blaming • Tend to language utilized • Pacing •
TRAUMA INFORMED COUNSELING • How to assess? How to talk about? • • How to foster safety? • Environment/Experiences/Interpersonal • How to keep in treatment? • How to understand behaviors? • How to help them understand their behaviors? • How to maintain compassion?
“ Words cannot integrate the disorganized sensations and action patterns that come from the core imprint of ” trauma. van der Kolk, 2004
THE INSUFFICIENCY OF WORDS • Talking doesn’t always help – Trauma is experienced, we have to help them have a different experience (physical, emotional, relational) – Talking about the experiences can sometimes exacerbate symptoms and traumatic memories – Be ready to stop the content of conversation if clients become dysregulated • Undoing the unbearable state of aloneness – Fosha
UNDOING PROCEDURAL MEMORY • Procedural Learning – Mindfulness is the key to changing procedurally learned responses • We make the implicit – > explicit • We make the explicit -> experiential • New experiences change the brain • New pathways • New response options
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