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THE TRAUMA SPECTRUM
AND ITS CLINICAL
IMPLICATIONS
ROBERT SCAER, M.D.
[email protected]
www.traumasoma.com
THE ROOTS OF
TRAUMA
A THREAT TO LIFE
IN THE FACE OF HELPLESSNESS
THE FIGHT /FLIGHT / FREEZE
RESPONSE
THE FREEZE RESPONSE
• NUMBING THROUGH ENDORPHINS
• VAGAL (PARASYMPATHETIC) TONE
• BIMODAL SYMPATHETIC /
PARASYMPATHETIC CYCLING
(ACCELERATOR / BRAKE
ANALOGY)
LESSONS FROM THE WILD:
THE CRITICAL IMPORTANCE
OF DISCHARGING
THE FREEZE RESPONSE
FREEZE/IMMOBILIZATION
AND SURVIVAL
BABY CHICKS
IMMOBILIZED
NOT
IMMOBILIZED
SPONTANEOUS
RECOVERY
BEST
DROWNING
SURVIVAL
IMMOBILIZED
FORCED
RECOVERY
INTERMEDIATE
DROWNING
SURVIVAL
WORST
DROWNING
SURVIVAL
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!
ORBITOFRONTAL
CORTEX
CEREBRAL CORTEX
HYPOTHALAMUS
HPA AXIS
ORGANIZES RESPONSE
TO THREAT
ANTERIOR
CINGULATE GYRUS
MODULATES
AMYGDALA
SENSORY
INPUT –
HEAD AND NECK
HIPPOCAMPUS
DECLARATIVE MEMORY
COGNITIVE MEANING
AMYGDALA
EMOTIONAL
CONTENT
LOCUS
CERULEUS
EARLY WARNING
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
MEMORY MECHANISMS
IN TRAUMA
• DECLARATIVE (EXPLICIT) MEM0RY
- FACTS AND EVENTS
• NON-DECLARATIVE (IMPLICIT)
MEMORY
- EMOTIONAL ASSOCIATIONS
- PROCEDURAL MEMORY
-SKILLS AND HABITS
- CONDITIONED SENSORIMOTOR
RESPONSES
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
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!
KINDLING /
NEUROSENSITIZATION
THE DEVELOPMENT OF
SELF-PERPETUATING
NEURAL CIRCUITS
THROUGH THE STORAGE OF
PROCEDURAL MEMORY CUES
OF A TRAUMA
DISSOCIATION :
THE PERCEPTUAL
EXPERIENCE
OF THE
FREEZE RESPONSE?
WHAT LIFE EVENTS
CONSTITUTE
A TRAUMATIC
EXPERIENCE?
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
WHY DO THE MAJORITY
OF TRAUMA VICTIMS
EXPOSED TO TRAUMA
NOT DEVELOP PTSD?
WHY DO SOME VICTIMS
EXPOSED TO MINOR
TRAUMATIC EVENTS
DEVELOP PTSD?
RESILIENCY VS.
VULNERABILITY TO
TRAUMA
OUR PRIOR BURDEN
OF LIFE TRAUMA
CREATES AN ENVIRONMENT
OF VULNERABILITY TO
FURTHER TRAUMATIC EVENTS
THOSE LIFE EXPERIENCES
MOST LIKELY TO
REPRESENT TRAUMA
HAVE MEANING FOR
SURVIVAL BASED ON
PAST EXPERIENCE
THE ROLE OF
DEVELOPMENTAL
NEUROBIOLOGY
IN RESILIENCE TO
TRAUMA
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
LEARNED
HELPLESSNESS
ONCE YOU FREEZE
YOU TEND TO
FREEZE / DISSOCIATE
AGAIN!
THE LEGACY OF
IMPAIRED ATTACHMENT
AND DEVELOPMENTAL
TRAUMA:
A LIFETIME OF
AUTONOMIC
AND EMOTIONAL
DYSREGULATION
IF THE ABSENCE OFNURTURING
IS TRAUMATIC STRESS,
WHAT ARE WE MISSING HERE?
THE UNRECOGNIZED
SOURCES
OF TRAUMA
UNRECOGNIZED SOURCES
OF TRAUMA
• PREVERBAL TRAUMA
• PEDIATRIC AND ADULT MEDICAL
TRAUMA
• CULTURALLY ENDORSED
TRAUMA
• “LITTLE TRAUMAS”
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
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
THE NEONATAL ICU
• TUBES: BREATHING, SUCTIONING,
FEEDING
• NOISE, BRIGHT LIGHTS,
ISOLATION
• PAIN: TRACHEOSTOMIES, MAJOR
SURGERY, ARTERIAL / VENOUS
PUNCTURES / CUTDOWNS
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
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
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
PEDIATRIC MEDICAL TRAUMA
• 1986 - PATENT DUCTUS SURGERY WITHOUT
ANESTHESIA DISCONTINUED
• 1988 - 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
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
PEDIATRIC MEDICAL
TRAUMA
• CIRCUMCISION
* CIRCUMCIZED MALES HAVE A
GREATER PAIN RESPONSE TO
SUBSEQUENT IMMUNIZATION SHOTS
THAN NON-CIRCUMCIZED MALES
* USE OF EMLA CREAM EFFECTIVE
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
ADULT MEDICAL TRAUMA
• 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
MEDICAL
TECHNOLOGY:
TRAUMA BY THE
CAREGIVER
“I CAN’T FIND
ANYTHING WRONG,
BUT WE’D PROBABLY
BETTER GET AN MRI”
ORDERING TESTS TO
AVOID MEDICAL /
LEGAL LIABILITY
NEW TECHNOLOGY AND
THE TRAP OF THE
“UNEXPLAINED”
ABNORMALITY
THE INFALLIBILITY OF
TECHNOLOGY AND
“EFFORT AFTER
MEANING”
REJECTION OF THE
PATIENT IF THE TESTS
ARE NORMAL:
“IT MUST BE
PSYCHOLOGICAL”
THE DILEMMA
OF AN
IMPERFECT SCIENCE
THE INSIDIOUS
REINFORCEMENT OF
THE FEAR OF ILLNESS
BY THE MEDIA AND
PHARMACEUTICAL
INDUSTRY
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.
“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
TRAUMATIC
REENACTMENT
• SEXUALLY MOLESTED BOYS:
INCREASED DRUG ABUSE,
VIOLENCE AND CRIMINAL
BEHAVIOR
• 14 JUVENILES CONDEMNED TO DEATH:
12 PHYSICALLY ABUSED, 5
SODOMIZED
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
REEXPERIENCING
AND THE
ANNIVERSARY
SYNDROME
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
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”
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
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
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
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
REENACTMENT
IN DAILY LIFE
• MATURATIONAL ARREST IN
TRAUMA
• OUR CHOICE OF MATES
• OUR CHOICE OF CAREERS
• OUR CHOICE OF RECREATION
• OUR CHOICE OF SUBSTANCES
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