Understanding the role
of trauma in patient
care
Darryl Tonemah PhD
Who? What? Where? When? Why?
How?
Gracie
MWB
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https://www.youtube.com/watch?v=Ahg6qcgo
ay4
From Biology to Sociology
High 5’s
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When the midbrain is activated a non-traumatized
patient reacts in elevated arousal-with several possible
self-regulatory responses, based on resources. Signals
are sent simultaneously to the frontal brain and lower
brain for appropriate responses
MRI’s show that for a patient who has been
traumatized the perceived threat is NOT processed
through dual signals. Instead ONLY the lower brain –
amygdala-survival instincts is activated. (Levine, Kline, et. Al)
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Trauma is the unfinished cycle of energy, it is
stored in our nervous system. We’ve learned a
lot from animal research on why Zebras don’t
get ulcers. (Sapolsky, 1994)
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Trauma is in the constriction (lack of options)
and incompletion of the cycle
We think too much! Don’t rationalize fear,
shame, blame
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The baby brain (Stiles, 2008)
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500,000 cells per minute-Neurogenesis
8000 cells per second
Synaptogenesis-1.8 million connections per
second to make a complete brain
Even at this rate baby brains never make the
birth deadline. About 83% of synaptogenesis
continues after birth.
Wiring isn’t complete until the early 20’s
Stress In Utero (Beydoun, 2008), (Lou, 1994)
-Lower baby IQ, averaging around 8 points lower in the
babies first year of life
-Inhibit babys future motor skills, attentional states, ability
to concentrate, difference still observable into school
years, if chronic stress is not alleviated
Stressed cont.
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Damage the babys stress response system,
epigenetics
Shrink the size of the babys brain
Types of Toxic Stress (Guttelning, 2006)
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Too Frequent- no break
Too Chronic- Break up, divorce, death of loved
one
Too much for you- If you are stressed all the
time, so is the baby
“I need to be safe” (Gopnik, 2000), (Wilson, 1998)
During the attachment process the brain is seeking
“Am I being touched?”
“Am I being Fed?”
“Who is safe?”
If the brains requirements are being fulfilled the baby
develops healthy bonds and healthier behaviors
If they are not being fulfilled and the baby regularly
experiences angry or hostile environments the babys stress
responders become hyperactive
Safety cont.
If the brains requirements are being fulfilled the
baby develops healthy bonds and healthier
behaviors
-If they are not being fulfilled and the baby
regularly experiences angry or hostile
environments the babys stress responders become
hyperactive.
-If they are exposed to silence and neglecthyPOcorticalism- Unplugging, blank stares
The brain itself is changed by stress
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“What fires together, wires together”
Complex process of “sculpting” the brain,
converting experience into neuronal changes
Cortisol, Brain-Derived Neurotrophic Factor (BDNF)
 Chronic stress and depression:
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shrink the hippocampus and prefrontal cortex
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↓ Memory, selective attention, executive function/decision making
potentiate growth of the amygdala
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↑ Fear/hypervigilience, anxiety, aggression
McEwen, Physiol Rev 2007;87:873-904
Original Trauma
Amygdala
Any input which
amygdala
interprets as like
original trauma
Recreates body state
at time of original
trauma
Cortisol
Adrenaline
Original emotion re-experienced: fear, rage, sadness
Adapted from LeDoux, The Emotional Brain, 1996
Big feeling are confusing to little
kids. (Lebrach, 2008) (Tucker, 1995)
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Ability to verbally label an emotion is an
important self regulation strategy.
If a young person is not aware of the emotion
they are experiencing, they may not understand
how to react to it socially
We are born with survival
mechanisms
(Levine 2001)
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The basis of trauma is physiological
Often there is no time to THINK when facing a
threat, our primary response is instinctive, in the
midbrain, not the frontal cortex
It is difficult to THINK our way to healing
Cognitive behaviorism is more effective with
stress and cognitive self calming methods
Stress in Children
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Positive
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Normal/necessary part of healthy development
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Brief increases in heart rate and stress hormones
Tolerable
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More severe, longer lasting stressor
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First day with new caregiver; immunization
Loss of a loved one, natural disaster, injury
If buffered by relationship with supportive adult(s), brain and body
can recover
Toxic
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Strong, frequent, prolonged adversity
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Abuse, neglect, caregiver mental illness, poverty
If no adult support, can disrupt brain and organ development longterm
Center on the Developing Child at Harvard Univ.
Stress and Trauma
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Stress: anything that requires a response, can be
“good” or “bad”
Trauma: anything that overwhelms our ability to
respond, especially if we perceive that our life or
our connection to things that support us physically
or emotionally is threatened
So what factors make it more likely that a
stressful situation will become traumatizing?
Posttraumatic Stress Responses
“the long-term consequences of trauma are
far-reaching…”
Context of the trauma
Age/stage of life
Loss of family/cultural coherence
Pre-trauma characteristics
Life conditions post-trauma
Trauma is in the nervous system,
not the event
Fight-Flight-Freeze
-M. Kline
Because of their limited capacity to defend
themselves children are particularly susceptible to
Freezing and therefore are very vulnerable to
being traumatized
How does the jolt of energy in
trauma affect us in the long run?
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Depends on what happens during and after the
overwhelming event
The excess “Jolt” of energy, must be used up
The younger the child the few resources he/she
has to protect him/herself
When a traumatic event occurs, the imprinting
of neurological patterns is dramatically
heightened. Remember why are brain is put in
our noodle? (Sapolsky, Kline, Levine 2007)
Developing Trauma Symptoms
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Related to the level of shutdown as well as the
undischarged survival energy that was originally
mobilized for flight or flee
When the brain sets a sensory motor impulse
into action but the limbs cannot move (or if the
movement itself could be dangerous e.g.
Molestation, surgery) symptoms are likely to
develop
Although the event may have lessened in
conscious memory, the body doesn’t forget (Levine,
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Learning to “befriend” the feeling in small
increments, we can make the connection to the
past and discharged the paralyzing sensations we
experience.
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The heightened arousal state should be time
sensitive, not constant
Universal Symptoms of Trauma
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1. Hyperarousal
2. Constriction
3. Dissociation
4. Feelings of numbness or shutdown (or
“freeze”) (Levine Et al)
Hyperarousal
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Revved up internal state. The stimulation is
coming from within the child, from the nervous
system that they cannot turn down. When there
is perceived stress, the sympathetic nervous
system acts to engage the child. The child who
cannot pendulate gets stuck in this mode.
Hyperactivity, can’t sleep, cannot deeply relax,
hypervigilance, difficulty falling and staying
asleep, exaggerated startle response. Often
resembles ADHD
Constriction
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Once the bodys CNS has been hyperaroused,
adrenaline is released into the blood stream to
preapre the large motor muscles for moveent.
Certain muscles, by their nature, must tense or
constrict in order to perform. But with trauma,
the whole body braces. This includes tightening
of the mucles, joints, and internal organizes, as
well as the sensory and respiratory systems. The
primary symptom is shutdown.
Constriction cont.
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Child more withdrawn, shy, more dependent than before,
lethargy, fatigue, stiff awkward appearance, rigid gait, poor
coordination. Ability to see hear, smell feel, taste decreases-food
may be less interesting to them.
Relaxing would mean letting down the guard of protection
Digestion problems, tummy aches, diarrhea and constipation.
Shallow breathing, hyperventilation can limit oxygen flow to the
brain and body, causing fatigue and lethargic behavior, often
mistaken for laziness
Freeze/Dissociation
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A child experience freeze will often be spared
the initial impact of the incident thorugh the
mechanism of physiological shock and
dissociation. This numbing (mediated by
internal secretions of endorphins) serves to
stamp down the physical and emotional pain of
the event
Unable to cry
Dazed
Freeze cont.
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Sometimes we say “They are tough”
Shock
Too numb to feel pain or emotions due to
endorphins and epinephrine boost
Can last decades
Recognizing Symptoms
Physical: Loss of appetite, sleep disturbance
Emotional: Anger, shame, irritability
Spiritual: Feeling, alone, isolation, shame
Cognitive: Confusion shortened attention span
Behavioral: Repetitive play, aggression
Posttraumatic Stress Responses
 PTSD
 Depression
 Anxiety
 Demoralization- To undermine the
confidence or morale of; dishearten:
Kroll, JAMA 2003;290:667-670
Adverse Childhood Experiences (ACE)
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Physical, emotional, sexual abuse; mentally ill,
substance abusing, incarcerated family member;
seeing mother beaten; parents divorced/separated
--Overall Exposure: 86% (among 7 tribes)
Physical Abuse-M
Physical Abuse-F
Sexual Abuse-M
Sexual Abuse-F
Emotional Abuse
Household alcohol
Four or More ACEs
Non-Native
30%
27
16
25
11
27
6
Native
40%
42
24
31
30
65
33
Am J Prev Med 2003;25:238-244
ACEs and Adult Health
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ACE Score ≥4
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4-12 x risk for alcoholism, drug abuse, depression and suicide
attempt
2-4 x risk for smoking, teen pregnancy, STDs, multiple sexual
partners
1.4-1.6 x risk for severe obesity
Strong graded relationship at all levels of ACEs for almost all
outcomes, including heart disease
Am J Prev Med 1998;14:245-258 and Circulation 2004;110:1761-6
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Across 10 countries, adults who experienced ≥3 childhood
adversities
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Hazard ratios 1.59 for diabetes, 2.19 for heart disease
Risk similar to the association between cholesterol and heart disease
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Both in magnitude as well as population prevalence
Arch Gen Psychiatry 2011;68:838-844
--What is your ace score?
Cook, et al. 2005. Psychiatric Annals 35(5) p. 392
Goldilocks
Historical Trauma-Colonization,
Residential Schools
Trauma is in the freeze-Lack of Options
Squeeze
Imagine your home, your neighborhood, your
community, without the sound of childrens
laughter
What is multigenerational/historic
trauma?
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Cultural trauma:
–is an attack on the fabric of a society, affecting the essence of the
community and its members
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Historical trauma:
–cumulative exposure of traumatic events that affect an individual and
continues to affect subsequent generations. “The collective
emotional and psychological injury both over the life span and
across generations, resulting from a cataclysmic history of
genocide.”
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Multigenerational trauma:
–occurs when trauma is not resolved, subsequently internalized, and
passed from one generation to the next.
Maria Yellow Horse Brave Heart
Historical Trauma
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Trauma(s) that are often intentionally inflicted and occur
at more or less the same time to a defined group of
people—these traumas:
Have effects like individual traumas, plus
Because the traumas are so pervasive, affect caregivers and
elders, affect community and cultural infrastructures and
are targeted at a specific group—they have huge effects
on:
People’s/communities’ abilities to cope with and adapt to
traumatic event and aftermath
 Abilities to interpret the meaning/psychologically incorporate
the trauma
 Patterns of trauma transmission to subsequent generations
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Some Behaviors/Beliefs We Can
Have as the Result of Trauma
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Distrust—of the government, institutions, our own
leaders, supervisors, etc. even to our own detriment-“they” are out to get us
Sense of never having “enough”
Spend/eat/use what you have now as it may be taken
from you
We will not live to be old, so it doesn’t matter what we
do now.
“Love” is not to be trusted and is often linked with
emotional/physical/sexual abuse
Behaviors cont.
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Different threshold for “normal” behaviors (That’s just
the way it is)
Anger, rage “out of proportion” to situation
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Escalation of emotions/voice if demands aren’t met
Dissociation: can look like disinterest, “spaciness”
Desensitized to loss
Distrust of providers
Overly dependent on providers
Its genesis was relatively recent and its transmission is
consistent
Intergenerational Transmission of HTR:
Research Findings
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No clinically significant difference between children of holocaust
survivors and Jewish non-survivor controls in terms of PTSD;
however, when the survivor children were exposed to stressful
events, they were significantly more likely to develop PTSD or
sub-threshold PTSD symptoms than controls (Danieli, 1998).
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Similar multigenerational effects have been documented among
Japanese internment survivors and offspring.
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For AIAN offspring, increased sensitivity or hyperarousal to
stressful events, in particular to events that act as reminders of
their colonized status may predispose AIANs to trauma responses
and corresponding symptoms.
Promoting Resilience
Heavy Runner and Marshall (2003)
 Spirituality
 Family Strength
 Elders
 Ceremonial Rituals
 Oral Traditions
 Tribal Identity
 Support Networks
Promoting Resilience
Cutler (2006)
 Spirituality
 Social interest (giving back to the community)
 Acceptance of a Tiospaye (identification of and being welcomed into a
traditional family and community)
 Support from family
 Cross-cultural competence (ability to function in both traditional and
non-traditional culture)
 Staying active and involved in growth activities
 Self-maintenance activities (connection to the natural
world,
connection to sacred places, meditation, comfort from pets, sports, exercise,
healthy diet, etc.)
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Trauma isn’t in conversation, its in sensation
Good News
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The body wants to get rid of the trauma
We just have to be good stewards of the process
Preparation for the tough stuff
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Dealing with trauma of others is very hard
Dealing with our own is even harder
We need to understand ours before we can be
helpful with others
Prevents transference and counter-transference
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There is a dilemma when patients with trauma
histories are placed with providers who harbor
their own resolved trauma. The showdown is
not pretty. It is predictably a disaster. The
student needs a teacher who can access the best
of their humanity at the worst of times. -Levine
Understanding the physiological (and to a lesser
degree) the psychological aspects of trauma,
harmful events that often limit a patients potential
to fulfillment can be transformed into experiences
that expand their ability to obtain a sense of
mastery, resilience, power, and possibility (Kline 2001)
Sensations Vocabulary Box
Different then emotions list
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Cold/warm/hot/chilly
Twitchy/butterflies
Sharp/dull/itchy
Shaky/trebly/tingly
Hard/soft/stuck
Jittery/weak
Relaxed/calm/peaceful
Empty/full
Sensations vocab cont.
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Flowing/spreading
Strong/tight/tense
Dizzy/fuzzy/blurry
Numb/prickly/jumpy
Owie/tearful/goose-bumpy
Light/heavy/open
Tickly/cool/silky
Still/clammy/loose
Practicing the felt sense
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Where
Don’t rationalize just experience
Let it relax voluntarily
Grounding and centering
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Although few words are used to in the process
of deactivating the trauma charge the ones you
choose are important. Equally important is your
pace, your tone, and your own sensation
responses.
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Not hard, just different
It requires us to change from realm of thought
and emotion to that of sensation
A significant amount of academic and social
success is gathered around ability to self soothe
Do not attach meaning or definition-uses
different part of the brain
As nature move in cycles, so do we. We have to
accept the pacing-often we try to rush to the
conclusion
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Taste and Touch
Cards
A child resources- external and
internal
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Children are born with natural internal
resources, but need an adult to mirror and
nurture them, so they are readily accessible.
Resources are uniquely personal
If an adult believes that it does or should create
comfort, but it does not, it is not a resource for
the child
External Resources
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Loving caregivers who help developmental
needs
Other nurturing family members
Other resources that stimulate and/or comfort
A caring community
Internal resources
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Natural Gifts and Talents
Energetic or Kinesthetic qualities-making
friends, high physical intelligence
Personality characteristic- Wit, Wisdom,
Charisma, thoughtful, integrity
Spiritual
Resources Activity
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Fold a piece of paper I half. On one side list
your external resources, on the other your
internal resources. If you are not sure which
side it belongs on, put it on both
Look at your list and notice which ones jump
out as the strongest supports in your times of
stress. Focus on each and notice sensations and
emotions emerge, and where they are located.
List your sensations
Resources activity cont.
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Are there categories of missing or weak
resources such as few satisfying relationships, or
lack of spirituality.
List ways to enhance these areas
Make a list of your childrens external and
internal resources
Repeat steps
Be sure not to impose ideas on the child, let the
lead
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We are learning more and more about trauma
for individuals. The next challenge to assess
how to deal with it corporately.
Be Well, lets take care of each other