Trauma midterm
What are examples of hyper-aroused behavior?
Screaming Head-banging Throwing Punching holes in the wall
disorganized attachment
caregiving is scary and you see your caregiver frightened. More common with developmental or complex trauma, sometimes described as "bizarre" behaviors. When we say trauma is fragmenting, you get fault lines, cannot do the interhemispheric communication Problems emerge when adults are too scary and too under helpful, it does not help kids be able to do their own work
anxious attachment
comes from caregiving that is sometimes really good and available, sometimes gone. Goal: keeping you close
What is hypervigilence?
Over-attunement to environment (mention faces study with ACES kids)
Amygdala
"Smoke detector" - amygdala "The amygdala is our early-warning system. It processes emotion before the cortex even gets the message that something has happened. [...] releas[es] hormones that stimulate the visceral muscles of the autonomic nervous system [...] Lastly, the amygdala sets in motion an accompanying somatic nervous system (skeletal-muscle) response. A similar process occurs with other types of stimuli, including trauma. When someone is threatened, the amygdala perceives danger through the exteroceptive senses (sight, hearing, touch, taste and/or smell) and sets in motion the series of hormone releases and other somatic reactions that quickly lead to the defensive responses of fight, flight, and freeze. Adrenaline stops digestive processes (hence the dry mouth) and increases heart rate and respiration to quickly increase oxygenation of the muscles necessary to meet the demands of self-defense. The amygdala is immune to the effect of stress hormones and may even continue to sound an alarm inappropriately."
Hippocampus
"The hippocampus, however, is highly vulnerable to stress hormones, particularly adrenaline and noradrenaline, released by the amygdala's alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function" - suppression of narrative memory ability? Hippocampus - our brains are constantly creating new connections with other parts of brains (they get rid of connections that are no longer needed), with stress hormones, important synapses are shut down because it is too overwhelming o Born with all the neurons you ever need, dendritic pruning, thickening and refining of the neurons you need and getting rid of the ones you don't - lose neurons you don't need and have refined ones that you do need
You can only process feedback at the level of your brain that you make it to:
"Therapy" - cortex Relational work - limbic system Regulation work - diencephalon/cerebellum Somatic work - brain stem
Corpus callosum
"fault lines" -The corpus callosum is the major interconnection between two hemispheres. -Integrated motor, sensory, and cognitive performance between the cerebral cortex on one side of the brain to the same region on the other side What is happening? -Not a lot of back and forward between the left and right (emotional, sensory) brain -Less processing/ children will be not as good to pay attention to both parts of the brain -Logic and reasoning can show up when fear is manifested -Dissociative symptoms are the result of less connectivity in the corpus callosum -Dr. Titer - looking at neglect and sexual abuse -> smaller/thinner corpus callosum. What this began to build curiosity about was that when inter-hemispheric communication is underdeveloped, the inability to merge cognitive strategies with effect. Lack of processing = structural dissociation. -"Martin Teicher has observed a correlation between a history of abuse and/or neglect and under-development of the corpus callosum compared to normal controls (2004) which would also support the hypothesis that trauma is associated with structural dissociation of right and left brain-mediated parts of the personality.
Compensatory effect
"workaround," neuroplasticity (brain's ability to change), new connections can form over repetition. There is the ability for the brain to develop with repetition and skill development, practice.
The Window of Tolerance
-High activation - hyperarousal, hyper-defensive, emotional reactivity, hypervigilant, intrusive images, obsessive/cyclical cognitive processing Ex. of high activation: headbanging, punching, running Ex. of low activation: minimal movement, catatonic, numbing behaviors, chronic masturbation, substance use -Low activation - hypoarousal, disabled defensive responses, numbing, collapsed, flat affect. Being on the CUSP of low activation and window of tolerance = more dangerous in terms of suicide compared to pure low activation
Neurobiological changes re: trauma
-90% of child's brain development happens before age 5, 10% after this (most of this last 10% is higher-order, executive functioning) -"Trauma in childhood may be more detrimental than trauma experienced in adulthood because of the interactions between trauma and psychological and neurodevelopment" -Brain stem - basal body functions (heart rate, blood pressure, etc) this part is most disrupted Ex. kid seems totally fine, but if you check their heart-rate and it's beating super fast **These are some core trauma symptoms** -Cerebellum - balance -Limbic system - "The primary structures within the limbic system include: Amygdala: Hippocampus: memory, associated with learning and emotion Thalamus: Hypothalamus: basal ganglia, cingulate gyrus" Fight, flight, freeze Fight: adaptive, agentic, advocacy, highest level of activation People with this reflex will do the best in life Flight: Avoidant Freeze: dissociative coping, strong correlation to terror People with this reflex will do the worst in life Freezing is highly adaptive in combat and mass shootings, not so much elsewhere. Also includes submitting a response. "Teflon" presentation, also agreeance organized around safety. Reduced prefrontal cortex activation Increased use of Back brain -instinct, protect, fight or flight reaction "Dysregulated autonomic activation inhibits activity in the prefrontal cortex" -> impacts learning, problem solving, verbal communication
Rapport Building
-Affect Management: Managing feelings Content: words exchanged Process: what's happening underneath -Modeling/ Narrative: Hegemonic modeling: speaking to the dominant narrative Narrating thoughts bud do not insert yourself in the narrative -Limit to NO question: asking so many questions can push to overload -Framing treatment: "what are we doing here?" -Affect not fact: Curiosity not judgment
Secondary Traumatic Stress
-Bearing witness to a traumatic narrative event which can lead to PTSD symptoms -Multiple STS is what leads to vicarious trauma -specific, not related to your own trauma exposures. Panic and PTSD-like symptomology without own personal trauma narrative, from an experience that is not yours. (compares to PTSD) *happens after a single trauma exposure event, where vicarious trauma happens over time from several of these events
Define complex trauma
-Multiple experiences of adversity(traumatic events), gets in the way of development (chronic underdevelopment = a hallmark of complex trauma) resulting in neurological and physiological changes. -Examples of experiences of adversity: abuse or neglect, loss of parent, witnessing a death, witnessing interpersonal violence, excessive drug use, poverty (not having basic needs met. Neglect by design because you're working three jobs, malnourishment, stigmatization, prison or jail history within family)
Dissociative Coping
-Our capacity for affect tolerance and the achievement of an integrated sense of self later in life is dependent upon these self-regulatory abilities acquired during early development, both the ability for interactive regulation (to be soothed by others) and auto-regulation (soothing ourselves) *Affect tolerance: things emerge and you have the bandwidth and ability to deal with it (able to self-soothe) *Integrated sense of self: if we were friends and knew you really well and watched you have an argument with a partner, I would still feel like I really knew you -Not a chameleon, "I am who I am consistently with everyone" -In addition, because dysregulated autonomic arousal inhibits activity in the prefrontal cortex, even the child's ability to learn, problem-solve, and verbally communicate is dependent upon self-regulatory capacity and therefore on the quality of early attachment -Without interactive regulation from securely attached parents, small children must depend on their ability to alter consciousness when soothing is needed and, on the body's, innate "fault lines" for compartmentalizing overwhelming experiences
Difference between complex trauma and PTSD
-PTSD - hypervigilance, intrusive memories, flashbacks, avoidance. Intrusive memories, avoidance, flashbacks, panic/high affect related to traumatic triggers. It is a good dx for encapsulated and/or single-event trauma. -PTSD is Acute responses to overwhelming stressors that have happened recently -Complex trauma is the only dx that holds interpersonal difficulties as part of it, as opposed to PTSD which does not (complex trauma also includes negative self-image, dysregulated affect). Kids with complex trauma often get dx'ed with ADD, ODD, anxiety NOS, dysthymia/depression. -Complex Trauma- History of multiple experiences of adversity or trauma that get in the way of development and cause neurological and physiological changes EX: one year old baby who has been witnessing its parents fighting would not be complex trauma because there is no history of traumatic experiences. The baby is too young and you cannot tell what the effect is on the child. It would be PTSD
Adversity
-Poverty, needs not met, neglect (parents working), stigmatization, marginalization -Speaks to the physiological and psychological impact -How the social and interpersonal environment reacts Ex. Bullying is not adversity but the way the environment reacts to create creates adversity *The idea poverty can be biased because not all children who experience it have complex trauma
Trauma is complex/formulation cheat sheet
-Type of exposure - what happened -Age/developmental stage of exposure - you can only bear what happened with the developmental skills that you have at the time -Origin of exposure - who did it? -Public versus private-public vs. private support (trauma being in the public eye vs dealing with it privately) -Chronicity - how long its been happening -Lasting impact - the effect it's had on them -Social support - who do you have around you, who did you lose as a result of what happened to you -Layers of oppression (racism, homophobia, etc.) -Presence/absence of additional resources -Presence/absence of additional vulnerability
List at least 5 childhood or adolescent behavioral adaptations to complex trauma.
1. Aggressive behavior - fight redirected is agentic and therefore adaptive Ex. child running up to kelly, hugging her leg and then biting it. She's learned that bad things happen to you and your body no matter what you do, so she started the process that she is used to. She will hurt you before you can hurt her 2.Examples of hyper-aroused behavior Screaming, destruction, headbanging, throwing, anxious perseveration 3.Examples of hypo-aroused behavior (numbing) Masturbation, substance use 4.Dissociation - adaptive in the moment, is associated with long-term psychopathology in the long run 5.Splitting between people - in order to get needs met. You don't bear what you can't tolerate 6.Child refuses to leave the classroom - knows the teacher can't touch him so he can safely get his needs met 7.Fecal smearing - toileting can result in feeling out of control, so they do this in order to feel in control again and to express the overwhelming feelings they are experiencing 8.Hoarding tampons- shame, showing others that you're bleeding can be triggering. By putting them somewhere as quickly as possible you're trying to get it over with as soon as possible restrictive/disorder eating- will not eat or will eat excessively because it is how they feel like they have control
Core competencies in complex trauma tx:
1.Safety: The installation and enhancement of internal and environmental safety. 2. Self-regulation: Enhancement of the capacity to modulate arousal and restore equilibrium following dysregulation across domains of affect, behavior, physiology, cognition (including redirection of dissociative states of consciousness), interpersonal relatedness and self-attribution. 3. Self-reflective information processing: Development of the ability to effectively engage attentional processes and executive functioning in the service of construction of self-narratives, reflection on past and present experience, anticipation and planning, and decision making. 4.Traumatic experiences integration: The transformation, incorporation, or resolution of traumatic memories, reminders and associated psychiatric sequelae into a nondebilitating, productive, and fulfilling existence through such therapeutic strategies as meaning-making, traumatic memory containment or processing, remembrance and mourning of the traumatic loss, symptom management and development of coping skills, and cultivation of present-oriented thinking and behavior. 5. Relational engagement: The repair, restoration or creation of effective working models of attachment, and the application of these models to current interpersonal relationships, including the therapeutic alliance, with emphasis on development of such critical interpersonal skills as assertiveness, cooperation, perspective-taking, boundaries and limit-setting, reciprocity, social empathy, and the capacity for physical and emotional intimacy. 6. Positive affect enhancement: The enhancement of self-worth, esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery-seeking, community-building and the capacity to experience pleasure.
Trauma Exposure Response
After trauma exposure one can experience Vicarious trauma, Secondary Traumatic stress, and burnout, AS WELL AS post traumatic growth Post-traumatic growth Appreciation of life, relationships with others, new possibilities in life, personal strengths, and spiritual discharge Umbrella term for vicarious and secondary traumatic stress - the way that you respond to the traumatic experiences
"People don't get better from trauma" What would you say to this?
Brains can change. Neuroplasticity -Compensatory effect: the brain can change from experiences of life. Your body can find alternative ways to do things -Your brain can adapt and heal, people can change, you have to work very hard for it
What does a person need to be able to build trust?
Care-taking, safety (tissues, towels) Consistency → predictable responses = safety/ limit boundaries Compassionate but what are we doing (working together) and what are we not doing
Dendritic pruning
Dendritic pruning -process of thickening and refining of neurons you need. You get less good at a lot of things and more good at the necessary things cortisol gets in the way of this, you end up with delays or neurological complications (don't notice or respond to body sensations) resulting from lack of refinement going on.
avoidant attachment
Dismissal Sending the message, "I don't want you." Minimize distress and vulnerability
Why do we focus on safety and stabilization first when engaging in trauma treatment?
Establish a safe base Can't talk about trauma without skills to talk about it and handle it Establish safety in body and safety in a relationship The clarity in what happens in therapy, skills that will be learned
Teacher: Let's just give the kid Ritalin for freaking out during class, he has ADHD. What do you say?
He's in a flight mode, where he's on edge because he doesn't know he's safe Hes been experiencing lots of scary things repeatedly, so he's still in flight mode, that's why he's acting this way Idk if medication is the answer when there's lots of factors at play. There might be some attention stuff, but there's a clear link to me between what he experienced and how he's behaving. Let's use meds as a last resort. Medication works when its organic, doesn't work when its not organic
Cortisol
Heightened cortisol activates long -term memory consolidations, but long term sustained cortisol impacts memory consolidation - that's how you get somatic experiencing, inconsistent or reverberative memories Chronic levels of too much stress/trauma/increased cortisol -> never able to process, store memories. Higher cortisol in people who've experienced trauma. Intergenerational trauma - children had lower cortisol levels, marker is broken. Theory is that activation system is ineffective, which is why there is more PTSD symptomology in offspring.
HPA axis
Inter- and trans- generational trauma: HPA axis, transmission of genes that are passed on so that children have biological system that is primed to respond and stays longer in stress "The HPA axis is a term used to represent the interaction between the hypothalamus, pituitary gland, and adrenal glands; it plays an important role in the stress response."
What are the domains of impact for complex trauma (Symptoms)
Interpersonal skills -Learned understanding of what safe relationships are -Can't understand why people do the things they do, think that people are a threat when they may not be -Attachment issues -Mentalization, wonder about what else is happening beyond yourself Somatic Functioning/complains -Sleep Mood changes Risk-taking (substance use at a young age) Understanding of the world, the world is bad place Affect dysregulation Executive functioning (focus, and academic success)
Traumatic Reminder
Intrusive memories and experiences of my own loss related to theirs Being flooded with memories and sensations, unresolved thoughts, unresolved traumatic experiences Client says something, and it brings up a traumatic event -Feeling it somatically
Countertransference
Is this evocative of a narrative in my life that I am playing out with you in my therapeutic relationship It is an undone narrative The drive and the intensity for why you are feeling a certain way Feelings towards a client/patient are stemming from a narrative from the clinician's life
What are examples of hypo-aroused behavior?
Low affect Minimal movement Numbing behaviors (over-eating, substance abuse, going catatonic, chornic masterbation) -Pulls you out of whatever you're feeling
ambivalent attachment
Push/pull Deeply desirous of two different things at the same time; push-pull. Caregiving both good and bad. "When you are away from me I feel alone, but when you are close I'm scared." Often found in BPD
What would you do first with a case
Start with rapport between therapist and client Set up what treatment is, what would happen Coping skills, find a use for treatment so they come back
Youre sitting down with a caregiver who just told you that he experienced sexual abuse. Parent says, "now my kid will be gay and damaged for rest of life" What do you say?
Talking to ANXIETY "it gets better but it takes a lot of work and time" The brain has the ability to change over time if the right interventions are provided There's an intense amount of repetition needed in order to practice new skill Kind of like physical therapy when someone breaks their knee The homophobic piece: abuse doesn't have an effect on sexuality
Neurobiologial changes: Rewired pathways in the brain
The window of tolerance much smaller, small triggers sends them back to the trauma Thicker pathways for threat and fear, see world as not safe. Thicker and enhanced neurons in this part of their brain. Less adaptive for assessing and appraising, regulation, Fight flight freeze submit Wired to see a threat, not an appraisal. The prefrontal cortex (appraisal) is less active Elevated cortisol from the limbic system, the stress hormone -Should elevate in the morning and got down when melatonin comes in -Complex trauma, body can't return to normal levels of cortisol
Vicarious Trauma
Transformation of a helper's inner experience, in the result of an empathetic engagement to a client's material -Emotional residue to being exposed to hearing trauma stories from clients -Framework shift of how a clinician views the world due to a clients' exposure to their own world -your entire world changes due to the trauma exposure. Likely the result of multiple experiences of secondary stress. (compares to complex trauma) - the emotional residue of exposure that counselors have from working with people as they are hearing their trauma stories and become witnesses to the pain, fear and terror that trauma survivors have endured Faced with neutral stimulus, you put a layer of terror over it - a state of tension and preoccupation of the stories/trauma experiences described by clients Example: seeing a bag of sand and your first thought is "it's a dead body" Happens over time
secure attachment
flexibility, reciprocity. Can be stressed w/out snapping. 75% of people have this style.
Hypervigilance
over incorporation of information and lack of ability to create gradient. (face study?). Over-attunement to your individual environment
Transgenerational trauma
trauma that has been transmitted across more than two generations · -If your parents have experienced overwhelming stress, mothers are transmitting genes that are turned on and passed to children
Intergenerational Trauma
trauma that has been transmitted between two generations
Burnout
you've lost the capacity to bear witness, so you have an apathetic response (exhaustion, disengagement)- it is the exhaustion, depletion, disengagement that comes as a consequence of high workload and organizational demands Contributing factors - professional isolation, emotional drain of always being empathic, ambiguous successes, continual non-reciprocal giving