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

SAMHSA Trauma and Justice Strategic Initiative Definition

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.

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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

• 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

PTSD in Veterans

So What Happens in Trauma??

NEUROBIOLOGY BASICS

NEUROBIOLOGY BASICS

NEUROBIOLOGY BASICS

NEUROBIOLOGY BASICS

NEUROBIOLOGY BASICSThe 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 DYSREGUL ATION

• Disrupted Concentration

• Disturbed Executive

Functioning

• Trust

• Shame

• Social Difficulties

• Hyper-alert (orienting)

• Hypervigilance

• Aggressive

• Impulsivity

• Avoidance

• Disrupted Sleep

• Shutting Down

• Overreacting

• Decreased Patience

• Helplessness

• Emotional detachment

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

Judith Herman, 1992

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.

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”

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

T h e P e r v a s i v e E f f e c t s o f T r a u m a

• 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.

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)

TREATING TRAUMA

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

PRESENT FOCUSED TREATMENT

van der Kolk

To be safe in the here and

now you have to give

people what they needed in

the there and then.

“

”

• Psycho-educational

• Normalizing (Avoid Pathologizing symptoms)

• Directive

• Validating

• Attuning

• Collaborative

• Non-Blaming

• Tend to language utilized

• Pacing

TRAUMA INFORMED CARE

• 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?

TRAUMA INFORMED COUNSELING

van der Kolk, 2004

Words cannot integrate the

disorganized sensations and

action patterns that come

from the core imprint of

trauma.

“

”

• 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

THE INSUFFICIENCY OF WORDS

• 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

UNDOING PROCEDURAL MEMORY

• 5 Core Organizers (Pat Ogden)

• Cognition

• Emotion

• Five-sense Perception

• Movement

• Inner Body Sensation

• We help clients recognize how experience is organized and what is dissociated

THE ORGANIZ ATION OF EXPERIENCE

• Directed mindfulness (Ogden)

• Slow down the pace of speech

• Direct attention to five-core organizers

• Make simple observations

• Ask simple, direct questions

• Provide options for describing experience

• Connect/Disconnect five-core organizers

IN THE FACE OF DYSREGUL ATION

Breathing (Outbreath)

Activate Digestive System

Distraction

Containment

Self-soothing

Grounding

Down-Regulation Strategies

Focus on movement

Shift towards novelty

Increase blood flow

Mobilization

Engage the body

Temperature

Up-Regulation Strategies

• Progressive Muscle Relaxation

• Breathing practices

• Body Scan

• Safe place Imagery

• Containment imagery

• Yoga-Calm

SKILL BUILDING

EMDR

Prolonged Exposure

Cognitive Processing Therapy

Brainspotting

Comprehensive Resource Model

Sensorimotor Psychotherapy

Somatic Experiencing

Accelerated Resolution Therapy

Acceptance and Commitment Therapy

Narrative Exposure work

PROCESSING TRAUMA

Neurofeedback/Biofeedback

Yoga

Martial Arts

Body Focused – Dance/Movement Therapy

Experiential therapies – including Equine, Psychodrama

Healing Touch/Body Work

Accupressure/Accupuncture

Tai Chi

Expressive/Factual Writing

OTHER WAYS TO HELP PEOPLE HEAL

• Moderate Research Support

• Anti-depressants

• SSRIs, Tricyclics, Monoamine Oxidase Inhibitors

• Trazodone for sleep

• Buspirone for Anxiety

• Benzodiazepines (Recent studies by VA are showing poor

outcomes for Benzodiazepines)

• Mood Stabilizers

• Anti-andrenergic Agents

• Propranolol

• Prazosin

Role of Psychopharmacology

Check out:

www.mntraumaproject .org

for local resources, written resources, and more

information about local opportunities to learn more

about trauma and its treatment

For Further Questions:

Please E-mail

r yan@mntraumaproject .org

Or

Ryan.vanw yk@nor thmemorial.com

Thank You