ptsd: a different brain after trauma deborah grassmanarnp ceo… · 2019-02-08 · 8/10/2017 1...
TRANSCRIPT
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PTSD: A Different Brain after Trauma
Deborah Grassman ARNPCEO, Opus Peace
“The wound is cut deep.
Somehow war has snuck past my skull and ripped my brain apart.
Too many distortions and emotions to find.
The pain smells like rotten flesh.
It comes and goes, leaving a stain…
Wishing I could erase it and start fresh.
The mind plays cruel tricks after hours of
no sleep.
Nightmares turn into reality whether you are awake or not.
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Even when you survive…You become a black sheep hearing bone‐chilling screams. Fire power put me in shock.
It feels like a dream – like those friends I lost never existed.
The confusion is unbearable. I’m in a time warp.Trapped in my subconscious, I miss my life.I feel like I’m in hell and I’ve already died.Always on edge, I can’t leave home without my knife.
Home in the States, I’m at war with my mind.Nobody understands. Nobody is patient enough to care.
My loved ones never see the signs because I’m so confined.
Most of the time, I’m smiling.It’s just to make others happy.On the inside, I’m screaming and fighting for my life.I keep wondering if there’s a God, then why am I so unhappy?
I should be thankful I’m alive.Yet, I’m disappointed and sad that I survived.The soldiers that died, if they were alive
would have thrived.I’m just scared and weak all the time.Angry and frustrated, I try to stay isolated to
protect myself from committing any crime.This is the soul of a kid that Americans call
“A Hero.”
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(“Burning Vision”. Artist: Tommy Bills)
“This is what I see.One eye sees everything you do,
and one eye always sees Vietnam.”
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Understanding PTSD(Often Applies to Chronic Illness/Stress)
Acute TraumaX
____________________________________________________________PTSDSame end‐point: Different Routes and Rates
Chronic TraumaX
xx
Example of Caregiver Chronic Stress
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The Body Keeps the ScoreBessel Van Der Kolk
Also: DSM‐V
Good News• 1990s: Brain Research Explodes
– Imaging Tools – Gene/DNA – “Neuroplasticity”
• Evidence‐based practice now possible. • Trauma changes the brain; some genes turn on and others off; nerve circuits change.
• PTSD and TBI research with advent of recent wars• Research is showing that NON‐pharmacological approaches are holding the most promise (pharmacological success has plateaued).
Bad News• Funding for NON‐pharmacological approaches is poor, results are under‐reported, and still wrongly considered a “soft” science.
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Three Modalities:
1. Medication to shut down inappropriate alarm systems (but also shut down frontal lobe).
2. Using the frontal cerebral cortex via: processing the trauma, connecting with others, etc.
3. Helping the body feel safe with experiences that contradict the helplessness of trauma.
Neruoplasticity Research:How the Brain Can be Changed
PTSD Medications• Serotonin Reuptake Inhibitors (like Prozac) are very
helpful x 6 months (then, symptoms tend to resume.)• Are needed to shut down inappropriate alarm
systems. • Play an important role, especially in two scenarios:
‐At the beginning of treatment when symptoms may be at their worst which prompted coming in for initial treatment‐Allow time to start the more LONG‐LASTING, but slower‐onset therapies that have been shown to re‐wire the brain to begin working (ie. BODY Therapies such as yoga) to begin working.
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Van der Kolk:
“The drug revolution that started out with so much promise may, in the end, have done as much harm as good.”
• Underlying issues are not addressed. • Be careful about medications that numb body sensations.
• Drugs can help control feelings and behaviors but can interfere with engagement, motivation, pleasure, dulling desirable parts of personhood.
• Use carefully and with discrimination.
Yoga: 10 weeks of Yoga practice markedly reduced PTSD symptoms of patients who had not responded to medications and other modalities.
Massage: Re‐trains the mind to feel physical sensations instead of numbing them; tolerate and enjoy touch.
EMDR/EFT/Neuro‐feedback: Go on internet for info
Neuroplasticity Research:Helping the Body Feel SAFE
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Primitive: Survival
Emotional Brain (Trauma imprints here)
(Limbic System)
Rational (Frontal Cortex)
Reflex: Doesn’t go up to the brain at all (Full maturation in mid‐20s)
Understanding Our Three Brains:The Big Picture
Fear is the Basis for our Survival…Competing
Adrenalin and Relaxation Pathways
Bias toward the “Negative,” Adrenalin PathwayDuring trauma, higher centers of brain NOT engaged.
(“lost my senses” or “couldn’t think straight”, “don’t know what I was thinking!”)
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Fear is the Basis for our Survival…Competing
Adrenalin and Relaxation Pathways
Bias toward the “Negative,” Adrenalin PathwayDuring trauma, higher centers of brain NOT engaged.
Understanding the Fear‐Based Brain
Sensory Cortex
ThalamusHypothalamus
Amygdala
Hippocampus
Amygdala Hijack:PTSD Begins
Amygdala stays ON
Healing: Toning down the amygdala byhelping it know that the body is safe.
Amygdala
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A Different Brain after Trauma:PTSD is, in fact, in your Head!
• Radical shift between the amygdala and the cortex makes it much harder to control emotions and impulses because the higher brain center goes off‐line and automatic responses take over.
• Stress hormones spike quickly to even small stimuli and take a longer time to return to normal levels (effects of cortisol).
• Brain’s filter system is DRAMATICALLY altered: Can’t take in GOOD stimuli and it focuses on BAD/Dangerous stimuli.
• Energy is spent trying to suppress inner chaos and the brain is less capable of spontaneous, present‐moment engagement.
• Coping: numbing what lower brain is feeling or acting out what the lower brain is feeling (often alternating between both).
A Different Brain after Trauma:The Result?
• Stop being curious about the world and instead become scared of it.
• Become wary of any further demands.
• Lose your self‐confidence.
• Can’t imagine a new future for yourself!
• Leads to hopelessness.
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Faulty Memory Regulatory SystemsSocial Memory
• Memories are in story context for social purposes.
• Flowing events: beginning, middle, end.
• Orderly sequence without large gaps.
• Don’t re‐live the
physical sensations, & intense emotions.
Trauma Memory
• PTSD Memories are INTRUSIVE, raw and fresh; separate, disorganized incomprehensible fragments
• Some details seared in and some left out completely; sequencing & context lost.
• PTSD Memories are dissociated. Not assembled into a story due to disconnections in brain at the time of trauma.
• Re‐live trauma, physical sensations, stark images
PTSD: Diminished Functioning of Left Brain
“Sequencing Center”Leads to less capacity to:
• Organize
• Create coherent plans
• Follow‐through on intentions
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After TraumaFlashbacks and reliving can become more
problematic than the original trauma. There’s no way of knowing when it’s going to recur. Loss of control.
Survival mode means emotional limbic system brain is pretty much running the show. Past feels alive and the present feels chronically unsafe.
Either:• Too hyper vigilant to enjoy everyday
pleasures• Too numb/dissociated to absorb new
experience or be alert to signs of real danger (become expert at ignoring their “gut” feelings), don’t defend self.
PTSD Hinders Relationships
• You stay defensive.
• Can’t be open.
• Isolation isn’t good for others.
• Isolation isn’t good for self.
• We are PROFOUNDLY social creature (Mirror cells in the brain).
• Mammals need to feel safe in their relationships. It’s the basis of survival.
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• Yoga (VDK: “Results would make front page news if it was a pharmaceutical.”)
• EMDR: 60% CURE rate!! (no other treatment or pharmaceutical can make that claim)
• EFT (VDK: “Single, most frequently intervention I use. Teach to clients BEFORE we explore the trauma.”
• Neuro‐Feedback: especially for children• Meditation: Scans of people who meditate LIGHT UP!• Massage: Re‐trains the mind to:
‐ feel physical sensations instead of numbing them ‐tolerate and enjoy touch and re‐connect with self.‐until a body feels safe to be touched, loved, it can’t reintegrate
because it will defend instead of stay open.
Body Therapies: Hold the most LONG‐TERM promise.
Research: What Helps
StoicismThe more out of touch with your feelings,
the more you cannot sense your body,
the more you will exile parts of your self holding these feelings into unconsciousness.
But they still register in the body!
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What HelpsRe‐Home Exiled Parts of Self?
Re‐Visiting, NOT Re‐living
•Occurs in the Right Brain where trauma and sensations are stored.•Re‐living re‐traumatizes and activates the emotional brain where the memories are stored.•De‐sensitization therapy (re‐living) helps with phobias (ex: spiders, germs, etc.) NOT trauma. •It can cause even further numbing and disconnection (ex: berated kids who numb out yelling parents good that a kid can numb that out, but kid will grow into an adult!)•Don’t plunge into trauma stories until people feel safe in their bodies (ex: EFT)
Re‐living
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•Done in Left Brain •Needs to be done with self‐compassion in order to re‐home.•Writing to address personal trauma impact research study:3 groups writing on:‐a topic‐their trauma ‐how their trauma impacted them ‐ONLY the LAST group had dramatic improvement.
Writing to yourself IS POWERFUL.
Re‐Visiting
Clinicians: Keep Both Brains On‐LineDevelop a Zone of Tolerance
• Acting out when triggered. Get them talking about it. • Numb out when triggered, DON’T have them talk, have them
notice the sensations they are feeling.
• Numbed out ‐‐‐‐‐‐‐window‐‐‐‐‐‐‐‐ Acting out vigilanceof tolerance
Numbing end of the spectrum harder to treat than acting outActing out is re‐living what you can’t remember.
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Van der Kolk: Resilience
• All who survive trauma are resilient in their own way, even those who commit suicide or who become alcoholics.
• Don’t insult people by telling them they should be more resilient!
• Respect what they have been through. There is a reason they are doing what they are doing.
• Instead, help them feel safe in their bodies.
Grassman: Resilience
• Resilience is not an infusion. Don’t try to instill it.
• Resilience is a quality of the soul that is innate. It’s already there. It’s a matter of uncovering it.
• How to uncover?
• Unmourned loss and unforgiven guilt.
• Effect of telling people to be more resilient?
• More guilt.
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Factors Influencing the Development of PTSD
Research: Identifies many, but there are two consistent front runners:
• Lack of Support when trauma occurred
• Helpless to fight or flight
Not getting needed support and protection at the time of the occurrence(s).
• 9/11 vs. Katrina stats.
• WWII kids stats
• Combat: no time, place + stoic culture discourages.
• Abused child: abuser is the person who should be supporting/protecting
A‐L‐O‐N‐E
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• Not being able to either fight/flee the trauma. (Leaves the stress chemicals circulating in the body where they get stored into body memory).
• PTSD is largely caused by immobilization (helpless)
Helpless to fight or flight
Helplessness at End of life
• As traumatized Veterans get weaker, come to hospice, they start feeling HELPLESS. They are losing control. Makes them MORE controlling, even agitated.
• We give an anti‐anxiety medication, it does not calm them down, it makes them more agitated (paradoxical reaction). Why?
• Anti‐anxiety medication decreases your control, makes you feel helpless, and that feeling acts as a trigger for the original trauma.
• Intervention: Help people come to peace with their helplessness. Hand‐Heart connection.
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Agitated Nursing Home Patient?Think PTSD
“I can do this.”Connecting with part of herself
holding painful memories.
Neurons that fire togetherwire together!
Replace trusting fear with trusting self again.Anxious energy vs. connected with self
Personal application today: self and others.Resist urge to help her leave!
(But don’t overwhelm)
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Becoming Buddies with our Soul:It Starts with the Brain
RE‐WIRING Old HardwareINSTALLING New Software
Important for Healing:Parts of the Brain
that Give Us a Sense of Self (ME)Anterior Cingulate
Medial Prefrontal Cortex
Orbital Prefrontal Cortex
Insula
Posterior Cingulate
Center corridor of the Brain: SENSE OF SELFAfter trauma: scans show markedly lower activity
Can’t feel or evaluate internal sensations
Healing: Activate the “ME” brain
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Holds on to “bad”: Survival
GOOD flows through: Head vs. Heart
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+
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+
+
++++
Brain Acts as a Sieve Separator
Behold, Behold, Behold: 5‐10 sec
Laughter is the Best Medicine
Laughter involves:
• Cortex
• Hippocampus Endorphin Release
• Amygdala (natural pain and stress reducer chemical)
Other Benefits:
• Dilates blood vessels increasing blood flow
• Reduces inflammation
• Boosts immune response
• Reduces levels of stress hormones: cortisol, epinephrine (adrenalin)
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Beauty
Breathing• Gasp vs. Sigh of Relief
• Stillness after exhalation
• We come in on an in‐breath
• We go out on an out‐breath
• Heart Rate Variability Marker (reflects functioning of emotional brain)
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“Took my Breath Away”• Is the AUTOMATIC response
• THEN, can apply the rational brain to decide to let your breath be taken or to breathe. (It takes 3‐5x longer to counteract stress stimuli). Plus, it takes several seconds for the memory trace to be transferred from short‐term to long‐term memory) So, have to linger in the counteraction.
• Need a Guide who is not afraid.
Re‐Homing: A Personal Example•In my 20s, lost, no sense of self: mother, husband, 2 toddlers. •Yoga gave me a sense of self. Activated my ME brain. Has been a lifesaver throughout my life.•Few years ago I suffered a trauma that caused PTSD. Triggers would cause me to “disappear” – leave. •Bicycling.
Activating “ME” BrainRe‐training Amygdala
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Mindfulness
• Progressive Relaxation (top down, not bottom up due to tendency of traumatized to dissociate and escape body)
• Body awareness
No Need to Feel Guilty for:
• The built‐in, hard‐wiring circuitry of your human brain.
• The PTSD you may now suffer.
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Do Need to Feel Responsible for:
• Developing self‐compassion and kindness for decisions you made in the past.
• Awakening parts of your body where memories are currently stored.
• Transforming your brain by installing new software.
• Cultivating Honesty, COURAGE, and Humility to do the work.
Relevant Anatomy: Clinical Application
2 Anatomical Re‐minders:
• Amygdala Hijack: Needs de‐activated (calmed down)
• “Me” Brain: Needs activation
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Do you Still Think that Past Trauma isn’t Relevant NOW?
“The greatest sources of our suffering
are the lies we tell ourselves.” ‐Elvin Semrad
Psychiatrist(Bessel Van Der Kolk’s teacher)
Soul Injury FilmEvent Format• Locally‐assembled panel to provide commentary and answer audience questions• 2 CEs for Nurses, Social Workers, Clergy, Alcoholism and Drug Abuse Counselors,
Addiction Professionals, Marriage & Family Therapy, Mental Health Counseling, Death Education and Counseling, Nursing Home Administrators, Psychologists
Materials include:• Panel Discussion Manual• Marketing & Strategizing Guidelines• “Ask Me about Soul Injury” buttons • Congressional “Soul Injury Awareness Month” National Proclamation• Monthly Insight ActivitiesCost: $25 for the on‐demand webcast and $50 (plus $9 for shipping and handling) for
the DVD.To register:
• Go to https://hospicefoundation.org/HFA‐Products/Soul‐Injury
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Stay in Touch!
Leave your business card with me (or write email address on paper)
www.OpusPeace.org or www.Soulinjury.org (Tools, Blogs)