Title: TRAUMA, THE FREEZE RESPONSE AND ITS CLINICAL SYNDROMES ROBERT SCAER, M'D' scaermdpcmsn'com www'traum
1TRAUMA,THE FREEZE RESPONSEAND ITS
CLINICALSYNDROMESROBERT SCAER,
M.D.scaermdpc_at_msn.comwww.traumasoma.com
2RENE DESCARTES
- 18TH CENTURY PHILOSOPHER CREDITED (BLAMED) FOR
CARTESIAN DUALISM -
- THE RATIONAL MIND OR SPIRIT ARE SEPARATE FROM
THE AFFAIRS OF THE BODY - - PSYCHOLOGICAL VS. PHYSICAL
- - MENTAL ILLNESS VS. PHYSICAL ILLNESS
- - PSYCHOSOMATIC / SOMATIZATION AN
EMOTIONAL CAUSE FOR AN ILLNESS OR SYMPTOM
3THE MIND / BRAIN / BODY CONTINUUM
- THE BODY
- A SET OF SPECIALIZED SYSTEMS WHOSE FUNCTION AND
STRUCTURE ARE DETERMINED BY BRAIN PROCESSES, AND
WHOSE EXPERIENCE IN TURN INFLUENCES AND CHANGES - BRAIN PROCESSES AND STRUCTURE
4THE MIND / BRAIN / BODY CONTINUUM
- THE BRAIN
- A PLASTIC, FLUID AND EVER-CHANGING ELECTRICAL /
CHEMICAL SYSTEM WITH NEW SYNAPSES AND NEURONS
GENERATED BY CHANGING EXPERIENCE AS OLD ONES ARE
DISCARDED
5THE MIND / BRAIN / BODY CONTINUUM
- THE MIND
- A PERCEPTUAL EXPERIENCE
- GENERATED BY
- A COMPLEX SET OF SYNAPSES,
- NEURONS AND NEUROCHEMICAL STATES, DETERMINED BY
INSTINCT, - GENES AND EXPERIENCE
6MINDBRAINBODY
- ALL EXPERIENCES THAT ARE PERCEIVED BY THE BRAIN,
CONSCIOUSLY OR UNCONSCIOUSLY, CHANGE BOTH THE
BRAIN AND THE REGION OF THE BODY RECEIVING THE
MESSAGE OF THE EXPERIENCE - i.e NO PHYSICAL OR EMOTIONAL SYMPTOM IS
PSYCHOLOGICAL
7THE ROOTS OF TRAUMA
- A THREAT TO LIFE
- IN THE FACE OF HELPLESSNESS
- THE FIGHT /FLIGHT / FREEZE RESPONSE
8THE FREEZE RESPONSE
- NUMBING THROUGH ENDORPHINS
- VAGAL (PARASYMPATHETIC) TONE
- BIMODAL SYMPATHETIC /
- PARASYMPATHETIC CYCLING
- (ACCELERATOR / BRAKE
- ANALOGY)
9LESSONS FROM THE WILDTHE CRITICAL
IMPORTANCEOF DISCHARGINGTHE FREEZE RESPONSE
10FREEZE/IMMOBILIZATIONAND SURVIVAL
- BABY CHICKS
- NOT
- IMMOBILIZED IMMOBILIZED IMMOBILIZED
- SPONTANEOUS FORCED
- RECOVERY RECOVERY
- BEST INTERMEDIATE WORST
- DROWNING DROWNING DROWNING
- SURVIVAL SURVIVAL
SURVIVAL
11ANIMALS 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!
12ENDORPHINS 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
-
-
13CEREBRAL CORTEX HYPOTHALAMUS HPA AXIS
ORBITOFRONTAL CORTEX ORGANIZES RESPONSE TO
THREAT
SENSORY INPUT HEAD AND NECK
ANTERIOR CINGULATE GYRUS MODULATES AMYGDALA
HIPPOCAMPUS DECLARATIVE MEMORY COGNITIVE MEANING
AMYGDALA EMOTIONAL CONTENT
LOCUS CERULEUS EARLY WARNING
14THE HYPOTHALAMIC/PITUITARY/ADRENAL AXIS
15THE HPA AXIS IN TRAUMA
- INITIAL INCREASE IN CRF
- INITIAL INCREASE IN SERUM CORTISOL
- LATE PTSD DECREASED BASELINE CORTISOL, BUT
INCREASED - CORTISOL RELEASE WITH NEW TRAUMA
- i.e. SENSITIZED HPA AXIS
16TRAUMA DAMAGES THE BRAIN
- CORTISOL AND THE HIPPOCAMPUS
- - DECREASED BRANCHING, NEURONAL DEATH
HIPPOCAMPAL ATROPHY - - GLUTAMATE AND NMDA RECEPTORS
- IMAGING STUDIES IN PTSD
- - SCRIPT-DRIVEN IMAGERY
- DECREASED PERFUSION, RIGHT MEDIAL PREFRONTAL
CORTEX AND - HIPPOCAMPUS, BROCAS AREA
17MEMORY MECHANISMS IN TRAUMA
- DECLARATIVE (EXPLICIT) MEM0RY
- - FACTS AND EVENTS
- NON-DECLARATIVE (IMPLICIT) MEMORY
- - EMOTIONAL ASSOCIATIONS
- - PROCEDURAL MEMORY
- -SKILLS AND HABITS
- - CONDITIONED SENSORIMOTOR
- RESPONSES
18MEMORY 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
19TRAUMA AS A MODEL OF CONDITIONING ANDPROCEDURAL
MEMORY
- A CAPSULE OF PROCEDURAL MEMORY CUES FOR
- - SOMATOSENSORY,
- - EMOTIONAL,
- - AND AUTONOMIC FEELINGS
- - AND EMOTION-LINKED
- DECLARATIVE MEMORY
20KINDLING / NEUROSENSITIZATION
- THE DEVELOPMENT OF
- SELF-PERPETUATING
- NEURAL CIRCUITS
- THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF
A TRAUMA
21WHAT LIFE EVENTSCONSTITUTEA TRAUMATIC
EXPERIENCE?
22THOSE LIFE EXPERIENCES MOST LIKELY TO CAUSE
TRAUMATIZATION HAVE MEANING FOR SURVIVAL OF THE
ORGANISM
23WHY DO THE MAJORITY OF TRAUMA VICTIMS EXPOSED TO
TRAUMA NOT DEVELOP PTSD?WHY DO SOME VICTIMS
EXPOSED TO MINOR TRAUMATIC EVENTSDEVELOP PTSD?
24RESILIENCY / VULNERABILITY TO TRAUMA
- VULNERABILITY
- FEAR-CONDITIONED AND KINDLED VULNERABILITY TO
RETRAUMATIZATION BASED ON THE PRIOR CUMULATIVE
BURDEN OF LIFE TRAUMA - WE MUST REEXPLORE WHAT WE DEFINE AS TRAUMA,
ESPECIALLY IN INFANCY AND CHILDHOOD
25THE ROLE OFDEVELOPMENTALNEUROBIOLOGYIN
RESILIENCE TOTRAUMA
26THE 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
27LEARNED HELPLESSNESS
- ONCE YOU FREEZE
- YOU TEND TO
- FREEZE AGAIN!
28THE LEGACY OFIMPAIRED ATTACHMENT AND
DEVELOPMENTAL TRAUMA
- A LIFETIME OF
- AUTONOMIC
- AND EMOTIONAL
- DYSREGULATION
29(No Transcript)
30SYMPATHETIC SYMPTOMS IN PTSD
- AROUSAL, ANXIETY,
- PANIC, PHOBIAS,
- MUSCULAR BRACING, TREMOR, PAIN, TACHYCARDIA
31PARASYMPATHETIC SYMPTOMS IN PTSD
- CRAMPS, DIARRHEA, INDIGESTION, FATIGUE,
WEAKNESS, COLLAPSE, NUMBING, BRADYCARDIA,
CONSTRICTION, COGNITIVE DULLING
32SYNDROMES OF CHRONIC PTSD
- PARASYMPATHETIC DOMINENCE
- DEPRESSION,
- DISSOCIATION,
- SOMATIZATION,
- AFFECT DYSREGULATION,
- SOCIAL WITHDRAWAL
33DISSOCIATION PSYCHOBIOLOGY
- SCHORE (2005)vagal outflow from the dorsal
vagal nucleus is the psychobiological engine of
dissociation - early trauma expressed as emotional neglect and
abusepredictdissociation. - i.e. IMPAIRED ATTACHMENT AND RIGHT O.F.C.
DEVELOMENT LEADS TO AUTONOMIC DYSREGULATION, AND
THE EMERGENCE OF DORSAL VAGAL FREEZE /
DISSOCIATIVE STATES
34DISSOCIATION?THE PERCEPTUAL COMPONENT OF
THE FREEZE RESPONSE?
35THE VAGUS NERVE COMPLEX
- VAGAL NUCLEI PROMOTE ENERGY CONSERVATION
THROUGH CONTROL OF CARDIOVASCULAR AND VISCERAL
FUNCTION
36THE DORSAL VAGUS NERVE
- THE DORSAL VAGAL COMPLEX (DVC)
- - THE DORSAL VAGAL NUCLEUS
- - PRIMITIVE, REPTILIAN
- - LOW O2 UTILIZATION
- - THE DIVE REFLEX (APNEA, BRADYCARDIA)
- - THE FREEZE RESPONSE, THE
- RISK IN MAMMALS, AND
- VOODOO DEATH
37POSTTRAUMATICREGIONAL CYCLICAL AUTONOMIC AND
ENDOCRINE DYSREGULATIONA COMMON LINK TO MANY
PSYCHOSOMATIC DISORDERS
38DISORDERS OFREGULATION
- CYCLICAL SYMPATHETIC /
- PARASYMPATHETIC SYMPTOMS
- SUBTLE OR NO PHYSICAL FINDINGS
- NO DEFINITIVE DIAGNOSTIC LABORATORY FINDINGS
- ie PSYCHOSOMATIC DISORDERS
39THAT REGIONOR PART OF THE BODYTHAT PROVIDES
SENSORY INPUT TO THE BRAINREGARDING A TRAUMATIC
EVENTMAY LATER BE SUBJECTED TOSELECTIVE
REGIONALAUTONOMIC DYSREGULATIONTHROUGH THE
PROCESS OFDISSOCIATION
40SOMATIC DISSOCIATION
- SPLITTING OFF OF A REGION OF THE BODY FROM NORMAL
CONSCIOUS PERCEPTION THAT RESULTS IN A
PHYSIOLOGICAL CHANGE IN THAT BODY REGION
41THE STIGMATA ENIGMA
- REPLICATION OF THE WOUNDS OF CHRIST
- APPEARANCE IN ECSTATICS, DEVOUT CHRISTIANS
PRONE TO RELIGIOUS TRANCE-LIKE STATES
(?DISSOCIATION) - APPEARANCE ON THURSDAYS AND FRIDAYS, THE DAYS
OF CHRISTS PASSION - CONFIRMED IN MANY STUDIES, INCLUDING BY JANET
- STIGMATA IN CLINICAL PRACTICE
- THIS DOES NOT DIMINISH THE SACRED NATURE OF
RELIGIOUS STIGMATA
42REFLEX SYMPATHETIC DYSTROPHY
- REGIONAL AUTONOMIC VASOMOTOR DYSREGULATION WITH
BURNING - PAIN (CAUSALGIA)
- TROPHIC AND DYSTROPHIC
MANIFESTATIONS - AVOIDANCE, DYSTONIA,
- HYPERPATHIA, HYPERALGESIA
- RELATIONSHIP TO TRAUMA
43CHILDHOOD TRAUMA AND DISEASE IN ADULT LIFE
- FELITTI, AJPM, 1998
- THE ACE STUDY
- GRADED CORRELATION BETWEEN THE SEVERITY OF
CHILDHOOD TRAUMA AND THE LEADING CAUSES OF DEATH - -HEART DISEASE, CANCER, COPD, FRACTURES, LIVER
DISEASE, OBESITY, ALCOHOLISM, SUICIDE
44WHIPLASH AND PTSDA MODELFOR THESOMATIC
MANIFESTATIONS OF TRAUMA
45THE DILEMMAS OF WHIPLASH
- DISABILITY EXCEEDS SEVERITY OF MVA
- DELAYED ONSET OF SYMPTOMS
- DIAGNOSIS OF MTBI IN LOW VELOCITY ACCIDENTS
- SYMPTOM MAGNIFICATION AND SOMATIZATION
- PERMANENCE OF SOFT TISSUE INJURIES
- POST-CONCUSSION SYNDROME QUANDRY
46DEMOLITIONS DERBY DRIVERS
- 40 DERBY DRIVERS
- AVERAGE NUMBER OF DERBIES
- - 11 PAST 3 YEARS, 30 OVER CAREER
- AVERAGE NUMBER OF ACCIDENTS
- - 48 CRASHES / DERBY, 54 REAR END
- NECK PAIN INCIDENCE
- - 27 DRIVERS PAIN lt 21 DAYS
- - 2 DRIVERS PAIN gt 3 MONTHS
- - 1 DRIVER PAIN gt 1 YEAR
47THE WHIPLASH SYNDROME
- CHRONIC PAIN
- -CERVICAL AND LUMBAR MYOFASCIAL PAIN
- -TEMPOROMANDIBULAR JOINT SYNDROME
- -POST-TRAUMATIC HEADACHE
- -THORACIC OUTLET SYNDROME
- NEUROLOGIC SYMPTOMS (POST- CONCUSSION SYNDROME)
- -COGNITIVE IMPAIRMENT
- -AUDITORY/VESTIBULAR SYMPTOMS
- -VISUAL SYMPTOMS
- -AUTONOMIC SYMPTOMS
48THE WHIPLASH SYNDROME
- PSYCHOLOGICAL SYMPTOMS
- ANXIETY, PANIC ATTACKS, PHOBIAS
- NIGHTMARES, IMPAIRED SLEEP MAINTENANCE
- IRRITABILITY, MOOD CHANGES, LABILE EMOTIONS
- STIMULUS SENSITIVITY, EXAGGERATED STARTLE
- CHRONIC FATIGUE
- SOMATIZATION AND DEPRESSION
49THE WHIPLASH SYNDROME
- A CONSISTENT AND REPRODUCIBLE SYMPTOM COMPLEX
- i.e. A SYNDROME,
- BUT ONE WITHOUT A LOGICAL
- PATHOPHYSIOLOGICAL BASIS
50WHIPLASHRECONSTRUCTEDTHE GAIN IN PAINLIES
MAINLYIN THE BRAIN
51SYNDROMES OF PROCEDURAL MEMORY
- WHIPLASH SYNDROME
- MYOFASCIAL PAIN
- PIRIFORMIS SYNDROME
- CUMULATIVE TRAUMA DISORDER
- PHANTOM LIMB / CHRONIC PAIN
- TICS (HABIT SPASM)
- TORTICOLLIS
52SYNDROMES OF PROCEDURAL MEMORY
- STUTTER
- SPASTIC DYSPHONIA
- PREMENSTRUAL SYNDROME
- POSTPARTUM DEPRESSION /
- PSYCHOSIS
- MULTIPLE CHEMICAL SENSITIVITIES
53DISEASES OF SOMATIC DISSOCIATION
- REFLEX SYMPATHETIC DYSTROPHY
- MYOFASCIAL PAIN
- ? SJOGRENS SYNDROME
- ? INTERSTITIAL CYSTITIS
54DISEASES OF FREEZE / DISSOCIATION
- FIBROMYALGIA / CHRONIC FATIGUE SYNDROME
- IRRITABLE BOWEL SYNDROME (IBS)
- GASTRO-ESOPHAGEAL REFLUX DISEASE (GERDS)
- MITRAL VALVE PROLAPSE / DYSAUTONOMIA
- MIGRAINE
- ASTHMA
55FIBROMYALGIA
- DIFFUSE SOFT TISSUE PAIN
- TENDER POINTS
- NON-RESTORATIVE SLEEP
- CHRONIC FATIGUE
- ALLERGIC (HYPERIMMUNE) SYMPTOMS
56FIBROMYALGIA
- DEPRESSION
- COGNITIVE IMPAIRMENT
- NEUROLOIC SYMPTOMS
- - NUMBNESS
- - OCULAR SYMPTOMS
- - COGNITIVE / EMOTIONAL SYMPTOMS
57FIBROMYALGIA CHEMISTRY
- DECREASED SEROTONIN, TRYPTOPHAN
- DECREASED SERUM CORTISOL
- UNSTABLE HPA AXIS
- INCREASED CSF SUBSTANCE P
58DISORDERS OFCOGNITION AND SLEEP
- ATTENTION DEFICIT / HYPERACTIVITY DISORDER
- COGNITIVE DEFICITS IN TRAUMA
- SLEEP DISORDERED BREATHING /
- SLEEP APNEA
- ? NARCOLEPSY
59ENDOCRINE AND IMMUNE RESPONSES IN TRAUMA
- LOW SERUM CORTISOL, SENSITIZED HPA AXIS IN LATE
PTSD - INCREASED IMMUNE STATE (SENSITIZED PERIPHERAL
LYMPHOCYTES) IN LATE PTSD - POSSIBILITIES OF DISEASES OF THYROID, ADRENAL,
MENSTRUAL AND IMMUNE DYSFUNCTION
60DISEASES OFIMMUNE AND ENDOCRINEDYSFUNCTION
- AUTOIMMUNE DISEASES
- - SYSTEMIC LUPUS, RHEUMATOID ARTHRITIS,
MULTIPLE SCLEROSIS, GRAVES DISEASE,
THYROIDITIS, TYPE I DIABETES - ENDOCRINE DISORDERS
- - AMENORRHEA, MYXEDEMA
-
61CONCLUSIONS
- PSYCHOLOGICAL
- (SOMATIFORM, CONVERSION)
- SYMPTOMS NOT ONLY
- REPRESENT CHANGES IN
- BRAIN PHYSIOLOGY, BUT
- PATHOPHYSIOLOGICAL
- CHANGES IN THE
- SYMPTOMATIC ORGAN
62CONCLUSIONS
- MANY UNEXPLAINED PHYSICAL SYNDROMES AND DISEASES
MAY BE EXPLAINED BY THIS PATHOPHYSIOLOGICAL MODEL
63CONCLUSIONS
- MEDICAL SCIENCE MUST SHED THE CONCEPT THAT A
SYMPTOM NOT MEASURABLE BY CURRENT TECHNOLOGY IS
PSYCHOLOGICAL, AND THEREFORE INVALID.
64CONCLUSIONS
- PHYSICIANS MUST REJECT THE PEJORATIVE IMPLICATI0N
OF THE TERM PSYCHOSOMATIC, AND END FURTHER
TRAUMATIZATION OF PATIENTS BY THIS ATTITUDE.