TRAUMA, THE FREEZE RESPONSE AND ITS CLINICAL SYNDROMES ROBERT SCAER, M'D' scaermdpcmsn'com www'traum

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TRAUMA,THE FREEZE RESPONSEAND ITS
CLINICALSYNDROMESROBERT SCAER,
M.D.scaermdpc_at_msn.comwww.traumasoma.com
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RENE 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

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THE 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

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THE 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

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THE 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

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MINDBRAINBODY

• 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

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THE ROOTS OF TRAUMA

• A THREAT TO LIFE
• IN THE FACE OF HELPLESSNESS
• THE FIGHT /FLIGHT / FREEZE RESPONSE

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THE FREEZE RESPONSE

• NUMBING THROUGH ENDORPHINS
• VAGAL (PARASYMPATHETIC) TONE
• BIMODAL SYMPATHETIC /
• PARASYMPATHETIC CYCLING
• (ACCELERATOR / BRAKE
• ANALOGY)

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LESSONS FROM THE WILDTHE CRITICAL
IMPORTANCEOF DISCHARGINGTHE FREEZE RESPONSE
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FREEZE/IMMOBILIZATIONAND SURVIVAL

• BABY CHICKS
• NOT
• IMMOBILIZED IMMOBILIZED IMMOBILIZED
  
• SPONTANEOUS FORCED
• RECOVERY RECOVERY
• BEST INTERMEDIATE WORST
• DROWNING DROWNING DROWNING
• SURVIVAL SURVIVAL
  SURVIVAL

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ANIMALS 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!

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ENDORPHINS 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

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CEREBRAL 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
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THE HYPOTHALAMIC/PITUITARY/ADRENAL AXIS
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THE 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

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TRAUMA 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

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MEMORY MECHANISMS IN TRAUMA

• DECLARATIVE (EXPLICIT) MEM0RY
• - FACTS AND EVENTS
• NON-DECLARATIVE (IMPLICIT) MEMORY
• - EMOTIONAL ASSOCIATIONS
• - PROCEDURAL MEMORY
• -SKILLS AND HABITS
• - CONDITIONED SENSORIMOTOR
• RESPONSES

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MEMORY 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

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TRAUMA AS A MODEL OF CONDITIONING ANDPROCEDURAL
MEMORY

• A CAPSULE OF PROCEDURAL MEMORY CUES FOR
• - SOMATOSENSORY,
• - EMOTIONAL,
• - AND AUTONOMIC FEELINGS
• - AND EMOTION-LINKED
• DECLARATIVE MEMORY

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KINDLING / NEUROSENSITIZATION

• THE DEVELOPMENT OF
• SELF-PERPETUATING
• NEURAL CIRCUITS
• THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES OF
  A TRAUMA

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WHAT LIFE EVENTSCONSTITUTEA TRAUMATIC
EXPERIENCE?
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THOSE LIFE EXPERIENCES MOST LIKELY TO CAUSE
TRAUMATIZATION HAVE MEANING FOR SURVIVAL OF THE
ORGANISM
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WHY DO THE MAJORITY OF TRAUMA VICTIMS EXPOSED TO
TRAUMA NOT DEVELOP PTSD?WHY DO SOME VICTIMS
EXPOSED TO MINOR TRAUMATIC EVENTSDEVELOP PTSD?
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RESILIENCY / 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

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THE ROLE OFDEVELOPMENTALNEUROBIOLOGYIN
RESILIENCE TOTRAUMA
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THE 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

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LEARNED HELPLESSNESS

• ONCE YOU FREEZE
• YOU TEND TO
• FREEZE AGAIN!

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THE LEGACY OFIMPAIRED ATTACHMENT AND
DEVELOPMENTAL TRAUMA

• A LIFETIME OF
• AUTONOMIC
• AND EMOTIONAL
• DYSREGULATION

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(No Transcript)
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SYMPATHETIC SYMPTOMS IN PTSD

• AROUSAL, ANXIETY,
• PANIC, PHOBIAS,
• MUSCULAR BRACING, TREMOR, PAIN, TACHYCARDIA

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PARASYMPATHETIC SYMPTOMS IN PTSD

• CRAMPS, DIARRHEA, INDIGESTION, FATIGUE,
  WEAKNESS, COLLAPSE, NUMBING, BRADYCARDIA,
  CONSTRICTION, COGNITIVE DULLING

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SYNDROMES OF CHRONIC PTSD

• PARASYMPATHETIC DOMINENCE
• DEPRESSION,
• DISSOCIATION,
• SOMATIZATION,
• AFFECT DYSREGULATION,
• SOCIAL WITHDRAWAL

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DISSOCIATION 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

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DISSOCIATION?THE PERCEPTUAL COMPONENT OF
THE FREEZE RESPONSE?
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THE VAGUS NERVE COMPLEX

• VAGAL NUCLEI PROMOTE ENERGY CONSERVATION
  THROUGH CONTROL OF CARDIOVASCULAR AND VISCERAL
  FUNCTION

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THE 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

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POSTTRAUMATICREGIONAL CYCLICAL AUTONOMIC AND
ENDOCRINE DYSREGULATIONA COMMON LINK TO MANY
PSYCHOSOMATIC DISORDERS
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DISORDERS OFREGULATION

• CYCLICAL SYMPATHETIC /
• PARASYMPATHETIC SYMPTOMS
• SUBTLE OR NO PHYSICAL FINDINGS
• NO DEFINITIVE DIAGNOSTIC LABORATORY FINDINGS
• ie PSYCHOSOMATIC DISORDERS

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THAT REGIONOR PART OF THE BODYTHAT PROVIDES
SENSORY INPUT TO THE BRAINREGARDING A TRAUMATIC
EVENTMAY LATER BE SUBJECTED TOSELECTIVE
REGIONALAUTONOMIC DYSREGULATIONTHROUGH THE
PROCESS OFDISSOCIATION
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SOMATIC DISSOCIATION

• SPLITTING OFF OF A REGION OF THE BODY FROM NORMAL
  CONSCIOUS PERCEPTION THAT RESULTS IN A
  PHYSIOLOGICAL CHANGE IN THAT BODY REGION

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THE 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

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REFLEX SYMPATHETIC DYSTROPHY

• REGIONAL AUTONOMIC VASOMOTOR DYSREGULATION WITH
  BURNING
• PAIN (CAUSALGIA)
• TROPHIC AND DYSTROPHIC
  MANIFESTATIONS
• AVOIDANCE, DYSTONIA,
• HYPERPATHIA, HYPERALGESIA
• RELATIONSHIP TO TRAUMA

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CHILDHOOD 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

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WHIPLASH AND PTSDA MODELFOR THESOMATIC
MANIFESTATIONS OF TRAUMA
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THE 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

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DEMOLITIONS 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

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THE 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

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THE 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

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THE WHIPLASH SYNDROME

• A CONSISTENT AND REPRODUCIBLE SYMPTOM COMPLEX
• i.e. A SYNDROME,
• BUT ONE WITHOUT A LOGICAL
• PATHOPHYSIOLOGICAL BASIS

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WHIPLASHRECONSTRUCTEDTHE GAIN IN PAINLIES
MAINLYIN THE BRAIN
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SYNDROMES OF PROCEDURAL MEMORY

• WHIPLASH SYNDROME
• MYOFASCIAL PAIN
• PIRIFORMIS SYNDROME
• CUMULATIVE TRAUMA DISORDER
• PHANTOM LIMB / CHRONIC PAIN
• TICS (HABIT SPASM)
• TORTICOLLIS

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SYNDROMES OF PROCEDURAL MEMORY

• STUTTER
• SPASTIC DYSPHONIA
• PREMENSTRUAL SYNDROME
• POSTPARTUM DEPRESSION /
• PSYCHOSIS
• MULTIPLE CHEMICAL SENSITIVITIES

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DISEASES OF SOMATIC DISSOCIATION

• REFLEX SYMPATHETIC DYSTROPHY
• MYOFASCIAL PAIN
• ? SJOGRENS SYNDROME
• ? INTERSTITIAL CYSTITIS

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DISEASES OF FREEZE / DISSOCIATION

• FIBROMYALGIA / CHRONIC FATIGUE SYNDROME
• IRRITABLE BOWEL SYNDROME (IBS)
• GASTRO-ESOPHAGEAL REFLUX DISEASE (GERDS)
• MITRAL VALVE PROLAPSE / DYSAUTONOMIA
• MIGRAINE
• ASTHMA

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FIBROMYALGIA

• DIFFUSE SOFT TISSUE PAIN
• TENDER POINTS
• NON-RESTORATIVE SLEEP
• CHRONIC FATIGUE
• ALLERGIC (HYPERIMMUNE) SYMPTOMS

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FIBROMYALGIA

• DEPRESSION
• COGNITIVE IMPAIRMENT
• NEUROLOIC SYMPTOMS
• - NUMBNESS
• - OCULAR SYMPTOMS
• - COGNITIVE / EMOTIONAL SYMPTOMS

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FIBROMYALGIA CHEMISTRY

• DECREASED SEROTONIN, TRYPTOPHAN
• DECREASED SERUM CORTISOL
• UNSTABLE HPA AXIS
• INCREASED CSF SUBSTANCE P

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DISORDERS OFCOGNITION AND SLEEP

• ATTENTION DEFICIT / HYPERACTIVITY DISORDER
• COGNITIVE DEFICITS IN TRAUMA
• SLEEP DISORDERED BREATHING /
• SLEEP APNEA
• ? NARCOLEPSY

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ENDOCRINE 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

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DISEASES OFIMMUNE AND ENDOCRINEDYSFUNCTION

• AUTOIMMUNE DISEASES
• - SYSTEMIC LUPUS, RHEUMATOID ARTHRITIS,
  MULTIPLE SCLEROSIS, GRAVES DISEASE,
  THYROIDITIS, TYPE I DIABETES
• ENDOCRINE DISORDERS
• - AMENORRHEA, MYXEDEMA

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CONCLUSIONS

• PSYCHOLOGICAL
• (SOMATIFORM, CONVERSION)
• SYMPTOMS NOT ONLY
• REPRESENT CHANGES IN
• BRAIN PHYSIOLOGY, BUT
• PATHOPHYSIOLOGICAL
• CHANGES IN THE
• SYMPTOMATIC ORGAN

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CONCLUSIONS

• MANY UNEXPLAINED PHYSICAL SYNDROMES AND DISEASES
  MAY BE EXPLAINED BY THIS PATHOPHYSIOLOGICAL MODEL

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CONCLUSIONS

• MEDICAL SCIENCE MUST SHED THE CONCEPT THAT A
  SYMPTOM NOT MEASURABLE BY CURRENT TECHNOLOGY IS
  PSYCHOLOGICAL, AND THEREFORE INVALID.

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CONCLUSIONS

• PHYSICIANS MUST REJECT THE PEJORATIVE IMPLICATI0N
  OF THE TERM PSYCHOSOMATIC, AND END FURTHER
  TRAUMATIZATION OF PATIENTS BY THIS ATTITUDE.