Sexual Assault Victim Issues and Impact

download report

Transcript Sexual Assault Victim Issues and Impact

Why Survivors of Trauma Feel and Act the Way
They Do: Understanding the Neurobiology of
 Janine M. D’Anniballe, Ph.D.
 Children’s Roundtable Summit
 Seven Springs, PA
The Stress-Trauma Continuum
 Normal
 Situational
 Traumatic
What is Trauma?
Physical, sexual abuse, neglect
Domestic violence
School or gang violence
Divorce/custody battle
Natural Disasters
Severe motor vehicle accidents
Witnessing or hearing about any of the above
Trauma and Culture
 Cultural/Gender
differences in the
perception and expression
of trauma
 Historical trauma
 Forms of traumatic injury
 Psychological
 Spiritual
 Brain/Body
Trauma Symptoms as Adaptations
Substance abuse
Indiscriminant sexual behavior
Self-harm and suicidal gestures
Continued contact with the abuser
The freeze response
Avoidance or withdrawal
Eating disorders
Engaging in high risk behaviors
The Neurobiology of Trauma
Trauma is not purely a psychological issue
The past becomes present because of the
way that the brain dysregulates and changes
after traumatic events
What fires together wires together
Trauma “echoes” in the brain – and treatment
needs to quiet the reverberations of the echo
Neurobiology of Trauma
Synaptic Activity
More on the Sympathic Nervous System Response
 HPA axis: hypothalamic-pituitary-adrenal
 This system is responsible for bringing the body back into
 The following chemicals/hormones are released:
 Catecholamines (epinephrine and norepinephrine) –
responsible for fight or flight
 Corticosteroids (glucocorticoids, cortisol) – control energy
and body’s immune functioning
 Opiods – prevent pain, inhibit memory consolidation
 Oxytocin – inhibits memory consolidation, promotes good
 These chemicals are POWERFUL substances ….
Sympathic Nervous System Response
 If trauma is too severe, too long, triggered often …
Catecholamines are chronically increased; damage to
memory, rational thought, hypervigilance, inability to
distinguish danger signals
Corticosteroids are chronically low; reduced immune
functioning (lupus, Graves disease, RA, fibromyalgia),
catecholamines aren’t regulated
Opiod levels increase (equivalent to 8 mg of morphine);
flat affect
Oxytocin increased– memory impaired; bonding to perp
Other Neurotransmitters of Importance
 Serotonin – inhibitory; involved in emotion and
mood. Too little serotonin has been shown to lead to
depression, problems with anger control, obsessivecompulsive disorder, and suicide.
 Dopamine – inhibitory (meaning when it finds receptor
sites, it blocks the firing of the neuron); controls arousal,
alertness, attention; vital for giving motivation; Drugs like
cocaine, opium, heroin, and alcohol increase the levels of
dopamine, as does nicotine.
 GABA – inhibitory; acts like a brake to the excitatory
neurotransmitters that lead to anxiety.
Structures of the Brain: The Limbic
The Amygdala
 an almond-sized structure that stores memories of fearful
responsible for regulating safety, and regulates heart rate
and blood pressure, via the parasympathetic /sympathetic
nervous system.
monitors incoming stimuli for anything threatening
activates the fight-flight-freeze stress response when
“danger” is detected
imaging studies reveal hyper-responsivity here during the
presentation of traumatic scripts, cues, reminders
increased amygdala reactivity is genetic
The Hippocampus
 a finger-sized cluster of neurons, is the hub of memory and
learning because all conscious memory must be processed
through this structure of the brain.
 functions like a memory chip in a computer. It is involved
in verbal and emotional memory.
 highly sensitive to stress hormones (e.g., cortisol).
The Adolescent Brain and Trauma
 Cortex still developing until mid-20’s
 Not able to execute cause and effect thinking
consistently – even without trauma
 Dopamine is helpful to increase judgment and
impulse control; trauma disrupts dopamine
 Brain hemisphere integration (via the corpus
callosum) is effected – rational thought vs.
overwhelming emotion
Neurobiological Changes in Children
with PTSD (DeBellis et al., 1999)
 Study: University of
Pittsburgh, took MRI
scans of the brains of 44 children with
histories of abuse and diagnoses of PTSD
and compared them with 61 healthy
controls who had not experienced abuse.
The average age of the subjects was 12
More details from DeBellis, et al:
 Abused children excreted greater amounts of cortisol and
catecholamines than non-abused kids
 Abused children had 7-8% less cerebral volumes
(impairing memory, dysregulating arousal)
 Neurons enlarge with age and axons thicken. Between the
ages of 5 and 18 years, the process of coating the neurons
in the central nervous system with a myelin sheath is most
influential in determining brain size
 In the PTSD children, the corpus callosum did not grow
with age compared with controls, which may be due to a
failure of myelination.
The Adverse Childhood Experiences
(ACE) Study (Robert Anda, MD Co-Principal Investigator)
 Examined the health and social effects
of ACEs throughout the lifespan of
17,421 Kaiser members in San Diego
 ACEs: children exposed to household
substance abuse, separation/divorce,
mental illness, battered parent, criminal
behavior; abuse or neglect
ACE findings
 The higher the ACE score, the higher the
incidence of:
Intercourse by age 15
Teen pregnancy
Teen paternity
Depression/suicide attempts
Rick of being victimized as an adult
Substance abuse
HIV risk
Hippocampal Volume Reduction in PTSD
MRI scan of the hippocampus in a normal control and patient
with PTSD secondary to childhood abuse. The hippocampus,
outlined in red, is visibly smaller in PTSD. Overall there was a
12% reduction in volume in PTSD.
Bremner et al., Am. J. Psychiatry 1995; 152:973-981;
Bremner et al., Biol. Psychiatry 1997; 41:23-32;
The Prefrontal Cortex
 Highly developed in primates and humans
 Allows “executive control” – or at least
guidance – over more primitive brain
 Middle region is critical to relational
functioning, empathy, connecting
 Helps us with:
Being able to focus
Memory and reason
Self-awareness, reflection, emotions, impulses
The Prefrontal Cortex (PFC)
 Connected with the amygdala and
exerts inhibitory control over stress responses
and emotional reactivity; goals, reason,
controls habits
 Prefrontal cortex actually shrinks with
PTSD; children/adolescents/young adults
don’t have developed PFC
 Successful SSRI treatment restored PFC
activation patterns
High Arousal (Fear) = Impaired
Prefrontal Cortex
 Stress chemicals disable the mid cortex and
limbic brain takes over
So what activates the Prefrontal and Medial
- Meditation and mindfulness practices
- these kick-in “top-down” brain functioning
versus “bottom-up”
The Insular Cortex and the
Embodied Self
 Trauma = disembodiment
 Mindfulness = embodiment
 Research:
 (Lazar, 2005): 20 people with extensive
meditation experience vs. 15 controls; in
meditators, no age-related thinning of PFC
area associated with emotion and thoughts
 (Britta, 2008): Significant thickness in PFC in
Traumatic Memory
Factors that Influence Traumatic
 Continuous Memory
 Dissociative/Incompl
ete Memory
- Single traumatic
- Natural or accidental
- Adult victim
- Validation and
support present
- Repeated events
- Deliberately human
- Child victim
- Denial and secrecy
When Amygdala is highly
activated, it interferes with
Hippocampus functioning
Self-Harming Behavior
 Deliberate destruction or alteration of body tissue
without suicidal intent
 Prevalence:
13% to 25% in adolescents (Rodham & Hawton, 2009)
11% of college-aged students
middle school populations have higher prevalence
since that is the age at which most individuals
initiate self-injury. (Whitlock, Eckenrode, et al., 2006;
Gollust, Eisenberg, & Golberstein, 2008).
Self-Harming Behavior
Why do people self-injure?
Psychological Reasons
 to exert self-control or
 as a distraction
 to get attention
 to attain group
Neurobiological Reasons
 to unconsciously
rebalance brain chemistry
 to evoke emotion when
feeling numb (up
 to stimulate a high
Neurobiological explanations for SelfHarming Behavior: EOS and Serotonin
 Self-harm activates the endogenous opiod system (EOS)
 The EOS system regulates pain – releases endorphins,
adrenaline and dopamine … promotes calm, well-being
 Low serotonin is correlated with suicide attempts,
aggression, and impulsivity
 Impact of an adverse rearing environment: Peer-reared
monkeys have lower seratonin activity in comparison to
maternally raised monkey (Higley et al., 1993)
Fight, Flight, or Freeze
A lesson from Jakey Cat
Jakey Cat (RIP)
The Freeze Response: Tonic
 Autonomic Nervous
System: sympathetic and
parasympathetic nervous
 Both systems heightened
simultaneously under
extreme stress
 Tonic immobility as an
adaptive survival
response; if you move in
the animal world – the
predator will chase and
If you don’t remember anything from
this presentation, remember ….
 The more the neural system is activated, the
more it will change
 What fires together, wires together
 Trauma leads to dysregulation of the
autonomic nervous system and the limbic
 Memory is often corrupted by trauma; recall
impaired; the past is present
Neurobiological Conclusions
• Any trauma during birth to 25 has the potential to disrupt
typical neurodevelopmental processes and contribute to
long-term consequences
Chronic abuse and multiple traumas have a greater
neurobiological impact
Permanence/impermanence of the damage is debatable.
Teicher (2002) suggests effects are irreversible BUT some
evidence suggests that neurogenesis is possible
Prolonged stress leads to exposure to glucocorticoids
(adrenal steroids) and elevated levels of catecholamines
(adrenaline, serotonin, dopamine)
Result: impaired cognition, emotional/behavioral
regulation, potential autoimmune disorders
The Insidious Nature of the Vicarious
 Brainstorm: how does this work impact us?
 What are the signs that let us know we are not being
 What are you and your agency doing to address
vicarious trauma?
Symptoms of Vicarious Trauma
 Feel very emotional during/after a session or
 Difficulty sleeping
 Nightmares
 Vivid mental replaying of client’s trauma
 Revenge fantasies
 Lack of interest in sex or romance
 Numbing, flat affect, loss of humor or warmth
Symptoms of Vicarious Trauma
Generalized anxiety, worry
Feelings of being overwhelmed
Feelings of incompetence
Low grade depression, listlessness, “ the
 Pervasive cynicism (in self or in the work
 Tendency to talk more about our own trauma
 Seeing others as potential victims or abusers
Assess and Address Vicarious Trauma
 How do we cope with hearing horrible stories and
dealing with difficult cases?
 Caseworkers may feel more “helpless” to help a
trauma survivor; particularly when there are multiple
 Perhaps not as many concrete things to do (e.g., help
with reporting, advocacy, restraining orders, etc.)
 One sign of vicarious trauma and/or burnout: OUR
Common Pejorative Language Used When
Working with Trauma Survivors
“She’s manipulative.”
“She’s a multiple.”
“He’s crazy.”
“She’s a cutter.”
“He’s a train wreck.”
“She’s Borderline.”
Implications, Reactions, Alternatives
 Describe difficult things that we experience with
clients in behavioral terms
 Reframe symptoms as adaptations: e.g.,
“manipulation” – communicating indirectly;
“resistance” – clients protecting themselves from
further harm they expect from the relationship
Strategies that Address
Neurobiological Issues
 The “helping” relationship (can be
therapeutic, first responder, any
system response)
"There is no more effective
neurobiological intervention than a
safe relationship"
-- Bruce Perry
The Importance of Relationship
 Oxytocin and vasopressin are linked to bonding
and relationships characterized by strong
 Positive attachments directly
rewire the wiring of the orbitofrontal cortex to the Limbic
system to mediate emotional
response; balance sympathetic
and parasympathetic systems
Importance of Empowerment
 Making decisions
develops the cortex
 Involved clients in
treatment decisions (e.g.,
court, child welfare)
 Avoid using relationships
as consequences (e.g.,
restricting family visits,
peer connections)
 Avoid pathologizing
Psychotropic Medication for
Adolescents and Adults
 A comprehensive review of pediatric trials
conducted between 1988 and 2006 suggested that
the benefits of antidepressant medications likely
outweigh their risks to children and adolescents
with major depression and anxiety disorders.
Increased Hippocampal Volume
With Paxil in PTSD
Hippocampal Volume (mm-3)
Left Hippocampus
Right Hippocampus
Effects of 9-12 months of treatment with 10-40 mg paroxetine.
(Vermetten et al. Biol Psychiatry, 2003)
ADHD and PTSD: The
importance of accurate diagnosis
 Richard Friedman, NYT, April, 2012: “Are We
Drugging our Soldiers”
 “Since PTSD is basically a pathological form of
learning known as fear conditioning, (ADHD)
stimulants could plausibly increase the risk of getting
the disorder.”
 “Because norepinephrine enhances emotional
memory, a soldier taking a stimulant medication,
which releases norepinephrine in the brain, could be
at higher risk of becoming fear-conditioned and
getting PTSD in the setting of trauma. “
Engaging and Exercising the Brain: Neurobics
It is important to challenge the brain to learn new
 Learn new content/skills
 Drive home from work a different way
 Operate mouse with non-dominant hand
More Neurobics:
 Try to include one or more of your senses in an
everyday task: Get dressed with your eyes closed,
wash your hair with your eyes closed, close your
eyes and eat – identifying food by taste
 Combine two senses: Listen to music and smell
flowers, listen to the rain and tap your fingers,
watch clouds and play with modeling clay at the
same time
 Break routines: Go to work on a new route, eat
with your opposite hand, shop at new grocery
store, switch places at the meeting table
Transforming from the Sympathetic to
the Parasympathic System
 The more anxiety we have, the less optimally
our brains function
 Sympathetic System 
Ready to react, on alert, high arousal
 Parasympathic System 
Relaxed, comfortable, intentional, optimal
Three Quick Ways to Activate the
Parasympathic System
 Breathing – particularly the exhale
 Mindfulness practice
 Relaxing the pelvic muscles:
1) While sitting, put hands under the buttocks
and find the sits bones
2) Touch the two bony points just below the
waist on your right and left side
3) Visualize a square; breathe into the square
to expand that area; release and relax all
muscles there
Safe Physical Contact
(with humans or animals)
 Touch lowers
cortisol, increases
limbic bonding
 Massage
 Contact with
animals: lowers
cholesterol, blood
pressure, and
triglyceride levels
Scout in Crested Butte, CO
Psychosomatic State Shift
 Thickens the cerebral
cortex (due to trauma,
 Increases attention span,
sharpens focus, improves
 Restores synapses, similar
to sleep
Study: Boston-area workers who
meditated for 40 minutes a day had
significantly thicker cortexes than
controls (Lazar et al, 2005)
More Research on Meditation
 (Grant et al., 2011) 13 meditators, 13 non-
meditators. Gave thermal stimulation to calf.
The more meditation experience, the lower
the pain ratings. Amygdala was less active!
 (Kimbrough, 2009) – Modified Mindfulness
Based Stress Reduction (MBSR) for Adults
with PTSD and Histories of Childhood Sexual
Abuse; depression, anxiety, and PTSD
symptoms decreased
Trauma = split between mind and body
Yoga = unifying mind and body
 Yoga increases heart rate
variability (HRV); an indicator
of the body’s ability to respond
more flexibly to stress
 Benefits of controlled breathing
activates parasympathetic
system similar to those
receiving ECT, and taking an
 2010 study from Boston U.
School of Medicine; yoga
increasing GABA levels
(GABA involved in alcohol
More Benefits of Yoga to Mitigate
Effects of Trauma
 Research shows
that yoga decreases
oxidative stress in
the cells after an
eight week practice.
Less inflammation,
less cell damage,
less acidity in the
body = health
Janine and Scout Practicing
 Rebalances melatonin; enhances sleep cycle
 Releases endorphins (endogenous opioids)
 Promotes tryptophan which enhances mood;
precursor to serotonin
Sleep, Rest, and Relaxation
 Sleep deprivation
keeps nervous
system on highalert; cortisol is
 Serotonin and
dopamine rise when
sleeping, resting
 The brain reads a drop in blood sugar as “danger” and
begins to produce adrenaline. Adrenaline can be produced
in a split second, leaving one feeling tense, jittery, weak,
and dizzy. With someone who suffers from PTSD, these
constant drops in blood sugar can cause mood swings into
panic, anger or desperation
 Avoid stimulants (sugars, caffeine, non-herbal tea,
nicotine, and simple carbohydrates such as white bread,
white rice, cakes, cookies, candy bars, soda and ice cream)
 Avoid some fruit like bananas, grapefruit, melons, honey,
and dates because they are high in sugar content
Eating to Manage PTSD
 Eat berries such as strawberries, raspberries,
blackberries and wild blue berries. These are high
in fiber, lower in sugar .
 Eat a combination of lean protein and complex
carbohydrates every two to three hours, this
prevents the sugar spike and crash. Good sources
of proteins are eggs, white meat from chicken or
turkey and fish.
 TIP: eat an egg before bed! It helps keep blood
sugar even throughout the night and decreases the
likelihood of waking shaky or in a panic.
Strategies to Reduce Trauma
in the Courtroom
Physical Environment
 Be child and family friendly
Chester County Courtroom
Allegheny County Courtroom
Strategies to Reduce Trauma
in the Courtroom
Physical Environment
 Be creative
Dogs in Court, Bucks County Pennsylvania
Strategies to Reduce Trauma
in the Courtroom
Physical Environment
 Decrease fear of the unknown
 Maintain existing healthy
 Start and end with strengths
 Be aware of proxemics and
boundaries in the courtroom
System Strategies
 Assure that all professionals are trained in
trauma and understand it
 Lead the development of trauma
informed/focused community resources
 Recognize gaps and services and encourage
resource development
Strategies for Reducing Trauma
for Children & Youth
 Ensure child/youth is
prepared for court
 Give child/youth a
voice in court
 Focus on what is going
well for the child
Strategies for Reducing Trauma
for Parents
 Set the tone
 Encourage parents to bring a support person
 Reduce anxiety by reducing fear of the unknown
 Address trauma
Strategies for Reducing Trauma
for Professionals
 Reduce fear of the unknown
 End the week on a positive
 Find support from colleagues
 Keep perspective
Thank you for all that
you do for your
Contact Information:
Janine M. D’Anniballe, Ph.D.
[email protected]