Transcript Slide 1

Trauma and Transformation
AUSA Military Family Forum II
October 22, 2013
James S. Gordon, MD
Founder & Director
The Center for Mind-Body Medicine
“There is nobody normal here anymore.”
~Kosovar psychiatrist
Trauma
Trauma means “injury”—
to our mind, body, and spirit
It may come to any or all of us
Trauma is about loss
Where Does It Come From?
Causes of Trauma
War
Torture
Natural disasters
Historical Trauma/Racism
Child abuse
Spousal abuse
Rape and other violent crimes
Health crisis—life threatening illness
Health care itself
Witnessing any of these
Fight or Flight
A Survival Response
Fight or Flight
Marked by:
• Sympathetic Nervous System Activation
• Arousal and preparation
• Increased heart rate
• Faster breathing
• Muscular tension
• Coldness and sweating
• Decreased intestinal activity
• Dilated pupils
• Mediated by periorbital, frontal cortex (limbic system), hypothalamus,
and autonomic nervous system
The Freeze Response
• “Deer In Headlights”
• In extremely threatening situations, response
may be Parasympathetic dominance.
 Most primitive response
 Inhibition of motor function
 Slow heart rate, decreased blood pressure, etc.
• Higher baseline anxiety may predispose.
• May be persistent in those with PTSD.
Mongeau R et al. Neural correlates of competing fear behaviors evoked by an innately aversive stimulus.
J of Neuro. 2003 May; 23:3855-3868.
Porges, SW. Social engagement and attachment: A phylogenetic perspective. Ann NY Acad Sci. 2003 Dec;
\1008:31-47 .
Slide # 8
The Stress of Life
Hans Selye, 1956
In general, stress comes when fight or flight
is prolonged beyond immediate reaction and/or
repeated.
• Alarm (Fight or Flight)
• Adaptation
• Exhaustion
Slide # 9
EFFECTS OF
STRESS ON RATS
THAT WERE
FORCEFULLY
IMMOBILIZED
Adrenals
NORMAL
STRESSED*
Marked
enlargement
and dark
discoloration
Thymus
Intense
shrinkage
A group of
3
lymph
nodes
Intense
shrinkage
Inner
surface
of the
stomach
Numerous
blood-covered
stomach ulcers
Slide # 10
Hypothalamus
Pituitary
STRESS
Autonomic
nervous
system
Gastrointestinal
Peptic
ulcer
Endocrine
system
1. ACTH Feedback
2. Corticoid Feedback
3. Catecholamine Feedback
Limbic system
Corticoids
Corticoids
Adrenals
Catecholamines
Blood pressure, metabolism, etc.
Immune
system
Thymus
Spleen
Lymph nodes
Skin, etc.
Slide # 11
Stress Influences the Onset and Course
of Virtually All Illness
Coronary Heart Disease
Gastrointestinal Dysfunction
Progression of HIV/AIDS
Headaches
Recurrence of Herpes
Premature Death
Asthma
Eczema
Common Cold
Anxiety and related disorder
Acute Clinical Incidents such as Cardiac
arythmia, sudden Death
Cancer
Depression
Sleep-related ailment
Obesity
PTSD
Diabetes
Alzheimer's and cognitive decline
Pain and Chronic Pain
Cellular Aging
Source: Institute of Medicine
Slide # 12
STRESS…
May contribute in a
significant way to every
major illness and
condition including heart
disease, diabetes,
cancer, infections,
chronic pain, anxiety,
and depression, and
PTSD, as well as early
death.
The highly catabolic stress
hormones glucocorticoids
pass the blood-brain
barrier and easily bind to
receptors located in the
amygdala, hippocampus,
and frontal lobe – the
areas most responsible
for emotion, selfregulation and
appraisal, learning, and
memory.
Over time, they cause
structural changes to
these regions.
Biological Structure of Traumatic Stress
Excessive exposure to glucocorticoids has caused
observed changes in trauma-exposed people:
1) Hyperactivation of the Amygdala
2) Alteration in Hippocampal Functioning
3) Hypoactivation of the medial prefrontal cortex
(encompassing the anterior cingulate cortex (ACC),
ventromedial prefrontal cortex, subcallosal cortex,
and oribitofrontal cortex) results in an inability to
effectively control attention and response to traumarelated stimuli.
Ronak Patela, R. Nathan Sprengb, Lisa M. Shinc, Todd A. Girarda (2012)
Neurocircuitry models of posttraumatic stress disorder and beyond: A
meta-analysis of functional neuroimaging studies. Neuroscience &
Biobehavioral Reviews. July 2012
Trauma Among Military and Veterans
• Up to 30% of veterans receiving treatment by the VA
are coded as having PTSD
• 349 active duty military members took their own
lives in 2012
• In 2012, more active duty military members
committed suicide than were killed in combat
• 22 veterans commit suicide every day
• Only 50% of veterans and active duty with
diagnosed PTSD ever seek out treatment
– Only half of those continue after the first session.
Walsh, M. February 2, 2013 “U.S. Vets Commit Suicide at an Alarming Rate: VA Study.” NEW YORK DAILY NEWS
http://www.fas.org/sgp/crs/natsec/RS22452.pdf
http://www.publichealth.va.gov/docs/epidemiology/ptsd-report-fy2012-qtr3.pdf
Diagnosis may be useful—and may
also be limiting
What is needed is an approach which gives
all active duty and veterans the tools they
need to deal with the stress they are
experiencing or may encounter.
• Without stigma
• Open to all
• In a context of small group support
Change and Trauma
Healthy systems (beings) move toward complexity
(includes differentiation and integration)
After trauma we tend to oscillate between rigidity
(withdrawal, inhibition, flashback) and chaos
(agitation, disorganization)
Effective therapeutic work entails helping those who
are traumatized to find a new level of homeostasis
which fosters continued growth and development
Lessons:
1) Ground mental health services in the
skills of self-care rather than the
treatment of disorders
Techniques of Self-Care
• Meditation
• Biofeedback and
autogenic training
• Guided Imagery
• Self-hypnosis
• Self-Expression in words,
drawings, and movement
• Yoga, Qi-Gong, and
other forms of physical
exercise
• Individual and Group
Support
2) Make these services universally
available -- and compulsory
3) Work with the body as well as the mind
Mind-Body Approaches
• Directly address issues of hyper-arousal by
promoting physiological relaxation response
• Balance the sympathetic fight or flight with
the parasympathetic relaxation response
• Remedy the freeze response by using active
physical techniques
• Offer, through meditative practice and a
meditative approach, a more relaxed
perspective on trauma, traumatic memories,
flashbacks, dreams.
4) Make group approaches standard
5) Use medication only as a last resort
and in the context of an intensive and
comprehensive approach.
6) Find a way to provide true
confidentiality to those who seek help.
The CMBM Approach Acts By
• Quieting anxiety and agitation
• Providing perspective on flashbacks and nightmares
• Inviting but not forcing emotional openness and connection
• Increasing energy
• Restoring control
• Promoting hope
• Working with participants’ strengths and capacity for self-reliance
• Can be used by people of all ages (3 on up) and with all conditions
• Building cohesion and mutual support
• Enhancing resiliency in both professionals and those they serve
• Interfaces well with therapeutic and educational approaches
• Integrates well within existing structures: clinics, hospitals, community
groups
Global Reach: The CMBM Model
Capacity to fully and effectively train thousands in
cohorts of up to 300
United States
Military, Veterans,
and Families
350 clinicians who work with US military and
veterans and their families trained in
CMBM approach
Data on Training US Military
Initial Training San Diego 2009
Profile of Mood States (POMS)
p < 0.01
9
8
7
p < 0.01
p < 0.01
p < 0.05
p < 0.01
Score
6
5
Pre
Post
4
3
2
1
0
Anger
n = 86
Confusion
Depression
Fatigue
Anxiety
n = 87
n = 87
n = 88
n = 88
Findings (continued)
Posttraumatic Growth Inventory
p < 0.01
70
p < 0.01
p < 0.01
p < 0.01
p < 0.05
Normalized Score
60
50
40
Pre
Post
30
20
10
0
Relating to
Others
n = 83
New
Possibilities
n = 83
Personal
Strength
n = 82
Spiritual
Change
Appreciation
of Life
n = 83
n = 86
Preliminary Data on CMBM DoD/VA Study with Veterans
PTSD Checklist Total Score
68
66
64
Score
62
60
Control
58
Treatment
56
54
52
Pre
(n= 44 Treat; n = 45
Control)
•
•
Post
(n=32 Treat; n = 44 Control)
Follow-Up
(n= 25 Treat; n = 30
Control)
Uses PTSD Checklist (PCL)
*Preliminary data which has NOT been tested for statistical significance
“The Center for Mind-Body Medicine’s
program…is the most comprehensive of all
[treatments], giving participants a variety of
different strategies to choose from: breathing,
meditation, guided visual imagery, bio-feedback,
self-awareness, dance, self-expression, drawing.
And it is the one with the strongest evidence that
it works to cure PTSD.”
The New York Times, Sept 26, 2012
Research Supporting the CMBM
Model
Research Supporting the CMBM
Model
498 children in Gaza participated in 10week-long mind-body skills groups
show significant decreases in PTSD
symptoms, depression and
hopelessness.
Almost 80% who met the criteria for
PTSD no longer did after the groups
were over despite ongoing armed
conflict
Data from 500 adults in Gaza show
comparable results
Published in The International Journal
of Stress Mnagement , August 2011
 First
ever randomized controlled
trial published on any intervention
with children with post-war PTSD
 82 adolescents met PTSD criteria Harvard Trauma Questionnaire
 25% of Kosovar Albanians 15
years or older reported PTSD
symptoms
12 session mind-body group
 Significant decrease in PTSD
symptom scores (90%) maintained
at 3 month follow up
 Paper published in Journal of
Clinical Psychiatry, Fall 2008
CMBM Uses the “Unstuck” Approach
to Trauma
Unstuck: Your Guide to the Seven Stage Journey Out
of Depression
Profiles techniques designed to reduce stress, breakup fixed patterns by engaging the body and mind,
enhance a sense of community, and utilize innate
wisdom to facilitate creative solutions and promote
growth and healing.
Mind-Body Medicine
Food as Medicine
Learn the Science, Live the Techniques
A Feast of Science and Wisdom
October, 2014… .
San Francisco Bay Area, CA
.
June 5-8, 2014
San Francisco Bay Area, CA
WWW.CMBM.ORG