Carmen V. Russoniello, PhD., LPC, LRT, BCB, BCN Director, Psychophysiology Lab and Biofeedback Clinic East Carolina Universityrussonielloc@ecu.edu

PTSD: A Phychophysiological Perspective

Disclosure

In the spirit of full disclosure I acknowledge that I currently serve on the Scientific Advisory Committee of Biocom Technologies (unpaid) and own a small percentage of the company stock .

https://author.ecu.edu/cs-admin/mktg/basic_retraining_video.cfm

Kilo Company 3rd Battalion 26th Marines Namo Bridge Fall, 1969

“It is not the strongest of the species that survive, nor the most

intelligent, but the one most responsive to change.”

-Charles Darwin

The overall goal of the ECU Wounded Warrior Program is to increase performance and promote functional independence. The program involves methods to help

Marines learn how to control physical and emotional reactions to stress (resiliency), as well as techniques to increase strength, endurance, cognitive performance, social and life skills.

The program involves sessions both at Camp Lejeune and at the Biofeedback Clinic at East Carolina University.

PTSDWhen a person is exposed to extreme stress such as sexual abuse, war, or even the extended effects of a natural disaster, clinically significant symptoms often emerge.

The existence, frequency, intensity, and duration of these symptoms are dependent upon many factors, including, gender, age, and ethnic background of the person exposed to the stressor as well as the person’s social environment and ability to employ coping strategies.

Specific emotional and behavioral responses to stress have been observed and studied by mental health professionals in multiple settings, under different circumstances, over time. These symptoms have become the clinical indicators used for identifying the stress related disorder known as posttraumatic stress disorder (PTSD).

APA categorizes PTSD symptoms into three main clusters:

1.A traumatic event that is persistently re-experienced; 2.A persistent avoidance of stimuli associated with the trauma and 3. A numbing of general responsiveness and persistent symptoms of increased arousal. The symptoms must last at least one month and adversely affect normal functioning.

“the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience”. These persistent, post trauma symptoms were the basis for the development of the original PTSD diagnosis in 1980 and with some modification still serve as the diagnostic criteria. While this classification system is a useful is has some limitations such as the exclusion of some less common cognitive, emotional, behavioral and physiological-somatic symptoms.

• Inescapable Shock • Autonomic Nervous System • Sympathetic• Parasympathetic • Learned Helplessness • Defense Defeat Model

• Possible bipolar effect with parasympathetic becoming dominant and then sympathetic rather than rhythmic

Exposure of rhythmic environments to chemical or behavioral stressors can result in increases and decreases in the response (Antleman (1996, 1997)

Possible innate biological function designed to reset the rhythm

Sympathetic Dominance can produce: muscle bracing, bruxism, occular

divergence, tachycardia, diaphoresis, pallor, tremor, startle, hypervigilance, panic rage and constipation

• Symptoms of palpitations, nausea, dizziness, indigestion, abdominal cramps, diarrhea, and incontinence

• Self perpetuating symptoms causing continued dysregulation “free falling”

“The syndrome of trauma has now literally taken control of the body”

The ANS plays an important role in the development and maintenance of a wide range of somatic and mental diseases

In general autonomic imbalance and decreased parasympathetic tone may be the final common pathway linking negative affective states and ill health (Thayer & Brosschot, 2005)

Symptoms of dissociation mimic the bipolar nature of the defining symptoms of PTSD (arousal, reexperiencing, avoidance).

Altered perception of time, space, sense of self and reality.

Emotional Expressions can range from panic to numbing and catatonia.

Altered sensory perceptions may vary from anesthesia to analgesia to intolerable pain.

Motor problems include weakness, paralysis, and ataxia as well as tremors, dysarthia, shaking, and convulsions.

Cognitive Symptoms include confusion, dysphasia, dyscalculia, and extreme attentional deficits.

Perceptual symptoms include ignoral and neglect

Memory alterations may appear as hyperamnesia (Flashbacks), fugue states or selective traumatic amnesia.

Endogenous opiate reward systems contribute to the establishment of conditioned procedural memory in trauma.

Exposure to war trauma often results in a sustained period of analgesia (soldiers in wounded in battle require lower doses of morphine than in other non-combat related wounds)

Stress can induced analgesia in many forms of trauma

Relates to facts and events Plays an important role in conscious

recall of traumatic events) Involves the hippocampal and prefrontal

cortical pathways (inaccurate and subject to decay)

acquisition of new motor skills and habits to the development of emotional memories and associations, and to the storage of conditioned sensorimotor responses. Unconscious, implicit, and extremley resistant to decay when linked to emotional or threat based interventions. (Scaer, 2001)

Surgical Revolution Anesthesia introduced in 1846

Antibiotic Revolution Penicillin introduced in 1941

Endogenous Factor Revolution Personal healing

Attacking germs and more importantly “Bad Habits”

Walter Cannon (1896) Coined “flight or fight response” to

stress developed concepts of mind/body

model Emphasized the importance of the

parasympathetic systemSelye (1975)General Adaptation Syndrome Stages

alarm reactionresistanceexhaustion

The Defense/Defeat Model fight or flight immune system suppression Folkow (1993)

“environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological or biological changes that may place persons at risk for disease.”

Cohen, Kessler & Gordon (1995). Measuring Stress

“Technically speaking, a stress reaction is a mental and physical response to an adverse situation that mobilizes the body’s emergency resources, the flight or fight mechanism, which floods the body with hormones that arose to meet the challenge. Unfortunately modern life continually triggers this response when we can neither fight or flee, which can lead to chronic heightening of blood pressure and muscle tension, irritability, anxiety, and depression-and a lowering of immune effectiveness”.

(Daniel Brown, 2003. Stress, Trauma and the Body, p. 89).

Stress enhances susceptibility to disease

Both psychosocial & biological stressors evoke the flight or fight response

Stress Disinhibition Theory People engage in a broad

range of dysfunctional behaviors as a result of stress

commonplace stressful events produce immunological alterations

chronic stressors have been linked to the longer-term down-regulation of immune function

immunological changes have negative consequences for health Lonely Person with a Kind Heart

Endocrine system facilitates communication between the

mind and body acts as an internal intelligence carrying

information that regulates the organism receptors for catecholamines (adrenaline)

in immune cells nerve fibers go "into virtually every organ

of the immune system and form direct contacts with the immune system cells“ (Ader, 1993).

The Defense/Defeat Model fight or flight immune system suppression Folkov (1993)

The central nervous system that regulates the ANS balance is called the central autonomic network (CAN). The CAN work with networks to regulate the following functions:

Executive Social, Affective Attentional Motivational

Autonomic, cognitive, and

affective function assist humans

maintaining balance in the face of environmental

challenges

Inhibitory or negative

processes or feedback

circuits that permit

behavior and redeploy

resources needed

elsewhere

When negative circuits are

compromised positive circuits

develop and result in hypervigalance. The symptoms can be devastating and if not ameliorated can develop into

permanent conditions

A common subcortico neural system regulates defensive behavior including autonomic, emotional and cognition

When prefrontal cortex is taken “offline” for whatever reason parasympathetic inhibitory action is withdrawn and relative sympathetic dominance associated with defensive occurs

This can be measured by assessing parasympathetic contribution to overall HRV

Growing evidence supports the use of HRV as a predictor of hypervigilance and inefficient allocation of attentional and cognitive resources (Thayer & Brosschot, 2005)

“Autonomic Imbalance and Decreased Parasympathetic Tone in particular may be the final common pathway linking negative affective states and dispositions, including the indirect effects via poor lifestyles, to numerous diseases and conditions as well as increased mortality, and it may also be implicated in psychopathological conditions”.

Low HRV is associated with the following conditions

cardiac symptoms of panic attack Poor attentional control Poor emotional regulation Behavior inflexibility

Friedman and Thayer, 1998

Depression (Thayer et al., 1998) Generalized anxiety disorders ( Thayer

et al, PTSD (Cohen et al., 1999) Cardiovascular morbidity and mortality Diabetes (Ziegler et al., 2001)

Immune deficiency and inflammation contributing to: Aging CVD Osteoporosis Arthritis Alzheimer’s Periodontal disease Certain types of cancers as well as

muscle decline increased frailty and disability

The overall objective of Heart Rate variability training is to decrease ANS hyperarousal and improve its balance.

Wounded Warriors learn to control ANS responses to stress producing stimuli such as thoughts, memories and images associated with combat.

Decreasing arousal and maintaining ANS balance for increasing lengths of time is the goal of training.

Once it was observed that alpha waves were dysfunctional in vulnerable populations protocols were developed to help people learn to train alpha and theta waves as a method of improving function.

Peniston and Kulkosky showed increased alpha and theta brainwave production resulted in normalized personality measures; and prolonged prevention of relapse in alcoholics. The protocol has also showed efficacy as an intervention in drug addiction, depression and PTSD.

The graded stress exposure training program used in this study is one month in duration and consist of a pre assessment, 16 biofeedback sessions (four per week) a post session evaluation and a 3 month follow up.

Each week participants will be exposed to increasing stress producing stimuli: 1. Stroop Color Word Test, Math Stressor; Talk Stressor/Everyday Events 2. Talk Stressor/ Combat Experiences; 3. Images and Sounds of Combat; 4. Virtual Baghdad or Afghanistan (virtual reality exposure).

Each biofeedback session consists of 5 minutes of baseline followed by 5 minutes of the weekly stressor, followed by 20 minutes of HRV and neurofeedback training, followed by 5 minutes of the stressor; followed by 20 minutes of HRV and neurofeedback and finally 5 minutes of recovery data.

Preliminary clinical data collected so far indicate decreases in ANS hyperarousal and increases in parasympathetic activity. Reports on PHQ-SF 36 indicated positive changes in physical symptoms, and decreases in depression panic attack and anxiety.

Heart rate variability training changes Neurofeedback The Posttraumatic Stress Checklist (PCL) Deployment and Resilience Patient Health Questionnaire short form (PHQ SF-36) Profile of Mood States Salivary alpha-amylase (sAA) changes. Behavioral questionnaire assessing alcohol, drug,

nicotine use, nutrition habits etc. Self satisfaction inventory

Dysfunction in ANS and CNS flexibility and balance are associated with symptoms of PTSD in combat veterans.

Methods that are designed to restore balance in these systems are needed to ameliorate these symptoms.

Biofeedback/Neurofeedback is a safe method to achieve these goals.

To create an awareness and understanding of the components of effective health improvement programs.

To explore the specific application of health applications in the treatment of PTSD, anxiety, and depression.

Define the treatment components of health improvement programs and their prescriptive parameters

Review specific health improvement protocols for PTSD, Anxiety and/or Depression

The greatest revolution of our time is the knowledge that human beings, by changing the inner attitudes of their minds, can transform the outer aspects of their lives.

-William James

Exercise and Body Awareness Nutrition Stress Management Mental Focus Relaxation-meditation- and other

antidotes to stress (recreation/physical activity)

The overall focus is on positive behavioral change and coping.

The first requirement necessary for change is that you want to change!

We are all in different STAGES with respect to multiple behaviors in our lives.

DEFINITIONS:  Precontemplation

Someone in this stage probably has no intention of making change or adopting healthier habits.

 Contemplation Someone in this stage realizes the importance of specific

changes. They may be thinking of making some behavioral changes in the next six months.

 Preparation Someone in this stage is ready to make some behavioral

changes. They may already engage in some health behaviors some of the time but it is just not something they do regularly.

Action Someone in this stage has overcome all the obstacles and have

integrated behavioral changes but haven’t been doing it very long . They are doing it! (e.g., They are physically active on a regular basis– less than six months).

Maintenance Someone in this stage is has integrated the behaviors on

regular basis and has maintained these for more then six months.

PrecontemplationExample: Learn about all the benefits of being physically active. Start thinking about what being physically active could mean for you.

ContemplationExample: Remind yourself all the benefits you will get from being active. Picture yourself healthier and more energetic than ever before. Try to record your progress and improvements and make sure you have support from family and friends.

Preparation Set a start date. Tell everyone you know. Establish priorities. Make the change a high priority in your

life. Leave no room for excuses.

Stages of Change

ActionExample: Participate in activities that are not effected by the weather- join an exercise class or indoor sports league.Make physical activity a priority. Plan physical activity in your daily schedule. Make sure your family and friends know how important physical activity is to you.

 

MaintenanceMaintain your behaviors. Reinforce yourself.Examples: Try a new activity or sport.Vary your walking or cycling path.Change the music you walk to.Be active at different times during the day.

Stages of Change

Each level of the activity pyramid is important in helping you increase your physical activity level and overall health. Each day you should try to participate in a variety of physical activities. Remember not to limit yourself to one type of activity.

DEFINITIONS OF ACTIVITY PYRAMID LEVELS Aerobic Exercise: Aerobic exercise improves cardiovascular fitness and makes your heart and lungs stronger (3-5X/wk.).  Recreational Activities: Recreational activities may also improve cardiovascular efficiency or more simply said will make your heart and lungs strong (2-3X/wk.).  Leisure Activities: Leisure activities are low-level endurance activities.  Flexibility and Strength: Flexibility activities help to increase and maintain muscle flexibility. Strength exercises can help improve muscle strength (2-5X/wk.).  Sedentary: The top level of the pyramid signifies sedentary life. This is the smallest part of the pyramid and the activities here should take up the smallest amount of your leisure time.

Identify your personal activity levels based upon the activity pyramid.

Estimate the types of activities you do on an average week.

The purpose of this activity is to demonstrate the many inherent benefits of a recreational activity Think social, emotional, cognitive, physical, and

spiritual. Bingo: Swimming: Gardening: Arts & Crafts: Scuba Diving:

Goals Assist the patient/client create an

awareness of current nutritional patterns. Provide information to assist Marines/clients

in identifying healthy and unhealthy nutritional choices.

Assist Marines/clients in implementing strategies to change unhealthy nutritional patterns

Key Nutrients

Milk and Milk ProductsCalcium

Meat and Meat AlternativesProtein Iron

VegetablesFolic AcidVitamin AVitamin C

Fruits Folic AcidVitamin AVitamin C

Breads and Cereals:Complex Carbohydrates Fiber

Servings From The Food Guide Pyramid

Milk, Yogurt, and Cheese: 1 cup of milk or yogurt, 1 1/2 ounces of natural cheese, 2 ounces of process cheese

Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts: 2-3 ounces of cooked lean meat, poultry, or fish, 1/2 cup of cooked dry beans, 1 egg, or 2 tablespoons of peanut butter count as 1 ounce of lean meat

Vegetables: 1 cup of raw leafy vegetables, 1/2 cup of other vegetables, cooked or chopped raw, 3/4 cup of vegetable juice

Fruit: 1 medium apple, banana, orange, 1/2 cup of chopped, cooked, or canned fruit, 3/4 cup of fruit juice

Bread, Cereal, rice, and Pasta: 1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal, rice, or pasta

•Daily Servings and Guidelines

•Food Labels

•Calculating Calories

North Carolina State University A&T State University Cooperative Extension

North Carolina Governor’s Council on Physical Fitness and Health

Pace University

Made possible through a grant from Child Nutrition Services, the State Board Of Education and the Department of Public Education.

There is a need to identify automatic thoughts and patterns before intervention begins. One effective method is to have the

client/patient record a daily record of automatic thoughts ( A positive and negative thought diary!).

Can you name any?

1. All-or-nothing thinking2. Overgeneralization3. Mental filtering4. Disqualifying the positive5. Jumping to conclusions

Mind Reading Fortune telling

6. Magnification and minification7. Emotional Reasoning8. Labeling9. Personalization10. “Should Statements”

Challenge Automatic Thoughts Clarify the Problem and What Can Be

Done Taking Small Steps The Three “Cs” (‘Four)

Commitment Control Challenge and Closeness

The Relaxation Response Mini-Relaxation Response

The Quieting Response Autogenics Imagery

Anxiety PTSD

Each one to two-hour session includes a relaxation exercise, stretching and body awareness exercises, data collection, didactic presentation, experiential exercises, and self help assignments to reinforce skill development.

Theses protocol is applicable to PTSD, Anxiety disorders and most depressions.

Contraindications include individuals who are actively suicidal, psychotic or otherwise unable to comprehend the presented information and or\manage their own care.

Each one hour session includes: a relaxation exercise, stretching and body awareness

exercises, data collection, didactic presentation, experiential exercises and self help assignments to reinforce

skill development.

The protocol is applicable to: generalized anxiety, panic attacks or specific phobias such as social phobias

Contraindications include individuals who are:

actively suicidal, psychotic, unable to comprehend the

presented information, or unable to manage their own care

Session I The Mind\Body Connection Physiology of Stress Changing Behaviors

Session II Relaxation Response Diaphragmatic Breathing

Session III Benefits of Distraction Developing Mental Focus

Session IV Benefits of Exercise Movement/body Awareness Developing Mindfulness

Session V Stress Warning Signs Automatic Thoughts

Session VI Attitudes, Beliefs, and Assumptions Stress Hardiness Cognitive Restructuring Skills

Session VII Awareness and Choice Moods, Feelings, and Emotions Effective Coping & Problem Solving

Session VIII Social Support Self-Esteem Effective Communication

Session IX Relapse Prevention Setting Realistic Goals

Session X Review: Stress Hardiness Community Resource

Effects of treatment and the disorder may produce symptoms (anxiety, depression, physical dysfunction)

Designed to help Marines deal with PTSD symptoms

Designed to teach Marines how to take an active role in their healthcare

Designed to help Marines become resilient to stress

Session I The Mind\Body Interaction Physical, Emotional, and Cognitive

Effects of Stress Psychoneuroimmunology and other

Mind\Body Research Introduction to the Relaxation

Response Use of Recreational Activities Characteristics of Long-Term

Survivors

Session II The Importance of Exercise Diaphragmatic Breathing Yoga/Body Awareness Nutrition Information

Session III Stress Hardiness Control, Commitment, Challenge, Caring Short and Long term Goal Setting

Session IV Cognitive Restructuring Recognizing Negative Automatic

Thoughts Challenging Automatic Thoughts Using Positive Affirmations

Session V The Immune System Using Imagery

Session VI Recognizing emotions (Journal Writing) Dealing with Emotions of Fear, Anger,

Depression, and Guilt Family Patterns of Expressing Emotions

Session VIII Communication with Family and Health

Care Providers How My Diagnosis Affects Others

Session IX Living with Uncertainty Physical Self-Care Habits Support Networks Attitudes and Beliefs Action Skills to Change the Situation Life Experiences That Will Help

Session X Humor as a Coping Strategy (Cousins\Tribal Rituals) Recreational Activities Program Debriefing Staying Motivated Reflections and Thoughts to Remember Celebrate Life

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