THE TRAUMA THE TRAUMA SPECTRUM AND ITS SPECTRUM AND ITS

CLINICAL CLINICAL IMPLICATIONSIMPLICATIONS

ROBERT SCAER, M.D.ROBERT SCAER, M.D.scaermdpc@msn.comscaermdpc@msn.com

www.traumasoma.comwww.traumasoma.com

THE ROOTS OF THE ROOTS OF TRAUMATRAUMA

A THREAT TO LIFEA THREAT TO LIFE

IN THE FACE OF HELPLESSNESSIN THE FACE OF HELPLESSNESS

THE FIGHT /FLIGHT / FREEZE THE FIGHT /FLIGHT / FREEZE RESPONSERESPONSE

THE FREEZE RESPONSETHE FREEZE RESPONSE

• NUMBING THROUGH ENDORPHINSNUMBING THROUGH ENDORPHINS

• VAGAL (PARASYMPATHETIC) TONEVAGAL (PARASYMPATHETIC) TONE

• BIMODAL SYMPATHETIC / BIMODAL SYMPATHETIC /

PARASYMPATHETIC CYCLINGPARASYMPATHETIC CYCLING

(ACCELERATOR / BRAKE (ACCELERATOR / BRAKE

ANALOGY)ANALOGY)

LESSONS FROM THE WILD:LESSONS FROM THE WILD:

THE CRITICAL IMPORTANCETHE CRITICAL IMPORTANCE

OF DISCHARGINGOF DISCHARGING

THE FREEZE RESPONSETHE FREEZE RESPONSE

FREEZE/IMMOBILIZATIONFREEZE/IMMOBILIZATIONAND SURVIVALAND SURVIVAL

BABY CHICKSBABY CHICKS

NOTNOTIMMOBILIZED IMMOBILIZED IMMOBILIZED IMMOBILIZED IMMOBILIZED IMMOBILIZED

SPONTANEOUSSPONTANEOUS FORCED FORCED RECOVERYRECOVERY RECOVERY RECOVERY

BESTBEST INTERMEDIATE WORST INTERMEDIATE WORSTDROWNINGDROWNING DROWNING DROWNING DROWNING DROWNING SURVIVAL SURVIVAL SURVIVALSURVIVAL SURVIVAL SURVIVAL

ANIMALS THAT DO NOT ANIMALS THAT DO NOT DISCHARGE THE DISCHARGE THE

FREEZEFREEZE• ZOO ANIMALSZOO ANIMALS• LABORATORY ANIMALSLABORATORY ANIMALS• DOMESTIC ANIMALSDOMESTIC ANIMALS• HUMAN ANIMALSHUMAN ANIMALS

Q: WHAT DO THESE ANIMALS HAVEQ: WHAT DO THESE ANIMALS HAVE

IN COMMON?IN COMMON?

A: THEY ALL LIVE IN A CAGE!A: THEY ALL LIVE IN A CAGE!

SENSORY INPUT –

HEAD AND NECK

AMYGDALA EMOTIONALCONTENT

ANTERIORCINGULATE GYRUS

MODULATES AMYGDALA

CEREBRAL CORTEXHYPOTHALAMUS

HPA AXIS

HIPPOCAMPUSDECLARATIVE MEMORYCOGNITIVE MEANING

ORBITOFRONTALCORTEX

ORGANIZES RESPONSETO THREAT

LOCUS CERULEUS

EARLY WARNING

ENDORPHINS IN ENDORPHINS IN TRAUMATRAUMA

• RELEASED IN AROUSAL: STRESS INDUCED RELEASED IN AROUSAL: STRESS INDUCED ANALGESIA (S.I.A.)ANALGESIA (S.I.A.)- INHIBITS MINISTERING TO WOUND, SELF-CARE, - INHIBITS MINISTERING TO WOUND, SELF-CARE, - ALLOWS CONTINUED FIGHT / FLIGHT BEHAVIOR- ALLOWS CONTINUED FIGHT / FLIGHT BEHAVIOR

• MEDIATES FREEZE RESPONSEMEDIATES FREEZE RESPONSE- ANALGESIA INHIBITS PAIN BEHAVIOR- ANALGESIA INHIBITS PAIN BEHAVIOR

- IMMOBILITY PROMOTES SURVIVAL- IMMOBILITY PROMOTES SURVIVAL

MEMORY MECHANISMS MEMORY MECHANISMS IN TRAUMAIN TRAUMA

• DECLARATIVE (EXPLICIT) MEM0RYDECLARATIVE (EXPLICIT) MEM0RY- - FACTS AND EVENTSFACTS AND EVENTS

• NON-DECLARATIVE (IMPLICIT)NON-DECLARATIVE (IMPLICIT) MEMORYMEMORY- EMOTIONAL ASSOCIATIONS- EMOTIONAL ASSOCIATIONS

- PROCEDURAL MEMORY- PROCEDURAL MEMORY-SKILLS AND HABITS-SKILLS AND HABITS

- CONDITIONED SENSORIMOTOR- CONDITIONED SENSORIMOTOR

RESPONSESRESPONSES

MEMORY IN TRAUMAMEMORY IN TRAUMA

• TRAUMATIC STRESS: A TRAUMATIC STRESS: A LIFE THREATLIFE THREAT WHILE IN A STATE OF WHILE IN A STATE OF HELPLESSNESSHELPLESSNESS

• THIS LEADS TO THE THIS LEADS TO THE FREEZE RESPONSEFREEZE RESPONSE• DISCHARGE OF THE FREEZE RESPONSE DISCHARGE OF THE FREEZE RESPONSE

ALLOWS “COMPLETION” OF ESCAPE ALLOWS “COMPLETION” OF ESCAPE OR DEFENSE IN PROCEDURAL OR DEFENSE IN PROCEDURAL MEMORY, MEMORY, EXTINGUISHES EXTINGUISHES CONDITIONED CONDITIONED SOMATIC CUESSOMATIC CUES

TRAUMA AS A MODEL TRAUMA AS A MODEL OF CONDITIONING ANDOF CONDITIONING ANDPROCEDURAL MEMORYPROCEDURAL MEMORY

A “CAPSULE” OF PROCEDURAL A “CAPSULE” OF PROCEDURAL MEMORY CUES FOR: MEMORY CUES FOR:

- SOMATOSENSORY,- SOMATOSENSORY, - EMOTIONAL,- EMOTIONAL,

- AND AUTONOMIC “FEELINGS”- AND AUTONOMIC “FEELINGS”- AND EMOTION-LINKED- AND EMOTION-LINKED DECLARATIVE MEMORYDECLARATIVE MEMORYALL PERCEIVED AS BEING ALL PERCEIVED AS BEING

IN THE PRESENT!IN THE PRESENT!

KINDLING / KINDLING / NEUROSENSITIZATIONNEUROSENSITIZATION

THE DEVELOPMENT OFTHE DEVELOPMENT OF

SELF-PERPETUATING SELF-PERPETUATING

NEURAL CIRCUITS NEURAL CIRCUITS

THROUGH THE STORAGE OF THROUGH THE STORAGE OF PROCEDURAL MEMORY CUES PROCEDURAL MEMORY CUES

OF A TRAUMAOF A TRAUMA

DISSOCIATION :DISSOCIATION :THE PERCEPTUAL THE PERCEPTUAL

EXPERIENCE EXPERIENCE OF THE OF THE

FREEZE RESPONSE?FREEZE RESPONSE?

WHAT LIFE EVENTSWHAT LIFE EVENTS

CONSTITUTECONSTITUTE

A TRAUMATICA TRAUMATIC

EXPERIENCE? EXPERIENCE?

PERSONAL EXPERIENCEPERSONAL EXPERIENCE• MILITARY COMBATMILITARY COMBAT• VIOLENT PERSONAL ATTACKVIOLENT PERSONAL ATTACK• KIDNAPPING KIDNAPPING • HOSTAGE TAKINGHOSTAGE TAKING• TERRORIST ATTACKTERRORIST ATTACK• INCARCERATION AS A POWINCARCERATION AS A POW• TORTURETORTURE• NATURAL OR MAN-MADE DISASTERSNATURAL OR MAN-MADE DISASTERS• SEVERE MOTOR VEHICLE ACCIDENTSSEVERE MOTOR VEHICLE ACCIDENTS• CHILDHOOD SEXUAL TRAUMACHILDHOOD SEXUAL TRAUMA

WHY DO THE MAJORITY WHY DO THE MAJORITY OF TRAUMA VICTIMS OF TRAUMA VICTIMS

EXPOSED TO TRAUMA EXPOSED TO TRAUMA NOT DEVELOP PTSD?NOT DEVELOP PTSD?

WHY DO SOME VICTIMS WHY DO SOME VICTIMS EXPOSED TO EXPOSED TO MINORMINOR TRAUMATIC EVENTSTRAUMATIC EVENTS

DEVELOP PTSD?DEVELOP PTSD?

RESILIENCY VS.RESILIENCY VS.VULNERABILITY TO VULNERABILITY TO

TRAUMATRAUMA

OUR PRIOR BURDENOUR PRIOR BURDEN

OF LIFE TRAUMAOF LIFE TRAUMA

CREATES AN ENVIRONMENTCREATES AN ENVIRONMENT

OF VULNERABILITY TO OF VULNERABILITY TO

FURTHER TRAUMATIC EVENTSFURTHER TRAUMATIC EVENTS

THOSE LIFE EXPERIENCES THOSE LIFE EXPERIENCES MOST LIKELY TO MOST LIKELY TO

REPRESENT TRAUMAREPRESENT TRAUMAHAVE HAVE MEANINGMEANING FOR FOR SURVIVAL BASED ON SURVIVAL BASED ON

PAST EXPERIENCEPAST EXPERIENCE

THE ROLE OFTHE ROLE OFDEVELOPMENTALDEVELOPMENTALNEUROBIOLOGYNEUROBIOLOGY

IN RESILIENCE TOIN RESILIENCE TOTRAUMATRAUMA

THE EXPERIENCE-BASED THE EXPERIENCE-BASED DEVELOPMENT OF THE DEVELOPMENT OF THE

BRAINBRAIN• ALLAN SCHORE, 1996: ALLAN SCHORE, 1996: AFFECT AFFECT

REGULATION AND THE ORIGIN OF REGULATION AND THE ORIGIN OF THE SELFTHE SELF

* THE MATERNAL / INFANT DYAD: * THE MATERNAL / INFANT DYAD: FACE-TO-FACE ATTUNEMENT FACE-TO-FACE ATTUNEMENT

FACILITATES DEVELOPMENT OF THE FACILITATES DEVELOPMENT OF THE RIGHT ORBITO-FRONTAL CORTEX, RIGHT ORBITO-FRONTAL CORTEX, WHICH PROMOTES AUTONOMIC WHICH PROMOTES AUTONOMIC REGULATION, AND RESILIENCY TO REGULATION, AND RESILIENCY TO SUBSEQUENT STRESS/TRAUMASUBSEQUENT STRESS/TRAUMA

LEARNED LEARNED HELPLESSNESSHELPLESSNESS

ONCE YOU FREEZEONCE YOU FREEZE

YOU TEND TOYOU TEND TO

FREEZE / DISSOCIATE FREEZE / DISSOCIATE AGAIN!AGAIN!

THE LEGACY OFTHE LEGACY OFIMPAIRED ATTACHMENT IMPAIRED ATTACHMENT AND DEVELOPMENTAL AND DEVELOPMENTAL

TRAUMA:TRAUMA:

A LIFETIME OF A LIFETIME OF

AUTONOMIC AUTONOMIC

AND EMOTIONAL AND EMOTIONAL

DYSREGULATIONDYSREGULATION

10/23/01 R obert C . Scaer, M .D . 79

Autonomic Nervous System in Trauma

Homeostasis

Trauma

Sym

path

etic

(F

ight

/Flig

ht)

Para

sym

path

etic

(Fre

eze

)

FIGURE 8.2: THE AUTONOMIC NERVOUS SYSTEM IN TRAUMA- Tonic input into natural oscillatory systems may lead to increasing oscillations to the extremes of physiologic tolerance. This phenomenon may in part explain the self-perpetuated exaggerated autonomic cycling between arousal and dissociation in PTSD.

IF THE ABSENCE OFNURTURING IF THE ABSENCE OFNURTURING

IS TRAUMATIC STRESS,IS TRAUMATIC STRESS,WHAT ARE WE MISSING HERE?WHAT ARE WE MISSING HERE?

THE UNRECOGNIZEDTHE UNRECOGNIZEDSOURCESSOURCES

OF TRAUMAOF TRAUMA

UNRECOGNIZED SOURCESUNRECOGNIZED SOURCESOF TRAUMAOF TRAUMA

• PREVERBAL TRAUMAPREVERBAL TRAUMA• PEDIATRIC AND ADULT PEDIATRIC AND ADULT

MEDICAL MEDICAL TRAUMATRAUMA• CULTURALLY ENDORSED CULTURALLY ENDORSED

TRAUMATRAUMA• ““LITTLE TRAUMAS”LITTLE TRAUMAS”

FETAL SENTIENCEFETAL SENTIENCE

• CAPABLE OF CLASSICAL CAPABLE OF CLASSICAL HABITUATION HABITUATION AND CONDITIONINGAND CONDITIONING

• TACTILE, AUDITORY, OLFACTORY TACTILE, AUDITORY, OLFACTORY LEARNINGLEARNING

• RECOGNITION LEARNING OF RECOGNITION LEARNING OF MUSIC/SOUNDS/VOICES/RHYMESMUSIC/SOUNDS/VOICES/RHYMES

• PLAY/AGGRESSION BEHAVIOR OF PLAY/AGGRESSION BEHAVIOR OF FETAL FETAL TWINSTWINS

INTRAUTERINE TRAUMAINTRAUTERINE TRAUMA

• INCREASED FETAL PULSE / BP WITH INCREASED FETAL PULSE / BP WITH MATERNAL AROUSAL MATERNAL AROUSAL

• DEFENSIVE FETAL REACTIONS TO DEFENSIVE FETAL REACTIONS TO AMNIOCENTESIS AMNIOCENTESIS

• INCREASED FETAL ENDORPHINS ANDINCREASED FETAL ENDORPHINS ANDCORTISOL WITH FETAL CORTISOL WITH FETAL

NEEDLINGNEEDLING• LOW BIRTH WEIGHT WITH FREQUENT LOW BIRTH WEIGHT WITH FREQUENT

PRENATAL ULTRASOUND AND PRENATAL ULTRASOUND AND THIRD TRIMESTER MEDICATIONSTHIRD TRIMESTER MEDICATIONS

• LOW BIRTH RATE WITH MATERNAL LOW BIRTH RATE WITH MATERNAL DISTRESSDISTRESS

THE NEONATAL ICUTHE NEONATAL ICU

• TUBES: BREATHING, SUCTIONING, TUBES: BREATHING, SUCTIONING, FEEDINGFEEDING

• NOISE, BRIGHT LIGHTS, NOISE, BRIGHT LIGHTS, ISOLATIONISOLATION

• PAIN: TRACHEOSTOMIES, MAJOR PAIN: TRACHEOSTOMIES, MAJOR SURGERY, ARTERIAL / SURGERY, ARTERIAL /

VENOUS VENOUS PUNCTURES / PUNCTURES / CUTDOWNSCUTDOWNS

NEONATAL ICU OUTCOMESNEONATAL ICU OUTCOMES• 283 PREMIES ASSESSED AT 30 MONTHS283 PREMIES ASSESSED AT 30 MONTHS

* 19% SEVERELY DELAYED * 19% SEVERELY DELAYED DEVELOPMENTDEVELOPMENT

* 11% MODERATELY DELAYED* 11% MODERATELY DELAYEDDEVELOPMENTDEVELOPMENT

* 10 % SEVERE NEUROMOTOR * 10 % SEVERE NEUROMOTOR DISABILITYDISABILITY

* 7 % BLIND* 7 % BLIND* 8 % SEVERE HEARING LOSS* 8 % SEVERE HEARING LOSS* OVERALL, 49% WITH DISABILITY, * OVERALL, 49% WITH DISABILITY,

23% WITH SEVERE DISABILITY23% WITH SEVERE DISABILITY

THE AMERICAN WAY OF THE AMERICAN WAY OF BIRTHINGBIRTHING

• THE OBSTETRICALTHE OBSTETRICAL DELIVERY ROOMDELIVERY ROOM* * INDUCTIONINDUCTION

* * FETAL MONITORING FETAL MONITORING * FORCEPS * FORCEPS * SUCTION DELIVERY* SUCTION DELIVERY* C-SECTIONS* C-SECTIONS* NEONATAL SUCTIONING * NEONATAL SUCTIONING * HEEL STICKS, EYE * HEEL STICKS, EYE MEDS MEDS * COLD, BRIGHT, NOISY ENVIRONMENT * COLD, BRIGHT, NOISY ENVIRONMENT * SEPARATION / ISOLATION* SEPARATION / ISOLATION

THE AMERICAN WAY OF THE AMERICAN WAY OF BIRTHINGBIRTHING

• MATERNAL ANESTHESIA AND SLOW MATERNAL ANESTHESIA AND SLOW INFANT DEVELOPMENTINFANT DEVELOPMENT

• INCREASED RATE OF JUVENILE INCREASED RATE OF JUVENILE BEHAVIORAL PROBLEMS AND BEHAVIORAL PROBLEMS AND CRIMINAL VIOLENCE IN MALES CRIMINAL VIOLENCE IN MALES WITH NON-BRAIN INJURY RELATED WITH NON-BRAIN INJURY RELATED

BIRTH COMPLICATIONSBIRTH COMPLICATIONS

PEDIATRIC MEDICAL TRAUMAPEDIATRIC MEDICAL TRAUMA• 1986 - PATENT DUCTUS SURGERY 1986 - PATENT DUCTUS SURGERY

WITHOUT WITHOUT ANESTHESIA DISCONTINUEDANESTHESIA DISCONTINUED• 1988 - 1988 - AMAAMA : : INFANTS CAN FEEL PAININFANTS CAN FEEL PAIN - -

RECOMMENDS SURGICAL ANESTHESIARECOMMENDS SURGICAL ANESTHESIA• 1990’s - FIRST ANESTHESIA USED IN1990’s - FIRST ANESTHESIA USED IN

PEDIATRIC ICU’SPEDIATRIC ICU’S• 1997 – 1997 – AMAAMA: RECOMMENDS ANALGESIA: RECOMMENDS ANALGESIA

FOR CIRCUMCISIONFOR CIRCUMCISION• PRESENT: ANALGESIA NEEDS OF PRESENT: ANALGESIA NEEDS OF

PREMIES, PREMIES, NEONATES AND INFANTS NEONATES AND INFANTS ADDRESSEDADDRESSED

PEDIATRIC MEDICAL PEDIATRIC MEDICAL TRAUMATRAUMA

• PEDIATRIC E.R., ANESTHESIA, PEDIATRIC E.R., ANESTHESIA, SURGERY AND SURGERY AND HOSPITALIZATIONHOSPITALIZATION

* ISOLATION AND PHYSICAL * ISOLATION AND PHYSICAL RESTRAINTSRESTRAINTS

* INADEQUATE PAIN MANAGEMENT* INADEQUATE PAIN MANAGEMENT* ETHER ANESTHESIA* ETHER ANESTHESIA* IGNORAL AND ISOLATION FROM * IGNORAL AND ISOLATION FROM

CARE-GIVERSCARE-GIVERS* THE FEAR INSTILLED BY ISOLATION * THE FEAR INSTILLED BY ISOLATION

IN A IN A TERRIFYING ENVIRONMENTTERRIFYING ENVIRONMENT

PEDIATRIC MEDICAL PEDIATRIC MEDICAL TRAUMATRAUMA

• CIRCUMCISIONCIRCUMCISION* * CIRCUMCIZED MALES HAVE A CIRCUMCIZED MALES HAVE A

GREATER PAIN RESPONSE TO GREATER PAIN RESPONSE TO SUBSEQUENT IMMUNIZATION SUBSEQUENT IMMUNIZATION SHOTS THAN NON-CIRCUMCIZED SHOTS THAN NON-CIRCUMCIZED MALESMALES

* USE OF EMLA CREAM * USE OF EMLA CREAM EFFECTIVEEFFECTIVE

ADULT MEDICAL TRAUMAADULT MEDICAL TRAUMA

• THE SURGICAL THEATERTHE SURGICAL THEATER- - SMELLS, SOUNDS, MASKED FACES, IGNORAL OF SMELLS, SOUNDS, MASKED FACES, IGNORAL OF THE THE PATIENT, A STATE OF NAKED HELPLESSNESSPATIENT, A STATE OF NAKED HELPLESSNESS

- PRE-OP ANXIETY AND POST-OP COMPLICATIONS- PRE-OP ANXIETY AND POST-OP COMPLICATIONS

* INCREASED THIOPENTAL AND CIRCULATORY * INCREASED THIOPENTAL AND CIRCULATORY COLLAPSECOLLAPSE

* POST-OP AGITATION* POST-OP AGITATION

* POST-OP SOMATIC SX: SLEEP DISTURBANCE, * POST-OP SOMATIC SX: SLEEP DISTURBANCE,

PERSISTENT PAIN, BOWEL COMPLAINTSPERSISTENT PAIN, BOWEL COMPLAINTS

ADULT MEDICAL TRAUMAADULT MEDICAL TRAUMA

• AWAKENING UNDER ANESTHESIAAWAKENING UNDER ANESTHESIA

* 30-35,000 CASES / YEAR IN U.S.* 30-35,000 CASES / YEAR IN U.S.* USUALLY UNDETECTED* USUALLY UNDETECTED* OVERWHELMING HELPLESSNESS* OVERWHELMING HELPLESSNESS* PTSD: MAJOR NIGHTMARES, FLASHBACKS, * PTSD: MAJOR NIGHTMARES, FLASHBACKS,

AROUSAL, PHOBIAS. VIVID DECLARATIVE MEMORYAROUSAL, PHOBIAS. VIVID DECLARATIVE MEMORY* SOMATIC SX.: COMPARABLE TO WHIPLASH* SOMATIC SX.: COMPARABLE TO WHIPLASH* PARTIAL AWAKENING WITHOUT MEMORY MAY * PARTIAL AWAKENING WITHOUT MEMORY MAY

EXPLAIN POST-OP AGITATION AND UNEXPLAINED EXPLAIN POST-OP AGITATION AND UNEXPLAINED CHRONIC PAIN BASED ON PROCEDURAL MEMORYCHRONIC PAIN BASED ON PROCEDURAL MEMORY

MEDICAL MEDICAL TECHNOLOGY:TECHNOLOGY:

TRAUMA BY THE TRAUMA BY THE CAREGIVERCAREGIVER

““I CAN’T FIND I CAN’T FIND ANYTHING WRONG, ANYTHING WRONG,

BUT WE’D BUT WE’D PROBABLY BETTER PROBABLY BETTER

GET AN MRI”GET AN MRI”

ORDERING TESTS TO ORDERING TESTS TO AVOID MEDICAL / AVOID MEDICAL / LEGAL LIABILITYLEGAL LIABILITY

NEW TECHNOLOGY AND NEW TECHNOLOGY AND THE TRAP OF THE THE TRAP OF THE “UNEXPLAINED” “UNEXPLAINED” ABNORMALITYABNORMALITY

THE INFALLIBILITY OF THE INFALLIBILITY OF TECHNOLOGY AND TECHNOLOGY AND

“EFFORT AFTER “EFFORT AFTER MEANING”MEANING”

REJECTION OF THE REJECTION OF THE PATIENT IF THE PATIENT IF THE

TESTS ARE NORMAL:TESTS ARE NORMAL:““IT MUST BE IT MUST BE

PSYCHOLOGICAL”PSYCHOLOGICAL”

THE DILEMMATHE DILEMMA OF AN OF AN

IMPERFECT SCIENCE IMPERFECT SCIENCE

THE INSIDIOUS THE INSIDIOUS REINFORCEMENT OF REINFORCEMENT OF

THE FEAR OF ILLNESS THE FEAR OF ILLNESS BY THE MEDIA AND BY THE MEDIA AND PHARMACEUTICAL PHARMACEUTICAL

INDUSTRYINDUSTRY

GOVERNMENT ANDGOVERNMENT ANDTHE MEDIATHE MEDIA

• THE POLITICS OF FEAR: THE COLD THE POLITICS OF FEAR: THE COLD WAR AND THE WAR ON WAR AND THE WAR ON

TERRORTERROR• LESSONS FROM VIETNAM: LESSONS FROM VIETNAM: IMAGES IMAGES

OF WARFAREOF WARFARE• THE VISUAL MEDIA: IMAGES OF THE VISUAL MEDIA: IMAGES OF

HORROR AND THE POWER OF HORROR AND THE POWER OF TRAUMATIC REENACTMENT TRAUMATIC REENACTMENT

- - THE APPEAL OF C.S.I.THE APPEAL OF C.S.I.

““LITTLE TRAUMAS”LITTLE TRAUMAS”• MOTOR VEHICLE ACCIDENTSMOTOR VEHICLE ACCIDENTS• PARENTAL ALCOHOLISM AND PARENTAL ALCOHOLISM AND

MENTAL ILLNESSMENTAL ILLNESS• RACIAL, GENDER AND JOB RACIAL, GENDER AND JOB

DISCRIMINATIONDISCRIMINATION• VIOLENCE IN THE MEDIA AND VIOLENCE IN THE MEDIA AND

ENTERTAINMENTENTERTAINMENT• BULLYING IN SCHOOLSBULLYING IN SCHOOLS• PERSONAL DEBTPERSONAL DEBT• THE INSURANCE INDUSTRYTHE INSURANCE INDUSTRY• THE LEGAL SYSTEMTHE LEGAL SYSTEM

TRAUMATIC TRAUMATIC REENACTMENTREENACTMENT

• SEXUALLY MOLESTED BOYS: SEXUALLY MOLESTED BOYS: INCREASED INCREASED DRUG ABUSE,DRUG ABUSE,

VIOLENCE VIOLENCE AND AND CRIMINAL CRIMINAL BEHAVIORBEHAVIOR

• 14 JUVENILES CONDEMNED TO 14 JUVENILES CONDEMNED TO DEATH: DEATH:

12 12 PHYSICALLY ABUSEDPHYSICALLY ABUSED, 5 , 5 SODOMIZEDSODOMIZED

TRAUMATIC TRAUMATIC REENACTMENTREENACTMENT

• CHILDHOOD SEXUAL ABUSE: CHILDHOOD SEXUAL ABUSE: HIGHER HIGHER ADULT INCIDENCE OF ADULT INCIDENCE OF RAPE, RAPE, SPOUSAL ABUSE, SPOUSAL ABUSE, PROSTITUTION, PROSTITUTION, POSING FOR POSING FOR PORNOGRAPHYPORNOGRAPHY

• SELF MUTILATION: CHILDHOOD SELF MUTILATION: CHILDHOOD HISTORY OF HISTORY OF PHYSICAL AND PHYSICAL AND SEXUAL ABUSE, MULTIPLE SEXUAL ABUSE, MULTIPLE

SURGICAL PROCEDURESSURGICAL PROCEDURES

REEXPERIENCING REEXPERIENCING AND THEAND THE

ANNIVERSARY ANNIVERSARY SYNDROMESYNDROME

TRAUMATIC ATTACHMENTTRAUMATIC ATTACHMENT

• ABUSIVE PARENT / CHILD BONDINGABUSIVE PARENT / CHILD BONDING• ABUSIVE SPOUSE / VICTIM ABUSIVE SPOUSE / VICTIM

BONDINGBONDING• KIDNAPPED VICTIM / CAPTOR KIDNAPPED VICTIM / CAPTOR

BONDINGBONDING• WE SEEK THE NEGATIVE WE SEEK THE NEGATIVE

CHARACTERISTICS OF OUR CHARACTERISTICS OF OUR CAREGIVERS IN OUR MATESCAREGIVERS IN OUR MATES

ENDORPHINS AND ENDORPHINS AND TRAUMATIC REENACTMENTTRAUMATIC REENACTMENT

• VICTIMS OF TRAUMA VICTIMS OF TRAUMA SEEKSEEK REEXPOSURE REEXPOSURE TO TO SITUATIONS SIMILAR TO OLD SITUATIONS SIMILAR TO OLD TRAUMA TRAUMA TO ACHIEVE ENDORPHIN TO ACHIEVE ENDORPHIN RELEASE, AS RELEASE, AS WELL AS “COMPLETION”WELL AS “COMPLETION”

““THE COMPULSION TO REPEAT THE THE COMPULSION TO REPEAT THE TRAUMA”TRAUMA”

ENORPHINS AND ENORPHINS AND TRAUMATIC REENACTMENTTRAUMATIC REENACTMENT

• ENDORPHINS MEDIATE HUMAN ENDORPHINS MEDIATE HUMAN ATTACHMENT AND BONDINGATTACHMENT AND BONDING

• LOSS OF MATERNAL BONDING AND LOSS OF MATERNAL BONDING AND SOCIAL SUPPORT:SOCIAL SUPPORT:

* DECREASED ANTERIOR * DECREASED ANTERIOR CINGULATE OPIATE RECEPTORS (THE CINGULATE OPIATE RECEPTORS (THE CINGULATE INHIBITS FEAR CINGULATE INHIBITS FEAR CONDITIONING)CONDITIONING)

* SEEKING ENDORPHINS THROUGH* SEEKING ENDORPHINS THROUGH

TRAUMATIC REENACTMENTTRAUMATIC REENACTMENT

ENDORPHINS AND ENDORPHINS AND TRAUMATIC REENACTMENTTRAUMATIC REENACTMENT• SELF-MUTILATION, SELF-STARVING: SELF-MUTILATION, SELF-STARVING:

INCREASED OPOIDS, WITH INCREASED OPOIDS, WITH RELIEF FROM AROUSALRELIEF FROM AROUSAL• REWARDS OF POST-TRAUMATIC REWARDS OF POST-TRAUMATIC

REUNION AFTER ABUSEREUNION AFTER ABUSE• REWARD SYSTEMS IN EXTREME REWARD SYSTEMS IN EXTREME

SPORTS AND ENDURANCE SPORTS AND ENDURANCE ATHLETICSATHLETICS

ENDURANCE AND ENDURANCE AND EXTREME SPORTSEXTREME SPORTS

• ? HIGHER INCIDENCE OF CHILDHOOD ? HIGHER INCIDENCE OF CHILDHOOD TRAUMA IN HIGH ENDURANCE TRAUMA IN HIGH ENDURANCE

SPORTS ATHLETESSPORTS ATHLETES• RESTORATION OF DEPRESSED RESTORATION OF DEPRESSED

ENDORPHIN LEVELS THROUGH ENDORPHIN LEVELS THROUGH EXTREME EFFORTEXTREME EFFORT

• ““FEARLESS”: TRAUMATIC FEARLESS”: TRAUMATIC REENACTMENT THROUGH REENACTMENT THROUGH

RISK-TAKINGRISK-TAKING

GENDER ISSUES IN TRAUMAGENDER ISSUES IN TRAUMA• DISSOCIATION AT THE TIME OF DISSOCIATION AT THE TIME OF TRAUMA TRAUMA

A A MAJOR PREDICTOR OF PTSDMAJOR PREDICTOR OF PTSD• INCIDENCE OF DISSOCIATION INCIDENCE OF DISSOCIATION ANDAND PTSD PTSD

MUCH HIGHER IN WOMEN (3:1)MUCH HIGHER IN WOMEN (3:1)• PERRY: ANTHROPOLOGICAL PERRY: ANTHROPOLOGICAL

IMPLICATIONS OF THE FREEZE IMPLICATIONS OF THE FREEZE RESPONSERESPONSE• A MODEL FOR VIOLENCE IN MALESA MODEL FOR VIOLENCE IN MALES• ENDORPHIN HABITUATION AND ENDORPHIN HABITUATION AND KINDLINGKINDLING

REENACTMENTREENACTMENTIN DAILY LIFEIN DAILY LIFE

• MATURATIONAL ARREST IN MATURATIONAL ARREST IN TRAUMATRAUMA

• OUR CHOICE OF MATESOUR CHOICE OF MATES• OUR CHOICE OF CAREERSOUR CHOICE OF CAREERS• OUR CHOICE OF RECREATIONOUR CHOICE OF RECREATION• OUR CHOICE OF SUBSTANCESOUR CHOICE OF SUBSTANCES

CONCLUSIONSCONCLUSIONS• MANY NEGATIVE LIFE EVENTS, IF MANY NEGATIVE LIFE EVENTS, IF EXPERIENCED IN A STATE OF EXPERIENCED IN A STATE OF HELPLESSNESS ASSUME THE HELPLESSNESS ASSUME THE DEFINITION DEFINITION OF TRAUMAOF TRAUMA• SUCH EXPERIENCES MAY BE SUCH EXPERIENCES MAY BE CULTURALLY CULTURALLY DETERMINED, AND DETERMINED, AND CONSIDERED TO BE CONSIDERED TO BE “NORMAL”“NORMAL”• INEXPLICABLE BEHAVIOR MAY INEXPLICABLE BEHAVIOR MAY REFLECT UNCONSCIOUS REFLECT UNCONSCIOUS RECAPITULATION RECAPITULATION OF PRIOR OF PRIOR TRAUMATRAUMA