The Neuroscience ofThe Neuroscience of TraumaTrauma:: Applying Brain Applying Brain Research to EA PracticeResearch to EA PracticeEAPA INTERNATIONAL ‘06EAPA INTERNATIONAL ‘06

Cardwell C. Nuckols MA, PhDCardwell C. Nuckols MA, PhD

Cnuckols@elitecorp.orgCnuckols@elitecorp.org(407) 758-1536(407) 758-1536www.gwcinc.com/drnuckols.htmwww.gwcinc.com/drnuckols.htm www.hci-online.com/cnuckols www.hci-online.com/cnuckols http://www.hazelden.org/OA_HTML/http://www.hazelden.org/OA_HTML/hazCSrdSrchResults.jsp?event=&cg=-hazCSrdSrchResults.jsp?event=&cg=-200&kw=NUCKOLS200&kw=NUCKOLS

Default Mode BrainDefault Mode Brain

““Here and Now” Here and Now” Supports individual and species Supports individual and species

survival at most basic levelsurvival at most basic level Sensory stimuli elicitSensory stimuli elicit

– ENGAGEMENTENGAGEMENT– AVOIDANCEAVOIDANCE– INDIFFERENCEINDIFFERENCE

Engagement or Engagement or AvoidanceAvoidance Sensory data internalizedSensory data internalized Brain edits data according to:Brain edits data according to:

– ““Mirror of Memory” (EGO)Mirror of Memory” (EGO)– USING INTERNAL CONTENT TO FILL USING INTERNAL CONTENT TO FILL

“GAPS” AND RESOLVE “GAPS” AND RESOLVE DISCREPANCIESDISCREPANCIES

Feature Detectors and our “Mirror Feature Detectors and our “Mirror of Memory" define “meaning”of Memory" define “meaning”

Feature DetectorsFeature Detectors

Temporal Lobe (“What”)Temporal Lobe (“What”)– Object identificationObject identification

Parietal Lobe (“Where”)Parietal Lobe (“Where”)– Spatial informationSpatial information

Limbic, Dorsolateral Prefrontal and Limbic, Dorsolateral Prefrontal and Orbitofrontal Circuits (“If”)Orbitofrontal Circuits (“If”)– Engagement or AvoidanceEngagement or Avoidance

Dorsolateral Prefrontal (“How”)Dorsolateral Prefrontal (“How”)– Novel situations requiring problem solvingNovel situations requiring problem solving

Feature DetectorsFeature Detectors

Trauma survivors may lack Trauma survivors may lack adequate feature detectorsadequate feature detectors

They may not have They may not have representations for empathy, love representations for empathy, love and/or happinessand/or happiness

Such words could have little or no Such words could have little or no meaning and elicit no meaning and elicit no corresponding body states.corresponding body states.

One-Half Second LagOne-Half Second Lag

Between receiving a stimulus and Between receiving a stimulus and becoming awarebecoming aware

Multiple reflection of the stimulus Multiple reflection of the stimulus in the “mirror of memory” (EGO)in the “mirror of memory” (EGO)

Stimulus becomes a reflection of Stimulus becomes a reflection of our EGO-Identityour EGO-Identity

Misattuned Primary Misattuned Primary CaregiverCaregiver Lack of “resonance”Lack of “resonance” Triggers dysregulated statesTriggers dysregulated states Not able to repair these statesNot able to repair these states

– States become traitsStates become traits– Defenses are embedded in evolving Defenses are embedded in evolving

personalitypersonality– Potential Personality DisordersPotential Personality Disorders

Borderline Personality DisorderBorderline Personality Disorder

Maladaptive Brain Maladaptive Brain DevelopmentDevelopment Especially secondary to Especially secondary to

“relational trauma”“relational trauma”– Severe Affective Severe Affective

DysregulationDysregulation Loss of emotional self-regulationLoss of emotional self-regulation Expressed as loss of ability to Expressed as loss of ability to regulate the Intensity and regulate the Intensity and Duration of affectDuration of affect

Maladaptive Brain Maladaptive Brain DevelopmentDevelopment

Paralimbic areas Paralimbic areas of the right of the right hemisphere are hemisphere are preferentially preferentially involved in the involved in the storage of storage of traumatic traumatic memoriesmemories

GenderGender

MaleMale– Limbic system has different Limbic system has different

connectivity patternsconnectivity patterns– Delayed cerebral maturationDelayed cerebral maturation– More susceptible to “relational” abuseMore susceptible to “relational” abuse– Hyperarousal patternHyperarousal pattern– Externalizing disordersExternalizing disorders

Conduct DisorderConduct Disorder

GenderGender

FemaleFemale– DissociationDissociation– Internalizing disordersInternalizing disorders

Affective DisordersAffective Disorders Anxiety Disorders Anxiety Disorders Somatoform DisordersSomatoform Disorders

– Conversion DisorderConversion Disorder– Pain DisorderPain Disorder– HypochondriasisHypochondriasis

Treatment GoalsTreatment Goals

Stabilization, Trust and SafetyStabilization, Trust and Safety Learn to Live Gracefully in the Learn to Live Gracefully in the

PresentPresent Develop Higher Order FunctionsDevelop Higher Order Functions Establish a Sense of SelfEstablish a Sense of Self

– PersonalityPersonality

Stabilization, Trust Stabilization, Trust and Safetyand Safety What has changed?What has changed? Closed contractClosed contract StabilizationStabilization

– PhysiologicalPhysiological PropranololPropranolol

– PsychologicalPsychological– SocialSocial

TrustTrust– Validate feelingsValidate feelings

TrustTrust

Validate feelingsValidate feelings– AngerAnger– Self-criticalSelf-critical– DepressionDepression– WithdrawalWithdrawal

Enter the map of the worldEnter the map of the world– ““World has fundamentally changed”World has fundamentally changed”– ““World is unfair”World is unfair”

TrustTrust

Past history of assessmentPast history of assessment Past experience with rulesPast experience with rules Power issues in therapeutic Power issues in therapeutic

relationshiprelationship CaseCase

– 35 yo female (Marsha) having 35 yo female (Marsha) having difficulty at work with supervisors difficulty at work with supervisors that she fears may interfere with that she fears may interfere with future promotionsfuture promotions

Learning To Live Learning To Live Gracefully In The Gracefully In The PresentPresent Mindful AwarenessMindful Awareness ““Mindfulness is defined as paying Mindfulness is defined as paying

attention, in the present moment, on attention, in the present moment, on purpose, without grasping on to purpose, without grasping on to judgments.” (Siegel, 2006)judgments.” (Siegel, 2006)

Mindful awareness improves:Mindful awareness improves:– Cardiac functionCardiac function– Endocrine functionEndocrine function– Immune functionImmune function

Empathy, compassion and interpersonal Empathy, compassion and interpersonal sensitivity seem to be improvedsensitivity seem to be improved

Learning To Live Learning To Live Gracefully In The Gracefully In The Present-Treatment Present-Treatment ConsiderationsConsiderations Mindfulness MeditationMindfulness Meditation Positive Connections to OthersPositive Connections to Others

– Mirror NeuronsMirror Neurons– Therapeutic RelationshipTherapeutic Relationship

Positive Connection to a Higher Positive Connection to a Higher Power of our ChoicePower of our Choice

Learning from Therapeutic Learning from Therapeutic “Ruptures”“Ruptures”

Therapeutic Therapeutic RelationshipRelationship

A SECURE ATTACHMENT A SECURE ATTACHMENT THAT PROMOTES GROWTH THAT PROMOTES GROWTH OF NEURAL INTEGRATIVE OF NEURAL INTEGRATIVE FIBERS (ESPECIALLY FIBERS (ESPECIALLY ORBITOFRONTAL CORTEX)ORBITOFRONTAL CORTEX)

Therapeutic Therapeutic “Ruptures”“Ruptures”

PT appraises TH facePT appraises TH face

Generates empathic failureGenerates empathic failure

Activates right brain imprinted Activates right brain imprinted pathological internal object pathological internal object relationsrelations

Therapeutic Therapeutic “Ruptures”“Ruptures” Programs PTs “Hot Theory of Mind”Programs PTs “Hot Theory of Mind”

Creates expectations of immediate Creates expectations of immediate dysregulationdysregulation

PTs brain shifts dominance from PTs brain shifts dominance from Left Linear processing to Right Non-Left Linear processing to Right Non-linear processinglinear processing

Therapeutic Therapeutic “Ruptures”“Ruptures” Rupture of Therapeutic RelationshipRupture of Therapeutic Relationship

Induces chaotic state associated with Induces chaotic state associated with

early traumatic experience stored in early traumatic experience stored in “mirror of memory”“mirror of memory”

“ “Splitting”-evaporation of positive and Splitting”-evaporation of positive and

enhancement of negative enhancement of negative

Therapeutic Therapeutic “Ruptures”“Ruptures”

Rapid emotional instabilityRapid emotional instability

HYPERAROUSAL DISSOCIATIONHYPERAROUSAL DISSOCIATION

Repairing Therapeutic Repairing Therapeutic “Ruptures”“Ruptures” Therapist must recognize and Therapist must recognize and

regulate the negative affect regulate the negative affect within self and clientwithin self and client

Therapist on a non-verbal level Therapist on a non-verbal level must detect, monitor and self-must detect, monitor and self-regulate countertransferenceregulate countertransference

““Reparative withdrawal” for self-Reparative withdrawal” for self-regulationregulation

Repairing Therapeutic Repairing Therapeutic “Ruptures”“Ruptures” Model for CT that self-Model for CT that self-

disorganization can be regulateddisorganization can be regulated Use psychoeducation to express Use psychoeducation to express

verbally what just happened moving verbally what just happened moving from right hemisphere to leftfrom right hemisphere to left

Increase organization in limbic Increase organization in limbic structures that mediate the structures that mediate the emergence of adaptive capacities emergence of adaptive capacities (Schore)(Schore)

Prefrontal Cortical (PFC) Prefrontal Cortical (PFC) CircuitsCircuits

ORBITOFRONTAL CIRCUITORBITOFRONTAL CIRCUIT– Modulates pursuit of rewardModulates pursuit of reward

RiskRisk ContextContext Potential consequencesPotential consequences

– In conjunction with amygdala In conjunction with amygdala can can stimulate or inhibit ANSstimulate or inhibit ANS

– If damaged-impulsivity, social If damaged-impulsivity, social inappropriateness, disregard for rules and inappropriateness, disregard for rules and consequencesconsequences

Orbitofrontal CortexOrbitofrontal Cortex

Modulates instinctive behavior and Modulates instinctive behavior and internal drivesinternal drives

Processes face and voice Processes face and voice information for appraisal of information for appraisal of external environmentexternal environment

Therefore, integrates external and Therefore, integrates external and internal environmentinternal environment

Early developmental trauma has Early developmental trauma has negative impact on OFCnegative impact on OFC

Orbitofrontal Directly Orbitofrontal Directly Connects To:Connects To: HypothalamusHypothalamus

– Head ganglion of ANS & locus of Head ganglion of ANS & locus of drivedrive

AmygdalaAmygdala Reticular formationReticular formation

– Brainstem regulation of arousalBrainstem regulation of arousal Frontal cortexFrontal cortex

Orbitofrontal Circuit Orbitofrontal Circuit ControlsControls

AUTONOMIC NERVOUS SYSTEMAUTONOMIC NERVOUS SYSTEM

PARASYMPATHETIC SYMPATHETICPARASYMPATHETIC SYMPATHETIC

DISSOCIATION HYPERAROUSALDISSOCIATION HYPERAROUSAL

(FREEZE) (FIGHT/FIGHT) (FREEZE) (FIGHT/FIGHT)

Parasympathetic Parasympathetic Nervous SystemNervous System Conservation/WithdrawalConservation/Withdrawal

– ““Disengage”Disengage”– ““Allow healing”Allow healing”

Shame (Blushing)Shame (Blushing) Repetitive Dissociative SymptomsRepetitive Dissociative Symptoms

– TicsTics– StutteringStuttering– Poor eye contactPoor eye contact– Somatic complaintsSomatic complaints

Parasympathetic Parasympathetic Nervous SystemNervous System Passive StatePassive State

– Increased endogenous opioidsIncreased endogenous opioids– Increased behavior-inhibiting cortisolIncreased behavior-inhibiting cortisol

Increased cortisol in Type D infants with Increased cortisol in Type D infants with abuse hxabuse hx

Reduced cortisol in Type D infants with Reduced cortisol in Type D infants with neglect hxneglect hx

Hypocortisolemia in adulthood is Hypocortisolemia in adulthood is predictor of PTSDpredictor of PTSD

What if hypercortisolemia in adulthood What if hypercortisolemia in adulthood related to autoimmune disorders?related to autoimmune disorders?

Sympathetic Nervous Sympathetic Nervous SystemSystem ““Fight or Flight”Fight or Flight” Increased CortisolIncreased Cortisol

– InsomniaInsomnia– Increased serum lipidsIncreased serum lipids– Promotes obesity (abdominal area)Promotes obesity (abdominal area)– DiabetesDiabetes– HypertensionHypertension– AtherosclerosisAtherosclerosis– Suppresses immune systemSuppresses immune system– Peptic ulcerationsPeptic ulcerations– Atrophy of HippocampusAtrophy of Hippocampus

Relapse DynamicRelapse Dynamic

HYPERAROUSALHYPERAROUSAL

TX STRESSTX STRESS DISSOCIATIONDISSOCIATION

Response To ThreatResponse To Threat HYPERAROUSAL DISSOCIATION

HYPERVIGILANTREACTIVETACHYCARDIANOREPINEPHRINEFLIGHT: PanicFIGHT: TerrorOLDER CHILDRENMALES

DISENGAGESUSPENSION OF TIMEBRADYCARDIAENDOGENOUS OPIODSFREEZE: FearDEREALIZATIONDEPERSONALIZATIONCOMPLIANTYOUNG CHILDREN FEMALES

Kindling & Somatic Kindling & Somatic ComplaintsComplaints

INTERNAL AND EXTERNAL CUESINTERNAL AND EXTERNAL CUES

TRIGGER USELESS REFLEXIVE, SELF-TRIGGER USELESS REFLEXIVE, SELF-PROTECTIVE MOTOR RESPONSES, PROTECTIVE MOTOR RESPONSES, PAIN, SENSORY EXPERIENCES AND PAIN, SENSORY EXPERIENCES AND EMOTIONAL STATESEMOTIONAL STATES

AFTER EACH AROUSAL SENSITIVITY IS AFTER EACH AROUSAL SENSITIVITY IS INCREASEDINCREASED

Kindling & Somatic Kindling & Somatic ComplaintsComplaints

PROGRESSIVE CUE-BASED PROGRESSIVE CUE-BASED SENSITIZATION (MAY RESPOND TO SENSITIZATION (MAY RESPOND TO ANY EXCESSIVE EXTERNAL ANY EXCESSIVE EXTERNAL ENVIRONMENTAL STIMULI-SMELLS, ENVIRONMENTAL STIMULI-SMELLS, LOUD NOISES,FLASHES OF LIGHT)LOUD NOISES,FLASHES OF LIGHT)

PTSD SYMPTOMS WORSEN WITH PTSD SYMPTOMS WORSEN WITH INCREASE IN SOMATIC COMPLAINTSINCREASE IN SOMATIC COMPLAINTS

Working With Working With Hyperarousal And Hyperarousal And DissociationDissociation MedicationsMedications Symptom listSymptom list

– What are you feeling?What are you feeling?– What is happening around you?What is happening around you?

Help client make connection between Help client make connection between internal state and external realityinternal state and external reality

““Mindfulness” and tolerance of Mindfulness” and tolerance of feelingsfeelings

Behavioral Exposure Behavioral Exposure TherapyTherapy International Society for Traumatic International Society for Traumatic

Stress StudiesStress Studies– Behavioral Exposure TherapyBehavioral Exposure Therapy

Imaginal ExposureImaginal Exposure– Repeated recounting of traumatic memoriesRepeated recounting of traumatic memories

In Vivo ExposureIn Vivo Exposure– Confronting trauma related situationsConfronting trauma related situations

Virtual RealityVirtual Reality– Computer simulationComputer simulation

– May be mediated by Prefrontal Cortical May be mediated by Prefrontal Cortical inhibition of Amygdalainhibition of Amygdala

Clinical Case StudyClinical Case Study

29 yo female (Peggy) in early recovery 29 yo female (Peggy) in early recovery for cocaine addiction with history of for cocaine addiction with history of early life traumaearly life trauma– Use of grief letter with elements of Use of grief letter with elements of

Imaginal and In Vivo Behavioral ExposureImaginal and In Vivo Behavioral Exposure What do you remember?What do you remember? How has it impacted your life?How has it impacted your life? How do you feel about it now?How do you feel about it now?

Decrease hyperarousal and intrusive Decrease hyperarousal and intrusive symptomssymptoms

Behavioral Exposure Behavioral Exposure Generally Combined Generally Combined WithWith

Relaxation TrainingRelaxation Training– Controlled BreathingControlled Breathing– Muscle RelaxationMuscle Relaxation

PsychoeducationPsychoeducation Cognitive RestructuringCognitive Restructuring

– Safety, trust, power, esteem and Safety, trust, power, esteem and intimacy intimacy

Anticipated ResultsAnticipated Results

Balance the Sympathetic and Balance the Sympathetic and Parasympathetic branches of the ANSParasympathetic branches of the ANS

Ability to tune into others including the Ability to tune into others including the experience of empathyexperience of empathy

Emotional balance including the ability Emotional balance including the ability to inhibit impulsesto inhibit impulses

Self-Knowing Awareness thru Self-Knowing Awareness thru autobiographical narrativeautobiographical narrative– Horizontal IntegrationHorizontal Integration

Anticipated ResultsAnticipated Results

Fear Extinction from GABA fibers Fear Extinction from GABA fibers extending down to amygdala-calming extending down to amygdala-calming the conditioned fear responsethe conditioned fear response

Becoming aware of the input from our Becoming aware of the input from our bodies (gut, heart, etc.) allowing bodies (gut, heart, etc.) allowing intuitive wisdomintuitive wisdom

The capacity to think of the larger The capacity to think of the larger good and act in a pro-social mannergood and act in a pro-social manner– Vertical IntegrationVertical Integration

Trauma Treatment In Trauma Treatment In Early Recovery from Early Recovery from Addictive DisorderAddictive Disorder Estimated 30-60 percent of individuals with Estimated 30-60 percent of individuals with

substance abuse disorders have PTSDsubstance abuse disorders have PTSD Joint Treatment of PTSD and Cocaine AbuseJoint Treatment of PTSD and Cocaine Abuse

– Therapy combinesTherapy combines Substance abuse treatmentSubstance abuse treatment Behavioral exposure for PTSDBehavioral exposure for PTSD

– 39 participants, 15 completed course of therapy39 participants, 15 completed course of therapy 66% reduction in intrusive symptoms66% reduction in intrusive symptoms 70% reduction in avoidance symptoms70% reduction in avoidance symptoms 47% reduction in hyperarousal symptoms47% reduction in hyperarousal symptoms

(NIDA Notes,Vol.18,No.1)(NIDA Notes,Vol.18,No.1)

REFERENCESREFERENCES

http://www.medscape.com/http://www.medscape.com/viewprogram/1917_pntviewprogram/1917_pnt

http://psychiatry.jwatch.org/cgi/content/http://psychiatry.jwatch.org/cgi/content/full/2004/624/4?q=etocfull/2004/624/4?q=etoc

http://www.sciencemag.org/cgi/content/http://www.sciencemag.org/cgi/content/fill/304/5672/881fill/304/5672/881

http://www.sfn.org/content/Publications/http://www.sfn.org/content/Publications/

BrainBriefings/posttraumaticdisorder.htmlBrainBriefings/posttraumaticdisorder.html

REFERENCESREFERENCES

http://websfn.org/content/Publications/http://websfn.org/content/Publications/BrainBriefings/parental_care_brain.htmlBrainBriefings/parental_care_brain.html

http://web.sfn.org/content/Publications/http://web.sfn.org/content/Publications/BrainBriefings/child_abuse.htmlBrainBriefings/child_abuse.html

http://www.childtrauma.org/print/print.asp?http://www.childtrauma.org/print/print.asp?REF=/CTAMATERIAL/neuros-1.aspREF=/CTAMATERIAL/neuros-1.asp

http://www.medscape.com/viewarticle/http://www.medscape.com/viewarticle/441133_print441133_print

REFERENCESREFERENCES

Psychiatric Annals, Volume 33, Number 1, Psychiatric Annals, Volume 33, Number 1, January, 2003.January, 2003.

““After The Trauma: What Doesn’t Help and After The Trauma: What Doesn’t Help and What May”. Harvard Mental Health Letter, What May”. Harvard Mental Health Letter, November, 2003.November, 2003.

Beitman and Viamontes. The Neurobiology of Beitman and Viamontes. The Neurobiology of Psychotherapy. Psychiatric Annals. Volume Psychotherapy. Psychiatric Annals. Volume 36, Number4, April, 2006, pg 214.36, Number4, April, 2006, pg 214.

Siegel, Daniel. An Interpersonal Neurobiology Siegel, Daniel. An Interpersonal Neurobiology Approach to Psychotherapy. Psychiatric Approach to Psychotherapy. Psychiatric Annals. Volume 36, Number4, April, 2006, pg Annals. Volume 36, Number4, April, 2006, pg 250.250.

Reference SitesReference Sites

Handouts for Parents and Handouts for Parents and ProfessionalsProfessionals– http://www.zerotothree.orghttp://www.zerotothree.org

Information for ProfessionalsInformation for Professionals– http://http://

www.childtraumaacademy.comwww.childtraumaacademy.com The National Center for PTSDThe National Center for PTSD

– http://www.ncptsd.org//publicationshttp://www.ncptsd.org//publications