Trauma and Brain Function: Neurobiological Impact of Trauma

[00:00:00]CEUs are available at AllCEUs.com/Trauma-CEU i'd like to welcome everybody today's  presentation on the neurobiological  impact of psychological trauma and the hpa axis or our threat response system now what we're talking about is not necessarily  ptsd we're talking about the impact of trauma on our hpa axis and if we have excessive  stimulation of that hpa axis it can contribute to traumatic injury but not every trauma  causes traumatic injury and we do want to remember that there are things that we go through  that or you may have gone through which may have not been caused traumatic injury it was traumatic  but you had enough resources and resilience and all that kind of stuff that it didn't cause injury  or long-lasting effects and there are other things or or somebody else may have gone through a  similar situation and not had those resources and experienced traumatic injury from it so we  do want to recognize that every trauma impacts every person differently at every point in  time what was stressful for you five years ago may not be stressful now or vice versa maybe  five years ago you were just kind of walking on sunshine and right now you've got a lot of  stress and you're already worn down so we're going to start by defining and explaining the hpa axis  identifying the impact of trauma on the hpa axis and the impact of chronic stress and cumulative  stress on the hpa axis finally we'll identify symptoms of hpa axis dysfunction and interventions  that are useful for people who are experiencing hpa axis dysfunction i'm going to say that a lot  hpa axis stands for hypothalamic pituitary adrenal axis i call it our threat response system for  short just because i get tired of saying hpa axis this presentation is based in part on the  article post traumatic stress disorder the neurobiological impact of psychological  trauma that was published in 2011.

[00:02:15]attention therapists all ceus is grateful to  our new sponsor the diversion center they offer workbooks that are 100 editable and delivered to  you in a word document on topics including anger management substance use disorders domestic  violence parenting and shoplifting addiction each workbook can be used for individual  or group sessions and is over 120 pages you have the option to add or remove  content insert your name as the author and reprint and resell the workbooks to your  clients go to privatelabelworkbooks.com and take advantage of their buy one get one free bundle  offers remember that's privatelabelworkbooks.com neurobiological abnormalities in ptsd or trauma overlap with the features found in traumatic  brain injury imagine that we actually see physiological changes shrinkage of the hippocampus  and other physiological changes as the result of environmental situational emotional trauma not just actual traumatic brain  injury like from a concussion the response of an individual to trauma depends  not only on the stressor characteristics you know let's look at what's what actually happened  but also on factors specific to the person such as the perception of their stressor how close  did this occur to the person's safe zone we have places where we feel safe you feel safe in your  home hopefully you feel safe at work hopefully if this whatever this trauma is occurs somewhere  where you thought you were safe suddenly you don't feel safe anymore it's going to have a stronger  impact than for example if you experienced a traumatic incident when you were on vacation  a thousand miles away from your house your similarity to the victim if you are the victim  then obviously you're very similar to the victim if you are interacting with people and maybe you  are the parent of the victim or the great aunt of the victim um or even you are a therapist working  with the victim or the survivor and you feel a great deal of similarities with that person then  it may impact you more one of the things i see in emergency service personnel is we have some  uh first responders that go out to say a child drowning and it impacts them don't get me wrong it  impacts everybody but the ones that tend to have a stronger reaction also tend to have or have had  similarly aged children at home at some point so it's very similar they can almost see their child  in that position and the degree of helplessness how powerless that person felt which kind  of goes along with what joseph pointed out trump trauma definitely is affected by or our  ability to handle trauma is affected by our age children need to have those social supports  they need to have their parents their primary attachment figures there to help them feel safe  children need to have a lot of other resources because they don't have as many experiences so  something that may not seem like a big deal to us may seem like a really big deal to a 10 or a 12  or heaven forbid a five-year-old and they don't understand things the same way that we do they  are also very egocentric a lot of times they feel they think that something they did caused  the problem or something they didn't do may have caused the problem or in the in  the case of say a hurricane they may over generalize and start having fears whenever any  thunderstorm comes along because they were in that hurricane so they think that every storm is going  to be a hurricane we do need to make sure that we work with children after stressful  incidents to make sure that they understand what happened to the best of their ability they  may not get death they may not get addiction and we need to help them depersonalize it so they  understand it wasn't something they did or didn't do we need to present them the information  in a way that they will understand and keep reiterating to them that they're safe and help  them feel safe recognize that a lot of children's behaviors when they are experiencing trauma  are often reactions that are designed to elicit control or structure or comfort from those  primary caregivers regression acting out those sorts of behaviors we want to look and  say what is this behavior communicating to us people who've had prior traumas tend to have  a stronger reaction to successive traumas they've found that people who are in a state  of hypocortisol ism um and we're going to talk about that in a little while but people who've  experienced prior traumas and it's impacted their physiology actually are at a greater risk for  developing ptsd from future traumatic events it is they're already primed so to speak or  whatever you wanna however you wanna call it the amount of stress in the preceding months also  contributes to our reaction if you've had a great six eight twelve months leading up to  whatever this trauma was then you're probably stocked up on emotional cognitive social resources  your energies built up however if you have had a hell of a year and a lot of times they say  that bad things come in threes usually by the time you get to that third thing you're done  you're exhausted um but if you've had stressors and challenges even small ones they add up and  they can wear down your recovery resources your recovery capital so you may not be in the place  to have the resilience that you you might have had should you have not had such a hard time in the  past few months current mental health or addiction issues obviously if you've got something currently  going on then you're starting 20 yards back and we need to take that into consideration  people who are currently symptomatic for some sort of mental health issue are  probably going to have more difficulty dealing with the traumatic stress because their  neurotransmitters are already out of whack and the availability of social support and  i'm going to talk about this multiple times but there are critical windows here social  support in the first 24 hours is the most critical if somebody gets social support in the first  24 hours it helps them process what's going on before they start compartmentalizing it we can  only experience crisis oriented stress for so long before we start having to kind of try to pack it  up and do something with it after about 24 hours 24 to 48 hours it's still there it's still raw  but people have caught their breath a little bit and they've started to push it back and social  support is still helpful here because it's still easily accessible to process after about 72  hours people have had to pack it up and put it on that back burner for a little while because  it is too overwhelming to continue to feel that level of distress and it makes it harder  sometimes to access it after about 72 hours some people may start saying you know what  i've got it it's not that big of a deal and in reality it probably is they have just  put it away in a box somewhere that is going to require energy at some point in time  the vast majority of the population has experienced trauma but their reaction is  limited to an acute transient disturbance it may be a few days a couple of weeks something  like that the signs and symptoms of ptsd reflect persistent adaptations of the body systems the  neurobiological systems to the experience trauma and you notice i crossed out the word abnormal  adaptations it is a very normal adaptation the stuff that happens because when we're under  stress that hpa axis kicks off and i'm fond of it when it's working well because it helps us  survive it tells us fight or flee let me give you the energy so you can fight or flee but when  it stays active for too long it starts causing lots of problems such as you know destruction  of neurons and all that kind of stuff one of the things that the body does is try to dampen that a  little bit um so we're not running so hot so often and but that reaction you know our body's  reaction to try to balance out that persistent high level of cortisol glutamate norepinephrine  results in changes in our neurochemical system the hypothalamic pituitary adrenal access the  hpa axis or our threat response system controls reactions to stress and regulates many body  processes i want you to think about why why does the hpa axis control these things digestion  well when we've got a fight or flea it is not time to be resting and digesting it's time to get  that food out of the system to speed things up and focus the energy on you know protecting ourselves  the immune system when people are fighting or fleeing you know cortisol actually suppresses the  immune system suppresses initially suppresses and inflammation in order to divert all that energy  to the current crisis so people's immune system goes down mood and emotions are altered when that  hpa axis is activated norepinephrine glutamate adrenaline those are coursing through your system  some dopamine those are your go get them those are your excitatory neurochemicals which means it is  turning down your body's turning down if you will the dial on serotonin which is more of a calming  and gaba which is sort of our natural value and our endogenous opioids those are going you  know now is not the time to worry about pleasure now is not the time to worry about reproduction  so estrogen progesterone and testosterone all get altered in their levels and the  receptors that are being activated so our sexuality and our libido goes down so you can  see somebody who has a persistently activated hpa axis may have digestive problems reduced  immunity mood issues because that serotonin and gaba is not helping to help the person feel  calm and happy and relaxed and all those things additionally that low serotonin also reduces  pain threshold so people tend to feel more pain energy storage and expenditure is also all over  the place so people with for example diabetes have a hard harder time controlling their blood  sugar cortisol one of the things it does is tell your body dump glucose dump glucose we need that  fast energy so if cortisol is constantly surging through your body then you've constantly got  glucose surging through your body so that glucose insulin balance it ain't there and it's important  for people to remember that that they may feel hypoglycemic faster they may get a little bit  edgier faster these are all things that we need to recognize when people are experiencing stress help  them understand why they're having these different systems or symptoms and why it makes sense from  a survival point of view and to a certain extent that's awesome i am glad your body is focusing  to try to help protect you the ultimate result of hpa axis activation is to increase levels  of cortisol in the blood during times of stress we call cortisol our our stress hormone  and it's there to help us get motivated but when the hpa axis kicks off cortisol goes really  high and it can eventually cause some problems cortisol's main role is in releasing glucose into  the bloodstream to facilitate the fight-or-flight response it also suppresses and modulates the  immune system digestive system and reproductive system cortisol plays a big role now when we  think about people who experience chronic stress what hormone do they have that is generally very  high i'll give you a hint it's cortisol we're not necessarily just talking about some trauma we  can be talking about chronic ongoing stress they found that there are a lot of lifestyle factors  that contribute to hpa axis hyperactivation the body reduces its hpa axis activation  when it appears that further fight or flight may not be beneficial remember think about a  a bath you know you're running a bath you turn that hot water you know wide open that is your  hpa axis that's your fight or flight that is the heat the get up and go but it starts getting  a little too hot and you want to turn on the cold so you don't burn yourself well your  body does the same sort of thing it wants to protect those neurons wants to protect  your body from running too hot so to speak but eventually what happens that hot water you  only have so much well unless you have limitless hot water but most of us still have a hot water  tank and eventually that hot water runs out and then it starts running cold if you want to  think about it that way the body's trying to balance against the excessive heat of  the hpa axis but the hot water runs out the body doesn't cue into the fact that that's  happened yet so it continues to try to protect you from that excessive stimulation which can lead  to feelings of depression it also can create a situation called hypocortisolism  where the body is actually blocking cortisol from going through because it's  saying okay we can't have this much cortisol going into the system because it's overdoing  it kind of like flooding a garden with water you know that would be if the if the farmer put  on a nozzle so he wasn't putting so much water out into the garden hypocortisolism is seen in stress  related disorders such as chronic chronic fatigue syndrome burnout and ptsd and it's actually a  protective mechanism designed to conserve energy during threats that are beyond the organism's  ability to cope so this other reason for feelings of flatness and apathy after persistent  or ongoing hpa axis dysfunction is the body going i've only got so much energy left and i'm going to  conserve that right now so when there is a problem i can spring into action oh but there's a  problem with that when they spring into action then the hpa axis goes from apathetic and  kind of flat and the person is you know blah feels blah to emotional dysregulation there is  no middle ground when the hpa axis has gone into this um hypocortisol or glutathio glucocorticoid  resistant state so we see a lot more emotional dysregulation until we can get that hpa axis  re-regulated and we need to look at all the causes for dysregulation including sleep disturbances  excess caffeine pain mood issues cognitions lack of social support you know  there's a whole list of biopsychosocial triggers for stress and stress activates that  hpa axis dysfunctional hpa axis activation will result in abnormal immune system responses which  generally suppressed immune system for a while but the interesting thing is initially the  hpa axis suppresses inflammation but after a stress response the way the system's supposed to  work the cortisol subsides and inflam inflammatory cytokines are released into the body why because  they circulate around and find any places of injury cause inflammation cause blood to go to the  area for repair and rejuvenation so it makes sense but if that hpa axis stays activated and  never kind of calms down then you have this weird situation where you've got cortisol in the  system but you've also got circulating systemic inflammation what do we know about suppressed  immune system and increased inflammation a lot of times that's related to the  development or exacerbation of autoimmune issues there can be increased inflammation and  allergic reactions irritable bowel syndrome such as constipation and diarrhea reduced  tolerance to physical and mental stresses including pain you know it could be the person is  just edgy and irritable i say just and they also may have difficulty tolerating pain tolerating  hunger tolerating blood sugar alterations and there are altered levels of sex hormones because  the body is still getting this message that it's not safe to procreate our our little you  know ankle biters aren't going to be safe yet fatigue interestingly enough when we  experience extended hpa axis activation one of the symptoms is fatigue and fatigue  is actually an emotion generated in the brain which prevents damage to the body when the brain  perceives that further exertion could be harmful so i was at the gym today and i was doing  a lactic acid threshold workout which you know those suck i'll just tell you and  after about 30 minutes of working at 98 to 102 of my max heart rate i was starting to feel really  fatigued i was like i don't know if i can finish this segment here that was my brain going okay  you done pushed the envelope it's time to back off because you're getting to the point where you  could start hurting yourself fatigue in sports is largely independent of the state of the muscles  themselves and is more related to core temperature glycogen levels i was fasting before i worked  out so my blood sugar i had run through it by that point my blood sugar was really low my core  temperature was high oxygen levels in the brain thirst sleep deprivation and level of muscle  soreness and fatigue so thankfully i only had two of those things working against me so i  was able to complete my workout but fatigue can be cumulative and we want people to recognize that  and this is true during daily living too not just in sports if people's blood sugar levels are not  adequate if they're there's not getting enough oxygen to the brain they're breathing shallowly  if they're dehydrated sleep deprived and have muscle fatigue for whatever reason and sometimes  people who are depressed report feeling a lot of heaviness and muscle fatigue then you know you  can see that they may be experiencing ongoing fatigue that may be unrelated to sports it's more  related to that hpa axis activation because the body is still acting as if it is being stimulated  by something like running from a lion or sports psychological factors that can be involved in  reducing fatigue including your emotional state if you are enthusiastic about it which most  of us are not enthusiastic about trauma but if you're enthusiastic about it it can reduce  fatigue which is why athletes tend to see that finish line and they start to get enthusiastic  and they can push past that fatigue we want to help people see the finish line we want to help  people feel efficacious we want to help people see the progress that they've made and see that  their destination is not unreachable knowledge of an endpoint you know if you're just you keep going  and it's like eventually maybe you'll feel better you know it's hard to keep going but if you  know that okay this is 10 weeks of therapy or you know this is a mile run or  whatever it is or you know that this pain you know you had surgery and the doctor  says you know in three to six weeks you should be feeling significantly less pain that i know  shoulder surgery is a huge hugely painful surgery and but people who go through it they know okay  this is really hideous right now but i know hopefully after this recovery period  i will feel better other competitors or motivators can reduce fatigue so if we have  good social support for people who are around us when people are going through trauma that  can be seen as motivators not competitors necessarily when we're talking about trauma  but they are people that are there to motivate us to cheer us on from the stands so to  speak if we want to keep with this analogy and visual feedback can help reduce fatigue  use baseline charts use journals use logs to help people see that they are gradually improving  fatigue is one sign that the body is getting ready to down regulate the hpa access to start holding  on to those energy reserves in counseling practice we need to figure out how we can reduce fatigue  and help clients restore hpa axis functioning and a lot of it comes back to incur having them have a  survivor mentality and a positive emotional state helping them devise an end point so that they  can see getting social support and motivation and making sure that they are rested  nourished and all those other things low cortisol has been found  to relate to more severe ptsd or hyperarousal symptoms sensitized negative  feedback loop in veterans diagnosed with ptsd showed that they had greater  glucocorticoid responsiveness so what does that mean that means that people  who've experienced extended hpa axis activation they go into that period of hypocortisolism and  then when there is a threat there is a greater cortisol response so when there  is a stressor instead of having you know a little bit of cortisol dumped into  the system it is wide open generally low cortisol is seen in people who have experienced extended  stress as a result of trauma or or chronic stress but when a threat is perceived  there's an exaggerated stress response and i call this flat or furious so they either  feel kind of flat or they are super agitated evidence points toward a role of trauma experience  in sensitizing the hpa axis independent of ptsd development so hpa access can dysregulate we can  have problems with it even if the person doesn't develop diagnosable ptsd which is why i always  say we want to look for traumatic injury we don't necessarily want to just hold it out there  for only people who meet the criteria of ptsd as i mentioned earlier those with prior  trauma histories are often more at risk of ptsd from later traumas so we can help them  hopefully prevent the development of ptsd if we notice that they have had a history  of trauma or chronic stress they do have an hpa axis that is dysregulated or  dysregulating we can help them start to take positive holistic steps  to re-regulate that hpa axis so if there is another trauma which in life  there's going to be occasional um if there is another trauma they are at less risk of developing  ptsd because they're not hypocortisol-ish core endocrine features of trauma include abnormal  regulation of cortisol and thyroid hormones okay hypocortisolism in ptsd occurs due to increased negative feedback sensitivity of the hpa axis  we've already talked about that studies suggest that low cortisol levels at the time of exposure  to trauma often predict the development of ptsd glucocorticoids your cortisol interferes  with the retrieval of traumatic memories and an effect that may independently independently  prevent or reduce ptsd symptoms cortisol that fight or flight stress hormone interestingly says  you know what you really don't want to remember that so it prevents some of our traumatic  memories from being solidified if you will which is another reason that when people are  experiencing stress when they're experiencing hpa axis dysregulation they have a harder  time with concentration and learning because that cortisol circulating through their system is  inhibiting the formation of memories and learning core neurochemical fact features of trauma or  ptsd include abnormal regulation of catecholamine serotonin amino acids peptides and opioid  neurotransmitters each of which is found in brain circuits that regulate and integrate  stress and fear responses the take-home message from that is there are core actual changes in  dozens not just not just these but dozens of hormones and chemicals in our body as a result  of hpa axis activation and extended hpa axis activation or hypocortisolism glucocorticoid  resistance results in a whole different set of hormone and chemical changes it's important for  us to recognize this it doesn't mean it can't be rebalanced i don't want to say fixed i want to  say rebalanced we can help people give their hpa access a break but eating better getting good  sleep practicing good cognitions those things aren't going to fix it overnight it's kind of like  gaining weight think about if you gain a hundred pounds you're not gonna lose a hundred pounds  in two three weeks what they're carrying is a hundred pounds of stress if you want to look at  it that way and it's going to take time of living right reducing their stress practicing some of the  tools that they learn in counseling and dealing with any remaining traumatic memories that  they've got in those boxes in order to help them re-regulate that hpa axis the catecholamine family  of neurotransmitters includes dopamine are let's keep doing that again and again neurochemical  norepinephrine which is our focus and let's go get it neurochemical and both of those are derived  from the amino acid tyrosine so we got to eat foods that have tyrosine it's not hard anything  with protein in it in order to let our body make those neurotransmitters when a stressor  is perceived the hpa axis releases cortico crh which interacts with norepinephrine to  increase fear conditioning and encoding of emotional memories enhancing arousal and vigilance  and increa in integrating endocrine and autonomic responses to stress so when that fear response  takes over that fight-or-flight reaction takes over the body actually secretes chemicals that  make us hyper vigilant that make us more aware of what's going on and alert to threats which is  great from a survival perspective in the short term in the long term it really sucks there's  an abundance of evidence that norepinephrine accounts for certain classic aspects of  trauma symptomatology including hyperarousal heightened startle responses and increased  encoding of fear memories so remember that cortisol initially blocks the encoding  of those memories but in an extended exposure the norepinephrine is going to  counterbalance that because remember in an extended exposure the body starts turning  down or blocking the cortisol from going through for a lack of a more clinical explanation  right now which means norepinephrine surges and takes over it becomes can become more powerful  and is able to start encoding those fear memories poor serotonin transmission in trauma may cause  impulsivity hostility aggression depression and suicidality too little serotonin is associated  with depression too much serotonin is associated with anxiety too little serotonin is also  associated with impulsivity and low pain tolerance now you don't need to memorize these  but i think it's important and i try to teach this as much as possible there are  multiple types of serotonin receptors and serotonin is responsible for or integrated in  just about every body system and reaction there is out there from appetite and blood pressure to  heart rate impulsivity memory mood respiration sexuality sleep sociability and it goes  on interestingly certain ssri selective serotonin reuptake inhibitors most of  them focus on this 5-ht-1a receptor but look at all the other receptors that are  out there and they're throughout our body and some of those can get a little bit wonky and  if you're taking something that acts on 5ht1a to help with your mood and your cognition and  your appetite and your sleep because you're having those symptoms of depression but it's actually  your 5-ht 2a receptor that's wonky guess what you're not going to feel much response from that  particular ssri so we do want to educate patients that there are multiple serotonin receptors there  are multiple different medications that target different serotonin receptors but it's not always  about the serotonin norepinephrine dopamine and some of our other thyroid and gonadal hormones are  also involved in the functioning of the receptors for all of our neurotransmitters  and mood depression can be caused by imbalance of any of our neurotransmitters not  just serotonin gaba has a profound anxiolytic effect in part by inhibiting the norepinephrine  circuits when gaba is released gaba is created from glutamate so it reduces glutamate levels but  it also inhibits inhibits the norepinephrine so gaba turns down it's the cold water if you want  to think of it that way to the hpa axis hot water patients with ptsd have decreased peripheral  benzodiazepine binding sites gaba is our one of our natural benzodiazepines so patients with  b ptsd don't have as many receptors for gaba as patients who haven't experienced trauma which is  kind of interesting so it's harder for that gaba system to work if there are fewer receptors  in the body it may indicate the usefulness of emotion regulation and distress tolerance  skills due to potential emotional dysregulation one of the things we need to do is help reduce  excitotoxicity which is the fancy word for too much glutamate and norepinephrine in order  to reduce distress improve stress tolerance in and enable acquisition of new skills harder to  learn new skills when that cortisol level is high we need to help people develop those distress  tolerance skills so they can get into their wise mind which is partly turning down the  adrenaline turning down the norepinephrine turning down the cortisol so they can  focus and think and learn and remember our glutamate receptors or nmda receptors  are implicated in synaptic plasticity or our brain synapses ability to function and adapt as  well as learning and memory glutamate binds to our nmda receptors and high levels of glutamate  are secreted during high levels of stress so when glutamate is going through our body there's  fighter flea let's get that energy let's you know get to it those nmda receptors are um super  activated you know they are on fire if you will which can lead people to feel anxious  hyper vigilant all those other things one of the things that they found with the  ketamine is that it actually blocks the nmda receptors one of the interesting side  effects and too much to go into right now except for to hit the highlights you can read the  article by clicking on the hyperlink but ketamine actually blocks those receptors so it blocks  the glutamate but it doesn't lead people to feel depressed it actually leads to more focus and  more controlled energy so it redirects that system instead of turning it off completely what it's  doing is helping the body redirect that energy to more task oriented goals overexposure of  neurons to glutamate so too much glutamate in our brain is excito toxic which means it  actually starts causing brain cells to die and results in loss of volume of the hippocampus  in people who've experienced trauma elevated glucocorticoids or cortisol increases sensitivity  of the nmda receptors so the more cortisol we have the more sensitive those glutamate receptors  are so when the glutamate comes comes in they are super excited rendering the brain more vulnerable  to excitotoxic insults so instead of being you know turning on the heat a little bit when  that glutamate hits those nmda receptors that have been sensitized all of a sudden you know it's like  charcoal that's been primed with lighter fluid things we need to remember it may take  clients who've experienced trauma who have high levels of cortisol more time to master  new skills because it's harder for them to focus that norepinephrine is focused on fight or  flea not learning memory and concentration if the brain becomes excitotoxic during stress it  inhibits learning and memory so exposure therapies for these particular clients may or may not be  super helpful if it's increasing the excitotoxic environment in their brain too much can be  dangerous which is why exposure therapies need to be taken uh very seriously and not just  done by somebody who hasn't been well trained endogenous opioids or our natural opioids that  we have act on the same nervous system receptors as morphine and heroin opioids even the endogenous  ones are system depressants they slow things down and ex in exert inhibitory influences on the  hpa axis so the opioids along with gaba and serotonin help turn things down a little  bit alterations in our endogenous opioids may be involved in certain ptsd symptoms such as  numbing stress-induced analgesia and dissociation recognizing that again these symptoms are merely  outward manifestations of changes in the neurobio biology of the patient now trexon we all know that  as the anti-overdose drug basically appears to be effective in treating symptoms of dissociation and  flashbacks in traumatized persons the naltrexone basically goes in and blocks those opioid  receptors so the person is not experiencing the emotional numbing and the stress-induced  analgesia which they may not be real keen on highlights um one of the things that this  does point out is the risk for opioid abuse for people with ptsd they may be self-medicating  because they figured out they may not consciously have put two and two together but they figured  out when they use opioids they get some relief a hallmark feature of ptsd  is reduced hippocampal volume the hippocampus is a part in the brain  that is implicated in the control of stress memory and context contextual aspects of  fear conditioning so the hippocampus tells us let's look around and identify all the triggers or  signs that there is a threat prolonged exposure to stress and high levels of cortisol damages the  hippocampus this reduction in hippocampal volume may reflect the accumulated toxic effects of  repeated exposure to glutamate and increased glucocorticoids or that whole flat fat sorry  flat and furious sort of situation which if you're working with somebody for example who  has borderline personality disorder symptoms there's a lot of flat to furious and emotional  dysregulation in people with those symptoms so we do want to recognize that they may be  experiencing trauma on a regular basis what not necessarily what we perceive as traumatic but  for them they are going from flat to furious and that's exhausting and from a neurochemical  standpoint it is reflective of trauma decreased hippocampal volumes might also  be a pre-existing vulnerability factor for developing ptsd we've already talked about  how hypocortisolism or glucocorticoid resistance makes people more prone to develop ptsd well  they've said well maybe it's that or maybe it's only people who've had that for so long  that it's reduced the volume of their hippocampus they're not really sure but we do know that  prior trauma prior alterations of the hpa axis do prime people for being more at risk for  later development of ptsd the amygdala is a limbic structure involved in emotional  processing and is critical for the acquisition of fear responses it is a very primitive area  of our brain but it is there to protect us functional imaging studies have revealed hyper  responsiveness in ptsd patients during the pres presentation of stressful scripts cues and  trauma reminders so again looking at the hpa axis goes from flat to furious there's a  dump of cortisol whenever some somebody who is experiencing hypocortisolism is exposed to future  stressors ptsd patients further show increased amygdala responses to general emotional stimuli  even the ones that are not trauma associated such as emotional faces so they tend to be more  emotionally raw emotionally responsive sensitive whatever you want to say so things that are  totally not related to the trauma can trigger a much stronger response in them than in someone who  didn't have that pre-existing hpa axis dysfunction early adverse experiences  including prenatal stress even you know when it's the baby's still cooking  and stress throughout childhood has profound and long-lasting effects on the development of our  neurobiological systems thereby programming subsequent stress reactivity and vulnerability  to develop ptsd kids who've experienced a bunch of adverse childhood experiences everything  from environmental stress to poor nutrition to exposure in utero to drugs and alcohol you  know there's a lot of different insults that the pediatric brain can experience may set them  up without any overt traumatic experience may set them up to be at risk for emotional  dysregulation and potentially even eventually ptsd later in life so it's really important that  we get in there with early prevention programs a variety of changes take place in the brains  and nervous systems of people with ptsd pre-existing issues causing  hypocortisolism the brain has already down regulated it started blocking  the cortisol receptors so to speak so there is not as much glutamate and norepinephrine  and stuff released if cortisol can't get through then it can't trigger the release of all of  those excitotoxic chemicals like glutamate and norepinephrine so if the body's already down  regulated the person may experience more ptsd remember if that cortisol can't get through  then when norepinephrine is released there is more fear in coding cortisol is the one  that blocks that fear in coding this points to the importance of prevention and early intervention  of adverse childhood experiences remember that people with hypocortisolism may or may not have  ptsd i recently wrote an article about lifestyle factors that contribute to hpa axis dysfunction  and they found that or i found in the research that exposure to noise for example people who  live near wind farms or airports tend to have much higher rates of use of antidepressant medications  and symptoms of hypocortisolism and symptoms of hyperactivated hpa axes than people who aren't  exposed to that chronic noise for example hypocortisolism sets the stage for the flat  and the furious leading to toxic levels of glutamate upon exposure to stressors reduction of  hippocampal volume and persistent negative brain changes now once that hippocampal volume has been  reduced a lot of times there's no building it back up the good thing is most humans only use a very  small proportion of our brain so there is a lot of room for workarounds if you will so i don't  want people to think that oh i've already shrunk my brain so there's nothing i can do totally  not not it in most cases there are a lot of workarounds think about people who've experienced  massive strokes um or massive brain injury a lot of them regain their abilities to walk  to talk to write to do whatever they did before sometimes not a hundred percent but a lot  of times the brain is very um receptive to functioning it wants to help people do what  they need to do and it develops its own little workarounds which i think is really cool people with ptsd are more  reactive to emotional stimuli even stimuli unrelated to  trauma this is so important for our clients to understand as well as their  loved ones and us as clinicians because it highlights the need for really good self-care and  really good distress tolerance skills and coping skills and awareness mindfulness  of trauma so they become more aware of okay this is going on it's stressing me out and they can intervene early before they become super dysregulated you know sometimes they can  notice that oh this is going to be stressful and they can prepare ahead of time they may be able  to mitigate stressors so they mitigate or at least reduce the impact on that hpa axis because  they can start developing a certain level of control over their reactions through biofeedback  and the use of a lot of other skills that they can learn purposeful action acceptance and  commitment therapy uh cognitive processing therapy um dialectical behavior therapy those are the  big you know buzzwords if you will for hpa axis resolution or rebalancing in addition  to healthy healthy nutrition exercise circadian rhythm balancing making sure that  people are maintaining their circadian rhythms and nutrition sleep exercise and circadian rhythms all  of those if they are out of whack if they are poor then they can contribute to hpa axis activation  that includes the use of caffeine and nicotine i know i i loved my caffeine before i  had to give it up but it's important to help people recognize that  there are things that they're doing in their daily life which may be  contributing to them continuing to feel flat or have the experience  of emotional dysregulation feelings of fatigue set in when the brain  perceives that continued effort is futile and or the brain says can't run keep running this  hot you know i'm going to have to turn on some some cold water because we can't keep keep  sitting in this hot bath reducing fatigue can be accomplished in part with psychological factors  including motivation and knowledge of competitors knowing what is what you're dealing with can  help people feel a sense of personal control feedback about frequent successes encouragement helping them know that endpoint remember  all those fatigue things that we looked at there are a lot of things that we can take from  sports and translate to hpa axis activation because when that hpa access is activated it's  telling us to fight or flee so fight or run if you will both of those are sort of sport type things  when that hpa axis is activated what happens our heart rate goes up our breathing increases it's as  if our body is doing something physiolog physical but sometimes we're still sitting still so we  can take some lessons from that and help people identify ways to feel empowered hopeful and  less fatigued 46 of people in the u.s are exposed to adverse childhood experiences so  there is a lot of room for early intervention we also can provide everyone not just people  with traumatic injury but everyone instruction and skills to handle emotional dysregulation  including mindfulness being aware of triggers preventing them when possible having a plan  to mitigate them if you couldn't prevent them vulnerability prevention and awareness what makes  you more likely to respond strongly to something you know for me too much um too much  sugar not enough food low blood sugar or not enough sleep tends to make me more  vulnerable i tend to get really cranky emotion regulation skills distress tolerance  skills and problem solving skills of those exposed to trauma education about and normalization of  their heightened emotional reactivity it's your brain's way of trying to protect you totally makes  sense it may really tick you off right now but if you look at it from you know have a little bit  of a cognitive restructuring and look at it as a survival mechanism then we can look at ways  to help your brain calm down recognize it safe and develop new strategies  for dealing with the stress okay so i went through a  lot of stuff in 55 minutes um and there's if you want to download  that article that um this is based on which oops post-traumatic stress disorder the neurobiological  impact of psychological trauma it is a tough read i will tell you it takes you have to sit down you  can't have the tv going and really focus on it and maybe take it in chunks it's a longer article  but it has so much wonderful information in it that i strongly recommend if you work with people  who've experienced trauma even adverse childhood experiences you take a look at it remember  that not every trauma causes traumatic injury so one of the adverse childhood experiences  for example is divorce well not every person experiences divorce as and gets traumatic injury  from it it may actually be an improvement of a situation so we do want to not necessarily tell  people that they're wrong if they don't think they were injured by it but we want to take into  consideration the fact that they may have been injured by it and every experience we go  through impacts our phenomenological reality so the divorce that your parents went through when  you were six the experiences you had at school the experiences you had last week all impact the  way you react to every situation henceforth and forevermore now you can choose you can become  aware of how the past is impacting you now and choose how it impacts you now but that is sort  of one of those advanced skills after people start being able to get that hpa access to recalibrate  and respond a little bit more mildly to distress