Neuroscience of Trauma, Part 1
Introducing our capstone episode of the season, and arguably one of the most important topics we've discussed to date.
As it turns out, trauma is proven to play a much more direct role in our lives than we may have realized (as you'll hear around the 22-minute mark).
In this episode, as Laine walks us through some of the science most noted from neuroscientist Bruce Perry, we discover just how impactful trauma -- both "capital T" and "little T" -- can be.
In my experience while recording this episode, it took almost the entire hour+ to grasp the difference between these two traumas, and that shockingly enough, it's not the event that causes trauma.
There's a lot to cover on this topic, and to do it justice, we've decided to break it up into two episodes. You'll receive one more episode + a bonus meditation in November!
REFERENCES
What Happened To You Bruce Perry and Oprah Windfrey
Trauma-Informed Care in Behavioral Health Services. Rockville (MD)
PTSD History and Overview Matthew J. Friedman, MD, PhD
Traumatic Stress Center of Wales
How does your body remember trauma? Dr. Matthew Boland and Hilary L. Lebow
Response Variation following Trauma: A Translational Neuroscience Approach to Understanding PTSD Rachel Yehuda, * and Joseph LeDoux
Thirty-Year Study Links Neuroscience, Specific Trauma, PTSD, Image Conversion, and Language Translation Dee Spring PhD, ATR-BC, MFT
Relational Trauma and the Developing Right Brain An Interface of Psychoanalytic Self Psychology and Neuroscience Allan N. Schore
General Outline of Episode
This is the neuroscience of Trauma.
I’ll give you the numbers and then explain why they are very, very likely inaccurate
Prevalence -
According to the American Psychiatric Association
Estimated one in 11 (women twice as likely as men)
In America Latinos, African Americans, and Natives are disproportionately affected
According to the US Department of Veterans Affairs, “We don't know the exact number of people who have PTSD.” Reasons for this include no single study that asks everyone about it, not everyone remembering or knowing their diagnosis, there’s still a lot of stigma around this, being very misdiagnosed (get to that shortly), etc
Most of us will experience at least one trauma in our lifetime that could lead to PTSD
addiction(colloquially)
What do you think of it?
We most commonly think of it as being a veteran who has a flashback during the Fourth of July
addiction(clinically) - Clinically when it comes to trauma this is found in the DSM as “Trauma and Stress-Related Disorders” and it encompasses
Reactive Attachment Disorder - believe we covered this briefly in the neuroscience of attachment - this is an odd diagnosis because it's not one of the types of attachment - but is a diagnosis we give individuals who are withdrawn from their caretakers, not emotionally responsive to others and have experienced insufficient care
Disinhibited Social Engagement Disorder - this is the opposite of Reactive with the same origination - insufficient care, but it means that a child doesn’t have any restraint in interacting with unknown adults, has overly familiar behaviors, poor social boundaries - etc
Post-Traumatic Stress Disorder, Acute Stress Disorder, Adjustment Disorder and Unspecified Trauma
PTSD is what we think of most commonly when we hear a diagnosis of trauma and it's defined as exposure to actual or threatened death, injury, or sexual violence through experiencing, witnessing, or learning about it with distressing memories, dreams, dissociative reactions, psychological distressed or reactions in regards to the event. Experiencing avoidance of memories reminders, etc. Experiencing negative alterations in thoughts or mood and marked arousal (anxiety/hypervigilance). Which lasts more than a month and is clinically significant
Acute Stress Disorder is almost the same diagnosis - the major difference is we see symptoms directly after the event whereas ptsd can follow ASD or be diagnosed a long time after the trauma but PTSD can only be diagnosed if someone is experiencing symptoms longer than one month
Adjustment disorder is where we see distress or impairment due to a significant stressor
Trauma unspecified is usually where we see or suspect a trauma diagnosis but may not have enough information at the time
And I’m going to make two major claims here - One this is not enough by a long shot. Anyone who’s been working in this field, specifically with any training in trauma will tell you that we know we see the results of this without it meeting enough of the criteria (and yes we have unspecified/other but insurance does not cover it) And my other claim is trauma is often misdiagnosed because of this, but also because trauma is so new and there is not enough training on it at all - clinician’s are often looking for a big flashing sign that says ‘this is trauma’ and instead will diagnose something else when the origination - the cause is trauma. The diagnoses that are not under this but probably should be
Dissociative disorder - almost all of these we know have evidence of a traumatic occurrence causing them
Nightmare Disorder
But even beyond that, I will argue that Diagnoses that are often trauma that is misdiagnosed
Depression
Anxiety
Obsessive-Compulsive
Hoarding
Some cases of Anorexia and Bulimia
Chemical Dependency
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Antisocial Personality Disorder
Paranoid Personality Disorder
Borderline personality disorder
Avoidant Personality Disorder
Attention Deficit Hyperactivity Disorder
A - This is why I started this episode with I’ll give you the numbers of prevalence and then tell you why they are not accurate
This is a huge claim for me to make but I have the receipts
According to Gagnon-Sanschagrin, Shein, Urganus, Serra, Liang, Musingarimi, Cloudtier, Guerin and Davis state in their 2022 study that the proportion of patients with undiagnosed trauma may be substantial and specifically state that “patients being misdiagnosed with another mental health condition” as well as patients not seeking help due to stigma, not recognizing the symptoms, lack of disclosure - especially if a provider isn't looking
“Historically, PTSD has been predominantly studied among military individuals, likely due to the high prevalence of PTSD in this population However, this represents a minority (14%) of the overall PTSD population in the US, with 86% of the PTSD population comprising civilians. In addition, recent issues like COVID-19, civil unrest, and climate change. continue to occur around the globe, adding to the growing concern of increased exposure to natural and societal traumatic events among civilians. Thus, additional research in this already underrecognized and understudied population is more imperative than ever.
So why is this so missed? Why do I state that so many other diagnoses might be trauma? What is actually going on here - for that we should start at Caveman Jo
PART 1: Terms & Background Info (5-10 minutes)
So to be clear we have to trauma and a diagnosis
Dr. Friedman will argue that trauma has likely been around … specifically since caveman times honestly and will argue that some of Shakespeare's characters definitely seemed to meet the criteria. Dr. Perry states in the Illiad (so 800 BC) that Homer described trauma-related emotional deterioration, etc.
There were understandings of trauma before it was a full diagnosis. After the Civil War, we called it “soldier’s heart’ and ‘nostalgia” and with World War 1 we changed this to ‘shell shock” but specifically at this time it was seen honestly as a character flaw to the point where Dr. Rockville states “ World War II military recruits were screened in an attempt to identify those “who were afflicted with moral weakness,”. That being said this is when treatment did start even if this wasn’t a diagnosis at the time and it wasn’t fully understood.
As for what humans understand of trauma and of the diagnosis itself - that then is much newer. In fact, is just a little older than you or I.
In 1980, the American Psychiatric Association added PTSD to the DSM (specifically the DSM3) however I will argue we are not much more accurate about the diagnosis then, as we are now, even though we know so much more.
Dr. Friedman says in its inception in the DSM it was categorized as a catastrophic stressor outside of the range of the human experience, arguing that humans had the ability to handle ‘normal stressors’ from traumatic stressors and states “PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. One cannot make a PTSD diagnosis unless the patient has met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic.
So what’s so wrong with that? It is probably how most people think of this diagnosis, yes? And that is why we have to turn to neuroscience. The biggest problem with understanding this is understanding what humans label trauma and what the brain/body thinks of trauma
We think of trauma as an event - a natural disaster, murder, rape, war, death, a car accident - up to the point where something to that effect is measured in most trauma analysis - but it is none of those things
Trauma is not the event - but how the body responds to it - it is an uncontrolled, unplanned, overwhelming stress response
Dr Perry states not really being able to define it well is what is hard for this field, even this world to understand it. The word is used very casually. He says for most people it is just what you state - a bad event but says “Trauma is hard for the academic world to define and thus understand in its full scope. Part of that challenge is the bad event is subjective.”
Fire in a school
Dr. Perry “-key here is how does the individual experiences the event - not the event itself
But how do we fully understand it, how do we study it if it's hard to come up with a standard definition? The closest we’ve come is to look at Event - Experience - Effect
This is complex enough as adults - but what is key here - why I made the earlier claims that I did - is that this looks so much different on a developing brain
PART 2: What About Neuroscience (5 minutes)
Why are we looking at THIS TOPIC through this lens?
What unique perspective will Neuroscience show us in regard to this topic?
Much like Schizophrenia started the field of mental health in understanding that the tools we had been using to diagnose people were likely not completely correct and full of issues, trauma is really a fundamental piece of why we look to neuroscience for any of these. Trauma, in the field of mental health, was really the foundation for understanding that the brain changes and when it changes it causes issues that we then classify as mental or behavioral patterns.
We learned pretty quickly - honestly thanks to people like Dr. Perry or Dr. Levine that trauma changes your brain. And then when we had brain scans we could prove it. We learned that looking to neuroscience changed everything. Dr. Perry states “Over the years I’ve found that seemingly senseless behavior makes sense once you look at what’s behind it - and since the brain is the part of us that allows us to think feel and act whenever I’m trying to understand someone, I wonder about that’s person’s brain - something happened that influenced how their brain works” and states that the fundamental thing we need to change is to stop asking what’s wrong with you and start asking what happened to you? And what has happened that changed your brain?
It is because of trauma, really, that we look to neuroscience at all. We learned quickly that we can’t understand trauma without understanding the brain, and that started to slowly kick down some very big walls in the field of mental health.
**BREAK**
PART 3: The Science (30-35 minutes)
Two pieces - what is trauma and then what is developmental trauma
Trauma and the brain
When we started this podcast the first thing we talked about was to understand the brain you have to understand its structure and evolution. The bottom of the brain is your brainstem - that’s where basic regulation is occurring - brain control around breathing, heartbeat, digestion, etc.
The midbrain is activation - its movement, appetite, flight/fight/freeze/faun/flock it's your limbic system which is reward, memory, bonding, emotions
The Top Part is the cortex - it is what makes you you - it's your values, its hopes, its language, its logic, its creativity, its understanding time, it is all the complex parts
When we’ve been covering the sense this season - we talk a lot about how we understand the world - we take in information and process it and code it - we do this all the time - and when we code it we use it to make sense of the world
And we are always looking for safety. However when we feel unsafe, when something feels uncontrolled, shocks, or overwhelms the system - the system changes to keep you safe. It activates your brainstem by changing your respiration by speeding up so you can get more oxygen so you can flee or fight, it changes your heart rate to pump more blood so your muscles can work better, it shuts down your digestion to not interfere with fleeing or fighting, it changes your insulin to get more energy faster, it says we are activated and we need to act to live. Our amygdala sends messages to our HPA axis and we change from a connected person to a body focused on safety.
And the more this happens, the more our whole body changes. The more we learn that the world is unsafe and we need to protect ourselves. Our brain, our body rewires - our DNA itself can change.
But the additional part that is so important here is the coding. Take a person in a war zone. They learn that a certain sound means you better keep your head down, you better be prepared to fight or flee or you are dead. We code for that connection. And new information is processed against previous information. So a firework can have the same response - because we have coded a specific sound.
What is important is to understand that all experiences are processed bottom of the brain up. As we’ve discussed at great length - the lower parts of our brain are not as smart - but they are fast - we feel and act and then we think. And in fact, we feel and act and then we make sense of it.
And we process new information constantly. “All the sensory inputs from the outside world and our inside world give continuous feedback to the brain so that proper systems can be activated to keep us healthy and safe. If we’re thirsty we seek water, if we are hungry we seek food, if we sense danger we mobilize our stress response system.”
But this is where coding becomes huge because we process that information also through past experience and this is why development and talking about developmental trauma is complicated. We combine sensory input with memory to make sense of the world. But that means what happens when you are very young will have a huge impact. Take eye contact for example. Eye contact can be so important in nurturing, in feeling connected, and if that is your lived experience starting very young, you will code someone making eye contact with you as a chance to connect. For another person perhaps a parent has more intense eye contact when they are mad or yelling. For that person eye contact will impact their whole system differently and their nervous system will respond accordingly. - this is why trauma is so complex
And the earlier the experience the bigger the impact - because there is nothing else to compare it to. Earlier experiences wire us for life. Because of neural networks - our brain is set up to understand what is happening to us and make sense of it and they are sensitive to experiences - when you recognize someone walking down the street you are using your neural network. But because coding takes place all the time, we can have neural networks that are not as narrative as “Oh I recognize that person we used to work together”. We can meet strangers and think “Oh I really like or connect with this person” or the opposite - we have an intense early dislike - those are the same networks we are just not as aware of why we have the reaction - but we are reacting to something we experience that set up a process to respond accordingly.
This is where triggers come in.
Example - being yelled at “body’s core regulatory systems can be altered” Let’s say the person yelling at them smells like old spice deodorant.
Dr. Perry - the brain develops bottom up and inside out. “Each brain area has the capacity to create memory to change in response to experiences and to store these changes in its particular neural networks. In a young child, the cortex is not fully developed; in children younger than three the neural networks are not mature enough to create what's called linear narrative memory. However, in lower areas of the brain other neural networks are processing and changing as a result of our earliest experiences. Associations or memories are being created in those lower networks and that has a huge impact on how trauma is stored in the brain of the very young.” and often in ways that will impact us but we don’t understand - let me break that down because this is where it’s so import
Neural networks are also important for regulating our stress, making relationships, and finding rewards in what we do - Perry says when these three things wire together they create a foundation - and this is a major secret to understanding the brain and how it works or doesn't
And you might argue that this sounds too broad-sweeping. We were not all raised in a family of abuse or neglect. But as a young child, small things have huge impacts. An overworked, overwhelmed caregiver is not as responsive, not as consistent - this for an infant starts to activate the stress response system. It sensitizes it (stress response) - and starts to wire us to cope with the harm instead of connecting and exploring - it starts to put all of this into motion -and starts to create a worldview of I don’t matter.
And generations impact us moving forward. Historical trauma exists because we pass things on - not only literally through our DNA which can become more coded for survival but also through our experience of parenting or a lack thereof. The more stressed or activated your great-grandparents or grandparents were, the more the stress response activated in your parents, the more in you, and the more in your children.
Dr. Perry “The most important aspect of this pattern of stress activation. If the parent is consistent and predictable in nurturing the stress response system becomes resilient. If the stress response systems are activated in prolonged ways or chaotic ways as in the case of abuse or neglect they become sensitized and dysfunctional. Though we're generally not aware of it, we are continually sensing and processing information from the outside world based upon the input our brain and body respond in ways to help keep us connected alive, and thriving. When we are pushed out of equilibrium or balance we have a set of stress response systems that will be activated to help us. “
The way children are treated from the time they are born will in fact set them up to succeed or struggle. Do they know how to handle and process stress or are they set up to be reactive to survive at all costs, whether it helps out in the long run or not? It changes how your neural networks are formed, and how your core regulatory networks function.
The more we have an environment of chaos, confusion, inconsistency, and disruption - the more we don’t learn or have access to regulation early the more we as humans are set up to fail in our development. Our brain does not develop the way it should - the network of our brain does not organize as it should.
Dr. Perry “ Neuroplasticity is basically the changeability of the brain. One of the key principles of neuroplasticity is that the pattern of activation makes a big difference in how the neural network changes. For example, moderate predictable and controllable activation of the stress response system leads to a more flexible, stronger, and increased stress response capability that lets a person demonstrate resilience in the face of more extreme stressors. It's kind of like weightlifting for our stress response system. We exercise the system to make it stronger. The more we face moderate challenges and succeed the more capable we are of facing bigger challenges. That is something we see in sports performing arts clinical practice firefighting teaching almost any human endeavor experience can improve performance. That's why stress is not something to be afraid of or avoid. It is the controllability pattern and intensity of stress that can cause problems. Unfortunately for far too many people, the pattern of stress activation is unpredictable, uncontrollable, prolonged or extreme.”
And relationships matter because we are social creatures. Our very brain, our whole body is set up to connect and work with others. We literally experience other’s emotions as contagious. And we consistently scan the environment to understand if we are safe and can connect or if are we at risk.
All functioning is state-dependent - when we take in information that activates our stress response system (and remember if your early childhood was inconsistent this is WAY more things than you think it is) we get activated.
And when we are activated it changes how we respond, what we understand, what we are able to do. When we are calm and connected we can brainstorm, we can regulate, we can connect but as we become activated we lose access to that, we start to get reactive and respond quickly, and we don’t think creatively - we literally struggle to listen because our hearing changes thanks to our vagus nerve. And we lose functional IQ. At an alarm state, it drops down from around 120 to between 100 and 80, at Fear it goes down to 90-70 and at terror even lower. We can’t be intelligent becuase our brain doesn’t have access to the smartest parts of us.
And even outside of understanding that when we talk about trauma it's so much more than we think it is - even if we define it under the big scary topics - the ACES study showed we have, as humans, a greater prevalence of that than we acknowledge. In a 2019 study by the CDC, we found that 60% of Americans have had one of these experiences and almost a fourth of our population reports four or more. And honestly, the CDC researchers believe this is a drastic underestimate. Because it's hard to report on something you don’t remember. It's hard to remember something that happened before you were old enough to understand it. And sometimes trauma makes it so that our hippocampus doesn’t respond properly - so it's hard to remember at all.
We talk about trauma like it’s always PTSD. Perry states “It's really important to remember however that PTSD is not the only way that trauma impacts our mental and physical health. … In fact, the majority of long-term effects of trauma don't manifest as PTSD.”
It manifests as disassociating (the key way that small children survive adverse experiences because they are too small to flee or fight). Disassociation as a child or adult looks like not being able to focus or pay attention, can look like people pleasing, can look like hyper fixation or being in the zone (disassociating by focusing on one thing) to a full-on dissociative disorder
It manifests as nightmares
It manifests as feeling as though the world isn’t a good place, that you are not a good person, that there is no reason to continue, that nothing will ever be good
To be on alert for what might go wrong, constantly focused on possible bad things, feeling like you have to focus on all your worries and anxiety or something will go catastrophically bad up to the point where you might obsess over small things to give you a feeling of control or hoard what is around you to prepare or keep things the same, to harming yourself to control your body, to using chemicals to regulate an unregulated system, to exploding all the time at everyone because you have to keep yourself safe, etc
Why trauma matters - Dr. Perry says he has been taught that “these problems were all basically the same thing. these problems were all interconnected. In Western psychiatry, we like to separate them but that is missing the essence of the problem. We are chasing symptoms not healing people”
