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The Neurophysiology of Trauma

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The Neurophysiology of Trauma Powered By Docstoc
					 A Transpersonal Shift of
 Cognitive Processing Therapy
 in PTSD
Annual Conference of the ETPA
Friday, May 13, 2011
Universitatea de Vest, Timisoara, Romania

Patrick Marius Koga, MD.MPH
UC Davis School of Medicine &
Institute of Transpersonal Psychology, Palo Alto, USA
                  Outline
1. Videoclip : the White Flag Incident
2. The neurophysiology of danger appraisal and
   PTSD
3. The cognitive-emotional disconnect and
   incongruence
4. Cognitive Processing Therapy (CPT)
5. The limitations of CPT and rationale for
   Transpersonal Therapies (TP)
 The Story of a US Marine Corps Sergeant

• Robert Sarra co-founder of the Iraq Veterans Against
  the War(IVAW), is a nine-year veteran of the U.S.
  Marine Corps who served as an infantry sergeant in
  last year's invasion of Iraq.
• But the day he opened fire on an Iraqi woman, and
  saw the white flag in the hands of the dead woman
  that he'd mistaken for a suicide bomber, Sarra began
  a journey of trauma, of a severe moral/spiritual
  injury, and a profound change.
The White Flag Incident

      Play videoclip
                      Trauma Spectrum
White Flag Incident                     Axis I                              Axis II




            ASD            PTSD               CPTSD                        BPD
                                 Trauma exposure


               Single trauma

                          1.   Intrusion
                          2.   Avoidance           1.   Multiple & Prolonged Trauma
                          3.   Hyperarousal        2.   Affect regulation
                          4.   Social/occupational 3.   Memory/attention problems
                               disruption          4.   Self-perception
                                                   5.   Interpersonal difficulties
                                                   6.   Somatization
                                                   7.   Systems of meaning
PTSD is a failure to cognitively recover
              after trauma




            Bonanno (2004)
                    What is PTSD?
A biological failure?
- Inability to extinguish conditioned fear responses
A mental (cognitive-emotional) failure?
- Inability to accommodate emotionally a traumatic event
  without cognitive distortions. Cannot distinguish between
  dangerous and safe situations
A spiritual failure?
- Inability to circumscribe one’s traumatic experience in a larger,
  transpersonal context or scheme of things (a sacred , divine,
  or expanded plane of reality)
            PTSD as a Biological Failure
   Traumatic Event             Fight-Flight-Freeze Biological
    Responses




• Conditioned Emotional Reactions (classical conditioning)
• These lead to cognitive distortions, maladaptive beliefs, and
  avoidance
• PTSD Symptoms: Re-experiencing-> Arousal -> Avoidance
The Hiker and the Rattlesnake




                                LeDoux, Scientific American, 1994




                                                                9
                Cortex


              Sensory Thalamus




Amygdala
           Basic Neurobiology
               of Trauma
       The “high” road




        The “low” road




FEAR
VINE?




SNAKE?
VINE




Phew! Vine
SNAKE!




   SNAKE!


   Fear
SNAKE!



    Fear
No Threat




  No Danger



              Pre-Trauma Processing
              of “ordinary” stimulus
Threat!!




  Danger!!



             Post-Trauma Processing
             of “ordinary” stimulus
                      Trauma
                      produces an
                      anatomical
                      change in the
                      brain:
                      volumetric
                      increase of
                      amygdala

Post-trauma fear
network in Amygdala
      Battlemind: Dys-coordination of Threat Response &
      Dissociation

                                                           Sights
Medial Prefrontal Cortex         PFC bypass                Sounds
Anterior Cingulate Cortex +
                       _
           dissociation
                                 AMYGDALA +               Thalamus
                            +
                             _
     Hippocampus

                                                           Smells
                                 Coordinated
                                  Response
                                                                     19
Suicide
bomber!


     Fear
Post-trauma fear      A landscape of
network in Amygdala   fear-inducing
                      cues
(-)   Cortisol is released in
      relation to stressor
      severity. An important role
      of cortisol in stress is to
      contain other biological
      stress responses
     PTSD as Psychological Failure

Cognitive Processing Therapy (CPT)
Rationale: the patient is experiencing one or a
  combination of the following:
1.   Dissociation
2.   Hyperarousal
3.   Re-experiencing
Either way, the emotional-cognitive incongruence
produces cognitive distortions that need correction
                   Goals of CPT

• Developed to help trauma survivors
  – Understand how thoughts and emotions are
    interconnected
  – Accept and integrate the trauma as an event that
    actually occurred and cannot be ignored
  – Experience fully the range of trauma-related emotions
  – Analyze and confront maladaptive beliefs (“stuck
    points”)
  – Explore how prior experiences and beliefs affected
    reactions and were affected by trauma
 Based on Social Cognitive Theory
Trauma survivors try to make sense of and cope with
  trauma in 3 ways:
• Assimilation - Change memory or interpretation of event
  to fit existing beliefs
   – “I should have prevented it.”
   – “It wasn’t really rape.”
   – Forgetting it
• Accommodation - Change beliefs to accept what
  happened
• Over-accommodation - Change beliefs too much
   – “No man can be trusted.”
   – “The world is completely dangerous.”
   – “Nowhere is safe.”
        The 12 Sessions of CPT
Session 1: Introduction and Education
Session 2: Meaning of the Event*
Session 3: Identification of Thoughts and Feelings
Session 4: Remembering the Traumatic Event
Session 5: Second Trauma Account
Session 6: Challenging Questions
Session 7: Patterns of Problematic Thinking
Session 8: Safety Issues
Session 9: Trust Issues
Session 10: Power/Control Issues
Session 11: Esteem Issues
Session 12: Intimacy Issues and Meaning of the Event
                                  *Optional bereavement session available
                     Session 1-5
 Describe cognitive theory and information processing
 ◦ Assimilation, Accommodation, Over-Accommodation
 Describe two types of emotions following trauma
 ◦ Natural (mad, glad, sad, scared) must feel and habituate
 ◦ Manufactured (guilt, shame) based on interpretations
 Lay out rationale and course of treatment
 ◦ Goals: 1) Accept reality 2) Change beliefs 3)Feel emotions
 Client writes repeatedly about the meaning of the event
 Introduce Beck’s Faulty Thinking Patterns
 ◦ Patterns are automatic, create negative feelings, and self-
   defeating behavior. Ask client what tendency(s) they have.
 Use challenging questions to work through “stuck points”
 Session 6: Socratic Challenging Questions

• Clarification – “Tell me more” questions: “What do you mean when
  you say…?”; “What exactly does that mean?”
• Probing Assumptions – “Why” or “how” of beliefs: “How did you
  come to this conclusion?”
• Probing Reasons and Evidence – “How do you know this?”; “What
  evidence is there to support what you are saying?”
• Questioning Viewpoints and Perspectives – “How else might you
  look at this?”; “What would your friend or loved one say about this?”
• Analyzing Implications and Consequences – “Then what would
  happen?”; “What are the consequences of that assumption?”
• Questions about the Questions – “What is the point of asking that
  question?”; “Why do you think you asked that question?”
Session 7: Patterns of Problematic Thinking

1. Jumping to conclusions when evidence is
   lacking or even contradictory
2. Exaggerating or minimizing the meaning of an
   event
3. Disregarding important aspects of a situation
4. Oversimplifying events or beliefs as good/bad
   or right/wrong
5. Over-generalizing from a single incident
6. Mind-reading
7. Emotional reasoning
                                             Challenging Beliefs Worksheet

A. Situation     B. Thoughts                 D. Challenging Thoughts        E. Problematic            F. Alternative Thought
                                                                            patterns

Describe the     Write thought(s)            Use Challenging                Use the Problematic       What else can I say
event, thought   related to Column A.        Questions to examine           Thinking Patterns         instead of Column B?
or belief        Rate belief in each         your automatic thoughts        sheet to decide if this   How else can I interpret
leading to the   thought below from          from Column B. Is the          is one of your            the event instead of
unpleasant       0-100%                      thought balanced and           problematic patterns      Column B?
emotion(s).      (How much do you            factual or extreme?            of thinking.              Rate belief in alternative
                 believe this                                                                         thought(s) from 0-100%
                 thought?)
I feel                                       Evidence?                      Jumping to conclusions    Because of my time in
uncomfortable     While I was in Iraq        For: This did happen in        I am drawing the          Iraq, I have some
and unsafe       I couldn’t tell friend      Iraq.                          conclusion that all       understandable, but
with Middle      from foe. It was            Against: That was over 3       Middle Easterners are     irrelevant, feelings around
Easterners       impossible to tell          years ago in a totally         untrustworthy and         Middle Easterners. As a
(e.g., recent    who was the enemy           different place.               dangerous to me.          group, they are not
cab ride)        and might try to kill       Habit or Fact?                                           dangerous to me. 90%
                 me. 80%                     It has become a habit to       Exaggerating or
                                             distrust all people,           minimizing
                                             especially Middle              Disregarding important    G. Re-rate how much you now
                                             Easterners.                    aspects                   believe the thought in Column B
                                             Low versus high probability?                             from 0-100%
                 C. Emotion(s)               There is a low probability     Oversimplifying
                 Specify sad, angry, etc.,
                                             that any Middle                                          40%
                 and rate how strongly                                      Overgeneralizing
                 you feel each emotion       Easterner would try to
                 from 0-100%                 harm me.                       Mind reading              H. Emotion(s)
                                             Based on feelings or facts?                              Now what do you feel? 0-100%
                 Fear 70%,                   My feelings are derived        Emotional reasoning
                 Anger 50%,                  from my service in Iraq.       Because I feel scared     Fear 50%
                 Frustration 50%             Are they relevant today?       around Middle             Anger 20%
                                             They are not relevant          Easterners, I am in       Frustration 30%
                                             today.                         danger around them.
                                             Irrelevant factors?
Session 8-12: progressing from Safety
 Issues to the Meaning of the Event

  CHALLENGE
• cutting the Gordian
   knot of a cognitive
   distortion when
   CBT/CPT is
   ineffective



   Analogy: a Zen koan, transcending the binary mind
             PTSD as Spiritual Failure
     No evil?
 “We are not merely human
   beings having a spiritual
   experience; we are
   spiritual beings having a
   human experience”

       Teilhard de Chardin



Rationale for TP: theodicy is a missing link in CBT/CPT
CBT/CPT = Egoic/personal model
Spirituality= Trans-personal model




              Self
Combat vs other
Traumatic Exposures



• Combat trauma relatively unique
   – Tends toward multiple events over an extended period of time
     (7-12 months) with multiple deployments
   – Actions proscribed in other contexts are sanctioned and even
     celebrated (e.g. killing) within rules of engagement
   – Multiple roles – observer, direct victim, actor/perpetrator
      • May expand the range / intensity of symptoms
      • May increase the relevance of symptoms like guilt, shame
      • May increase ethical / moral / spiritual injury
Impact of Traumatic Events Model
                           Personal History
                           Risk & Resiliency factors
                           Biology, prior stressful experiences, learning
                           from family / peers, observational learning,
                           family history / traditions / culture



                                           Traumatic
                                           Event

Physical Response                                                           Interpretation of Trauma
Fight / Flight / Freeze



                                                          Causal                     Meaning                Cognitive
                                                          Attributions               Attributions           Dissonance

Physical Outcome
Health / Injury or disability
/ Death                                                                      Changes in Thoughts /
                                                                             Beliefs, World Assumptions



                                                       Post-traumatic                                  Spiritual
                                                       Growth, Resilience,                             Struggle /
                                                       Maturity                                        Moral Injury


                                                                                    Psychological
                                                                                    Problems
                Interpreting Trauma
        Causal                     Meaning                     Cognitive
      Attributions                Attributions                Dissonance
WHY  did the event         Can I trust people?          How   does this event fit
 happen?                    Am I still safe?              with my previous view
Who is to blame?           What does this mean
                                                           of the world?
   self / others / God      about me?                    Can I hold the event
   Did my reactions help      Do I control my future?    alongside my core
    or hurt situation          Am I worthwhile?
                                                           assumptions without
Isthe event Fair, Right,                                  tension
                            What  are my lessons
 Just?                                                    Since I can’t change
                             learned?
                                                           the trauma - how do my
                            What does this mean
                                                           thoughts / beliefs have
                             for my future?
                                                           to change?

       Potential Distortions / Errors (especially w/o feedback)
           Moral Agency
                  Bandura, 2002



Moral Reasoning
                          •Self-Monitoring
Self-Regulatory           •Moral Judgment
Mechanisms                •Anticipatory Positive /
                          Negative Self-Sanctions

            Selective Moral Disengagement


Moral Actions        Immoral Actions
Selective Moral Disengagement
                        Bandura, 2002



          Moral Justification
Conduct   Advantageous Comparison
          Euphemistic Labeling
                                        Displacement /
                                        Diffusion of Responsibility
          Minimizing, Ignoring,
Effects   Misinterpreting the
          Consequences


          Dehumanizing
Victim    Blaming Victim
    Moral Injury: A New Construct

• Betrayals
  – types: leadership, peers, civilians, own
    standards
• Atrocities
  – Disproportionate violent response
• Incidents involving death or harm to
  civilians
• Within ranks violence
  – Sexual assault; friendly fire; fragging
MI Signs/Symptoms

• Social problems           • Existential issues
  – Isolation; aggression     – Fatalism; nihilism
• Trust issues              • Negative self
  – Intimacy impairment       – Self-loathing;
• Spiritual changes             damaged self image
  – Loss of faith           • Familiar psychological
                              – Depression; guilt;
                                shame
  “ Dante’s Five Steps” : Red flag spiritual
 issues relevant to combat stress recovery
Grief (Loss of Other)
   Guilt (Loss of Moral Self-Respect)
     Lack of Forgiveness (Loss of Control)
       Spiritual Struggle (Loss of Faith)
             (helplessness)
            Hopelessness ( Loss of Meaning)
    Grief                             Guilt
• Common in war             • “painful feeling with
                              accompanying beliefs that one
   – Early Hoge study –       should have thought, felt, or
     90% reported knowing     acted differently.”
     someone killed            – Commission - Doing
                                  something I shouldn’t have
• Many other types of             done
  losses                       – Omission - Failing to do
                                  something I should have
• Spirituality frequently         done
  involved in coping           – Survivor guilt - Surviving
                                  when someone else didn’t
                    Guilt Context
•       Circumstances in the traumatic environment that
        increase emotional distress / guilt magnitude
    –     Infliction of harm
    –     Close proximity / direct involvement
    –     Harm caused to someone close
    –     Harm caused is irreparable
    –     Harm is human caused vs. “act of God”
    –     All behavior options equally bad
    –     Negative outcome is arbitrary or unfair
    –     Blame from others
       Lack of Forgiveness
• Forgiveness directions
  – Self / Others / God
• Lack of forgiveness associated with
  more severe PTSD, more severe
  depression
• Re-experiencing symptoms (memories /
  nightmares) may be seen as “proving”
  that forgiveness “doesn’t work” or that
  they are incapable of being forgiven
               Lack of Forgiveness
      Question (Seldom/Never)                      OIF     GP
I have forgiven myself for things that I          80.0%   24.2%
have done wrong.

I have forgiven those who hurt me.                74.0%   16.1%

I know that God forgives me.                      50.0%   11.5%

* OIF (N=50 OEF/OIF veterans in PTSD treatment)
* GP (N=654 males in Nat’l Rep. Sample)
                            Theodicy
• Problem of Evil
   – Why does Trauma happen?
   – If God is all powerful AND God is all good – WHY?
• This is not an abstract question for Trauma survivors!
• Traditional Solutions
   – Diminish God’s role
       • God couldn’t prevent, God doesn’t intervene
   – Diminish Evil’s role
       • Evil is good in disguise / all things work for good
   – Diminish self – take on inappropriate guilt / blame
• Janoff-Bulman: Shattered assumptions
   – Trauma shatters core beliefs of survivors i.e. self-worth,
     meaning, goodness
          Spiritual Struggle
• AKA – Negative Religious Coping
• Characterized by
  – Questions/tension about God’s presence /
    power / character
  – Expressing chronic strong anger at God
  – Expressing frequent discontent with
    congregation and clergy
  – Punitive appraisals of negative situations
     • God is punishing me for my sins
  – Discomfort / tension re: faith / loss of faith
                      Loss of Faith
                                                I abandoned my religious

• Loss of faith during
                                                   faith during the war.

                                       Agree

  / following combat                  Neutral

  stress                             Disagree


• Difficulty                                    0%    20%    40%    60%    80%    100%



  reconciling faith                             Difficulty reconciling beliefs with
                                                    traumatic warzone events

  with combat                           Agree

  experiences                          Neutral


                                     Disagree
•   N=100 Vietnam veterans in PTSD
                                                 0%    20%    40%    60%    80%       100%
    treatment
                        Loss of Faith
                Question                     Response

Percentage who report                           60.0%
“significant loss of faith”

Average age for loss of faith               24.0 years old

Percentage of those reporting                   62.1%
faith loss where loss is recent
(<5 yrs)
* N=50 OEF/OIF veterans in PTSD treatment
              Loss of Meaning
• Meaning at it’s most basic is the story
  we tell ourselves and others about our
  experience
  – We choose our meaning
     • Meaning = perception + interpretation
        – PROBLEM: Both are subject to distortion – especially
          during trauma
  – Meaning through being meaningful
     • Who do I matter to?
     • All spiritual traditions place great emphasis on service and
       involvement in the lives of others as a source of meaning

				
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