JESUS SALVADOR A. LIGOT, JR., M.D. Clinical Assistant Professor of Psychiatry State University of New York at Buffalo POST-TRAUMATIC GROWTH NO FINANCIAL DISCLOSURES. POST-TRAUMATIC STRESS DISORDER Exposure to actual or threatened death, serious injury, physical and sexual violence Intrusive symptoms: Nightmares, flashbacks, intense psychological distress Avoidance of stimuli Negative alterations in cognition and mood (detachment and isolation) Hyperarousal and hypervigilance Self destructive behaviors > alcohol & substance abuse Negative sequelae: Depression, suicidal ideations and attempts, homicidal ideations, attempts and aggression Source: DSM –V, American Psychiatric Association NEURAL CIRCUITRY OF FEAR NEURAL CIRCUITRY OF FEAR Threat Thalamus Amygdala & visual cortex Amygdala – receives threat; initiates the “fight or flight” response, sends signals to the hypothalamus and activates the sympathetic nervous system releasing adrenaline, cortisol and NE causing increased HR, RR, increased blood flow to muscles, pupils dilate, fat mobilized Concurrently, detailed information sent to the visual cortex -> contextual info to hippocampus NEURAL CIRCUITRY OF FEAR Hippocampus relays info back to amygdala and the amygdala determines whether there is an actual threat or not fight or flight response gets turned off if no threat. PTSD > overactive amygdala > impaired hippocampus (helps in the contextual understanding of fear). > decreased volumes of the frontal cortex – impairs the extinction of fear responses “ The brain enters a vicious cycle of emotional and cognitive excitement, and like a runaway train just keeps on picking up speed.” (Le Doux, 1996) NEURAL CIRCUITRY OF FEAR PTSD State of high alert Systems are still responding to a trauma that happened months or years ago. Amygdala is overactive – sympathetic overdrive – > CRH & NE increase fear conditioning, enhance arousal and vigilance. Parts of the brain that should be overriding amygdala– hippocampus and frontal cortex are dysfunctional Brain unable to differentiate things that should trigger a fear response and things that should not. Nemeroff, Post-traumatic stress disorder: the neurobiological impact of psychological trauma, Dialogues in Clinical Neurosccienses, 2011 FOUR OUTCOMES OF PTSD Actively symptomatic , at times with self-medication with drugs and/or alcohol Recovery with some residual impairment Full Recovery /Resilience Post-traumatic growth - positive psychological change resulting in above baseline functioning (Tedeschi, 2011). Trauma becomes the catalyst for positive change Warner, 2013, Promoting Post-traumatic growth RESILIENCE Ability to adapt successfully to acute stress, trauma or more chronic forms of adversity Psychosocial factors: Optimism and positive emotionality Ability to harness social support Spirituality : ability to find meaning Use of active coping strategies such as problem solving and planning • Lower levels of denial and avoidant coping behavior Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009 NEUROBIOLOGY OF RESILIENCE The H-P-A Axis: Resilience associated with less stress induced increase in CRH (corticotropin- releasing hormone) and cortisol. Neuropeptide Y – counteracts anxiogenic effects of CRH in amygdala, hippocampus, hypothalamus. In people who are resilient, NPY balances out CRH • BDNF (brain-derived neurotrophic factor) > promotes functioning of the hippocampus Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009 H-P-A Axis NEUROBIOLOGY OF RESILIENCE • BDNF (brain-derived neurotrophic factor) > promotes functioning of the hippocampus GENETICS: 1.) CHR1 receptor gene – regulation of H-P-A axis. 2.) Serotonin transporter gene – short allele (5 HTTLPR) 3.) COMT gene – low functioning allele increases NE and dopamine – increases anxiety 4.) NPY gene 5.) SNP in gene encoding BDNF – reduced hippocampal Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009 NEUROBIOLOGY OF RESILIENCE EPIGENETICS : • Meaney and colleagues Compared offspring of high nurturing and low nurturing maternal rats (i.e. licking) Offspring of high nurturing rats – less anxious, attenuated responses to stress Offspring of less nurturing rats - epigenetic changes affecting the hippocampus resulting in behavioral deficits Nestler et al, Psychobiology and Molecular Genetics of Resilience, Nat. Rev. Neurosci., 2009 POST-TRAUMATIC GROWTH • Change beyond the ability to resist and not be damaged by stressful events • Seismic – shaking one’s foundation to the core • Beyond pre-trauma levels of adaptation • Ironically, those who score highest on dimensions of coping will report relatively little growth • Struggle with trauma is crucial for post-traumatic growth but PTSD is not a pre-requisite Tedeschi, Interview, November 2016 POST-TRAUMATIC GROWTH Positive psychological change (Tedeschi, 2004) Attempt to find meaning and resolve (Morris, 2007) Human capacity for resilience & potential growth Recovery from trauma is not about putting the shattered world back together as it was but rebuilding the shattered world in a way that is better(Dorotik-Nana, 2016) Tedeschi and Calhoun, 2004. Psychiatric Times POST-TRAUMATIC GROWTH Implication: We are capable of growth experiences in the context of suffering and struggle as well in the aftermath of traumatic events, losses, abuse and betrayal. (Ferentz, 2016) Not everybody ends up with learned helplessness but some come out of it with learned optimism. (Seligman, Positive Psychology, 1998) In order to reach a place of transformation, there has to be a place of struggle (Ferentz, 2016. Helping people move from heartache to healing.) POST-TRAUMATIC GROWTH HISTORICAL CONTEXT Victor Frankl: “Man’s Search for Meaning” William Sledge: Study of POWs by Vietnamese > showed that the POWS who were held captive longest and had been subjected to harshest treatment reported most positive changes’ Richard Tedeschi, Ph.D. and Lawrence Calhoun, Ph.D. of UNCC (University of North Carolina at Charlotte) > pioneers in the field of post-traumatic growth Upside, Rendon, 2015 POST-TRAUMATIC GROWTH 5 Dimensions of Posttraumatic growth (Tedeschi and Calhoun) 1.) Rediscovering personal strengths 2.) Belief in new possibilities 3.) Improvement in relationship with others 4.) Spiritual growth 5.) A newfound appreciation of life Post Traumatic Growth Inventory: tool to measure PTG Tedeschi and Calhoun, 1996 PTG Inventory (Tedeschi & Calhoun) 21-item standardized questionnaire 5 Research Validated PTG Factors Relating to Others New Possibilities New Personal Strengths Newfound appreciation of life Spiritual Change Tedeschi and Calhoun, 1996 , PTG Inventory (Tedeschi & Calhoun) PTG Inventory (Tedeschi & Calhoun) POST-TRAUMATIC GROWTH Writing a new life narrative Challenging one’s assumptive world-view i.e. “ Good things happen to good people and bad things happen only to bad people.” (Why me ?) • Assimilation: Person wishes to maintain or retain pre- existing assumptions. Person fits the new trauma related information into his world view (maladaptive) • Accomodation: Reconstructing world view to achieve congruence with the new trauma-related information , POST-TRAUMATIC GROWTH Deliberative rumination/Reflective pondering : Intrusive thoughts must not be avoided. It is the catalayst to rethinking the meaning attached to event. This will allow survivors to construct a new view of themselves. Cognitive reframing of one’s story from that of mental defeat and hopelessness to one that is hopeful and optimistic (Narrative reframing) Upside, Rendon, 2015. FACILITATING PTG Cognitive Behavioral Therapy – CPT (Cognitive Processing Therapy)- reappraisal, reviewing of cognitive styles, assumptions Mindfulness-based therapy – promotes direct reduction of intense and inappropriate emotional states , e.g. relaxation training Upside, Rendon, 2015 FACILITATING PTG • Expressive writing : writing forces people to break ideas and events into smaller units; also facilitates deliberative rumination Study of Smyth (2008) comparing group of veterans with PTSD who wrote about time management vs trauma – the ones who wrote and reflected about their trauma showed improvement in severity and decrease in stress indicators (cortisol). Upside, Rendon, 2015 FACILITATING PTG Art therapy : including music and dance >Process of deliberate rumination – creative process > Subjects who scored high in openness to new possibilities have usually high creativity. • Spirituality /Spiritual counseling In 103 studies of PTG, religious coping often correlated with growth more than community support and enthusiasm His Excellency President Elpidio Quirino • Birth: Vigan, Ilocos Sur • 2nd child among 8 • Father: jail warden • Mother: school teacher • Modest and humble beginnings President Elpidio Quirino Foundation Vigan, Ilocos Sur UNESCO World Heritage Site • Taught grade school students in a village/barrio school while in high school • Walked 10 kilometers everyday to earn money • Made sketches of Filipino heroes and won prizes for them • Saved up money to be able to transfer to Manila High School Supported himself to go to school by working as a clerk in the Manila Police Department He did sketches and illustrations for some publications President Elpidio Quirino Foundation • Captain of the debating team in Manila High School and debated with another future president • University of the Philippines College of Law • Topnotcher in