NEUROPSYCHOLOGY OF STRESS

AND TRAUMA

BY
DR. NADER KORHANI
 Neuropsychology of Stress and Trauma

• Epigenetics, Telomeres, and neurobiology of

Attachment, childhood stress and trauma

• Latest Research and literature on Mind-Body

Connection

• Secondary Psychophysiological Responses to Stress

and Trauma in Adulthood

• Interpersonal Neurobiology, Mindfulness Training, and

Key Principles for Therapeutic Interventions
 Neuropsychology of Stress and Trauma

• Neuropsychology:
The study of the relationship between behavior, emotion, and cognition; Brain
development and function; and the dynamics of how both sides influence each-
other.
• Stress:
Stress is your body's way of responding to any kind of demand or threat. When you
feel threatened, your nervous system responds by releasing a flood of stress
hormones, including adrenaline and cortisol, which rouse the body for
emergency action.
• Psychological Trauma:
A type of damage to the mind that occurs as a result of a severely distressing event.
Trauma is often the result of an overwhelming amount of stress that exceeds
one's ability to cope, or integrate the emotions involved with that experience. A
trauma can be result of a single event, or repeating events of being
overwhelmed over a period of time of various length.
What are the stress mechanism?
 Adrenomedullary Response - SAM
Occurs through the activation of the sympathetic-adrenal medulla
(SAM) complex:
• Perception of stress causes the hypothalamus (via nervous
connection) to activate sympathetic fibers
• Sympathetic fibers activate the adrenal medulla
• Adrenal medulla secretes the catecholamines: epinephrine &
norepinephrine
This causes:
• Increased heart rate, blood pressure, breathing rate & blood
glucose levels
• Shuts down digestive system
• Rapid, short-lived response to stress
Sympathetic Response to Stress

Hypothalamus causes:
Increases arousal in the sympathetic nervous system
• Increased heart rate & blood pressure
• Constriction of peripheral blood vessels
• Respiration rates increase
• Bronchial tubes dilate
• Pupils dilate
• Digestive processes decrease
Sympathetic activation prepares the body for intense
motor activity
Parasympathetic response to stress

Serves regenerative, growth-promoting, energy-conserving

functions
Its effects include the opposite of the effect of the sympathetic
nervous system
Functions under normal, non-stressful conditions
Also activated by the hypothalamus
• re-establishes homeostasis in the system
• reconstructive process following stressful experience
• slows the heart rate & decreases blood pressure
• decreases muscle tension
• slows respiration
• neutralizes fight or flight response
The General Adaptation Syndrome
Chronic Stress

•The body’s response to chronic stress differs from its

response to transient episodes of stress; there is a
different set of responses to more severe and
prolonged periods of stress. Stressors excite both the
S.N.S. and an axis comprising the hypothalamus,
pituitary gland and adrenal cortex.

•The hypothalamus induces the anterior pituitary gland

to secrete adrenocortico-tropic hormone (A.C.T.H.).
This in turn stimulates the secretion of cortisol and
other steroid hormones.

•Cortisol has the effect of elevating blood sugar and

enhancing metabolism; in the medium to long-term,
this causes a shift away from the synthesis of proteins,
including those proteins necessary for the immune
system. Thus, in the long term, this causes a
weakening of the immune system making the individual
vulnerable to a variety of illness conditions.
Pathways for the effect of emotional stress through the anterior and posterior
hypothalamus (Stoll, 1983).
Pathways for the effect of emotional stress through the anterior and posterior
hypothalamus (Stoll, 1983).
Epigenetics
Epigenetics
Epigenetics
Epigenetics

Early Brain
Environmental Physiology
Experiences Behavior
Our experiences or “nurture” can have long-
term effects on our brain and behavior

Genes can be turned “on” or turned “off”

through epigenetic changes

HOW DOES THIS OCCUR?

Epigenetic Control of Gene Activity

Early Brain
Environmental Physiology
Experiences Behavior

Our experiences or “nurture” can have long-

term effects on our brain and behavior

Genes can be turned “on” or turned “off”

HOW DOES THIS OCCUR?
through epigenetic changes
 Telomeres
Telomeres are a protective casing at the
end of a strand of DNA. Each time a cell
divides, it loses a bit of its telomeres. An
enzyme called telomerase can replenish
it, but chronic stress and cortisol
exposure decrease your supply. When
the telomere is too diminished, the cell
often dies or becomes pro-inflammatory.
This sets the aging process in motion,
along with associated health risks.
Telomeres
Stress and metabolizing high-fat and sugery food
Chronic stress wreaks havoc in neurally driven compulsive eating patterns. It can cause neuroplastic
changes that alter how we perceive and react to the world in ways that might be good for short-term
survival but not for longevity mechanisms. Stress impairs our executive function, which dampens our
ability to resist impulses. Chronic stress can increase the reward responsiveness of our brains. So if we
are at all prone to addiction, it's going to make us crave palatable food or drugs even more. It drives us to
choose comfort foods, whether unconsciously or with a strong intention. Now what's happening in the
body? We know that people with high stress develop greater levels of abdominal fat. Mouse models have
shown that pathway. The combination of high stress and [eating a lot of] junk food works synergistically
here. Stress leads to neuropeptide Y (NPY), a chemical that triggers the intra-abdominal fat cells to
mature and fill up with more fat. In a study, the high-stress caregivers who ate more comfort food had
higher NPY and abdominal fat. But this was not observed in the caregivers with the healthier diet, nor in
the low-stress controls with the junk food diet. In our next study we are putting high- versus low-stress
people on a high sugar diet, short term of course, to test these effects more experimentally. Elissa
Epel PhD UCSF Professor
How early in life do the negative effects of stress begin?

MATERNAL stress, toxin exposure,

EXPERIENCES nutritional status

oocyte transcription/translation

prenatal placental function,

environment physiology

postnatal
sensory stimulation,
maternal frequency & stability of care
behavior
Parental Experience
OFFSPRING Influences Offspring
DEVELOPMENT Development
 Programming of Fetal Stress
Response
maternal fetal
risk of prematurity
lower birth weight
Stress
increased stress response
risk of depression & anxiety
 Genes Altered in the Rat Placenta Following Chronic
Variable Exposure to Stress
Gene Gene Function Stress Effect
11BHSD-2 metabolizes corticosterone Decreased
DNMT1 maintenance DNA methyltransferase Decreased

Nr3c1 glucocorticoid receptor Decreased in male

11BHSD-1 metabolizes corticosterone Decreased
AFP Alfa-fetoprotein (binds estradiol) Decreased
AR Androgen receptor Decreased in females
AVPR1a Vasopressin receptor (social behavior) Decreased in males

DIO3 Iodothyronine deiodinase 3 Decreased in females

(inactivates thyroid hormone)
DLK1 Delta-like 1 homolog (adipogenesis) Decreased
DNMT3L DNA methyltransferase Decreased
IGF1R Insulin growth-like factor 1 receptor Decreased
IGF2 Insulin growth-like factor 2 Decreased
 Pathways of Prenatal Stress Effects

Monk, Spicer & Champagne (2012) Development & Psychopathology

How early in life do the negative effects of stress begin?

Anita Thapar & colleagues

 The Early Brain Development
• Newborns are born with twice as many neurons as adults. Within an
hour after birth, the infant starts to imitate the expressions of those around
them and prefer the configuration of the human face to any other visual
stimuli. (Meltzoff and Moore, 1977).

• Failure to Thrive: children can die from not being touched, spoken to,
looked at, etc. Even if their basic needs are attended to, the studies of
Romanian orphanages showed that children died due to the lack of
human attachment (Spitz).

• Human babies are designed to attach to caregivers. Babies are

designed to attract the kind of attention needed to survive.Whatever
neurological structure they bring into the world immediately begins
interacting with, and is changed by, the environment.
• The Early Brain Development cont.
• Facial expressions to communicate core emotions- anger, fear
and approval are the same in every culture and every human
being. We later learn the emotional display rules in our particular
culture. (Ekman 1993).

• Watching the face, listening to the emotional timbre of vocalizations,

and using subtle olfactory cues, mother and infant together begin
building attunement and shared emotional regulation.

• The “affective attunement” is contingent on the parent’s capacity to

provide a secure base and a holding environment so that the infant
feels connected and also responded to as a separate subjective
being (Siegel, 1999, Siegel & Hartzell, 2004, Trevarthen, 1993).

• The key is recognizing and responding to each other’s emotions.

 The Early Brain Development cont.
•“love is simply the brain’s way of nurturing
another brain.” Conversely, prenatal stress is
associated with medical problems, hyperactivity,
irritability, language deficits & lower IQ in baby.
The cause is elevated cortisol levels that in
effect “corrode” the developing brain.(Brizendine,
2007-Pregnancy changes).

•Genes do not determine behavior they increase

the probability of certain behaviors developing.
Genes interact with the environment and can
be turned on or off by exposure to the
environment. (see Epigenetics)

•Mirror neurons play a major explanatory role in

the understanding of a number of human features,
from imitation to empathy, and language learning.
It has also been claimed that damages in these
cerebral structures can be responsible for mental
deficits such as autism.
Self-regulatory mechanisms affected by caregiving
• Brainstem function (heart rate, respiration, attention)
• Vagus nerve (affects all body systems and sociality)
• Stress response (hypothalamic-pituitary-adrenal
axis)
• Anxiety (glucocorticoid receptors in hippocampus)
• Emotion systems (links between cortical executive
functions and subcortical emotion systems)
• Immune system (number and ratio of immune cells)
• Neurotransmitters (number and function of
serotonin, NMDA receptors)
 The Neurobiology of Child Abuse
- Martin Teicher
The Scientific American
March 2002
“Maltreatment at an early age can have enduring negative effects on a
child’s brain development and function.”

• Patients with physical and sexual abuse reported symptoms of temporal

lobe damage (specifically hippocampus and amygdala related) at a rate
113% higher than the control group.

• Hypothesis is that exposure to high levels of stress hormones (cortisol)

in development can alter or kill neurons in the hippocampus and other
limbic structures.

• Maltreatment before the age of 18 had greater impact than later abuse.

• Antisocial behavior resulting from child abuse appears to be

caused by overexcitation of the limbic system, the primitive
midbrain region that regulates memory and emotion.
 The Neurobiology of Child Abuse
- Martin Teicher
The Scientific American
March 2002

Summary:
•Limbic electrical irritability can produce symptoms of aggression,
exasperation, anxiety, self-destructive behavior and increased risk for
suicide.

•Reduced integration of right and left hemispheres and a smaller

corpus collosum may predispose the emergence of borderline
personality disorder.

•“If our society were truly to appreciate the significance of children’s emotional
ties throughout the first years of life, it would no longer tolerate children
growing up, or parents having to struggle, in situations that cannot possibly
nourish healthy growth.”
Stanley Greenspan, M.D., Child Psychiatrist and Former Director, Clinical
Infant Development Program, [U.S.] National Institute of Mental Health (As
cited in Mate, 2008).
 Negative feedback loop of stress
• Recent studies pointing out the mind and body feedback
loop when early childhood stress and developmental
disturbance may in turn lead to activation of genes that
cause oversensitivity to later stressful stimulus which
sequentially leads to greater susceptibility to physical health
problems resulting in more stress that may eventually
develop into a more permanent pattern of chronic stress,
mental health problems, and/or long term physical health
problems as result. They explained the early life experience
of the excessive and cumulative stress will lead to
compromised immune system and over the years, it will
eventually manifest itself in form of long term physical health
problems and disease in adulthood such as Diabetes and
Cushing disease. Honkoff, Boyce, and McEwen (2009)
 Neurobiology of Trauma
Trauma can be conceptualized as stemming from a failure of the
natural physiological activation and hormonal secretions to
organize an effective response to threat. Rather than producing
a successful fight or flight response the organism becomes
immobilized.
(Clinical Implications of Neuroscience Research in PTSD)
BESSEL A. VAN DER KOLK

Exposed to traumatic reminders, subjects had cerebral blood

flow increases in the right medial orbitofrontal cortex (Because
of its functions in emotion and reward, the OFC is considered to
be a part of the limbic system) insula, amygdala, and anterior
temporal pole, and in a relative deactivation in the left anterior
prefrontal cortex, specifically in Broca’s area, the expressive
speech center in the brain, the area necessary to communicate
what one is thinking and feeling.
RAUCH, S., B.A. VAN DER KOLK, R. FISLER, et al. 1996.
 Neurobiology of Trauma
Dr Daniel Siegel

Impaired integration and self-regulation in the prefrontal regions

can be seen within the brains of those individuals with unresolved
trauma or grief.

Lower mode states ensue when the functioning of the integrating

prefrontal regions become temporarily impaired.

Behavior is then driven by emotional states and impulses of the

lower regions of the brain.

This creates a lack of experience integration and response

flexibility, which is mediated by the
orbito-frontal region of the prefrontal cortex.
Neurobiology of Trauma

Secondary Responses to Trauma

•Depression
•Aggression
•Low Self-Esteem
•Identity Confusion
•Difficulties in Interpersonal
Relationships
•Guilt
Key Principles for Therapeutic Interventions
•Judith Herman recognized three general stages of recovery
from trauma.
1. Central task of the first stage is to establish safety.
2. Central task of the second stage is remembrance
and mourning.
3. Central task of the third stage is reconnection…”
(Trauma and Recovery1992)
An Interpersonal Neurobiology
- Daniel Siegel

Convergence of neurobiology and attachment

theory

• Human connections within relationships

shape the neural connections of the brain
from which the mind emerges.

• Relationships may not only be encoded in

memory, but may also shape the very circuits
that enable memory to be processed and
self-regulation to be achieved.
An Interpersonal Neurobiology

•Human connections within relationships shape the neural

connections of the brain from which the mind emerges.
•Relationships may not only be encoded in memory, but may
also shape the very circuits that enable memory to be
processed and self-regulation to be achieved.
•The right hemisphere of the brain is involved in self-soothing
actions.
•The left side is involved in more exploratory actions – an
interpreter function.
•Coherent narratives are a product of the integration of the left
and right hemisphere processes.
•The prefrontal region of the brain is a part of the integrated
circuitry that permits social and moral behavior.
•
 An Interpersonal Neurobiology
- Daniel Siegel
Basic Principles

• The mind is a process involving the flow of energy and

information.

• The mind develops as the genetically programmed

maturation of the brain responds to ongoing
experience.

• The mind (energy and information flow) emerges in the

transaction of neurophysiological processes and
interpersonal relationships.
Paradigms of Growth and Healing

Rewiring the Brain for Resilience

• Neuroscience
• Mindfulness
• Empathy
• Secure attachment
• Emotional-social-
relational
intelligence
Modern Neuroscience
• How neural structures/circuits develop
• How brain processes information;
communicates within itself
• How brain learns/installs patterns of
coping
• How brain rewires its memory patterns
Neuroplasticity

• Greatest discovery of modern

neuroscience
– Growing new neurons
– Strengthening synaptic connections
– Myelinating pathways – faster processing
– Creating and altering brain structure and
circuitry
– Organizing and re-organizing functions of
brain structures
• The brain changes itself - lifelong
Mechanisms of Brain Change

• Conditioning
• New Conditioning
• Re-Conditioning
• De-Conditioning
Conditioning
• Experience causes neurons to fire
• Repeated experiences, repeated neural firings
• Neurons that fire together wire together
• Strengthen synaptic connections
• Connections stabilize into neural pathways

• Without intervention, is what the brain does

• Conditioning is neutral, wires positive and

negative
Attachment Styles

• Secure
• Insecure-Avoidant
• Insecure-Anxious
• Disorganized
Attachment Styles - Secure
• Parenting is attuned, empathic,
responsive, comforting, soothing,
helpful
• Attachment develops safety and
trust, and inner secure base
• Stable and flexible focus and
functioning
• Open to learning
• inner secure base provides buffer
against stress, trauma, and
psychopathology
Insecure-Avoidant
• Parenting is indifferent,
neglectful, or critical, rejecting
• Attachment is avoidant of
people and emotions,
withdrawn, compulsively self-
reliant
• Stable, but not flexible
• Focus on self or world, not
others or emotions
• Rigid, defensive, not open to
learning
• Neural cement
Insecure-Anxious

•Parenting is inconsistent,
unpredictable
•Attachment is clingy,
needy, compulsive
caregiving
•Flexible, but not stable
•Focus on other, not on self-
world,
•Less able to retain learning
•Neural swamp
Disorganized

• Parenting is frightening or
abusive, or parent is
“checked out,” not “there”
• Attachment is paralysis,
fright without solution
• Lack of focus
• Moments of dissociation
• Compartmentalization of
trauma
 Attachment –Based Treatment (Phil Rich)

• Build a secure base

• Confidence in connections based on consistency
• Coherent sense of self
• Balance of affective and cognitive problem solving
• Cooperative and non-coercive strategies for get
needs met
• Frustration tolerance
• Empathy for others
• Moral understanding and moral reasoning
• Experience connection and relatedness to others
Goals of Attachment-based treatment

• Self-regulation, self efficacy, security

– This is achieved in treatment through:
• Empathic attunement
• Affirmation of the clients strengths
• Provide role models
• View irrational behaviors as insecure attachment
strategies
– Milieu: Attachment-informed treatment
environment
• Facilitative climate
 Mechanisms of Brain Change

• Conditioning
• New Conditioning
• Re-Conditioning
• De-Conditioning
Pre-Frontal Cortex

• Executive center of higher brain

• Evolved most recently – makes us human
• Development kindled in relationships
• Matures the latest – 25 years of age
• Evolutionary masterpiece
• CEO of resilience
 Functions of Pre-Frontal Cortex
• Regulate body and nervous system
• Quell fear response of amygdala
• Manage emotions
• Attunement – felt sense of feelings
• Empathy – making sense of
expereince
• Insight and self-knowing
• Response flexibility
• Planning, decision making
 New Conditioning

• Choose new experiences

– Focused attention,
compassionate listening,
gratitude practice
• Create new thoughts, new
experience of self
• Create new learning, new
memory
• Encode new wiring
• Install new pattern of response,
new habits, new ways of being
 Mindfulness and Empathy

•Two of the most

powerful agents of
brain change known to
science
•Mindful parenting
•Mindful schools
•Empathic parenting
•Empathy in the
schools
 What is mindfulness?
Mindfulness means paying attention to what’s
happening in the present moment in the mind,
body and external environment, with an
attitude of curiosity and kindness.
It is typically cultivated by a range of simple
meditationpractices, which aim to bring a
greater awareness of thinking, feeling and
behaviour patterns, and to develop the
capacity to manage these with greater skill and
compassion.
This is found to lead to an expansion ofchoice
and capacity in how to meet and respond to
life’s challenges, and therefore live with
greater wellbeing, mental clarity and care for
yourself and others.
MINDFULNESS PRACTICE:

Shift from Self-Critical Voice to

Self-Compassionate Voice
• Loving awareness of breathing
• Let a moment of discomfort arise; notice
where you feel in the body
• Notice any critical self-talk; notice the
words; notice the tone of voice
• Use critical voice as cue to practice: “May
I be kind to myself in this moment; may I
accept myself in this moment exactly as I
am.”
 Re-conditioning

• Memory de-consolidation –
re-consolidation
• “Light up” neural networks
• Juxtapose old negative with
new positive
• Neurons fall apart, rewire
• New rewires old
Modes of Processing

• Focused Attention
– Tasks and details
– Deliberate, guided change
– New conditioning and re-conditioning
• De-focused Attention
– Default network
– Mental play space – random change
– De-conditioning
An Interpersonal Neurobiology

In Daniel Siegel’s (2007) work on Mindfulness and emotional regulation.

1. “We create nonreactivity by developing the circuits in our brain

than enable the lower affect-generating circuits to be regulated by the
higher modulating ones…..this is called “response flexibility”
The way that we pause before action and consider the
various options that are most appropriate before we
respond.
2. States of “mindfulness”, can be achieved when we coordinate
our autonomic systems with our intentional systems.
For example breath awareness can create a state of
mindfulness that leads to emotional regulation, emotional
integration and ultimately resiliency.
3. While an intimate interconnection to others helps with emotional
regulation, an intimate intra-connection between our brains and minds
can directly impact emotional regulation also.
De-Conditioning

• Default network
• De-focusing, loosens grip of attention
• Creates mental play space, free
association
• Can drop into worry, rumination
• Can drop into plane of open possibilities
• Brain makes new links, associations
• New insights, aha!s new behaviors
 EMDR EYE MOVEMENT DESENSITIZATION REPROCESSING
EMDR can be
described as an eight
phase treatment for
PTSD and many other
psychological issues
including grief,
anxiety, substance
abuse, and depression.
Exposure and
cognitive components
is an important part of
this technique as it is
combined with lateral
eye movements.
 EMDR
• 5.Installing and strengthening the positive cognition
Client is encouraged to check emotional and cognitive reactivity on a ten point scale.

• 6. Body scan
Client is asked to check body and sensations. Many of the Trauma symptoms such as Stomach problems,
Intestinal problems, Gynecological problems, Weight gain or loss Chronic pain (back, neck, pelvic area in
women), Headaches, Skin rashes and other problems shows a strong physical component associated
with PTSD. It is therefore, reasonable that expect clients to have experiences that manifest themselves
physically or in form of sensations as they go through the exposure process of EMDR. This also helps
client to become more aware of the link between their psychological arousal and physical sensations both
during the arousal and when it decreases and becomes less intense.

• 7.Closure
The therapist validates client’s effort and helps them to set up plans to cope with uncomfortable feelings and
thoughts after the session. The therapist also goes over different techniques of guided imagery and
relaxation (e.g. creating and using safe place imagery) with client to ensure that appropriate coping skills
are applied if needed. This include an explanation of how to cope with triggering of any unpleasant
experiences.

• 8.Re-evaluation
The therapist evaluates and assesses client’s experience and progress after last session. The goal at this
point is to determine the best direction for continuing this process and supporting client with becoming
more skilled at evaluating their-own progress and building hope and confidence.
 Dialectical Behavioral Therapy

There are four main types of skills in DBT skills training.

1. Mindfulness Meditation Skills. These skills center on learning to

observe, describe and participate in all experiences (including thoughts,
sensations, emotions and things happening externally in the environment)
without judging these experiences as "good" or "bad."

2. Interpersonal Effectiveness Skills. The focus of this skill module is on

learning to successfully assert your needs and to manage conflict in
relationships.

3. Distress Tolerance Skills. Accept and tolerate distress without doing

anything that will make the distress worse in the long run (e.g., engaging in
self-harm).

4. Emotion Regulation Skills. Identify and manage emotional reactions.

De-Conditioning

• Reverie, daydreams
• Imagination
• Guided visualizations
• Guided meditations
• Brain “plays,” makes own
associations and links,
connect dots in new ways
• Reflect on new insights