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- From a greek word for physical wound
- an event is traumatic if it is extremely upsetting at least temporarily overwhelms the individual's internal resources and produces lasting psychological symptoms"



memory of event that comes back as involuntary

Intrusion Symptoms


try not to be exposed to cues

Avoidance Symptoms


Definition of Trauma

an event is traumatic if it is extremely upsetting at least temporarily overwhelms the individual's internal resources and produces lasting psychological symptoms"


Definition of trauma based on DSM PTSD criteria

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).


" During or right after the traumatic event.
" How did you respond to the event?
" Related to history of trauma, problems with stress tolerance and affect regulation, or cognitive predisposition

Peritraumatic Responses


During a traumatic event if you experience
" Derealization
" Depersonalization
Can increase chance of developing symptoms

o Peritraumatic Dissociation


" Fear, Horror
" Ex. You're at the bar and instead of freezing, you look for the nearest exit, scared but maintained some engagement with brain might not feel as helpless
" Helplessness
" Anger
" Shame, Guilt
Higher distress, more likely to develop symptoms

o Peritraumatic Distress


Response from others and context the helps reduce effects of trauma

1. Emotional Support
2. Non-blaming acceptance
3. Social acceptability of the traumatic event
4. Social location of person


FOUR main criteria for PTSD

1. Intrusion Symptoms
2. Avoidance Symptoms
3. Alterations in Cognitions and Mood
4. Alterations in Arousal and Reactivity


1. Inability to remember an important aspect of the event(s) (due to dissociative amnesia and not to head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
3. Persistent, distorted cognitions about the cause or consequences of the event(s) that lead to blame self or others.
4. Persistent negative emotional state (fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions.

Alterations in Cognition and Mood


1. Irritable behavior and angry outbursts (with little or no provocation).
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)

Alteration in arousal and reactivity


PTSD specifier

Dissociative Symptoms


Two Dissociative Symptoms for PTSD

1. Depersonalization
2. Derealization


Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling time moving slowly).

Ex. I don't feel like myself



Persistent or recurrent experiences of unreality of surroundings (e.g., the world is experienced as unreal, dreamlike, distant, or distorted).



Happens all the time even without a trigger
They are not related to a particular event or trigger
Related to repetitive, relational in nature, started in childhood
The person acts like this on a regular basis

Complex Trauma


Three main symptoms associated with complex trauma

1. Emotional Dysregulation
2. Loss of self-integrity or self integration
3. Compromised relationship with others.


Extreme Anxiety, someone honks "OMG WHAT HAPPENED"



Numbness, being here but not feeling anything, system is shutting down difficulty experiencing emotions



Associated with complex trauma

"Emotions we all have, just more intense and more frequent

Common denominators: self-estrangement, emotional deadness, feeling threatened by one's own emotions
- these emotions are taking over me

Feeling threatened by one's emotions - scared to feel, if I start feeling I'm going to fall apart, don't trust your emotions

-Anger, fear, depression, sadness helplessness

Emotional Dysregulation


Feeling like my emotions are taking over me associated with emotional dysregulation



"- I got so angry and next thing I know I come back to my sense and the house is destroyed
" "Hole" of who we are
" Negative view of self, self-loathing. This can also be dissociated
" Nobody loves me because I'm not good enough that's why no one came to protect me
" How come I couldn't defend myself?
" So painful we reject that part of ourselves
" Self-image filled by disparaging messages

Loss of self-integrity and self regulation


An example of . ______ related to complex trauma I got so angry and next thing I know the house is destroyed

Loss of self integrity


Dissociation as a self protective mechanism

Loss of self-integrity and self-integration


Difficulty Trusting

Realistic paranoia


Part of complex trauma
o Insecure, including disorganized attachment styles that are hard for others to read
- Hard people to read cues connection
- Is this person joking or insulting me?
o Risk for revictimization
- Risky behaviors as ways of coping
- What is known in relationships, which confirms negative view of self and others
- This is the way relationships are and we stay, this is normal
o Controlling others as a way to feel more in control.
o ´Taking care of others at their own expense, to feel valuable, to put the focus on others and not on self.
o Becoming hostile to others.
o Becoming flawless and self-sufficient.
- Negative view of self, dissociate we need to show we are okay, but there is this undercurrent of self-loathing
- "I'm not bad" no matter how much they accomplish it will never be enough
o Withdrawing from interpersonal contact.

Compromised relationship with others


a disorder where the child Does not seek comfort or respond to comfort

Reactive Attachment disorder


a disorder where the child Willing to go with any unfamiliar adult and does not check back with caregiver to make sure it is safe

Disinhibited Social Engagement


Diagnosis in children that must be present before age 5

Reactive Attachment disorder


Similarities in Reactive attachment disorder and Disinhibited Social Engagement

1. can develop into other disorders later on
2. criterion c and d regarding social neglect, repeated changes in caregiver, and growing up in an unusual setting
3. age: child has developmental age of at least 9 months


Differences in Time for PTSD and ASD

PTSD - disturbance is more than a 1 month, it can be prolonged stays longer and symptoms continue to be there
ASD - 3 days to a month, happens right after the event, symptoms can start fading away


Difference in symptoms in section B for PTSD and ASD

ASD - 9 from any sub categories

PTSD - you need the 4 intrusions, avoidance, alterations in cognition and mood, and alterations in arousal and reactivity, one from each category



Spinal cord

Central Nervous System


nerves and ganglia

Peripheral Nervous System


Muscles and Sense

We have more control over this one

Sensory Somatic Nervous System


Part of the Nervous System that Works by itself

Autonomic Nervous System


Two parts of the Autonomic Nervous System

1. Sympathetic
2. Parasympathetic


Accelerator. Arousal, activates fight/flight response

Sympathetic Nervous System


The brakes. Responsible for digestion, wound healing, mating.

Resting, things we can do if we are not in action



Three parts of the triune brain

1. The reptillian Brain
2. The Mammalian Brain
3. Neocortex


Systems dealing with EMOTIONAL INTENSITY

- Smoke detector (amygdala)
- Watchtower (medial prefrontal cortex [MPC])


systems dealing with CONTEXT, MEMORY how we store it

- Time dimension (dorsolateral prefrontal cortex [DLPC])

- Encoding explicit memory (hippocampus)


" Brain stem (without thalamus)
" All the things a baby can do: eating, sleeping, waking, crying, breathing, peeing, pooping…
" Where the RAS and Locus Coeruleus are (Pons)
" Regulates the energy levels of the body, the endocrine and immune systems

TheReptilian brain


" Limbic system.
" Thalamus, hypothalamus, amygdala, and hippocampus
" Manages the emotions
" Emotional Regulation, Emotional Functioning
" Monitors danger, discriminates between pleasurable and scary (amygdala)
" How do we respond?
" Contributes to memory (hippocampus)

The Mammalian Brain


o Specially the frontal lobe. Youngest part of our brain.
o Rational thinking, impulse control, abstraction, symbolic ideas, planning, coordination with others, language
o The most complex structure.
o Not as active in times of threat.
o The newest part of the brain



o When amygdala gets info from thalamus it does a quick check for danger
" Ex. Hear a loud noise, think it could be danger, first response is shock, comes from amygdala comes quickly from little information we have, but then we see outside and someone just dropped something

Low Road


quickly assesses whether stimuli means danger (smoke detector)



the watchtower further assesses if it is false alarm, takes a second look at what the thalamus sent

Medial prefrontal cortex (MPFC),


type of road
o The neocortex gets engaged, conscious awareness.
" Not too high peritraumatic stress
o Ex. After you scram and gasp, you realize its fake rat and you calm down and then talk it out
o Medial prefrontal cortex (MPFC), the watchtower further assesses if it is false alarm, takes a second look at what the thalamus sent

High Road


What happens to the MPFC when the peritraumtic stress is high?

The MPFC is NOT activated and we CAN NOT take a second look at the info sent from the thalamus. We just continue in fight or flight mode


" Time dimension of events
" Put a time context to a memory
" You know the memory happened then and it's not happening now
" Beginning and end
" Now and then

o Dorsolateral prefrontal cortex (DLPFC):


Encoding of EXPLICIT memories



Memories from birth and even before " Memories we store but we are not conscious about
" Emotions, perceptions, bodily actions, bodily sensations, schemas (mental models of experiences), priming (the nervous system gets ready to respond in a certain way)

Implicit Memory


Starts at 18-24 when hippocampus starts developing

Conscious memory that we can recall or retrieve, more aware of it, different level of awareness

These memories include a sense of self and a sense of context

Explicit Memory


_______ helps to integrate implicit memories to build explicit memories of an episode of you in a place and a time.



Memories about events, things, etc.

Factual Memory


memory of ourselves in specific episodes of our lives

Autobiographical Memory


When the ____ and ____ have been BLOCKED, implicit memories DO NOT become explicit

Hippocampus; Dorsal Lateral Prefrontal Cortex


How does the hippocampus get blocked?

Massive release of stress hormones

Very HIGH peritraumtic stress


What happens to the hippocampus when attention is divided or during dissociation?

o Conscious attention helps to engage the hippocampus.

If our minds turn the focus of attention away from the traumatic event (divided attention or dissociation) then the hippocampus CANNOT be engaged, will store implicit memories but cannot make connection
Ex. Rape, remember they pushed me then I noticed a ceiling had a crack (split attention) helps us survive that moment, not being aware of what's going on helps us survive, but the way these memories are stored is implicit, can't be made explicit because the hippocampus is not active.


Polyvagal Theory and Three Psychological Stages

1. Social Engagement
2. Fight or Flight
3. Freeze or Collapse



"Can happen all the time, even in times of no danger, constantly sending messages, reading body cues

Is this going well or is this turning into a dangerous situation?

Communicate emotional state and respond to other's emotional state through facial and vocal cues

Helps us decide if we are safe

Synchronize with other members of the tribe.

Respond to other people, Coordinate together

Working together, dancing

Being seen and heard by the people important in our lives can make us feel calm and safer

Social Engagement



if no one comes to our aid, and/or we are in immediate danger, the stress response kicks in.

Fight or Flight



if we can't get away, Unescapable, doesn't make sense to fight

We feel as little as possible and spend little energy

Reduced metabolism, heart rate plunges, gut empties, low air, brain shuts down

Least present as possible

We are conserving energy to possible fight after the danger is over

Other people and ourselves cease to matter, awareness shuts down, and we might not even register pain.

Ex. Cat and mouse, the mouse gets caught and shuts down, but when the cat lets go he has the energy to run away

Freeze or Collapse


Specific which connects serval organs and facial muscles to the brain of Polyvagal Theory

Vagus Nerves


_____ regulates three physiological states, perceived level of safety determines which one is activated Social engagement, fight or flight, or freeze and collapse

Autonomic Nervous System


The brain changes in a _____ way during _____ years of life

use - dependent, first 3 years


Exposure to ____ and ___ leads to RESILIENCE

Consistent and Moderate Stress


Brain organizes based on _____



Children develop on 2 continumm

1. Arousal
2. Dissociative


Blind Agression



More common in Males

Higher than Normal heart rate

Arousal Continuums


little by little shutting down

Person doesn't have a sense of will

Dissociation is more common in babies and infants

Dopamine, Endorphins

Dissociative D/0


More common in females

Lower than normal heart rate

Dissociative Continuums


main premise of attachment theory

" Goal: increasing or maintaining proximity to attachment figures to feel safe and/or comforted
" Ex. Kid playing on the playground peeking over his shoulder to make sure mom is watching. Once mom is gossiping with her friend, kid will walk over to make sure mom is still paying attention to him.


Reasons for attachment activcation

1. Distance from caregiver

2. External Cues for danger
Ex. A dog is coming, I need to run to my mom from

3. Internal cues of discomfort (e.g., getting sick, hunger)
Feeling hungry or pain, get moms attention to help
Can you attend to me?

If not activated, child would explore and engage with others. Secure dependence complements autonomy


Effective response from caregiver helps with ____

Emotional Regualtion


Two functions of a mother during attachment

1. secure base
2. safe haven


Cognitive component of attachment is associated with

Internal Working Model


Internal working model is based on _____, creates a future template



_______ for exploration
o Ex. Nephew 13 months, but I was a new figure and he would go and play with something then come back and hug mom to make sure everything is okay
o No danger but just want to make sure

Secure base


_____in times of danger
o Ex. When child is running from the dog or has pain, mom is the source of comfort
o Danger and I need your help
" Expected to be capable to provide support (the strong wise other)

Safe haven


Four Types of Attachment styles

1. Secure
2. Anxious
3. Avoidant
4. Disorganized


The parent is there sometimes but not all the time

Tries to get the parents attention and when they get the attention they don't know how to calm down


Constantly draw attention to themselves by crying, yelling, clinging or screaming.

They seem to have concluded thart unless they make a spectacle, nobody is going to pay attention to them

Are not comforted or relieved when their mother returns.



I know you are not going to come

Why am I going to cry if you're not going to come?

They don't cry when their mother goes away, and they ignore her when she comes back

Increase heart rate, constant state of hyperarousal.




The person we go to for help is the very source of pain

Come close then remove themselves

Ex. Walking backwards towards the caregiver

Seeking closeness and avoiding the parent




Attachment quality (security or insecurity) affects:

1. Affect regulation and expression
2. Information processing


Attachment qualities effect on affect regulation and expression

o Proximity to a responsive caregiver is an affect regulation device

Can develop a sense of "I can figure this out" or "I know if I ask I can get help"

Securely attached people can acknowledge distress and reach out for help/comfort
- Feeling my emotions isn't

Insecure/anxious people can become emotionally overwhelmed and might reach out in ways that are not effective
- Angry, blaming, ways that make it hard for the other person to respond

Insecure/avoidant people can physiologically activate but are emotionally disconnected and do not reach out for help
- High heart rate, high blood pressure, doesn't matter how much I express no one care.


Attachment quality effect on Information processing

Mediated by IWM

Secure attachment helps to have a better assessment of danger

Tendency to process information in a way that confirms IWM

For people with severe trauma history, the world is filled with danger

Emotional dysregulation (both excessive activation or detachment/dissociation) can affect processes like memory, planning, openness to new evidence, etc. (implicit memories, the abuse did happen)


Attachment quality effect on communication

Securely attached people are more able to:

o Read vocal and facial cues from others without being over sensitive or dismissive

oSending cues to others as
o Reach out
o Clearly communicate their needs

o Trust

o Be empathic, attune to others

o Be assertive,

o express themselves (opinions, interests)

o Problem-solve and collaborate with others


The caregiver response is activated when . . .

-Intense emotion
- External cues (dog)
-External cues from child (crying)
-Internal Cues (hormones)


Innate motivating force to care for and protect our children

Not as researched as attachment

The Caregiving System


Stimuli (images,sounds) gets sent to the ______ which then sends it to the two roads



medial prefrontal cortext is part of

emotion processing


Dorsal Lateral pre frontal corext is part of



the capacity to evaluate relative danger and safety in one's environment



Part of implicit memory
the nervous system gets ready to respond in certain ways