Pharmacists Should Understand Trauma, the Stress Response to Provide Effective Care

To understand trauma, we must first understand the complex structure of the brain. The human brain develops from the bottom up, starting with the part of the brain that is responsible for our survival. Next, we have the emotional center or the limbic system, which is responsible for memory, emotions, and encoding of pleasant and unpleasant experiences. The limbic brain also scans the environment for danger based on past experiences that have been encoded. The neocortex is the last part of the brain to develop because it is the least essential to survival. The neocortex is responsible for keeping the 2 other parts of the brain in check by applying rational thought and reasoning to our decisions. In times of distress, the neocortex is overtaken by the overactive limbic system and survival instincts, putting the body into the fight-or-flight response, a function of the autonomic nervous system (ANS).

When responding to stress, the brain uses 2 roads. The first is what neuroscientist Joseph LeDoux, PhD, calls the low road.1The low road is a shortcut that bypasses the neocortex and sends a sensory signal immediately to our emotional brain, where the amygdala is located. The amygdala, or the brain’s alarm center,prompts us to act and make decisions based solely on emotions. We also have thehigh road,in which the same sensory signal is sent to the neocortex, where our rational brain assesses the signal for danger and relays appropriate messages back to the amygdala. The high road takes about 8 times longer than the low road. This is important because when we sense danger, our body uses the low road to respond to danger by prompting us to running away. During trauma, individuals often resort to the low roadwhen making decisions.¹

In addition to LeDoux’s explanation, researcher Stephen Porges, PhD, has posited the polyvagal theory to explain the stress response. The polyvagal theory is best explained through the function of our ANS, which plays a key role in our stress response to danger.² The ANS is divided into 2 branches: the parasympathetic nervous system (PNS) and sympathetic nervous system (SNS).

Porges is particularly interested in the tenth cranial nerve. There are 2 sides to this vagus nerve: the ventral side (front) and the dorsal side (back). The ventral side responds to safety cues in our surroundings and interactions. It also supports feelings of physical safety and emotional connection to others. The dorsal side of this vagus nerve is responsible for danger cues. Its job is to pull us away from connections and into a state of self-protection.²

In his polyvagal theory, Porges describes 3 responses in the development of ANS2:

Immobilization: When the dorsal side of the vagus nerve responds to cues of extreme danger, it causes us to become immobile. This means we freeze, become numb, and shut down.

Mobilization: In response to danger, we tap into the SNS and spring into action with our adrenaline rush to get away from the source of danger.

Social engagement: When the ventral side of the vagus nerve responds to cues of threat, it causes us to seek deep emotional connections to feel safe, calm, connected, and engaged.

The purpose of the vagus nerve is to keep the body in homeostasis. Every day we are exposed to a vast amount of sensory information, and it is the job of the thalamus in the brain to distinguish between safe sensory information and irrelevant information. The thalamus feeds the safe sensory information to the amygdala, which then interprets the sensory information to determine whether it poses a threat.

When the amygdala senses danger, the SNS prepares our body for the fight-or-flight response. In her book The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, Nadine Burke Harris, MD, MPH, FAAP, uses the analogy of our body signaling “danger” when exposed to a grizzly bear in a forest.³ Faced with a grizzly bear, our stress response, initiated by the amygdala, activates both the sympatho-adrenomedullary (SAM) axis when danger is transient and the hypothalamic-pituitary-adrenal (HPA) axis when danger is prolonged. Both systems trigger the fight-or-flight response, a scientific way of stating that our body is becoming more efficient in responding to danger.

When activated, the SAM axis sends a signal to the adrenal glands to release more adrenaline, the same hormone runners experience when they experience a runner’s high. Adrenaline increases heart rate and blood pressure, expands the passages of the lungs to take in more oxygen, enlarges the pupils, redistributes blood to critical areas such as muscles responsible for running, and alters the body’s metabolism to maximize fuel sources in critical organs such as the brain.³

Our bodies activate the HPA axis when we are exposed to prolonged threats, triggering the release of cortisol. Cortisol is a longer-acting stress hormone that helps the body adapt to repeated stressors. In times of threat, cortisol raises blood pressure, keeps us alert and awake, inhibits clear thinking, and triggers our craving for high-fat, high-sugar foods. Cortisol also activates our immune system, causing it to become hypervigilant and ready to work at the slightest suggestion of danger. When danger subsides, both axis systems are turned off like a thermostat through a negative feedback loop, returning our body to homeostasis.³

Now replace Burke Harris’s example of the grizzly bear with a dysfunctional family system in which our developmental and emotional needs were not met. In these dysfunctional family systems, family members, colleagues, or other individuals may stimulate the same stress response in us. It can be difficult for family members to attend to their own emotional needs when tension, stress, and chaos are high. Family members may abandon their own needs in an attempt to control the family situation.

When the trauma we are exposed to is too intense or frequent, each stress response that was once adaptive turns maladaptive, and the HPA and SAM axis systems no longer function like a thermostat. The axis systems cannot turn off because our physiologic thermostat is broken, meaning every time we are exposed to trauma, our HPA and SAM systems blast us with cortisol and adrenaline.

In his book When the Body Says No: The Cost of Hidden Stress, Gabor Maté, MD, outlines the clear connection between stress and the body’s physiological response to it. With excessive cortisol in circulation, the inflammatory chemicals known as cytokines are developed and distributed throughout the body. When our autoimmune system is overactivated due to stress, the cytokines become misguided and start attacking our own body, putting us at risk of developing autoimmune diseases, cancer, and other cardiometabolic diseases.⁴

High levels of cortisol impair our rational thinking and memory storage. In her book, Burke Harris shows that children from marginalized communities who grow up in violent, chaotic, and traumatic environments have impaired development of the hippocampus, which is responsible for learning and storing memories. These children also have higher levels of cortisol in their blood stream.³

When the amygdala sounds the alarm bell of danger, the hippocampus scans our memory bank to relate our current experience to any past experiences. This explains why so many individuals with trauma fail to remember the details of what happened to them. Additionally, it is the job of the hippocampus to discern between present and past; however, in the brain of an individual with trauma, the hippocampus is overruled by the overactive amygdala, which cannot process time. For a patient with a hyperactive amygdala, the interpretation of an incoming threat is thus inaccurate.

“If any input is a match to a stored memory from past experience, the lower brain reacts as though the past experience is happening now,” explains researcher and author Bruce Perry, MD, PhD.⁵ This explains why for a person with trauma, danger can feel ever present, leaving them in a hyperaroused state with flashbacks.

The PNS prepares the body for rest, digestion, or a freeze response. When the PNS is activated, the body shuts down and may become completely immobilized. As explained before, when encountering a grizzly bear in a forest, we respond with fight, flight, or freezing. The PNS prepares us to freeze in case there is no way to escape from the bear. For someone facing intense trauma, dissociation or freezing is what happens when they cannot fight or flee. According to Perry in his book What Happened to You?Conversations on Trauma, Resilience, and Healing, dissociation is a complex mental capability that an individual uses in everyday life to disengage from an outside threat and focus on their internal world^.5

“When we daydream, when we allow our minds to wander, that’s a form of dissociation. And like the arousal response or threat, the dissociative response takes a person deeper and deeper into a protective mode,” Perry writes.⁵ In a dissociative state, the body releases endorphins, helping the body replenish and cope with the pain associated with the traumatic experience.

When an individual is stuck in a fight, flight, or freeze state, their body physiology adapts to the stressful environment. In the case of children, they are more likely to take their dysregulated adaptation of hypervigilance or daydreaming to environments outside their dysfunctional family system, such as the classroom setting. Because our health care system is diagnosis-focused, children with symptoms of trauma such as dissociation who struggle in school are often misdiagnosed with attention deficit hyperactivity disorder. Their fight-or-flight behaviors may cause the child to have trouble with peers, friends, and family. They may even become a danger to themselves or others. According to Perry, the lack of a trauma-informed academic system has a tremendous impact on a child’s education and well-being because these children often receive the wrong treatment for their unresolved childhood trauma.⁵

The Challenges of Living With Trauma

Living With Flashbacks: When trauma is not resolved, individuals may relive elements of their trauma over and over through flashbacks, which may return at any time. Flashbacks can present as nightmares when the individual is asleep. In other words, the trauma that started a long time ago is now being unconsciously played out in the body. Flashbacks induce the release of cortisol and adrenaline, leaving the individual overwhelmed while their energy is consumed by internal chaos. This experience leaves the individual stuck in the past and robs them of their day-to-day quality of life. Individuals often try to organize their lives to protect themselves from reliving those painful flashbacks. Some become involved in healthy activities while others turn to drugs or alcohol, hoping for a sense of control over the situation.

The Exaggerated Reaction: When the emotional brain is triggered by chronic stressors, the body’s alarm system or amygdala becomes overactive, sending false or exaggerated stress responses to other parts of the brain and body even when things are not factually dangerous. This explains why individuals with trauma are easily startled and have an exaggerated response to things that do not seem to warrant such a reaction. Furthermore, the overactive amygdala shuts down the prefrontal cortex, the part of the brain responsible for rational thinking and keeping emotions in check.

Loss of Agency: With the malfunctioning of the neocortex, an individual with trauma loses their sense of agency. This explains why some individuals with trauma have a poor sense of direction and purpose in life. They may ask others to validate their decisions, or they may fail to act because they cannot define where they stand or what they want. Some individuals with trauma grew up in a dysfunctional family system where expressing their authenticity was not only invalidated but a threat to their survival. They had no choice but to split their authenticity for the attachment and attunement they needed from their caregiver. These individuals grew up with poor vagal tone, lacking gut instinctto help guide them.

Risky Behavior: Individuals with trauma may do anything to escape uncomfortable feelings, including sleeping excessively, overeating, or using substances. According to researcher Patrick Carnes, PhD, chemical dependency becomes a solution to the trauma. The ACEs study conducted in the 1990s showed a direct correlation between trauma exposure and involvement in destructive activities such as substance use. With exposure to stress and high levels of cortisol, our dopamine receptors become desensitized, meaning we need more dopamine-inducing activities or substances to get the same amount of pleasure. Our bodies crave high-sugar and high-fat food, and with elevated cortisol levels, it is harder to metabolize the fat and sugar and easier for the body to store it as fat.

Dissociation: With dissociating or splitting, an individual learns to ignore their painful reality by separating from the experience and not letting it interrupt their day-to-day activities. In a dysfunctional family system, a child learns to split parts of their identity that were shamed or not validated by the primary caregiver. Children master splitting by creating a fantasy bond with the caregiver and learning to dissociate when the environment becomes too stressful and emotionally overwhelming. Some learn to daydream and leave their body psychologically while others develop amnesia, having no recollection of the traumatic incident. Whatever the dissociation strategy, it can be exhausting to the mind and body.

For example, in my clinical training in pharmacy school, I often caught myself zoning out in medical rounds. Although I was physically present, my mind was somewhere else. This caused me shame because my rotation evaluation came back with my preceptor calling me “aloof,” with the word underlined. My siblings would often tease me about being forgetful for misplacing my car keys and not remembering childhood experiences. In response, I mastered the art of showing I was present and saying enough to demonstrate my psychological presence.

Amnesia: There are 2 important times when we are not able to remember or thoughtfully articulate our experiences. The first is before we reach 2 years of age, because the language centers of our brain and the hippocampus are not fully developed. The second is when we experience trauma, when our hippocampus is overruled by the hyperactive amygdala and does not allow us to process information effectively. In his book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, Bessel van der Kolk, MD, explains that when our memory has shut down, we are not able to articulate emotionally significant information.⁶ Additionally, when we sense danger, the language center of our brain is hijacked by the hyperactive emotional brain, preventing us from thoughtfully articulating the danger.

Feeling Constantly Unsafe: Traumatic experiences are more easily stored and imprinted in our memories than pleasant events. It goes without saying that we tend to remember 1 negative thing we did instead of many positive things we did. This is because our emotional brain uses about two-thirds of its neurons scanning for danger. Our survival depends on looking out for danger, which is the job of the amygdala. As children, when our safety and security are threatened, our bodies adapt to look for danger. Over time, individuals can become addicted to bad news to validate the fact that we are in danger. Because our prolonged defenses have developed alongside an overactive amygdala, we end up believing everyone is out to get us.

Toxic Shame: Individuals with trauma live with a toxic shame about how they react to their trauma, particularly when they believe they are at fault or somehow broken. Shame keeps individuals with trauma isolated and in hiding. They believe they are defective, unworthy of love and attention. They think that if others knew how neurotic and out of control their behavior was, they would not want to be around them. They do not trust anyone would care for them, especially if the source of their trauma was a loved one.

Understanding all these responses and challenges is essential to help patients who may have experienced traumatic events. Although the brain and stress responses are incredibly complex, having a baseline understanding of the signs and symptoms of trauma can help pharmacists provide compassionate, trauma-informed care to all patients.

Interested in learning more? For more information about how to become trauma-informed, check out this article.

REFERENCES

1. LeDoux JE. Emotion, memory, and the brain. Sci Am. 1994;270(6):50-57. doi:10.1038/scientificamerican0694-50
2. Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76(suppl 2):S86-S90. doi:10.3949/ccjm.76.s2.17
3. Harris NB. The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. Mariner Books; 2018.
4. Maté G. When the Body Says No: The Cost of Hidden Stress. Vintage Canada; 2003.
5. Perry BD, Winfrey O. What Happened to You? Conversations on Trauma, Resilience, and Healing. Flatiron Books; 2021.
6. van der Kolk B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking; 2014.