Stress Physiology 101 Jorina Elbers MD Division of Neurology and Neurological Sciences Stanford Children’s Health

Objectives Discuss how we think about “stress” and “trauma” Discuss how the nervous system responds to stress How does stress in the body cause common problems faced in the classroom like behavior outbursts, restlessness, and medical symptoms. Discuss the impact of chronic stress on the body Discuss some strategies to reduce that impact

What does the body have to do with stress? “Stress” as an external source A distinct threat to the self, or sense of self vs. “Stress” as an internal state A constellation of physiological changes in response to threat

When does stress become trauma? 1) Stress that overwhelms a child’s ordinary coping skills 2) Results in negative beliefs or negative thoughts about ourselves 3) Leads to maladaptive coping strategies Big “T” trauma vs. little “t” trauma

Adverse Childhood Events (ACE) Study 13,494 patients from KP were mailed a questionnaire following standardized medical assessment regarding: History of physical or sexual abuse, neglect, domestic violence, alcoholism, drug use, emotional trauma Response rate 70.4% (9,508/13,494 patients) Scores graded out of 10 2/3 reported at least 1 ACE; 12.5% reported >4 ACE’s 28% reported physical abuse; 21% reported sexual abuse Number of ACE’s correlated to health outcomes for depression, stroke and heart disease Felitti, American Journal of Preventative Medicine, 1998

Violence Witnessing violence 27% of violent crimes involve family-on-family violence <5% of domestic violence is reported In the US, the average 18-year old will have viewed 200,000 acts of violence on TV Bullying: the intent to hurt, humiliate, socially isolate or extort a victim 3 million bullying incidents are reported each year in the US 250,000 students are attacked in school each month Teachers notice and intervene in 1/25 incidents (4%) Children who are bullies or perpetrators are likely to have a history of trauma

Shame = Threat to the social self Preservation of the social self is a fundamental human motivation The fear of being criticized, de-valued, humiliated and rejected activates the stress response system in the same manner as a physical threat Internalization of shame negatively affects human development We see ourselves as deficient, bad, permanently flawed This prevents “thriving” of the self This creates the desire to be “invisible” Necessary for thriving and, for children, surviving Shame is one of the most potent stressors in mammals

How does stress affect the nervous system? When threat is perceived by the limbic system, it activates the body’s stress response system Highly adaptable system Chronic stress can lead to physiological adaption of the stress response system “Nerves that fire together, wire together”

Evolution of the human brain

The Stress Response System X Autonomic nervous system HPA axis Sympathetic “Fight or flight” Parasympathetic “Faint or freeze” Cortisol released from adrenal gland

A Review of the Stress Response System Sympathetic Nervous System Parasympathetic Nervous System Vagus nerve Hypothalamus Pituitary Adrenal gland Sympathetic Chain Ganglion Increased HR/BP Increased blood flow Sweating Decreased digestion Epi NE Adrenal Medulla Ach Decreased HR/BP Activates digestion Wound healing Fuel mobilization Immune system activation/suppression Short-term memory storage CRH ACTH Cortisol

The “Classic” Stress Response Sympathetic and Parasympathetic response are reciprocal ↓ Parasympathetic activity (vagal tone) within milliseconds ↑ Sympathetic activity within seconds ↑ HPA activity within seconds Return to baseline PNS activity within 30 minutes of cortisol secretion System is meant for short bursts of activity to promote survival

The “Classic” Stress Response Sympathetic and Parasympathetic responses ↓ Parasympathetic activity (vagal activity) within milliseconds ↑ Sympathetic activity within seconds ↑ HPA activity within seconds Return to baseline PNS activity within 30 minutes of cortisol secretion System is meant for short bursts of activity to promote survival

Maladaptive defense strategies

Hyper-arousal: “Fight-or-flight” The fire alarm Hypervigilence Inattentiveness Exaggerated emotional response Panic attacks Fearfulness Aggression Hyperactivity

Hypo-arousal: “Faint-or-freeze” The circuit breaker “Checking-out” Amnesia, forgetfulness Avoidance Emotional numbing Self-harm behaviours Somatic symptoms: chronic fatigue, frequent headaches, abdominal pain, nausea, dizziness

Circuit breaker in action: Faint of freeze, mediated by parasympathetic nervous system in brainstem

“Hypoarousal” “Hyperarousal”

What is Somatization? Common co-morbidities: ADHD, depression, anxiety It is a physiological response to dysregulation of the nervous system, and It is not ”all in their head” More common in children Common somatic presentations in children: Headaches Stomach aches Dizziness Chronic fatigue Common co-morbidities: ADHD, depression, anxiety

What should you do about somatization? Recognize that recurrent physical symptoms without a medical explanation may represent somatization Recognize that this child may be experiencing stress that they are unable to cope with Help child to verbalize their symptoms of worry, sadness, anger, fear Introduce some stress reduction strategies to the whole classroom (breathing, yoga, imagery) Help to promote inclusiveness, and prevent isolation, in the class Discuss your concerns with the parents, and discourage absenteeism Refer to school counsellors or psychologists Report disclosures

What activates a child’s stress response ?

What activates your stress response?

Quiz

What thoughts and feelings did you have about yourself when you heard there would be a quiz? Self-doubt: “I’m not good at this stuff” Fear of failure: “I’m going to get this wrong” Wrong-doing: “I should have paid more attention” Powerlessness: “I don’t want to do this. Do I have to do this?” Competency & Agency: “Great! I can’t wait to show what I learned”

How do you carry stress in your body? Headaches Neck / shoulder tension or pain Clenched jaw / teeth grinding Heart racing / palpitations / chest pain Butterflies in your stomach Need to go to the bathroom Clenching your fists / sweaty palms Chronic fatigue Emotional outbursts / say things you don’t mean (neocortex goes offline) Waves of sadness/depression/hypoactivity

The “Chronic” Stress Response Vagal nerve withdrawal Excess epinephrine in the blood, spinal fluid and urine Excess or depleted cortisol levels Symptoms of a chronically activated stress response system: Trouble sleeping Frequent illnesses, poor wound healing Weight gain / difficulty losing weight Poor memory, difficulty concentrating Low energy / chronic fatigue

The Vital Vagus… The largest single nerve in the body Parasympathetic nervous system The largest single nerve in the body The vagus nerve is responsible for Rest Digest Repair Tells the brain what is happening in the body Regulation of the limbic system

The Vital Vagus… The largest single nerve in the body Parasympathetic nervous system The largest single nerve in the body The vagus nerve is responsible for Rest Digest Repair Tells the brain what is happening in the body Regulation of the limbic system

Low vs. High Vagal Tone Low vagal activity is found in people with: Migraine Sleep problems Hypertension / Cardiac arrythmias Obesity Anxiety/depression Chronic fatigue High vagal activity is associated with: Emotional regulation Attentional regulation Social connectedness Specifically, Vagal Tone is the degree to which the vagus nerve can cause the body to relax

Take a deep breath – it will be OK! X Vagus nerve

Take a deep breath – it will be OK! X Vagus nerve

Take a deep breath – it will be OK! Vagus nerve

Take a deep breath – it will be OK! Vagus nerve

Other things that increase vagal activity… Exercise Tai Chi Yoga Acupuncture Meditation (Loving Kindness & chanting “Om”) Oxytocin (the love hormone) Massage Music Dance Prayer Laughter

What tools do you have to regulate the stress in your nervous system? Recognize: you can control how your nervous system responds to external stresses around you Reset: Mindfulness practice Regulate your nervous system with breathing practice Reconnect to your physical body: Exercise, Yoga, Tai Chi, Martial Arts Relationships: Prioritize social-emotional connections Reprocess: pain, hurt and trauma Re-pattern: Neuroplasticity takes time

Take Home Points 1) Your body has a marvelous, interconnected system that is wired not just to survive, but to thrive 2) The stress response system is meant for short-term bursts of activity to promote survival, not for long-term chronic stress 3) Chronic stress leads to physiologic changes in the body that can result in poor health, depression and fatigue 4) Thankfully, there are many different ways to increase your vagal tone and regulate your nervous system, so find what works for you and thrive!