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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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”

9. Evolution of the human brain

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

11. 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

12. 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

13. 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

14. Maladaptive defense strategies

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

16. 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

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

18. “Hypoarousal”
“Hyperarousal”

19. 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

20. 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

21. What activates a child’s stress response ?

22. What activates your stress response?

23. Quiz

24. 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”

25. 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

26. 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

27. 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

28. 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

29. 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

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

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

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

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

34. 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

35. 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

36. 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!