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Friday, December 8 • 8:40am - 9:20am
Then, venom, to thy work! The Neurobiological and Behavioral Impact of Early Trauma

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Early trauma and adversity are highly prevalent. Childhood environments have a pronounced influence on how neural development is shaped, with an enduring effect on establishing default modes of responding to stimuli (including other people). During the sensitive period of brain development, our brains are very susceptible to the modulating effect of our surround. This becomes “locked in” and can be difficult to change with later experience. When a sense of safety is provided through benign caregiving, there is consolidation of pathways that can modulate emotional reactivity and establish nuanced, flexible modes of relating. However, when adversity if prominent, neural pathway development may be “accelerated” and incomplete, with responses to situations being driven primarily by emotions, with difficulty “thinking through” matters. Given the oftentimes confusing and distressing nature of the early environment, what is consolidated is a default of anxiety, suspiciousness, and expectation of hostility. This is accompanied by a magnification of risk assessment and an exaggerated neuroendocrine response – the release of stress hormones thus prepares the individual to deal with a threatening situation, even in the absence of an objective danger. Individuals with early adversity are often in “as if” situations, recasting their current circumstances in accordance with what has been laid down on a neural level during childhood. This increases the risk of psychiatric conditions such as anxiety, depression, post-traumatic stress disorder, personality disorders, and impulse control disorders. In addition, the threshold for experiencing a situation as menacing may be decreased, leading to increased reactivity and the potential to feel threatened by others, possibly responding with defense strategies. This is relevant for management of aggression and agitation in emergency room settings. The approaches to care by clinicians should take the potential role of trauma in our patients’ lives into account, as we as trying to establish rapport and provide a healing experience, as opposed to a retraumatizing one. This presentation will contrast how neural development unfolds in benign versus adverse environments, with a particular focus on the role of attuned caregiving in facilitating activity in areas of the brain associated with empathy and regulation of areas involved with emotional reactivity (e.g., the amygdala and insula). We will discuss the neurobiological changes associated with different psychiatric conditions, mapping the influence of trauma on neural pathways. We will also link the neuroendocrine and neural activation patterns with early encoding of adversity, and how the expectation of harmful interpersonal interactions can inform patients’ strong reactions to providers in settings that are overwhelming or perceived as hostile, as can be the case in emergency rooms. Finally, we will discuss how pharmacological and non-pharmacological interventions can help to manage agitation in psychiatric emergency settings, keeping this neurobiological backdrop in mind. The recovery model is one that maintains a trauma-informed care framework in mind when interacting with patients at all stages and levels of treatment.

Learning Objectives:
  1. Describe the impact of early trauma on neural circuitry and neuroendocrine pathways.
  2. Outline how trauma can predispose individuals to psychiatric symptomatology, including behavioral dimensions.
  3. Discuss how awareness of the role of trauma in patients’ lives can broaden our clinical approach in emergency room settings.

avatar for Christopher Miller, MD

Christopher Miller, MD

Associate Professor, University of Maryland School of Medicine
Christopher W. T. Miller, M.D. is an Associate Professor in the Department of Psychiatry at the University of Maryland School of Medicine. He obtained his medical degree in 2005 from the Universidade Federal de Santa Catarina, in Florianópolis, Brazil. He trained in Adult Psychiatry... Read More →
avatar for Sarah Van Remmen, MD

Sarah Van Remmen, MD

Medical Director of Psychiatric Emergency Services, University of Maryland
Dr. Van Remmen received her medical doctorate from the George Washington University, and then completed psychiatric residency at the University of Maryland/Sheppard Pratt Psychiatry Residency Program. She is currently the Medical Director of the UMMC Psychiatric Emergency services... Read More →

Friday December 8, 2023 8:40am - 9:20am PST
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