“Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body.”- Bessel van der Kolk, MD
From the desk of Linda M. Rio, MA, Marriage & Family Therapist – My training as a Marriage and Family Therapist primarily focused on how people develop and maintain relationships and ways to assist in enhancing these important building blocks in human interaction, mental and physical health. The role, impact, importance that the physical body plays on mental and emotional health was not at that time much discussed or taught. When I became aware of the potential impact a tumor, or other endocrine disorder, can have on the overall quality of life I began a quest to learn what more could be done to bring this information into greater awareness.
In recent years more and more research has shown there is an impact on the body, especially the pituitary, in instances when there has been intense emotional and/or physical trauma to the mind and/or body. A dual directionality in the relationship between the body and the mind has slowly received more attention within scientific and trauma-focused communities. Because the Hypothalamic-Pituitary-Adrenal (HPA) Axis has such import on not only physical but mental and emotional wellbeing I believe this is worthy of much attention and study from multiple scientific perspectives. It is also of great relevance to any patient and their family members to know that any assault, physical or mental, makes an impact and is not merely forgotten, although the exact nature of the impact is yet ill-defined and difficult to trace and science has yet to determine any direct, observable link. And it is important to know that stress, even trauma happens to all beings; it’s a part of life that we get hurt. The size and duration of the hurt along with whether or not there has been an opportunity for healing, comfort, safety is what matters. The topic of trauma’s link to pituitary disorders cannot, of course, be adequately covered here due to the immensity of the topic. The purpose of this article is to merely highlight that there does appear to be a link for some, not all, and that link has significant treatment implications.
What is trauma? This term has both formal and informal meanings and has evolved over the years. The origins of trauma as well as the interplay of biological and psychological factors within social and political contexts have long been debated. Semantically, trauma refers to an experience or event; nevertheless, people use the term interchangeably to refer to either a traumatic experience or event, the resulting injury or stress, or the longer-term impacts and consequences (Briere & Scott, 2006). Behavioral health professionals more broadly define trauma as resulting “from an event, series of events, or set of circumstances that are experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012, p. 7). This is sometimes referred to as “psychological trauma” to distinguish it from other types of trauma (Development Services Group, Inc, 2016). Some use this term as synonymous with the DSM IV diagnostic classification of Posttraumatic Stress Disorder but are diagnostically different. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition made changes to prior editions by having an entirely separate section for “Trauma-and Stressor-Related Disorders” (p.265, DSM V). PTSD, although likely the most well-known trauma diagnosis, is among several potential resultant effects of a catastrophic or aversive event(s). The incidence of those who’ve suffered a trauma who go on to qualify for the diagnosis of PTSD is 20%, with women experiencing this about twice as much as men (Sidran Inst., 2021). More practically, trauma is really something that almost completely overwhelms a person’s resources.
Trauma is known to affect the brain in a variety of ways. Two hormones, cortisol, and adrenaline particularly are involved in altering not only the brain’s perceptions of an event but also involved in how such an experience becomes encoded in the brain’s processing it into both short and long-term memory. Traumatic events, especially when chronic over a period of time can especially become encoded in the amygdala area of the brain resulting in symptoms typically thought of as trauma-related and disturbing for the patient.
In terms of understanding the effects of trauma researchers had various theories until the largest public health study was done from 1995-1997. The Adverse Childhood Experience Study, or ACE involved over 17,000 participants. The ACE Study Each type of adverse childhood experience counted as one point. Among the many findings from this groundbreaking study showed about two-thirds of the adults in the study had experienced one or more types of adverse childhood experiences and this was the first time researchers looked at the effects of several types of trauma instead of just one. Of those, 87 percent had experienced 2 or more types. Participants were average Americans. Seventy-five percent were white, 11 percent Latino, 7.5 percent Asian and Pacific Islander, and five percent were black. They were middle-class, middle-aged, 36 percent had attended college and 40 percent had college degrees or higher. Since they were members of Kaiser Permanente, they all had jobs and great health care. Their average age was 57 (Stevens, 20212). The study did not look specifically at pituitary disorders nor their relationship to early childhood trauma but did show a strong correlation with the development in adulthood of health problems, including addictive and destructive behaviors, for those who have a high ACES score.
It is safe to say that most individuals have been exposed to at least one traumatic event in their lifetime (Benjet, 2015). This is supported by the ACES study that showed almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs (Centers for Disease Control, 2021). It is also important to note that it isn’t what happens to a person, the event, but many other biological, psychological, cognitive, and other factors specific to an individual. For example, an auto accident is typically thought of as a traumatic event. But for an Indy 500, NASCAR, Formula 1, or other professional race care driver an accident may be considered just part of the job (depending upon the severity, of course). The brain’s nervous system was developed through an evolutionary process to support the body’s reactions to acute traumatic experiences and to have resources to recovery from these. Healing resources include flexibility and adaptive recovery skills along with the co-regulation that being with supportive, safe, nurturing people provides. The problem comes in when the nervous system is unable to rebalance itself, especially when a person isn’t surrounded by nurturing people necessary for a healthy recovery. In situations where there is severe trauma and/or there are a series of events that are chronic and then no soothing, healing processes exist then PTSD, dissociative, or other trauma responses develop.
The right brain plays a superior role in the regulation of fundamental physiological and endocrinological functions. The hypothalamic-pituitary-adrenocortical axis and the sympathetic adrenomedullary axis are both under the main control of the right cerebral cortex, this hemisphere contains “a unique response system preparing the organism to deal efficiently with external challenges” ( Wittling, 1997, p. 55).
Luis G. Sobrinho, MD., discussed fascinating research where he and colleagues found a relationship between the genesis of prolactinomas and environmental factors (Sobrinho, 2014). Their research group involved an interdisciplinary group of endocrinologists, a psychoanalyst, a social worker, and their students who interviewed pituitary patients diagnosed with hyperprolactinemia. After a year of bi-monthly interviews, they questioned the patients about their lives. One interesting finding showed menstrual disturbances in female patients started shortly after an important life event. Also, several of these patients acknowledged that they had been brought up without their father or with a violent, often alcoholic one. Finally, besides amenorrhea and galactorrhea, other symptoms such as weight gain, headaches, and secondary sexual dysfunction were commonly associated with the clinical onset of the disease. In this systematic study, participants were asked very specific questions. A control population consisting of patients who presented to the same clinic because of a benign, nonfunctioning thyroid nodule was included. Results of the study found that: 1) Absence of father or exposure to an alcoholic, violent one during childhood was significantly more common in patients than in controls. This was true for patients with prolactinomas and idiopathic hyperprolactinemia; 2) The onset of symptoms – menstrual disorders, headaches, weight gain, secondary sexual dysfunction, and spontaneous galactorrhea more often than not followed a traumatic life event. (Nunes et al. 1980). These observations raised the hypothesis that environmental factors preceded and were, therefore, causally related to the genesis of pathological hyperprolactinemia. In another part of the study, 37 sisters of patients with pathological hyperprolactinemia were interviewed and measured their morning prolactin levels on five different days. The results were compared to 72 controls matched for age, place of birth, and social class who presented to the same clinic because of benign, non-functioning thyroid nodules. All the women with paternal deprivation were compared to women brought up in a family with a present, non-violent father, the former group had significantly higher basal prolactin levels (14.7 ng/ml v. 9.4 ng/ml; p< 0.001). Also, hyperprolactinemia (a value > 20 ng/ml in at least one of the samples) and galactorrhea were more common in the former group than in the latter (12/50 v. 3/59, p < 0.005 and 14/50 v. 7/59, p< 0.03). The prolactin values of women with paternal deprivation, whether originally from the sisters’ group or from the control group, contained a population of outliers with high prolactin levels that amounted to nearly one-fourth of the whole group and that were responsible for the overall difference in the average values. (Sobrinho et al. 1984). These observations supported the formulation that paternal deprivation predisposes an important number of women to develop higher than average prolactin levels. Of these, a minority may proceed to develop a clinically relevant prolactinoma more determinant than genetics.
Another study of 830 pituitary patients compared to a control group reported a greater incidence among those with pituitary adenoma to have been exposed in early childhood either without a father in their lives or having a violent father (Sobrinho et al, 2012). Of course, both situations are potentially traumatic, especially when experienced by a young brain. A small pilot study (N = 24) of individuals having an endocrine disorder demonstrated that symptoms correlated significantly with various traumatic childhood experiences and preliminary results show the importance for mental health counselors to possess at least some basic knowledge of how trauma may influence cognitive and emotional processes in addition to having physical effects as well (Banker, Whitting, & Jensen, 2019). And it is important to note that the incidence of post-traumatic hypopituitarism (PTHP) is likely underestimated (Benfenga, 2019). Based on the review of the literature published between May 2000 and October 2018, defined that PTHP accounts for 7.2% of the total cases of hypopituitarism, and researchers continue to learn more about the effects of traumatic stress on the brain. Studies involving neuroimaging—such as magnetic resonance imaging, diffusion tensor imaging, and positron emission tomography—have revealed that traumatic stress can have lasting structural and functional effects on the parts of the brain implicated in the stress response (Bremner, 2006).
Psychobiological Treatment
When it comes to treatment there are many aspects from purely medical, to psychological, to also addressing the global impact on the family and others indirectly impacted by the original trauma as well as the impact of pituitary disease within a family. Within the psychological profession, there have been many treatments researched and others still being explored. The bottom line for those seeking psychological/emotional help is the importance of feeling physically and emotionally safe with whomever and in whatever is the treatment setting. According to leading brain and trauma researcher Dan Siegel, M.D., “The purpose of therapy for trauma is to create more integration in (the) brain.” (Buczynski, van der Kolk, Ogden, Lanius, Siegel, & Porges, 2021) Often those who have experienced traumatic events need to learn or re-learn how to truly care for themselves as they may have spent much time just trying to survive physically, psychologically, emotionally etc. Self-care is a term used frequently as recommended but this is a skill as well as a life-long goal. There are many self-soothing techniques that can help in learning self-care, especially to get through tough events (like upcoming neurosurgery) which can include massages, gardening, physical exercise in nature, wrapping in a soft blanket, etc. Many try more negative self-soothing like overconsuming alcohol or illegal drugs, addictive gambling, shopping, sex, and others that do serve a soothing purpose but are short-lived and generally add other problems on many levels and do not promote overall quality of life. Therapy treatment such as EMDR has been well researched and found very helpful for many not only in PTSD symptom reduction but useful to improve psychotic or affective symptoms and could be an add-on treatment in chronic pain conditions (Valiente-Gomez et.al., 2017). Mindfulness training has the research backing to show positive effects not only psychologically, but on the body as well including positive effects on the immune system, anxiety and depression, mental clarity, and cardiovascular health (Siegel, 2007; Mindful, 2020). Other approaches such as neurofeedback have also been shown effective for trauma treatment (Fisher, 2014). Other treatment methods include those considered Attachment-Based, Somatic, Brain Spotting, and more.
Often people who are unfamiliar with psychological treatment think that it is only about sitting on a couch talking about one’s mother. Treatment practices have come a long way since this approach, especially when there is a physiological/medical diagnosis also involved.
Trauma treatment involves much more than looking back at the past, which is often deemphasized in current treatment protocols. Therapy often involves an emphasis on the patient/client’s skills, positives, strengths as an initial step. Developing a place of strength is often a necessary resource in beginning the healing process. This approach is also far less frightening and intimidating for those who are reluctant to seek mental/emotional/relationship help. At the present time, the top researchers and theorists consider what most helps those who suffer from the effects of trauma is an approach that focuses on the integration of areas of the brain negatively affected along with the development of healthy connections. This approach acknowledges trauma’s effects on the mind as well as the body along with healing from a mind-body perspective. Emerging new possibilities are also being explored such as the use of pharmacological treatments with the administration of MDMA in conjunction with manualized psychotherapy in the treatment of some forms of PTSD (Mitchell et.al., 2021). This latest research using a novel pharmacologic approach shows great promise in offering help to those who meet criteria, including physician approval especially for anyone with a serious and/or underlying medical condition.
Of course, any psychological treatment must take into account the pituitary patient’s physical and mental/emotional readiness for treatment. For example, as much as a patient may desire to understand the roots of their trauma it may not be an appropriate time to delve deep into this right before having endoscopic or another surgical or serious medical procedure. At such a time a more supportive or cognitive-based approach may be recommended until medical stabilization has occurred and hormone levels post-surgery have been attained. Containing the desire to explore roots to and potential explanations for physical and psychological symptoms can be difficult for some but the timing of any intervention, medical or psychological, is crucial. Anxiety reduction as well as possible involvement of family and others who are part of the patient’s support system are often far more needed and beneficial during the intensive medical intervention phase. When surgery, radiation, pharmacological or other treatments are planned or in process it is often best to put the distant past aside in order to focus on ways to help the physical body prepare for invasive medical treatments as well as ways to promote physical healing too. And it is important to note that some medical treatments can in themselves be felt as traumatic and intrusive for some patients, especially if they have experienced prior medical experiences that were experienced as particularly painful and/or frightening. Invasive medical treatments and experiences in childhood, particularly, can leave long-lasting psychological effects that can then reemerge in later years when medical treatments are necessary. These are all reasons why collaboration between mental and physical health treatment teams and specialists is so vitally important for those dealing with a pituitary disorder, trauma, and those who love them.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Banker, J., Whitting, A.B.,& Jensen, J. (2019). Hormones and childhood trauma: links between physical and psychological. The Family Journal. Retrieved May 5, 2021 from https://doi.org/10.1177%2F1066480719844026
Benvenga S.(2019). The history of pituitary dysfunction after traumatic brain injury. Pituitary, 22 229–235. (10.1007/s11102-019-00949-9) [PubMed]
Bremner, J. D. (2006). Traumatic stress: Effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445–461.
Briere, J. N., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (1st ed.). Thousand Oaks, CA: Sage Publications.
Buczynski, R., van der Kolk, B.; Ogden, P., Lanius, R., Siegel, D. Porges,S. ( 2021). The neurobiology of trauma-what’s going on in the brain when someone experiences trauma? National Institute for the Clinical Application of Behavioral Medicine. https://www.nicabm.com/confirm/brain-trauma/
Centers for Disease Control (April 6, 2021). About the CDC-Kaiser ACE study. Retrieved June 7, 2021 from https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Fabout.html
Development Services Group, Inc., (2016). Behind the term trauma. Written under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. https://calswec.berkeley.edu/sites/default/files/4-3_behind_the_term_trauma.pdf
Fisher, S. (2014). Neurofeedback in the treatment of developmental trauma: calming the fear-driven brain. London: W.W. Norton & Co.
Mindul, Healthy Mind Healthy Life (2020). The science of mindfulness. Science. September 7, 2020. Retrieved June 7, 2021 from https://www.mindful.org/the-science-of-mindfulness/
Mitchell, J.M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., Ot”alora, M., & Garas, W. et. Al. (2021, May 10). MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine. https://www.nature.com/articles/s41591-021-01336-3
Sidran Institute (2021). Traumatic stress disorder fact sheet. Retrieved June 7, 2021 from https://www.sidran.org/wp-content/uploads/2018/11/Post-Traumatic-Stress-Disorder-Fact-Sheet-.pdf
Siegel, D. (2007). Mindfulness training and neural integration: differentiation and distinct streams of awareness and the cultivation of well-being. Social Cognitive and Affective Neuroscience, (2), 259-263. Retrieved June 7, 2021 from https://academic.oup.com/scan/article/2/4/259/1676806
Sobrinho, L.G. (2014). Psychological factors and pituitary disease, the chicken and the egg. In L.M. Rio (Ed.), The hormone actor in mental health: bridging the mind-body gap (pp. 105-118). London and Philadelphia: Jessica Kingsley.
Sobrinho, L.G., Duarte, J.S., Paiva, I., Gomes, L., Vicente, V., & Agular, P. (2012). Paternal deprivation prior to adolescence and vulnerability to pituitary adenomas. Pituitary, 15, 2, 251-257.
Stevens, J. (2012). The adverse childhood experience study- the most important public health study you never heard of began in an obesity clinic. Retrieved June 7, 2021, from https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/
Valiente-Gomez, A., Moreno-Alcazar, A, Treen, D, Cedron, C. Colom, F., Perez, V. Amann, B.L. (2017) EMDR beyond PTSD: a systematic literature review. Front. Psychol., 26 September 2017 | Retrieved May 18, 2021 from https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01668/full.
Van der Kolk, B. (2015). The body keeps the score. New York: Penguin Books.
Wittling, W. (1997). The right hemisphere and the human stress response. Aeta Physiologica Scandinavica, 640 (Suppl), 55-59.
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