Asthma and DMM. Mapping the stressasthma relationship in children onto DMM

Transcription

1 Asthma and DMM Mapping the stressasthma relationship in children onto DMM

2 Diagnoses and strategies There is no 1-to-1 correspondence between any diagnoses and attachment strategies or their modifiers SAA transcripts and Type A, B and C attachment strategies in children with asthma 31st August 2010 Simon R Wilkinson, Oslo University Hospital 2

3 A B C

4 Symptoms and strategies Asthma has many facets Cough-variant asthma Role of vagus and parasympathetic reflex Night-time asthma Sensitivity to bronchoconstriction raised at night in everyone Not correlated to allergens in bedding Increased caregiver stress first 6 m. Those with asthma associated with such allergens spared when parental role taken over by foster-parents in house Potential for accessory symptoms to vary in functionality and frequency with strategy 31st August 2010 Simon R Wilkinson, Oslo University Hospital 4

5 Illness, disease and predicament Sickness as what is attributed to another to explain drop off in function /changes in family relationships Illness as subjective discomfort Disease as the pathological changes Disorder as group of symptoms occurring together Predicament as the dilemma to be lived with as healthily as possible Health as well-being /affective balance Dis-ease at Ease 31st August 2010 Simon R Wilkinson, Oslo University Hospital 5

6 Why behaviour shown at a particular time Why now? - Proximal causes How developed to react that way? What is the general function of the behaviour? How did the behaviour develop phylogenetically? Nico Tinbergen, st August 2010 Simon R Wilkinson, Oslo University Hospital 6

7 Symptoms as part of illness language The transactional processes involved in attributing sickness and experiencing illness are informed by the predicaments being experienced by both the adult and the child The shared family language for complaining is more or less effective within the official medical system The ecology of the symptoms 31st August 2010 Simon R Wilkinson, Oslo University Hospital 7

8 Subjectivity is reading a sundial using a pocket torch. Piet Hein

9 Feedback hum Amplifier Meaning given to insignificant noise in the system.

10 Symptoms as part of illness language The transactional processes involved in attributing sickness and experiencing illness are informed by the predicaments being experienced by both the adult and the child The shared family language for complaining is more or less effective within the official medical system The ecology of the symptoms 31st August 2010 Simon R Wilkinson, Oslo University Hospital 10

11 microsystem exosystem HEALTH SERVICE mesosystem macrosystem Bronfenbrenner U. (1979) The ecology of human development. Harvard Univ Press

12 Stress components Physiology Behaviour Subjective experience Language available to convey how you are What is talked about There is no inherent reason for these to be coherent as they depend on attributions made and attachment strategies used. 31st August 2010 Simon R Wilkinson, Oslo University Hospital 12

13 Stress The stress language is more-or-less effective Uncontrollable stressors hypothetically associated with learnt helplessness and Dp modifier Suppression of aggression and negative affect to powerful other with Type A Depends on effective parasympathetic NS vagal bias Resetting of norms for pco 2 Disposing to bronchoconstriction and coughing 31st August 2010 Simon R Wilkinson, Oslo University Hospital 13

14 Porge s Polyvagal perspective Vagal system Bidirectional 80% fibres afferent Motor pathways Nucleus ambiguus regulates striated muscles above diaphragm» Incl. bronchi Dorsal motor nucleus regulates below diaphragm Sensory pathways To Medullary nucleus tractus solitarius Forebrain & Brainstem Regulation of visceral state and affect 31st August 2010 Simon R Wilkinson, Oslo University Hospital 14

15 System seen to enable visceral homeostasis in the face of challenge Includes facilitating approach and avoidance of others or immobilization (feign death) And mechanisms for communication Facial muscles Middle ear muscles to facilitate hearing human voice Vagus essential for social communication, selfsoothing and inhibiting sympathetic-adrenal influences Involved in regulation of cytokines and HPA axis 31st August 2010 Simon R Wilkinson, Oslo University Hospital 15

16 The myelinated vagus functions as a brake to sympathetic activation Withdrawl of myelinated vagal influence fight/flight increased HPA activity Respiratory sinus arrthymia as measure of the influence the myelinated vagus has on the heart Immobilisation dependent on unmyelinated vagus Mobilised if myelinated vagus or sympathetic dominance haven t lead to safety 31st August 2010 Simon R Wilkinson, Oslo University Hospital 16

17 Potential links to Sandberg s presentation Behaviour problems externalising disorders expect greater frequency Type C strategies protects asthma and less vagal tone Internalising disorders, incl. some depressed expect greater frequency Type A strategies Expect low expressiveness High family conflict can be parental Type C with child Type A Physiological dysregulation Type C > Type A 31st August 2010 Simon R Wilkinson, Oslo University Hospital 17

18 Can asthma attacks be seen as comparable to ina the symptom arises as a catastrophe when the trajectory of two opposing forces lead over a cusp? The stabilising myelin. vagal brake fails and a catastrophe happens. 31st August 2010 Simon R Wilkinson, Oslo University Hospital 18

19 Conditioning of the immune system Immune function changes on the basis of classical conditioning Learning about the temporal relationships between external and internal stimuli Associate a specific environmental context or smell/flavour with specific immune challenges Avoid place or food Reduce contact with allergen by coughing/sneezing Prepare body for antigen mast cell degranulation/antibody production 31st August 2010 Simon R Wilkinson, Oslo University Hospital 19

20 Acquisition phase Evocation phase Insular cortex important role in association, retrieval, retention and extinction of tastevisceral memories Central nucleus of amygdala (excl. Hippocampus) involved in acquisition Ventro-medial hypothalamic nuclei involved in evocation of immune system response Do children become conditioned to the smell of stressed parents? 31st August 2010 Simon R Wilkinson, Oslo University Hospital 20

21 Asthma Mast cell functioning responsive to conditioning protocolls Histamine release Anaphylactic shock Allergic rhinitis as a learned response Reversal of effects of asthma medication with changed expectancy of effect instructions 31st August 2010 Simon R Wilkinson, Oslo University Hospital 21

22 Pavlovian conditioning can be considered adaptive mechanisms by which an organism learns to anticipate the onset of a biologically important event, and initiates preparatory responses, including lymphoid and myeloid cells based responses. Schedlowski & Pacheco-López, 2010 Mechanism of learning in implicit memory systems both procedural and perceptuo-affective 31st August 2010 Simon R Wilkinson, Oslo University Hospital 22

23 Utr - Trauma and the immune system Epigenetic signatures for PTSD Independent of associated MDD or GAD X7 genes with significant correlations to number of potentially traumatic events Immune-related methylation profiles with PTSD Compromised immune reactivity Cluster of genes for sensory perception of sound hypersensitivity to contextual threat 31st August 2010 Simon R Wilkinson, Oslo University Hospital 23

24 Asthma, conditioning, epigenetic changes and trauma Equifinality Rapid activation and potentially implict learning about temporal order (SAM) classical conditioning Slow activation and diffuse changes not learnt as associated to people, events or places (HPA) Chronic stress vs Acute stress Self-report vs Observation Watch the polyvagal perspective 31st August 2010 Simon R Wilkinson, Oslo University Hospital 24