Dr Felicity de Zulueta

Transcription

1 Understanding PTSD within a neurobiological framework with implications for treatment Dr Felicity de Zulueta Emeritus Consultant Psychiatrist in Psychotherapy at the South London and Maudsley NHS FoundationTrust Hon. Senior Lecturer at Kings College London 2013

2 Programming the Brain Without the attachment to From birth to age 3 their caregiver infants are At birth baby s brain not capable of: has 50 trillion synapses and by age 3 Regulating their there are 1,000 hormones: biological trillion. regulators New synapses are formed and hard Regulating their +ve or wired whilst unused ve arousal and emotional ones are pruned i.e. thin corpus callosum reaction. & hippocampus. > dysregulation 2

3 Developing a mind New-born 3 months 15 months 2 years

4 The effects of severe emotional deprivation 4

5 The limbic system 5

6 The Limbic system: amygdala Amygdala Monitoring of nearly all sensory stimuli and is involved in regulating fear and aggression. In charge of emotional learning in early life and somatic organisation of experience. Prepares organism for action in face of danger receiving input either via neo-cortex or from rough fast thalamic input > activating fight, flight and freeze behaviour as in PTSD. 6

7 Traumatised brains In traumatised children brainstem and amygdala functions take charge: i.e. triggers release fear responses even when there is no danger: fight, flight and freeze response. Persistent traumatic activation of the stress response leads to a persisting fear state or trait a one time adaptive response to a chaotic and terrifying environment. 7

8 Hippocampus: integration and discrimination Enables remembering a sequences of events. Converts implicit memory into explicit mental images i.e. important in PTSD and its treatment. Integrates memories from different sensory modalities. Commits spatial and temporal dimensions to memory. Through its regulatory effect on the brain it greatly influences a person s mental state: e.g. a spider elicits a fear response in the amygdala but the hippocampus enables the person to remember it is harmless and regulate the arousal system. 8

9 The hippocampus and sensitivity to stress Excess and chronic exposure to stress hormones (cortisol) will change synapses and dendrites in hippocampus causing: Atrophy due to traumatisation and probably increased vulnerability to PTSD later on Loss of co-ordination by hippocampus of sensorimotor systems and affective systems. 9

10 Damaged hippocampi due to child abuse and neglect Smaller hippocampal volume has been reported in several stress-related psychiatric disorders, including: PTSD, borderline personality disorder dissociative identity disorder. 10

11 Functions of the orbit-frontal or prefrontal cortex Adjusts emotional responses and integrates the body s internal state with the environment. Regulates arousal (reticular activation system), the autonomic system (PS & SS via the mammalian vagus nerve in brain stem). Inhibits impulses from the amygdala. 11

12 Porges View of the ANS The metaphor of safety Environment: outside and inside the body Nervous System Safety Danger Life threat Optimal arousal level Rest and digest Parasympathetic ventral vagal system Social Engagement System Eye contact, facial expression, vocalization Hyper arousal Increased Heart Rate Sympathetic System Mobilization fight-flight Dissociated rage, panic Hypo arousal Decreased Heart Rate Parasympathetic dorsal vagal system Immobilization freeze Dissociated collapse Wheatley-Crosbie, adapted from Porges, 2006

13 The new vagus nerve The mammalian vagal pathway is myelinated and goes to the heart and bronchi and is linked to nerves that go to the striated muscles of the face + head The window to our autonomic state is the face and - of concern to us allis the flat affect, the wooden face. The reptilian vagus is critical in giving information about the state of our primary internal organs to our brain. 13

14 Our 3 responses to life events When people convey to us that they are safe by turning on the mammalian vagus we feel comfortable. When in danger we need to mobilise with our sympathetic system and turn off the mammalian vagus. When we cannot get away we resort to the reptilian vagus and reduce our cardiac output and our mobilisation. 14

15 When in danger When in danger we need to mobilise with our sympathetic system and turn off the mammalian vagus to become hypervigilant and hear the sounds of predators so the social engagement system is shut off leading to: > the wooden facial expression of PTSD > the hypersensitivity to high pitch noises like children s crying, a common trigger to domestic violence. 15

16 How the new vagus affects the social engagement system The social engagement system is maintained through the control of striated muscles in the face and the vagal regulation of the heart. As long as the social engagement system is functioning, the other 2 systems are kept in homeostatic balance. The features are: prosody (modulated voice), facial expressivity, gesture within a quiet safe environment which provide opportunities to help soothe and calm people down. 16

17 The role of play Play recruits the aspects of defensive systems with social engagement i.e.: we mobilise and yet we don t hurt each other The face to face contact is maintained or we use vocalisation cues to convey that we are safe to be with. So, if we inform people of the features of their body s responses, they can inhibit them at a natural level: mindfulness, yoga 17

18 Self organisation of the infant through brain to brain physiobiological regulation The brain is a self organising system organised through the mutual and rhythmic regulation of affect between caregiver and infant while feeding, changing, playing, talking. The infant imitates the caregiver s expression and thereby attunes with her/him via the brain s mirror neurones. These are active as from birth.

19 Mirror neurone experiment

20 Mirror neurones, attunement and empathy Through attunement the mirror neurone system simulates the facial expression and movements of the caregiver > insula> supra orbital cortical area producing in the child the emotion the caregiver is feeling. The caregiver s empathic interaction results in a child who can attune with others and put him/herself in the mind of another. 20

21 Laying down the templates for future interactions The daily interactions between infant and caregiver are recorded by the mirror neurones and provide the memories that the infant s brain synthesizes into internal working models (Bowlby, 1988 ). These are internal representations or templates of how the attachment figure is likely to respond to the child s attachment behaviour in secure/insecure attachments.

22 Attunement and empathy Attunement entails both low- and high-road circuits: Primal empathy, including nonverbal synchrony, is a subcortical, emotional resonance between individuals; Empathic accuracy requires activation of the prefrontal cortex as thought and feeling are joined in understanding the other (Goleman, 2006). Could this be emotional mentalisation? 22

23 Attunement, empathy and the secure attachment Communication in healthy parent-child relationships, in which parents attune their responses to their child s needs. With parental empathy, the child feels felt and develops a confidence in his or her experience. (Siegel & Hartzell, 2003) Self-esteem and self-confidence are built on this interpersonal dance of attunement and empathy leading to secure attachment. 23

24 Attunement and Internal Working Models

25 Reflective Functioning/Mentalisation The caregiver also induces reflective functioning in the infant by: giving meaning to the infant s experiences, sharing and predicting his/her behaviour This enables people to understand each other in terms of mental states, to interact successfully with others and is key to developing a sense of agency and continuity. (Fonagy and Target, 1997) Basis of Mentalisation Based Therapy

26 Insecure attachments An insecure attachment is one in which the infant does not have a mental representation of a responsive caregiver in times of need. These infants develop different strategies to gain proximity to their caregiver in order to survive. There are 3 types of attachment behaviour: Group C: Anxious ambivalent type (12%) Group A: Avoidant type (20-25%) Group D: Disorganised (15%)

27 Disorganised Attachment Infants show a disorganised response in relation to their caregiver (A+C) and Unresolved in the AAI.(Main and Hesse 1992). They freeze in trance-like states as in PTSD. Their caregivers are frightening or frightened suffering from PTSD, which may be triggered by the child.this behaviour leaves the child in a state of fear without solution referred to in DSM V s PTSD dissociative subtype.(main and Hesse 1992). Mentalisation is severely impaired: the more impaired, the more disturbed is the individual.

28 Fear without Solution and Structural Dissociation. The infant s psychobiological response to such states comprises 2 possible response patterns: 1. Fight-flight response mediated by the sympathetic system. This blocks the reflective symbolic processing with the result that traumatic experiences are stored in sensory, somatic, behavioural and affective states. 2. If fight-flight response is not possible, a parasympathetic dominant state takes over and the infant freezes in order to conserve energy, feign death and foster survival. Vocalisation is inhibited.

29 Structural dissociation around the fulcrum of the traumatic attachment Children in fear of their care-giver s rejection, hatred and violence will: Need to maintain their attachment to their desperately needed caregiver: the Traumatic attachment becomes the fulcrum of structural dissociation. Resort to splitting i.e. creating different representations of themselves and their caregiver resulting in a lack of self continuity in relation to the other as in BPD (Fonagy and Target,1997) i.e. multiple IWMs and accompanying selfother states resulting in Structural dissociation (DES 30 upwards) and resistance to change.

30 Other manifestations of the traumatic attachment The Moral Defence: by blaming themselves for their suffering, these children retain power and control as well as hope for a better parenting future (Fairbairn 1952). This reinforces the identification with the abusing caregiver through their IWM of child-in-relation-to abusing parent and increases the need to idealise the parent

31 Triangle of abuse Abuser V C A C A V Victim Colluder

32 1. The Psycho-biology of child neglect and abuse A limited capacity to modulate emotions: Sympathetic dominant affects: terror, rage and elation, Parasympathetic dominant affects: disgust, and hopeless despair. shame, Self-medicate with drugs or alcohol or cutting and anorexia or bulimia. Resort to violence to counter threat to Self

33 2. The Psycho-biology of child neglect and abuse. Changes in the HPA axis in response to stress or separation > Reduced levels of cortisol and increased glucocorticoid receptors > PTSD vulnerability. > Release of endogenous opiates > analgesia by cutting or self harm or Repetition - compulsion.

34 Implications of the phenomenon of dissociation Inexplicable shifts in affect and Discontinuities in train of thought. Changes in facial appearance, speech and mannerisms. Apparently inexplicable behaviour. Somatic dissociative phenomena. DIS.Q5 Use of the Dissociation Evaluation Scale to establish degree of dissociation (DES). PTSD =20, BPD= 30, DID 40 upwards

35 The individual sense of self Our sense of who we feel ourselves to be derives from: 1. Our intimate attachment experiences in the family > I feel - therefore I am, a sense of self closely intertwined with what our caregivers made us feel: lovable, special, or, if unwanted, bad, useless, ugly. 2. The secure attachment is a primary defence against trauma induced psychopathology (Schore 1996). 35

36 The social sense of self Is is constituted..also by an organisation of the social attitudes of the..the social group..to which he belongs (Mead, 1934.p. 158) You are what others make you feel you are (Zulu proverb). This view of Self dominates most non Western cultures i.e. Muslim, African and Far Eastern societies where shame plays a major role in the development of an individual s sense of identity. And is perhaps increasingly prevalent in our consumer culture particularly amongst the young i.e. you are what you wear and own. E.g.: the Barbie doll woman. 36

37 Wounding of the self and revenge Shame: the emotional reaction to a Self that has been totally invalidated is extremely important in triggering violent reactions in victims of chronic neglect and abuse: The basic cause of violent behaviour is the wish to ward off or eliminate the feeling of shame or humiliation - a feeling that is painful, and can even be intolerable and overwhelming - and replace it with its opposite, the feeling of power and pride (Gilligan, 2001, 29) 37

38 Resilience factors Secure attachment with all that implies. Empathic understanding from an outsider (teacher or relative) can compensate for effects of childhood abuse and protect against re-enactment and trauma. This continues to develop into early 20s. Reflective functioning as in Adult Attachment Interview (Fonagy and Target, 1997) Social support from family and community 38