Families, Children, Attachment and Complex PTSD.
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1 Families, Children, Attachment and Complex PTSD. Dr Felicity de Zulueta, Consultant Psychiatrist in Psychotherapy and Hon. Senior Lecturer at KCL Dr Walter Busuttil Consultant Psychiatrist and Director of Medical Services, Combat Stress
2 The legacy of war, terrorism and disasters Whereas loss, war, social dislocation and immigration are experiences most human beings seem able to overcome albeit painfully, some individuals develop Post Traumatic Stress Disorder (PTSD) as a result of the exposure to violence Grief due to loss, Depression and/or Anxietyare also common.
3 PTSD according to DSM-lV and ICD-10 For PTSD to be considered in DSM-lV: The person has been exposed to a traumatic event beyond the range of usual human experience in which both the following were present: The person experienced, witnessed or was confronted with event(s) that involved actual/threatened death or serious injury, or a threat to the physical integrity of self or others. (ICD-10: to cause distress to anyone) The person s response involved intense fear,helplessnessor horror. (Not in ICD-10)
4 Diagnostic Problems Most events qualifying for a diagnosis of PTSD are quite common and none are so powerful that exposure typically leads to PTSD (Kessler et al. 1999). Some people are more vulnerable than others ie people with psychological difficulties and previous mental illness. The most important risk factor is lack of social support(nice, 2005).
5 The case for PTSD as a Sensitisation disorder of the Attachment system Yehuda found that only victims of an RTA whose response led to a lower than normal release of cortisol, developed PTSD. She postulated that PTSD may reflect a biologic sensitisation disorder rather than a post traumatic stress disorder (1997). Wang attributes this sensitisation to changes in the attachment system ie suppression of cortisol levels observed by many in insecurely attached children (Wang, 1997).
6 Simple PTSD symptoms The persistent re-experiencing of the traumatic event: thro intrusive memories/images, nightmares, reenactment, intense distress and physiological reactivity. Persistent avoidance of reminders of the trauma, amnesia, detachment from others, reduced affect, sense of foreshortened future. Symptoms of increased anxiety and emotional arousal: sleep pbs, poor concentration, hypervigilance, exaggerated startle response and irritability. PTSD diagnosed if symptoms present for >1 month after event. Before, symptoms of Acute stress disorder.
7 Other common symptoms of PTSD Anger and irritability Guilt, shame or self blame. Substance abuse Feelings of mistrust and betrayal Depression and hopelessness Feeling alienated and alone Physical symptoms ie aches and pains eg: head aches.
8 Symptoms of PTSD in children and adolescents (1) Fear of being separated from the parents Losing previously acquired skills eg. Sleep problems and nightmares without a recognisable content Compulsive play in which aspects of the trauma are repeated.
9 Symptoms of PTSD in children and adolescents (2) Acting out the trauma through play and stories or drawings. New phobias and anxieties that seem unrelated to the trauma (ie fear of monsters). Aches and pains with no apparent cause. Irritability and aggression.
10 Complex PTSD in adults & Developmental Trauma in children DSM-lV acknowledges a constellation of symptoms usually seen in association with an interpersonal stressor: Childhood emotional, physical and sexual abuse and neglect, Domestic violence Incarceration as POW, concentration camp survivors Torture Hostage taking
11 Symptoms of Complex PTSD following prolonged childhood abuse (1) Impaired affect modulation Loss of a sense of a coherent self and Dissociative symptoms Self destructive/ impulsive behaviour often reenacting the trauma > re-traumatisation. Shame > ViolenceSomatic complaints Somatic complaints
12 Symptoms of complex PTSD -2 Feelings of helplessness, despair, Loss of previously held beliefs Loss of trust > Social withdrawal Impaired relationship with others Feeling constantly threatened > Social withdrawal Feeling permanently damaged> loss of self worth
13 Transmission of vulnerability to PTSD and the cycle of Violence Attachment research shows a 75% correspondence between a mother s attachment and that of her infant (Van Ijzendoorn et al. 1997). These findings show there is the potential for transmission of PTSD and trauma related violence in PTSD afflicted communities This underlies the importance of prevention and socially based treatment interventions.
14 The potential role of epigenetics in the transmission of a low cortisol response down the generations Low urinary cortisol levels have been found in adult holocaust survivors with PTSD and in their adult offspring (Yehuda, 1997, 2002). The Israeli soldiers whose parents were Holocaust survivors had higher rates of PTSD than their counterparts. Children of mothers who suffered from PTSD following the New York bombings also have lower levels of cortisol. Low cortisol levels predispose to PTSD in later life.
15 Attachment Research Our need for Social Supportwhen in a state of fear betrays humanity s essential attachment needs. Attachment research provides the Psycho-biological framework to understand both the origin and the symptoms of Post Traumatic Stress disorder and in particular complex PTSD. We therefore need to understand attachment disorders in order to treat patients suffering from PTSD.
16 Men and other mammals share the same emotions
17 PTSD as an attachment disorder involving the Right hemisphere Infants separated from their caregiver protest, despair and detach (Bowlby). Human infants are genetically predisposed to want access to an attachment figure when frightened! Without this attachment they die. When reunited with those we love, we have a nice warm feeling of safety largely produced by endogenous opiates: separation leads to a miserable state: We are all Opiate addicts
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19 The Brain substrate of Attachment Behaviour Involves: A great part of the right hemisphere. PET scan and Broca s area. and part of the supra orbital areaof the brain which is crucial in enabling us to empathise with others. Partly mediated by: endogenous Opiates and oxytocin (feel good factor) dopamine (energised state of feeling) serotonin (linked to levels of dominance in hierarchy).
20 Programming the Brain Without Mum or caregiver Infants are not capable of: Regulating their hormones after birth. Soothing or comforting themselves. Regulating their arousal and emotional reactions - whether positive or negative. From birth to age 3 At birth baby s brain has 50 trillion synapses and by age 3 there are 1,000 trillion. During that time, new synapses are formed and hard wired whilst unused ones are dissolved or pruned.
21 Hierarchy of brain function
22 The limbic system
23 Limbic system: hypothalamus, amygdala and hippocampus (1-4yrs) Primary developmental goals Emotional regulation Empathy In traumatised childrenbrainstem and amygdala functions take charge: ie triggers release fear responses even when no danger. 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.
24 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 via neocortex or from rough fast thalamic input,activating fight, flight and freeze behaviour as in PTSD.
25 Hippocampus: integration and discrimination Enables remembering a sequences of events. Converts implicit memory into explicit mental images 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: eg 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.
26 Functions of the Orbitofrontal cortex Adjusts emotional responses and integrates the body s internal state with the environment. Regulates arousal (reticular activation system), the autonomic system (PS & SS and vagus nerve in brain stem). Inhibits impulses from the amygdala. Involved in the generation of object permanence at 7 to 12 months ie an infant experiencing negative emotions can thereby generate the image/internal mental representation of the caregiver s response to an act. Important for our sense of identity.
27
28 Attunement with baby Brain to Brain communication The caregiver respondsto the infant s signals by holding, caressing, smiling, feeding, stimulating or calming, giving meaning. Her empathicinteraction results in a child who can put himself in the mind of another and interact successfully This sense of security protects him or her from the effects of trauma.
29 Laying down the Templates for future interactions These daily interactions provide the memories that the infants synthesize into internal working models (Bowlby). These are internal representations or templatesof how the attachment figure is likely to respond to the child s attachment behaviour.
30 Early implicit memory In first year of life, it includes emotional, behavioral, perceptual, and perhaps bodily (somatosensory) forms of memory. Includes the generalizations of repeated experiences, called working models by Bowlby.
31 Representation of the Self and Secure attachments (63%) Is closely intertwined with the internal representation with the attachment figure. A securely attached child has a mental representation of the caregiver as responsive in times of trouble. These children feel confident and are capable of empathy and forming good attachments. The secure attachment is the primary defence against trauma induced psychopathology (Schore 1996).
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33 Reflective Functioning The caregiver demonstrates reflective functioning by the capacity of giving meaning to the infants experiences, sharing and predicting his/her behaviour (Fonagy and Target, 1997). 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. Empathic understanding from an outsider (teacher or relative) can compensate for effects of childhood abuse and protect against re-enactment and trauma.
34 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%)
35 Anxious-Ambivalent Attachment (C) This infant is very upset when caregiver leaves the room and upon return she both clings to the caregiver and pushes her away. The caregiver is inconsistent in her respond to the infant s needs leading to angry clingy attachment behaviour. In adulthood this infant is classed as preoccupied in the AAI
36 Disorganised Attachment These infants show a disorganised response in relation to their caregiver (A+C). They freeze in trance like states like sufferers of PTSD. Their caregivers are frightening or frightened, suffering from PTSD, which may be triggered by the child herself. This behaviour leaves the child in a state of fear without solution (Main and Hesse 1992, 99) Reflective functioning is severely impaired: the more impaired, the more disturbed is the individual.
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