PTSD, Complex trauma and Disorganised Attachment

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1 PTSD, Complex trauma and Disorganised Attachment Implications for treatment Dr Felicity de Zulueta Emeritus Consultant Psychiatrist in Psychotherapy in SLaM and Hon. Senior Lecturer in KCL

2 PTSD according to DSM-lV and ICD-10 For PTSD to be considered in DSM-lV: The person has to have 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 or 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, helplessness or horror. (Not in ICD-10)

3 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 problems or whose mother suffered from PTSD. The most important risk factor is lack of social support (NICE, 2005).

4 Simple PTSD symptoms The persistent re-experiencing of the traumatic event: thro intrusive memories/images, nightmares, re-enactment, intense distress and physiological reactivity. Persistent avoidance of stimuli associated witth the trauma, amnesia, detachment from others particularly in relation to intimate relationships, reduced affect, sense of foreshortened future. Symptoms of increased arousal: sleep pbs, poor concentration, hypervigilance, exaggerated startle response and irritability and violence. PTSD diagnosed if symptoms present for >1 month after event. Before, symptoms of Acute stress disorder.

5 Implicit and Explicit Memory Implicit Memory Perception-Emotion-Sensation-Behavior MentalModels/Schema Explicit Memory Factual Memory Episodic Memory (self in an episode of time) (Autobiographical Memory)

6 Co-morbid depression PTSD is usually accompanied by depression Many of the symptoms of depression overlap with those of PTSD such as sleep problems, poor concentration and memory problems If very severe the accompanying depression can make it very difficult if not impossible to treat the PTSD

7 Symptoms of depression low mood, often worse in the mornings feeling irritable crying a lot loss of interest in your social life loss of self-confidence lack of energy, tiredness poor concentration feeling helpless, worthless or hopeless feeling guilty thoughts ofdeath/ suicide anxiety a loss of sex drive trouble sleeping disturbed eating patterns - loss or too much Unexplained/worsening aches and pains physical slowness

8 Complex PTSD &/or Developmental Trauma DSM-IV acknowledges a constellation of symptoms usually seen in association with an interpersonal stressor: Childhood physical and sexual abuse and Neglect, Domestic violence Incarceration as POW, concentration camp survivors Torture Hostage taking ie Stockholm syndrome

9 ACE study findings (Fellitti, 1998) The more Adverse Childhood Experiences an individual has endured, the greater the incidence of: Smoking, Severe Obesity, Alcohol and Drug use, Ischaemic heart disease, stroke, chest diseases Diabetes, hepatitis, sexually transmitted diseases. Depression, attempted suicide.

10 And what are the Adverse Childhood Experiences? Such as: Emotional abuse Physical abuse Sexual abuse Mother treated violently Household use of drugs or alcohol Presence of mental illness Parental Separation or Divorce Incarcerated household member

11 ACE score and the Risk of being Sexually Assaulted as an Adult Women Men > >5

12 Women 15 ACE score and the Risk of being a Victim of Domestic Violence Men > >5

13 ACE score and the Risk of Perpetrating Domestic Violence 15 Women Men > >5

14 Symptoms of Complex PTSD linked to disorganised attachment Impaired affect modulation Dissociative symptoms Somatic complaints Feeling constantly threatened Self destructive/ impulsive behaviour often reenacting the trauma ie shame > dissociation > violence ie Vietnam veteran and anniversary

15 Symptoms of complex PTSD -2 similar to PTSD Social withdrawal Impaired relationship with others Feelings of helplessness, despair, Feeling constantly threatened and in addition Feeling permanently damaged

16 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).

17 The effects of PTSD are transmitted down the generations Low urinary cortisol levels in adult holocaust survivors with PTSD and in their adult offspring (Yehuda, 1997, 2002). Israeli soldiers whose parents were Holocaust survivors had higher rates of PTSD than their counterparts. Children of mothers who suffered from PTSD following 9/11 have lower levels of cortisol via Epigenetic transmission. Low cortisol levels predispose to PTSD

18 Epigenetic transmission The environmental conditions in early life can structurally alter DNA: The mother, through her maternal behaviour, can affect DNA methylation of critical genes in the offspring (Jacobson, 2009).

19 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 and the epigenetic studies show there is transmission of the potential for PTSD and trauma related violence in PTSD afflicted communities This underlies the importance of prevention and socially based treatment interventions.

20 Attachment Research Our need for Social Support when in a state of fear betray 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 &/or BPD. We therefore need to understand attachment disorders in order to treat patients suffering from these conditions.

21 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 warm feelings through attunement largely produced by endogenous opiates: separation leads to a miserable state: We are all Opiate addicts (Panksepp)

22 Other important hormones involved in attachment Partly mediated by: endogenous opiates also released during traumatisation ie Livingstone, cutting and burning > addiction as self medication. dopamine (energised state of feeling) serotonin (linked to levels of domin. ance in hierarchy: importance of inequality? oxytocin (feel good factor, the love hormone ).

23 Programming the Brain Without Mum or caregiver Infants are not capable of: Regulating their hormones: biological regulators (Hofer). Regulating their +ve or ve arousal and emotional reactions. From birth to age 3 At birth baby s brain has 50 trillion synapses and by age 3 there are 1,000 trillion. New synapses are formed and hard wired whilst unused ones are pruned ie thin corpus callosum and hippocampus.

24 Hierarchy of brain function

25 The limbic system

26 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 neocortex or from rough fast thalamic input > activating fight, flight and freeze behaviour as in PTSD.

27 Traumatised brains In traumatised children brainstem and amygdala functions take charge: ie triggers release fear responses even when 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.

28 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.

29 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.

30 Damaged hippocampi due to child abuse Smaller hippocampal volume has been reported in several stress-related psychiatric disorders, including: (PTSD), borderline personality disorder with early abuse, and depression with early abuse. Patients with borderline personality disorder and dissociative identity disorder (DID) with early abuse have also been found to have smaller hippocampal and amygdala volume

31 Implicit and Explicit Memory Implicit Memory Perception-Emotion-Sensation-Behavior MentalModels/Schema Explicit Memory Factual Memory Episodic Memory (self in an episode of time) (Autobiographical Memory)

32 Understanding the infant brain

33 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 71/2 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.

34 Self organisation of the infant through physiobiological regulation The brain is a self organising system organised through the mutual and rhythmic regulation of affect between mother and infant. The infant imitates the caregiver s expression and thereby attunes with her/him probably via the brain s mirror neurones. These are active as from birth.

35 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). 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.

36 Attunement with baby Brain to Brain communication The caregiver responds to the infant s signals by holding, caressing, smiling, feeding, stimulating or calming, giving meaning and predicting future behaviour. Through attunement the mirror neurone system simulates the facial expression ot the caregiver > insula> supra orbital cortical area producing in the child the emotion the caregiver is feeling. Her empathic interaction results in a child who can put himself in the mind of another and attune with others.

37 Primary intersubjectivity

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 AAI (Fonagy and Target, 1997)

39 Reflective Functioning The caregiver 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

40 Representation of the Self and Secure attachments (63%) A securely attached child has a mental representation of the caregiver as responsive in times of trouble. Their sense of self is closely intertwined with the internal representation of the attachment figure. 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).

41 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%)

42 Disorganised Attachment Infants show a disorganised response in relation to their caregiver (A+C) and Unresolved in the AAI. 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 himself. This behaviour leaves the child in a state of fear without solution (Main and Hesse 1992, Reflective functioning is severely impaired: the more impaired, the more disturbed is the individual.

43 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.

44 Structural dissociation around the fulcrum of the traumatic attachment Children in fear of their care-giver s hatred and violence will: Need to maintain their attachment to their desperately needed caregiver > Traumatic attachment or Fantasy bond the fulcrum of structural dissociation. Resort to splitting ie 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) ie multiple IWMs

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

46 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 the abusing parent through their IWM of child in relation to abusing parent.

47 Borderline Personality disorder as defined in DSM-lV (1994) The essential features of the borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity that begins in early adulthood and is present in a variety of contexts as indicated by 5 or more of the following:

48 Clinical signs of structural and other forms of dissociation The phenomenon of dissociation should no longer be ignored in our understanding of such phenomena as: Inexplicable shifts in affect: eg monkey hand Discontinuities in train of thought. Changes in facial appearance, speech and mannerisms. Apparently inexplicable behaviour: eg fried eggs. Somatic dissociative phenomena: eg swollen eyelids The incoherence in the unresolved text of the AAI

49 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).

50 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 ie 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 ie you are what you wear and own. Eg: the Barbie doll woman.

51 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)