Far-Reaching Effects of Adversity. Trauma, Attachment, & Addiction: Healing Relational Wounds with. Mindfulness & Self-Compassion

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1 Trauma,, & Addiction: Healing Relational Wounds with Mindfulness & Self-Compassion Dr. Jon G. Caldwell, DO, PhD Medical Director & Researcher The Meadows of Wickenburg Child Maltreatment Interpersonal Challenges Risky / Unhealthy Behavior Mental Health Problems Adult Insecurity Maladaptive Parenting Relational Mental Health Addiction Far-Reaching Effects of Adversity Adverse Childhood Experience (ACE) Study 17,000 Kaiser members in CA participated ACE: abuse, neglect, household dysfunction Outcomes: quality of life, illness, death Findings: ACE are common; 2/3 (1 ACE), 1/5 (3+ ACE) Early initiation of tobacco & sexual activity Teen pregnancy, sexual partners & STD s Intimate partner violence ADDICTION Depression & suicide attempts 1

2 Physical Health and Wellness Far-Reaching Effects of Adversity Adverse Childhood Experience (ACE) Study 17,000 Kaiser members in CA participated ACE: abuse, neglect, household dysfunction Outcomes: quality of life, illness, death Findings: Lung disease (COPD) Liver disease Heart disease Autoimmune disease Poor health-related quality of life Far-Reaching Effects of Adversity How does relational adversity/stress in childhood lead to such diverse negative outcomes in adulthood?? Child Maltreatment Interpersonal Challenges Risky / Unhealthy Behavior System Disturbances Perceptions of Self/Others + Emotion Regulation Mental Health Problems Nervous System Dysregulation Adult Insecurity Maladaptive Parenting 2

3 Effects of Child Maltreatment Physical Neglect Emotional Neglect Physical Abuse Sexual Abuse Emotional Abuse Total Abuse/ Neglect Adult Insecurity Caldwell, Shaver, Li & Minzenberg, 2011 At Risk Mothers (N=94 ) Depressive Symptoms Lower Parenting Satisfaction/ Self Efficacy Emotional Abuse ** Emotional Abuse (EA) was the greatest predictor of mental health and relational problems in adulthood. High EA Low EA What is Trauma? Trauma is the unique and personal experience of an event, a series of events or a set of enduring conditions that is subjectively perceived as threatening and has the effect of overwhelming the individual s ability to integrate and regulate his or her experience at the levels of sensorimotor (body), cognition and emotion. Ogden & Minton,

4 Trauma and the Brain Frontal Cortex Neo Mammalian Brain Cognitive/Executive Fxs Top Down Regulation Analytical Reasoning Verbal Language Limbic System Mammalian Brain Automatic & Regulated Danger/Threat/Memory Emotional Center of Brain Brain Stem Reptilian Brain Instinctive/Automatic Arousal/Sleep Sensation/Impulse Trauma and the Brain (Child) Hippocampus Tightly connected to amydgala, records threat and surrounding details into memory. Frontal Cortex Top down regulation of threat response via language, reason, and cognitive resources. Amygdala Brain s smoke alarm for danger, triggers threat response and mobilizes the body for fight flight. Trauma and the Brain (Child) Hippocampus Tightly connected to amydgala, records threat and surrounding details into memory. Frontal Cortex Top down regulation of threat response via language, reason, and cognitive resources. Amygdala Brain s smoke alarm for danger, triggers threat response and mobilizes the body for fight flight. Integration Regulation 4

5 Trauma and the Brain (Adult) Hippocampus Tightly connected to amydgala, records threat and surrounding details into memory. Frontal Cortex Top down regulation of threat response via language, reason, and cognitive resources. Amygdala Brain s smoke alarm for danger, triggers threat response and mobilizes the body for fight flight. Trauma and the Brain (Adult) **Car Jacking** Hippocampus Tightly connected to amydgala, records threat and surrounding details into memory. Frontal Cortex Top down regulation of threat response via language, reason, and cognitive resources. Amygdala Brain s smoke alarm for danger, triggers threat response and mobilizes the body for fight flight. Non Emotional: Male/Female Frontal Lobe Emotional: Neutral/Fearful FEMALE NEUTRAL FEMALE Anterior Cingulate NEUTRAL FEMALE Limbic System FEARFUL Faster Women with Low Child Abuse Faster Slower Women with High Child Abuse Caldwell, Krug, Carter & Minzenberg, 2013 Slower

6 Theory Behavioral System Enhance survival/reproductive fitness Proximity, safe haven, & secure base Organize social attachment behaviors Internal Working Models (IWMs) Self/emotion regulation capacity Cargiving Behavioral System Reproductive fitness via protection Activated by child attachment cues Variety of behaviors to fit context Responsive, sensitive, boundaried, flexible, and unintrusive caregiving Factors in Time G1 Relationship Parent Factors Child History of Trauma Personality Education Level Mental Health G2 Child Factors Genes Temperament Health Status Context Factors Poverty/Crime Home Environment Co parent Involved Extended Family Social Support 6

7 Safe Haven / Secure Base Internal Working Models (IWM s) or Procedural Memory Mesocorticolimbic Pathways Dopamine Reward System Emotion-Related Attention Reward Cingulate Cortex Prefrontal Cortex Nucleus Accumbens Amygdala Hippocampus Thal Ventral Tegmental Area 7

8 Dopamine Reward Pathways & The System High Quality Maternal Caregiving (licking and grooming) Nest Building Pup Retrieval Strathearn, et al., 2011, Young, et al., 2011, for reviews Adult Pair Bonding Maternal Neglect Impairments in dopamine reward pathways can lead to maternal neglect. In adulthood, the neglected offspring show dopamine dysfunction in reward pathways and they show greater susceptibility to drugs like cocaine, which activate the reward pathway. Meaney, et al., 2002 Dopamine Reward Pathways & The System Mothers viewed pictures of their child and partner (compared to acquainted children and adults). fmri brain imaging revealed that maternal and romantic attachment activated similar areas of the brain and both significantly activated dopamine-related reward circuitry (nucleus accumbens, amygdala, ventral striatum, anterior cingulate cortex) and deactivated areas the brain associated with negative emotion. Bartels, et al., 2004 Mothers viewed neutral and emotional photos of their child. fmir brain imaging revealed that mothers with secure adult attachment (integration & regulation of childhood experiences) had greater activation in dopamine reward circuits when viewing child s happy face. However, mothers with insecure attachment responded to sad faces with greater insula activation (pain, disgust). Strathearn, et al., 2009 Mesocorticolimbic Pathways & Oxytocin (OXT) OXT is produced in thalamus and released via pituitary gland OXT has actions throughout body; eg, VTA, HIPP, AMYG, NAc, ACC ACC OXT receptor gene (OXTR) has been linked to autism, social Thal behavior, and infant attachment OXTR + adverse environment has been linked to mental illness PFC NAc OXTR has been linked to limbic fx AMYG OXT is related to high quality maternal behavior OXT is related to romantic attachment & pair bonding OXT is related to social cognition, prosocial behavior, and trust VTA HIPP OXT regulates social stress and aids in nervous system regulation Meyer-Lindenberg, et al., 2011, for review 8

9 Epigenetics of Oxytocin Mother DNA Methylation Me Pup Me Less Anxiety More Exploration Nervous System Regulation Higher Levels of Maternal Care OXTR expression in hippocampus = down-regulation of stress response and activation of reward pathways in brain Adult Chromatin Me Histones Kumsta, et al., 2013, for review Oxytocin and STUDY 1 OXT measured at 1 mo and 6 mo postpartum Mother & Father OXT levels were synchronized Fathers Elevated OXT = stimulatory play, object exploration, positive arousal Mothers Elevated OXT = loving gaze/affect, vocalization, and affectionate touch Gordon, et al., 2010, Feldman et al., 2010 Oxytocin and OXT Levels OXT Levels LOW HIGH Stimulatory Contact HIGH STUDY 2 OXT measured before and after 15 min parent-child play and touch session Affectionate Touch LOW Gordon, et al., 2010, Feldman et al.,

10 Oxytocin and STUDY 3 OXT measured before and after 15 min parentchild play and touch. Sessions were coded for levels of behavioral synchrony between parents and child. Higher levels of synchrony = Elevated OXT in child Gordon, et al., 2010, Feldman et al., 2010 Dopamine Reward Pathways & Oxytocin Child Abuse Neglect Relationships Nervous System Regulation Integration Physical Emotional Social Health Dopamine Reward Pathways & Oxytocin Abuse/Neglect = Brain Systems in Conflict In the context of unsafe, abusive, or neglectful attachment figures, two biological system are in conflict: Survival and development depends on connection, so the attachment system motivates toward relationship partner However, stress response system motivates away from potential threat The individual (unconsciously) adapts to unsafe situation via two primary insecure attachment dimensions: Avoidance (Love Avoidance) Anxiety (Love Addiction) 10

11 Adult Style Avoidant/ Dismissing High Avoidance Fearful/ Disorganized Low Anxiety High Anxiety Secure Low Avoidance Anxious/ Preoccupied -Related Anxiety anxiety is often linked to an inconsistently available attachment figure The individual adapts (procedural learning) by hyperactivating the attachment system, by amplifying their attachment needs Amplification of attachment signals to keep attachment figure close/attentive Like a slot machine, the inconsistent payout causes a person to keep adding coins, hoping for an occasional hit -Related Anxiety Intense desire for closeness, but also afraid of it leading to loss (ambivalence) anxiety is related to deep feelings of inadequacy and unworthiness Self blame; If I were better or enough, my attachment figure would stay When I am in need, I am afraid that my attachment figure won t be there for me or will abandon me 11

12 -Related Avoidance Often, attachment avoidance involves an attachment figure who is very enmeshing, dismissing, rejecting and/or abusive The individual cannot simply choose to NOT to attach, so he/she adapts The person procedurally learns to shutdown or deactivate the attachment system Suppressing attachment needs creates safe distance and reduces chances of enmeshment, rejection or abuse, while maintaining minimum level of contact -Related Avoidance avoidance is linked to strong feelings of distrust for the other person Less physical closeness, wariness of interdependence and intimacy Commitment to rugged individualism; Who needs them anyway? Individual seems unaffected, but is often defensive, walled off and prone to anger When I am in need, I can t trust that my partner will be there for me because they might make it about them, dismiss my concerns or outright reject/abuse me Insecure Patterns Hyperactivating Patterns My faults cause others to leave me Intense need for closeness Anxious about rejection & separation Cling, control, fear of letting go Dysregulation of negative affect Deactivating Patterns I can t trust and depend on others Downplay need for closeness Hide or dismiss vulnerabilities Avoid intimacy & interdependence Suppress emotion Related Anxiety Related Avoidance 12

13 Cognitive-Emotional Patterns N=388 70% 22 yrs - Related Anxiety - Related Avoidance Cognitive Rumination Emotion Suppression Negative Affect Emotional Ambiguity Emotion Dysregulation Hyperactivating Patterns Low Resiliency Deactivating Patterns Caldwell, J. G., et al (2012) Style & The Brain Anx Attach Rognoni et al., 2008 fmri; think/don t think of neg. attach scenes. Anx A ach showed emotion dysregulation during think condition. Avoid Attach showed less deactivation during don t think. EEG; social film clips. Anx A ach showed activation to sad/fear scenes, Avoid Attach had arousal to happy/love scenes. * * * Anxious Avoidant Avoid Attach NAc AMYG fmri; cognitive task w/ pos. (smile face) and neg. (angry face) feedback. Anx. A ach showed amygdala activity related to neg. feedback. Avoid A ach showed ac vity in reward pathways due to positive feedback. Secure Attach showed opposite patterns. Gillath et al., 2005 Vrticka et al., 2008 VTA Style & Oxytocin 26 males w/ insecure attachment, double blind, placebo controlled intranasal OXT Viewed relational scenes and chose 1 of 4 descriptive phrases related to attachment styles Males in OXT condition rated attachment scenes more securely, compared to placebo Buckheim et al., 2009 However, two studies give reason for caution: 31 males, double blind, placebo controlled intranasal OXT assessing memories of childhood maternal care and closeness. Those with Anx Attach remembered mother as less caring a er OXT (vs placebo), opposite was true for Anx Attach 14 males with Borderline PD vs 13 controls received OXT or placebo while playing social game assessing trust/prosocial behavior. Males with BPD and Anx Attach showed less trust and cooperative responses on OXT (vs placebo) Bartz et al., 2010,

14 Emotional Supp & Ambiguity Avoidance Dopamine Reward Pathways & Oxytocin Child Abuse Neglect Relationships Nervous System Regulation Integration Physical Emotional Social Health Anxiety Dopamine Reward Pathways & Oxytocin Emotion Dysreg & Rumination (+) Antidote to Insecure Patterns? - Related Anxiety - Related Avoidance Cognitive Rumination Mindfulness Emotion Suppression Negative Affect Emotional Ambiguity Emotion Dysregulation Regulation Hyperactivating Patterns Higher Low Resiliency Deactivating Patterns Caldwell, J. G., et al (2012) Mindfulness Mindfulness: A process of regulating attention to the present moment with a quality of curiosity, nonjudgment & acceptance Five Facets of Mindfulness (FFMQ; Baer, et al., 2006) Observing internal and external stimuli/experience Describing or mentally noting these experiences Acting with Awareness; not acting on auto-pilot Nonreactivity to inner experience, letting it be Nonjudgment and acceptance of inner experience 14

15 Mindfulness-Based Treatments Mindfulness-Based Stress Reduction (MBSR) Dialectical Behavior Therapy (DBT) Acceptance and Commitment Therapy (ACT) Compassion Focused Therapy (CFT) Mindful Self-Compassion (MSC) Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-Based Relapse Prevention (MBRP) Mindfulness-Based Relationship Enhancement (MBRE) Mindfulness-Enhanced Strengthening Families Program For Parents and Youth (MSFP) Somatic Experiencing (SE) Sensorimotor Psychotherapy (SP) Mindfulness Pause Recognize the Reactivity Allow and Accept Investigate Sense in the body Enlighten (Up) 15

16 Mindfulness & Compassion Training on the Brain 1. Attention Regulation 2. Body/Self Awareness DLPFC ACC Insula Thal 3. Emotion Regulation 4. Reward / Intention PFC NAc AMYG VTA HIPP Mindfulness is helpful in cultivating body awareness and regulation of attention and emotion. Compassion practices may facilitate emotion regulation and rewiring of reward pathways. Lutz, et al., 2008; Holzel, et al., 2011, for review and Mindfulness 1. Parenting that fosters attachment security is thought to also foster mindfulness Dan Seigel, 2007, Secure attachment and mindfulness share many of the same positive outcomes 3. The neurobiology of attachment security overlaps with that of mindfulness 4. Hyperactivating and Deactivating patterns are inversely related to mindfulness 5. Evidence that attachment insecurity is related to lower levels of mindfulness 6. Evidence that mindfulness intervention fosters security based emotion regulation Adult & Mindfulness N=21 N=28 N=35 Mindfulness Secure Anxious Fearful N=84 73% 22 yrs 16

17 REAC 2 H: Mindfulness Intervention REAC 2 H (Restoring Embodied Awareness, Compassionate Connection and Hope) 3 Day workshop focusing on relational trauma, attachment and mindfulness Instruction and experiential exercises aimed at bringing understanding, compassion and mindful awareness to the sensations (body), thoughts (mind), and feelings (emotions) associated with attachment experiences REAC 2 H: Mindfulness Intervention Day 1 Day 2 Day 3 Trauma/Attach Mindful Body Secure Attach EA 2 SE Embodied Awareness of Security Experiences Mindful Thoughts Insecure Attach NEA 2 T Non judgmental Exploration and Awareness of Thoughts Mindful Emotions Compassion Connection CA 2 RE Compassionate Awareness of Related Emotions Antidote to Insecure Patterns? Mindfulness & Avoidance Cultivate interest/curiosity about inner life Learn to stay with difficult thoughts/feelings Recognize/Allow/Accept vulnerabilities Capacity to trust and allow interdependence Mindfulness & Anxiety Cultivate compassion towards inner life Learn to regulate strong thoughts/feelings Meet rumination and fantasy with presence Capacity to be whole while in relationships 17

18 Emotional Supp & Ambiguity Avoidance (+) (+) Dopamine Reward Pathways & Oxytocin Mindfulness Self- Compassion (+) Child Abuse Neglect Relationships Nervous System Regulation Integration (+) Physical Emotional Social Health (+) Anxiety Dopamine Reward Pathways & Oxytocin Emotion Dysreg & Rumination (+) (+) Mindfulness Self- Compassion Summary Relational trauma disrupts attachment, which profoundly affects development and has far-reaching effects on wellbeing Insecure attachment experiences diminish ones capacity for nervous system Dysregulation increases chance of addictive behaviors and socio-emotional dysfunction anxiety & avoidance are linked to unhealthy cognitive-emotional patterns Mindfulness & Self-Compassion are powerful ways to restore the capacity for self-regulation and for intimate and authentic connection with self/others 18