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The Neurobiology of Affective Disorders in Adolescents

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					 The Neurobiology of Mood and
Antisocial Behaviour in Adolescents


Ian M Goodyer MA MD FRCPsych FMedSci
         Department of Psychiatry
         University of Cambridge
        The Psychopathology of Violence


•Anger and irritability are common features of
mood disorders

• Expressed as violent acts: Suicidality ; Non
suicidal self harm

•Aggression toward others

•Destruction of property (can lead away from
diagnosis if a presenting feature)
                      Non-Suicidal Self-Injuryand Suicidality Events
                               Over 28 Weeks’ Follow-Up
                                           No NSSI month pre-baseline (N=105)

                                           NSSI in month pre-baseline (N=58)
                                                                                                 Depressed Adolescents with
                                                                                                 pre-baseline NSSI had a 10-
                                  100




                                                                                                 fold greater risk of suicide
                                                                                                 attempt during treatment
Percentage With Self-Harm Event




                                                                                                 than those with no self-
                                  80




                                                                                                 injury
                                  60
                                  40




                                                                                                 For NSSI, χ2=39, df=1, p<0.0005;
                                                                                                 for suicide attempt, χ2=22, df=1,
                                                                                                 p<0.0005
                                  20




                                                         a                           b


                                                Class of Follow-Up Self-Harm Event
                                  0




                                        Non-Suicidal Self-Harm           Suicide Attempt

                                                                 Wilkinson PJ et al (2011) Am J Psychiatry. 2011 Feb 1. [Epub]
 Age at onset of depression




Maltreatment




  Spatz Widom, C. et al. Arch Gen Psychiatry 2007;64:49-56.
Neural Systems And Affective Disorders
                                 The Neural Maturation Gap:
                     Understanding The Importance Of Brain Development
                                                         Observation
                                                         Early consolidation of limbic-sub-cortical
                                                         reward processing networks.
                                           Drug use,     Later consolidation of neocortical control
                                           Psychosis,    networks.
                                           Depressions
                                                         Spike in drug use, psychotic and mood
Incidence




                                                         disorders in the neural maturation gap.

                                                         Hypothesis
                                                         Increased incidence of psychopathology in
                                                         adolescence associated with different
                                                         developmental rates for limbic and prefrontal
                                                         systems.

                                                         Proposed Mechanism
Neural development




                                                         Variation in rate of myelination of long
                                      Limbic System      distance cortico-cortical tracts predicts
                                      PFC                developmental reconfiguration of large scale
                                                         brain networks.

                                                         Experience dependent synaptic plasticity and
                                                         pruning of inactive connections are other
                                                         plausible mechanisms.
Proof of Principle: Differences in Volume of rAnterior
                       Cingulate

   N=19                  N=19




            19          19

                             Treadway M et al (2009) Plos One 4: e4887
Morning cortisol, child maltreatment decreased
       grey matter volume in the rACC

  Vol decrease in rACC: patients               Vol decrease in rACC: controls




  Corr abuse scales: patients                    Corr abuse scales: controls




                                   Treadway M et al (2009) Plos One 4: e4887
        Longitudinal change in amygdala activity
                  in depressed adults




Greater right amygdala activity in patients (n=17) relative to control subjects before
treatment. No significant difference between groups at the week 16 scan after treatment
.

                                         Chen CH, et al (2007) Biol Psychiatry 62(5):407-14
         Predicting clinical response at week 16




Faster symptom improvement strongly associated with greater grey matter volume in
anterior cingulate cortex, insula, and right temporo-parietal cortex.

Faster improvement was also predicted by greater functional activation of anterior
cingulate cortex.
Neural Systems and Antisocial Behaviour
Proof of Principle : Volumetric Loss In Emotion
               Processing Areas




Smaller amygdala volume      Amygdala: involved in fear recognition
in CD cases vs controls       and learning, experience of emotion

                      Fairchild et al (2011) Am J Psychiatry; epub April AiA:1–10
      A Neural Basis For Interoceptive And Social
               Exchange Deficits In CD




Anterior insula: involved in empathy, processing negative emotions, and
awareness of body states

          Fairchild et al (2011) Am J Psychiatry Fairchild et al.; epub April AiA:1–10
Functional Brain Networks
 Proof of principle: Functional brain networks change during normal
           adolescence and are abnormal in schizophrenia




                                                                                   Healthy




                                                                               Schizophrenia


  Brain functional networks in schizophrenia are less economically wired, less modular and less
  clustered – we will test the developmental hypothesis that psychotic disorders emerge as a
  consequence of abnormal brain network maturation in the youth age range

Alexander-Bloch et al (2010) Frontiers in Systems Neuroscience; Lynall et al (2010) J Neurosci; Fair et al (2009) PLoS
Comp Biol
       Mental Health And Neuroscience Network

•Partnership between University of Cambridge and UCL

•Characterise the structure and function of the normal brain
 in 14 to 24 year old well individuals

•Map deviant structure and functions in those with common
 mental illnesses arising in the adolescent years
(depressions, conduct disorders, psychoses, personality disorders)
Co-Investigators
Thanks to Funding Agencies

     Wellcome Trust
          MRC
         NIHR
          DoE
       Clinical Global Impression Over The ADAPT
                        Study Period



                                                                                 weeks




30% of severely depressed teenagers not helped by existing treatments:
violence is one key to this

                          Goodyer IM et al (2008) Health Technol Assess. 12(14):iii-iv, ix-60
Improving Mood With Psychoanalytic Psychotherapy
 And Cognitive Behaviour Therapy: THE IMPACT
                    STUDY
THE NEUROBIOLOGY AND
GENETICS OF CHILDHOOD
    MALTREATMENT


              Dr Eamon McCrory
   Consultant Clinical Psychologist & Senior Lecturer
         Developmental Risk & Resilience Unit UCL
                  e.mccrory@ucl.ac.uk
                                      TOM

Tom grew up with his Mother, Step-Father and younger brother. Both his parents
used drugs and drank heavily. Tom often witnessed violence at home and was
shouted at and hit by his Step-Father.

At the age of 8 Tom and his brother were removed from home, and after 3
placements were settled in a permanent foster family. Tom had serious behavioural
problems at school. He also missed his mum even though he knew she couldn’t look
after him.

In adolescence Tom was arrested for hitting another boy. As an adult he found
relationships difficult and was often depressed. By contrast, Tom’s brother did well at
school, and secured a regular job, and later settled in a stable relationship.
         GENES




                               ENVIRONMENT
NEUROCOGNITIVE
   FACTORS
Beliefs –Thoughts - Feelings




CHILD BEHAVIOUR
         GENES




                               ?
NEUROCOGNITIVE
   FACTORS
Beliefs –Thoughts - Feelings




                               ?
CHILD BEHAVIOUR
         GENES
                               1.   Gene X Environment


                               2. Brain Function

NEUROCOGNITIVE
   FACTORS
Beliefs –Thoughts - Feelings
                               3. Brain Structure


                               4. Resilience and Recovery
CHILD BEHAVIOUR
            Conclusions
    1. Maltreatment leads to a series of
neuro-cognitive changes that are adaptive in
  the short term – but which are ultimately
 maladaptive…increasing the risk of later
          mental health problems

     2. Biological differences mean that
  different children will respond differently
          to the same experiences
        1.   Gene X Environment
             Interaction
GENES

        Could the genes Tom and
        his brother carry mean that
        they responded to their
        experiences differently?
             Genetic Influences

•   There are no ‘genes’ for psychiatric disorders
    associated with maltreatment - rather there are
    many genetic variants adding a small increment
    of risk or vulnerability.

•   These genetic variants bias how all of us process
    emotion and respond to stress.
        GENES
                        Gene X Environment Interaction


    Serotonin Transporter Gene

•    Altered serotonin functioning is associated
     with depression
                                                   SS
•    The serotonin transporter helps removes
     serotonin from the synapse, terminating its        SL
     action
                                                   LL
•    There are two different forms of the gene:
     Short allele: S - Long allele: L.

•    We each have two alleles – most of us
     have at least one copy of the L allele.
‘S’ carries are more reactive to fear
     L/L     S/S     L/S
                              NORMAL
     5HTT    5HTT    5HTT    PARENTING




No differences in symptoms
        of depression
            S/S
                            MALTREATMENT
            5HTT




Significantly more likely
 to show symptoms of
       depression

  ‘Risk’ genotype
 GENES
                      Gene X Environment Interaction


                                                   SS +
                                               maltreatment
   Depression Score




                             Genotype



Children who have experienced maltreatment are more likely to
 show depression if they carry two copies of the S allele (SS)
              +
     GENES
                      MALTREATMENT

      S/S

      5HTT




                     * Regular * contact
              -      with a trusted adult



Risk of depression
    GENES
                 G x E Interaction: Summary


   The additive effects of a range of genetic variants contribute to
    a child’s relative vulnerability or resilience to psychopathology
    following maltreatment.


   In other words common genetic variants – that we all carry –
    make some of us more or less sensitive to emotional cues in
    the environment. Tom may have carried variants (or
    ‘polymorphisms’) that placed him at greater risk of poor
    outcome following his exposure to poor caregiving.


   However, POSITIVE environmental experiences (as well as
    negative ones) can alter the child’s outcome. It is possible that
    Tom’s brother benefited from such a reliable attachment figure
    and reduced his risk of depression.
                 2. Brain Function
NEUROCOGNITIVE
   FACTORS       How might Tom’s exposure
                 to physical abuse alter how
                 he processes emotion?
Brain Function


Pollak et al., 2009
Brain Function




              Pollak et al., 2009: Cognition
    % Image
39
                   Brain Function
• 10-14yr old children from a
  community sample referred to social
  services in the UK.                        Greater activation in left
                                             amygdala with angry vs.
                                                 neutral faces.
• Asked to complete a gender
  decision task in an fMRI scanner – is
  the face male of female?

• Preliminary data indicate a
  hyperactivation of the amygdala in
  this group.

• This is likely to represent the
  neurobiological locus of the
  observed hypervigilance to anger.
                                          McCrory et al. (in preparation)
Why might such hypervigilance
      be problematic?
                        Brain Function



                                                          Abused children




Children were instructed to attend to emotional faces while ignoring
angry voices. The larger N2 response seen here is associated with inhibitory control
and conflict resolution – indicating a greater attentional load.

                                                                            Pollak (2008)
    NEUROCOGNITIV
      E FACTORS
                    2. Brain Function: Summary



     Physical abuse is associated with increases in brain electrical
      activity when procesing angry faces – this may relate to
      hyperactivity of the amygdala – a key brain region involved in
      processing threat.

     Tom may have developed a greater level of hypervigilance –
      scanning the environment for emotional cues

     This was probably an adaptive response in his chaotic home
      environment and kept him out of danger….but may have made it
      much more difficult for him to concentrate and engage at school.

     The degree of hypervigilance has been correlated with greater
      levels of abuse and higher levels of anxiety.
                 3. Brain Structure
NEUROCOGNITIVE
   FACTORS       How might the experience of
                 maltreatment affect the
                 structural development of
                 Tom’s brain?
Key brain structures




                + Corpus callosum
              Timing matters!


 Ages of maximal effect:

Frontal cortex: 14-16 years

Corpus callosum: 9-10 years

Hippocampus: 3-5 years
    GENES
                 4. Resilience and Recovery

                 Are the effects of Tom’s early
                 experience fixed and
NEUROCOGNITIVE
   FACTORS
                 permanent?
   Adolescence is a period
of marked neurodevelopment
                         Adolescence
The frontal lobes undergo marked neuro-
biological change during adolescence.
This regions is associated with higher
order social cognitive skills, including:

• Perspective taking
• Empathy
• Emotional regulation

For Tom this is a period of significant
plasticity when new learning can occur. In
other words, at age 8 Tom’s brain is still
immature and will continue to develop until
his early 20’s.
                          McCrory et al.,
How do factors such as…

• Number of placement changes
• Professional support / intervention
• School affiliation
• Stable attachments
• Individual coping skills

…influence the development of key frontal regions
important in emotion regulation and effective social
functioning?




It is likely that Tom’s brother had one or more of these kind of protective
factors that have helped promote more effective social and emotional
skills, despite poor early care.
                    Overall Summary


•   Maltreatment is associated with different outcomes for different
    children due to individual genetic factors.

•   The brain is affected by maltreatment both functionally – adapting
    in different ways to experience – and structurally, i.e. in how
    different brain regions develop.

•   There remains a lack of research on resilience and recovery, but
    we do know there is a significant period of neuro-development in
    adolescence. Future work will be able to identify neural markers of
    resilience and how these associated with different environmental
    influences.
       Further Reading…




Journal of Child Psychology and Psychiatry
       51:10 (2010), pp 1079–1095

          e.mccrory@ucl.ac.uk
                 Acknowledgments



Dr Essi Viding

                      Developmental Risk & Resilience Unit, UCL
 Supporting Children‘s
    Development
                   An Attachment Approach
                          Pasco Fearon
Research Department of Clinical, Educational and Health Psychology
          What is Attachment?
 Intimate bond between baby and primary caregivers
 Behaviour serving to maintain proximity to a selective
  caregiver(s) in times of stress

 Works like a thermostat – triggered by cues of danger, brings
  about proximimty and feeling of safety

 Theorised evolutionary basis
 Develops early in infancy, most clearly evident at 7-9 months
  by proximity seeking and stranger anxiety
Example 1
Example 2
           Attachment Patterns
 Secure Attachment: seek proximity, communicate need for
  comfort, contact is effective

 Avoidant Attachment: avoids contact, minimizes expressions
  of need for contact

 Resistant Attachment: intense expression of distress, angry
  upon contact, contact not effective

 Disorganized Attachment: contradictory, fragmented,
  disoriented or fearful behaviour upon contact

 Disinhibited Attachment: extreme social disinhibition, lack of
  stranger caution, approach and receive comfort from
  strangers
                  Patterns of Care
 Security associated with sensitivity, defined by
     Awareness of infant attachment cues
     Accurate interpretation of infant cues
     Responsive to cues
     Appropriate response

 Insecurity associated with insensitive care
   Negative/rejecting
   Interfering/intrusive
   Inconsistent availability
 Disorganization associated with
   Frightening, frightened parenting
   Maltreatment
 Disinhibited Attachment associated with
   Institutional care, extreme neglect
60
            Consequences




Disorganized children show physiological hyperarousal
Consequences: Externalizing
        Problems
                      Origins
 Attachment patterns show little sign of being influenced
  by genes
 Fonagy, Steele & Steele (1991) showed that interviews
  conducted with parents before the child‘s birth predicted
  the child‘s attachment security at 1 year
 The capacity of adults to reflect on their own attachment
  experiences seems key
 Insecure States of mind: Dismissing, Enmeshed or
  Unresolved with respect to loss or trauma
                      Summary
 Attachment is critical for children‘s development
 Parental sensitive and responsive care promotes the
  development of secure attachments
 Insensitive or frightening parenting or maltreatment
  undermines the child‘s attachment
 The child is left vulnerable to becoming highly stressed and
  to developing behavioural problems
 A range of inter-dependent factors influence parental care
  (esp. own attachment experiences, psychiatric problems,
  deprivation, drug addiction, low social support)
Intervention
     Focusing on Attachment

Working with
 Parents‘              Promoting             Working with the
Attachment             Sensitivity            Relationship
 Histories

     Home Visiting                         Sensitive Discipline



                     Supportive Networks
Supporting Maltreated Infants
 Cicchetti, Rogosch & Toth (2006)
 Predominantly neglected infants
 Two interventions: Infant-Parent Psychotherapy,
  Parenting Education/Home visiting program

               IPP                              PPI
•Supportively exploring          •Home-based education
connections between parent‟s     program
past and current relationship    •Physical, psychological
•Focus on triadic interactions   development
(parent-therapist-baby)          •Parenting
•Empathic, non-judgmental        •Promoting education and
                                 employment, social support
                                 •Managing stress
Before Intervention
After Intervention
    Sensitivity-Based Intervention
 Moss et al. (2011).
 Similar approach with older children (preschoolers)
 8 home visits
   • Enhancing sensitivity by in-session interactions, discussion
     and video-feedback
   • Intervenors trained in attachment theory and research
   • 20-min discussion focused on recent family events
   • 10-15 min video recorded observation of interaction
   • 20 min video feedback session reviewing positive interactions,
     exploring feelings and thoughts of parent
   • 10-25 min
Impact on Attachment
                    Summary
 Maltreatment has a major impact on children‘s
  attachments and their long-term development


 We can make a difference


 Early intervention can dramatically improve the quality of
  children‘s attachments


 Doing so may reap long-term rewards
Thinking about the
Unthinkable

    Mentalizing Trauma

    Alessandra Lemma
   Traumatic events do not discriminate:

       Paul‘s story
   A trauma is an attack on our attachments

   It is experienced as a breach in the quality
    and felt security of our attachments
We feel distressed and we want to be
hugged

(or not…..)
   Traumatic experiences undermine the
    psychically integrating function of
    narrative

   Breakdown in the capacity to reflect on lived
    experience (i.e. to symbolise)
What causes PTSD?
   Exposure to objectively defined traumatic
    events is not sufficient to produce PTSD

    Vast majority of exposed persons do not
    develop PTSD, although some types of
    trauma carry a far higher risk than others
    (sexual assaults vs. automobile accidents)
   Early patterns of maladaptation and/or
    adversity can be seen as creating
    vulnerabilities

   These may interact with later factors to result
    in various kinds of mental health problems
   One set of risk factors is associated with the
    likelihood of trauma exposure:
         difficult temperament
         antisocial behavior
         Hyperactivity
         maternal distress
         loss of a parent in childhood
   A second set of risk factors is associated with
    the likelihood of developing PTSD after
    exposure:
         low IQ
         difficult temperament
         antisocial behavior
         being unpopular,
         changing parental figures
          multiple changes of residency
         maternal distress
   Another prominent post-trauma risk factor is
    ongoing stress in the aftermath of the
    ostensible traumatic event (Vogt et al., 2007)
   Unempathic responses in attachment
    relationships, which might resonate with
    earlier adverse attachment experience, play
    a significant role in vulnerability
   What happens after a trauma has biggest
    impact on whether a person develops PTSD
    (Brewin (2003)

   The most powerful post-trauma factor is lack
    of social support
   Reducing ―the trauma‖ to any single event is
    therefore arbitrary
The impact of trauma
on mentalising
What is mentalizing?

 Mentalizing is a form of imaginative
 mental activity about others or
 oneself, namely, perceiving and
 interpreting human behaviour in
 terms of intentional mental states
 (e.g. needs, desires, feelings, beliefs,
 goals, purposes, and reasons).
   Impact of attachment trauma on the capacity
    for emotion regulation and mentalizing

   Vulnerability stemming from traumatic
    childhood attachments:
   These relationships evoke extreme distress

                       AND

   Impair the development of capacities to
    regulate emotional distress—in part through
    compromising the development of
    mentalizing
   The overall aim of trauma treatment is to help
    patients to establish a more robust,
    mentalizing self

   So they are better equipped to mentalize
    trauma and relationship conflicts and thus
    able to develop more secure attachments
   There is far more to treatment required than
    processing traumatic memories.

   Attentiveness to strengthening emotion-
    regulation capacities is central
   Research has shown that the capacity for
    mentalizing is undermined in most people
    who have experienced trauma
   Mentalizing goes offline when defensive
    (fight-flight-freeze) responses come online
   The collapse of mentalizing in the face of
    trauma entails a loss of awareness of the
    relationship between internal and external
    reality (Fonagy & Target, 2000)
   Reliving the trauma takes the place of
    remembering the trauma
   Mental states are expressed in concrete
    goal-directed actions instead of mental
    representations such as words (e.g.the
    young person who communicates emotional
    pain through scars on her arms …)
   Following trauma, verbal reassurance means
    little.

   Interacting with others at a mental level has
    been replaced by attempts at altering
    thoughts and feelings through action
Therapeutic work with
traumatized young people
   Less emphasis on techniques and more on a
    way of thinking about the therapeutic process
    and the therapist‘s stance
   Mentalizing stance

       Focus is primarily on the patient‘s mind, not
        on the event.

       A mentalizing stance emphasises process
        over content
   The overall aim of treating traumatized
    patients is to help them to establish a more
    robust, mentalizing self, and thus to develop
    more secure attachments

   Mentalizing provides a buffer between feeling
    and action— a ―pause button‖ (Allen, 2001)
   Promoting mentalizing does not require direct
    processing of traumatic memories

   It requires mentalizing painful emotions and
    conflicts in the context of an attachment
    relationship.
   This treatment strategy runs counter to the
    young person‘s inclination towards defensive
    avoidance of thinking about what has
    happened to them
   The clinical priority is to reduce arousal so
    that the young person can think of other
    perspectives (mentalize)
   Establish a sense of “interpersonal
    security” (Sullivan, 1953) between worker
    and young person that will contain their
    anxiety
Psychoeducation


   Many traumatised young people fear they
    are going mad and are relieved when the
    therapist explicitly recognizes their
    symptoms as part of a known clinical
    picture.
   A trauma breaches the felt security of
    attachments, and the individual may also
    feel in some way ‗marked‘ as different by
    virtue of what they have endured
   Developing a narrative about the trauma

       The conscious and unconscious meanings
        and affects that are attached to the
        traumatic incident are a central part of the
        problem and recovery.
   Reconstruction is an important component
    of working with traumatized patients.

   The functioning of memory post trauma
    presents a particular paradox: patients
    complain of the intrusion of too much
    memory; but they may also present
    fragmented memories of the traumatic
    incident
   Working with the past in the present

       The aim is to help the young person to
        develop perspective on the past by
        reworking current experience (Bateman &
        Fonagy, 2004)
   The therapeutic relationship and
    enactments

       The young person may unconsciously seek
        to evoke particular responses from the
        therapist.

       The re-exposure to situations reminiscent
        of the trauma may be compelling and may
        exert tremendous pressure on the
        therapist.
   Objects of hope


       The therapist/worker potentially provides a
        point of re-entry into a non-traumatized
        world
   We can become objects of hope the young
    person can internalize and ―use‖ if we can
    bear the pain of being unable to rescue
    them
   We can sustain hope if we can bear to be
    the ‗hated other‘, who at times becomes
    indistinguishable in the young person‘s
    mind from the torturer or abuser
   The therapist‘s capacity to contain painful
    emotions and remain collaboratively
    engaged in a mentalizing stance models a
    way of approaching the contents of one‘s
    mind
      Legacy of Childhood
Maltreatment in Adulthood
  and reparative ways of working
                  through trauma
Frank Lowe, Consultant Social Worker
             & Adult Psychotherapist
              flowe@tavi-port.nhs.uk
118
Key points - there is a legacy from
maltreatment in childhood
   But it does not have a single face - it comes in different packages,
    sizes, shapes, colours etc

   Children do not simply grow out of maltreatment

   The degree of impact in adulthood will be influenced by various
    factors e.g. when, who, what and how severe and long it was

   Having an experience of good enough care (a secure attachment
    - capacity to reflect) is a protective factor

   How did significant others respond and did anyone stand by you?

   It is not a 'them and us' situation - childhood maltreatment is much
                                                               119

    more common than is assumed
Childhood maltreatment - sexual, emotional,
physical abuse or neglect is essentially traumatising
and the effects often persist into adulthood

    Childhood trauma is reliably associated with

   a range of mental health problems such as depression, alcohol
    and drug abuse, anxiety disorder, low self-esteem; sexual
    dysfunction (Rorty et al, 2005)

   physical health problems e.g. headaches, chronic back pain,
    shortness of breath, higher levels of gastrointestinal disorders
    and chronic pelvic pain ( see Felitti et al,1998; Spertus et al, 2003)

   poorer social functioning, resilience and quality of life

   sexual abuse, seems particularly linked to eating disorders
    (Rorty & Yager, 1996; Kent et al,1999)

   emotional neglect is associated with greater Social Anxiety
                                                            120

    Disorder (Simon et al, 2009)
    The legacy of childhood maltreatment is
    not straightforward or always visible

   Psychic vulnerability, distress, or wounds are not
    as visible as physical wounds

   Deep distress and damage is not always evident
    in the way someone looks or how they function

   Protective factors such as temperament, skills,
    and talents, the availability of resourceful others,
    social class, cultural heritage and access to
    treatment can affect the outcome of childhood
    maltreatment
                                                      121
Working below the surface – with
the „invisible‟ internal world
   Trauma….‖extends far beyond the visible,
    into the depths of the individual‘s identity,
    which is constituted by the nature of his
    internal objects – the figures that inhabit his
    internal world, and his unconscious beliefs
    about them and their ways of relating to each
    other‖ Caroline Garland (1998, p10)



                                             122
Coping with developmental tasks
and life stresses
   Children can develop defence mechanisms in response
    to maltreatment which can mask the damage done, which
    may emerge only later in life e.g. they may appear to be
    friendly, helpful and capable but in adulthood are confused,
    feel immense self loathing, self-harm, have problematic
    relationships and self-sabotage

   Face challenges with developmental tasks across the life span

   Previous trauma makes dealing with subsequent stressful
    incidents more complex and stressful

   Trauma can occur at any point in life and for many it can occur
                                                          123
    repeatedly throughout their lives
Childhood abuse and parenting

   Abused parents frequently repeat their own experiences with
    their own children and abusive patterns can be seen across
    generations

   These adults seem unable to protect their children e.g. they
    subtly encourage or turn a blind eye to abusive behaviour.

   There is much evidence of how 2nd and 3rd generation Jews
    were affected by parents who survived the Holocaust, e.g. how
    they inherited some of their parents anxieties and traumas

   It seems that the more hidden or denied the parents‘ traumatic
    history, the more likely that these will be carried unconsciously
                                                                124
    by their children
    Deep, lonely and inconsolable
    suffering
   Childhood maltreatment can cause long-term damage
    to the personality structure

   The adverse effects are more acute and profound when
    the abuse occurs early in the life of the child when they
    are less able to differentiate between self and the other -
    their sense of responsibility is greater

   There is a depth of damage that lingers in adult survivors
    of abuse

   Like a separate or hidden part of the core self it regularly
    intrudes into the adult‘s emotional and cognitive functioning
                                                            125
Maltreatment by primary carers
in the early years can lead to -

   an attachment to a traumatising object

   stultification of the child‘s development of self, and
    cognitive, emotional and relationship capacities

   an extreme impairment to a sense of autonomy

   work with such patients as adults being more
    difficult because of difficulties not only with trust but
    with difficulties with the real or inner self
                                                     126
    The effects
   The traumatic experience can be unspeakable- because it
    is pre-verbal or it is a way of protecting attachment figures

   The abuse can be completely forgotten for years and the memory is
    only retrieved during therapy

   Identification with an abuser. Part of the self remains in thrall to the
    abusing object and is unable to extricate itself

   Addictive nature of the abusive experience which may have filled an
    emotional gap and provided some emotional compensation for an
    isolated and deprived child

   Can affect choice of partner - an unconscious choice of someone who
    has also suffered maltreatment can facilitate a repetition of the
    original trauma
                                                                     127

   Actions can be the words that cannot be spoken
    Working through trauma
   This is slow difficult work
   Defences against pain, fear, anxiety which block growth includes anger,
    phantasies of omnipotence, avoiding vulnerability, trust, dependency and
    identification with the aggressor
   Working with the addictive nature of the abusive experience
   The compulsion to repeat past experiences will manifest in the transference
   Making conscious the trauma and its impact – remembering what has
    happened has to be explored
   What does the traumatic event means for the individual?
   Our earliest relationships not only shape later mental structure but have a
    continuing influence in the internal world
   The client needs time to become more familiar with their resistance to
    change and to work through and overcome it
   Working through is very arduous
   Often our task is to listen and bear witness

                                                                      128
    Working through
    trauma
   Always consider the possibility of childhood trauma not only in
    those adults who present with symptoms of complex trauma or
    PTSD, but should consider it even in high functioning adults

   Good/careful history talking is always essential in any treatment

   Promote reflection - enable client to make links between their
    current difficulties and their childhood experiences

   Be aware of secrets and lies as a way of protecting the abuser
    and protecting the self

   There is a compulsion to repeat past experiences in the
    transference and the attending to and handling of the
    transference is key instrument of treatment                129
    Practice challenges
   Many who have suffered insidious trauma, do not appreciate
    that it can have a cumulative negative emotional impact

   Engagement with help - dropout and relapse rates are dramatically
    higher in patients with eating disorders who reported previous
    traumatic events in comparison with those patients without a
    history of trauma

   Drop-out rates could represent an expression of hopelessness that
    interferes with cooperation and compliance

   Freud learnt that it was difficult to know whether an experience
    reported in therapy was real or a fantasy

   The past can never be fully known, memories change, and these
    events can be retranslated and reinterpreted and there is always
                                                               130

    something left untranslated, yet-to-be translated (Shinebourne,
    Conclusion
   The traumatic event is by its nature an unassimilated experience

   For many adults, their trauma is known and not known about - it
    remains disassociated

   Others remain silent, guilty, ashamed and protective of the abuser,
    not trusting or getting close to anyone

   Some live largely in a parallel world driven by their traumatic
    experiences in attempt to achieve some kind of mastery

   Childhood trauma touches and disrupts the core of one‘s self and
    affects one‘s identity or personality in adulthood

   To work with trauma the worker has to contain the unbearable
    states of the client and work in collaboration with him/her until they
    can face their reality, give meaning to experiences and positively
    learn from them                                                131
No Bullsh*t
   ―A traumatized patient….. needs to have a therapist
    survive what could be traumatic. The heart of the
    matter is that our moment of horror as therapists
    mirrors what the child could not cope with……
    Bringing the trauma into the room, into the
    relationship with the therapists, is what may enable
    us to make a difference. To do the necessary work
    safely we have to ensure that we have time and
    adequate personal and professional support for
    ourselves.‖ ,Margaret Rustin (2001)

                                                 132

				
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