Transcript Traumatically Disrupted Attachment:

How to recognize,
diagnose, and treat
toward optimal healing
Lark Eshleman, PhD
www.LarkEshleman.com
November 3, 4, 2010
9
– 10:15
 10:30
Brain-based research
on attachment and trauma
– 12:00
Brain research (continued)
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1 – 2:15
Best Practice based on
neurological understandings: sensory
processing disorder and other
“interrupted” developmental processes
2:30 – 4:30 Best practice based on
neurological
understandings: narrative,
Theraplay®, EEG Biofeedback, EMDR
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Brain-based research
on attachment and
trauma
Dr. Shore’s Central Assumption:
The social environment changes over the stages of
infancy and induces the reorganization of brain
structures
 The
growth of the brain occurs in critical
periods and is influenced by the social
environment.
 The
infant brain develops in stages and is
hierarchically organized.
 Genetic
systems that program brain
development are activated and influenced by
the postnatal environment.
Brainstem
Controls:
Heart Rate
Blood Pressure
Body Temperature
Respiration
Midbrain
Part of brain stem that
controls:
Arousal
Appetite
Satiety
Sleep
Motor Regulation
Limbic System
Locus for:
Affiliation
Attachment
Sexual Behavior
Emotional Reactivity
Enable:
Abstract Thinking
Concrete Thought
Cause & Effect
Thinking
Reasoning
Regulate
neuronal growth and
the time frame of brain growth
The
normal time frame for the
onset of the critical period of
orbitofrontal maturation is 10 to
12 months.
Decreased
production of
appropriate amounts of these
substances can disrupt the onset
of frontal lobe maturation.
A
centralized set of neurons containing dopamine arises
from the midbrain and helps promote activation of the
right prefrontal cortex.
The
activation leads to the engagement of the child with
her environment and the stimulation of reward centers
that produce endogenous endorphins.
Image of a Neuron
The
right prefrontal cortex develops
normally only if a child receives
emotionally attuned interaction with
primary caregivers.
The
right prefrontal cortex is highly
involved in creating social interaction
and the recognition of attachment
figures.
Schore A. (1994). Affect Regulation and the Origin of the Self:
The Neurobiology of Emotional Develoment. Hillsdale, NJ,
Lawrence Erlbaum Associates.
 Lack
of emotionally
attuned interaction
leads to decreased growth and differentiation of this
portion of the brain and impaired affect regulation.
Schore A. (1994). Affect Regulation and the Origin of the Self: The
Neurobiology of Emotional Develoment. Hillsdale, NJ, Lawrence
Erlbaum Associates.
Ongoing
research suggesting
much of psychopathology
could be attributed to
problems in brain timing.
Dr.
Rodolfo Llinas, of NYU
Medical School, suggests that
psychiatric and neurological
conditions could be
attributed to dysrhythmia
between thalamus and
cortex.
Hyper
or hypo-activation of the
sympathetic an/or parasympathetic
nervous systems
The
lack of Central Nervous System
shift from sympathetic to
parasympathetic predominance
between 14-18 months of age
This
region of the brain is critical for the
performance of “working memory”.
High levels of dopamine and
norepinephrine (catecholamines) are
released in the PFC during stress exposure,
causing “working memory” deficits.
Humans with lesions of the PFC
demonstrate “poor attention regulation,
disorganized and impulsive behavior, and
hyperactivity”.
Arnsten, A. (1998). Development of the Cerebral Cortex XIV. Stress Impairs
Prefrontal Cortex Function. Journal of Am. Acad. Child Adol. Psychology, 37
(12): 1337-1339.
Dr. Michael De Bellis, a Child Psychiatrist
at WPIC, studied the excretion of
catacholamines (ephinephrine,
norepinephrine, and dopamine), and
cortisol in prepubertal children who had
experienced PTSD secondary to abuse
These
children lived in stable home
environments during the study
Intergenerational
transmission of altered
DNA
Predisposes
subsequent
generations to PTSD and
anxiety disorders
Dr.
as:
Schore defines psychopathology
A
limitation of adaptive
stress-regulating capacities
This
is more likely to occur if right
prefrontal cortex, limbic system,
and hypothalamic development is
hampered by lack of appropriate
interaction with attachment figures
Leads
to impaired affect regulation
Short-Term
Anxious,
depressed,
agitated, and excessively
angry
Long-Term
Aggressive and
oppositional
Some may develop a form
of Attachment Disorder
The
attachment figure is the
regulator of the infants’
endocrine and nervous systems.
Attuned caregivers of securely
attached infants maintain the
child’s arousal.
Within
a moderate range that is
high enough to maintain
interaction
Without causing distress and
avoidance through over-intensity
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Neurological understandings:
sensory processing disorder and
other “interrupted”
developmental processes

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•
The brain’s “food” is sensory input.
Attachment theory and its neurological
underpinnings teaches that sensory input in
early childhood determines later behavior
and ability to cope. Deprived environments
compromise achievement of developmental
milestones, at least temporarily.
The nervous system “learns” movement and
behaviors (“output”) by repetition of the
sensory (afferent) input, coordination of
motor (efferent) output and the resulting
sensory feedback for further refinement.
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SPD was formerly known as Dysfunction in Sensory
Integration. It is currently being considered for
inclusion in the DSM-V.
SPD occurs in 5-15% of the general population.
SPD causes a child or adult to interpret sensory
information differently than the typical person. It
can impact 1 or all of the sensory systems.
Research and treatment has been around since the
1960’s starting in OT with Dr. A. Jean Ayres, an OT
and clinical psychologist.
 Check
out behaviors from morning
presentation.
 How many are similar to following behaviors
manifested in SPD?
 What do current studies tell about impact of
traumatic interruption in attachment and
occurrence of SPD?
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SPD can compel a person to behave
“differently” than others. The world can be
perceived as a potentially painful or
offensive place and so anxiety or
defensiveness can develop.
SPD can impact one or many life activities
including self care, work, school,
relationships, sleep, etc.
SPD often is comorbid with other
diagnoses such as learning disorders,
autism, & mental health diagnoses.
Sensory Processing Disorder
SensoryBased Motor
Disorder
(SBMD)
Sensory Modulation
Disorder (SMD)
Sensory
overresponsivity
Sensory
underresponsivity
Sensory
seeking/
craving
Miller et al; Am J Occ Ther Mar/Apr 2007 61:2
Dyspraxia
A.K.A.
DCD
Postural
disorders
Sensory
Discrimination
Disorder (SDD)
*Visual
*Auditory
*Propriocep
-tion
*Taste/Smel
l
*Tactile
*Vestibular
 Also
called “sensory regulation.”
 Child/adult has difficulty with incoming sensory
information and responding to it in an
appropriate manner.
 Often seen in auditory sense but any sense or
combination of senses can be involved.
 Child cannot always identify what is wrong.
 Behaviors can become entrenched.
 Small amount of sensory input can be perceived
as extreme or vice versa. Reactions are typically
in response to the perceived sensory message.
The person responds with what is seen as a dramatically
increased proportion to the sensory input
 The neurological threshold is assumed to be very low;
“hair trigger.”
 Child may respond to this tendency by trying to avoid
the stimulus input, controlling the environment so they
can reduce the stimuli, or develop other skills to spare
their nervous system from experiencing the sensory
insults.
 They often learn that their behavior is seen as “weird”
or unusual and may try to hide their true response or
avoid trying to explain it.

 May
respond to sensory input slowly or only
after a lot of input to the sensory receptors
(greater spatial or temporal summation).
 May appear to be unresponsive to their name or
have a high pain threshold.
 They are more at risk for injury and exposure to
dangerous situations. Parents need to be more
vigilant with these kids to avoid danger.
 Often accompanied by other behaviors that
cause them to appear apathetic and
assumptions may be made about their intellect.
 Occupational
Therapy assumes that people are
driven to “normalize” their nervous system.
Children with dysregulated systems often seek
out sensory experiences to help move them into
the normal range.
 Movement, tastes, smells, textures, touch
input, multisensory experiences can be
compelling stimuli for this person.
 A daily “sensory diet” helps provide the input
this person needs. They may need help choosing
the appropriate input. Ex: bike riding instead of
kicking.
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May be seen as clumsy or uncoordinated.
May have low muscle tone.
May have handwriting issues.
May have right/left discrimination issues.
Motor output manifests poor processing in the
brain.
May have poor posture.
May have gross and/or fine motor
un-coordination.
May have poor self-esteem from self perception of
motor incompetence. May give up trying new skills.
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•
…can compel a person to behave
“differently” than others. The world is seen
as a potentially painful or offensive place;
anxiety or defensiveness can develop.
…can impact many life activities including
self care, work, school, relationships, sleep,
etc.
…is comorbid with other
diagnoses such as learning disorders,
autism, & mental health diagnoses.
 Thorough
Evaluation, starting with Sensory
Profile
 Sensory
 EEG
Diet
Biofeedback
 Parent
and Professional Education
 Parent/Child
Group Practice
 Treating
Sensory Processing Disorder
increases chances of better healing of
attachment and trauma difficulties.
 Practice: With eyes covered, how frightening
is it for someone you don’t know to tell you
they’re going to touch you, but you can’t see
it coming?
 Ever feel “upset” and don’t know why? How
about if it’s all the time?

Creates a fuss when unhappy, calms when needs
are met

Plays and enjoys it!

Can change activity relatively easily (mastery)

Engages in reciprocal affection/attachment

If not (all of these things), something’s wrong
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How
do we achieve this for our
children?
 Parents’
mental and physical
health
 Right brain to right brain
“download” of healthy attachment
 Attunement
 Safe environment for learning
regulation
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External
regulation to teach and
support internal regulation
Expectations must meet ability
to develop positive self-esteem
Most predictive? Positive
coherent narrative of parent and
good parental attachment … 75 –
85%
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Opposing Poles of Complexity
Rigidity ……………………. Chaos
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These are for consideration only:
 Overanxious Disorder of Childhood
 Posttraumatic Stress Disorder
 Acute Stress Disorder
 Substance-Induced Anxiety Disorder?
 Mood Disorders, including Depression,
Dysthymic Disorder, Bipolar Disorder,
Substance-Induced Mood Disorder?
 Dissociative Disorders….
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1.
By Circumstance:
Examples:
Too many stressors
Not enough
resources/support
Traumatic Event
Others?
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2. By Teratogens, or other injury,
pre-birth or during critical brain
development periods. While we
still don’t know the totality of
effects of teratogens, we are
beginning to see “building
block” damage on brain scans.
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3. By genetic damage
New research by Rachel Yehuda,
Epigenetic research through
several major research
organizations
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 Neuropsychopharmacology
“Twin studies suggest that genes play an
important role in vulnerability to PTSD and
other anxiety disorders, but not the entire
role. The overall result of studies to date is
that risk is the product of multiple genes and
nongenetic factors working together.” (2010)
http://www.acnp.org/
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Impulsive
Distractible
Hyperactive
(driven-type)
Anxious (fear and physiological
arousal)
Agitation/Agitated depression
Emotional reactivity to “small pain”
Shame (despair)
Non-verbal LD, poor visuaspatials
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Manipulative
Holds
a grudge
Lacks empathy
Poor comprehension and expression
of emotions
Lack of body awareness
Poor balance/coordination
Nervous habits
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Unmodulated
voice
Poor eye contact
Poor social awareness
Lack of cause & effect thinking
Impatience
Aggressive
High pain tolerance
Lack of common sense
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Spaciness/daydreaming
Poor
concentration
Lack of motivation
Slow, variable response time
Cognitive anxiety
Depression/helplessness/hopelessne
ss
Perfectionist/low self-esteem
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Poor
receptive or expressive
language
Poor sequential processing
Poor reading comprehension
Poor calculation
Poor logic
Immune deficiency
Low thyroid function
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Hyperactivity
following sugar
(Hypoglycemia)
Hyperactivity with fatigue
Racing thoughts
Mood seings
Suicidal thoughts or actions
Panic attacks
Obsessive thoughts
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Compulsive
behaviors
Rages
Conduct
disorder
Oppositional defiant behaviors
Encopresis
Posttraumatic stress symptoms
Anorexia/bulemia/compulsive
overeating
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Addictions
(bipolar type)
Dissociative symptoms
Delusions
Pervasive developmental delays
Auditory processing deficits
Visual processing deficits
Scotopic sensitivity
Chemical sensitivities/autoimmune
dx
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Seizures
Vertigo
Tinnitus
Tremors
Motor
or vocal tics
Spasticity
Headaches
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Chronic
nerve pain
Sciatica
Sleep
walking
Nocturnal enuresis
Manic sleep behavior
Bruxism
Narcolepsy
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 Theraplay®
… play can go “under, around,
over,” when we can’t get “through.”
 EEG
Biofeedback (Neurofeedback) …
“bringing your brain to the gym,” to help the
brain effortlessly repair itself
 EMDR
(Eye Movement Desensitization &
Reprocessing) … open and secure pathways
from pre-verbal, “locked” trauma to allow
for safe processing
 Theraplay®
Right-brained, pre-verbal,
structured interactive play between parent
and child to enhance attachment, process
trauma, and teach regulation.
 Structure,
 Let’s
play!
Nurture, Challenge & Engagement
 Brain
wants to heal itself
 Children love to play novel games
 Repetition of a healthy “brain state” creates
a healthier processing brain
 “Beeps and points” are their own reward,
but feeling better is the ultimate reward!
 Numbers of games/programs, but I like
EAGER system of EEG Spectrum the best:
(EEGSpectrum.com)
 Eye
Movement Desensitization and
Reprocessing (EMDR)1 is a comprehensive,
integrative psychotherapy approach. It
contains elements of many effective
psychotherapies in structured protocols that
are designed to maximize treatment effects.
These include psychodynamic, cognitive
behavioral, interpersonal, experiential, and
body-centered therapies2.
 EMDR
psychotherapy is an information
processing therapy and uses an eight phase
approach to address the experiential
contributors of a wide range of pathologies.
It attends to the past experiences that have
set the groundwork for pathology, the
current situations that trigger dysfunctional
emotions, beliefs and sensations, and the
positive experience needed to enhance
future adaptive behaviors and mental health.