Lecture 6: Trauma & Personality Disorders PDF 2024

26/08/2024 Readings (non-assessable) Ford, J.D. (2017). Complex trauma & complex PERSONALITY & ITS DISORDERS posttraumatic stress disorder. In APA Handbook o...

26/08/2024 Readings (non-assessable) Ford, J.D. (2017). Complex trauma & complex PERSONALITY & ITS DISORDERS posttraumatic stress disorder. In APA Handbook of PSYU/PSYX336 Trauma Psychology (pp. 281-305). US: APA. Lecture 6: Trauma & personality Luyten et al (2020). Borderline personality disorder, complex trauma, & problems with self & Content warning identity. Journal of Personality, 88, 88-105 Stepp et al (2016). A systematic review of risk A/Prof Simon Boag factors prospectively associated with borderline email: [email protected] personality disorder. Personality Disorders: Theory, Research & Treatment, 7, 316–323 1 2 Outline Learning objectives 1) Introduction Describe & critically evaluate the DSM History of trauma & personality approach to trauma & PTSD PTSD & the DSM 2) Factors contributing to traumatisation Describe attachment theory & its relation to 3) Trauma & attachment theory complex trauma Attachment & personality development 4) Complex trauma Complex PTSD & dissociation Critically evaluate whether adverse childhood Is BPD a trauma-related disorder? experiences are sufficient for understanding the development of personality pathology 3 4 1. Introduction: trauma The complexities of trauma Trauma: Gk: Wound Various types of trauma: complex, betrayal, Physical & psychological trauma developmental, massive, cumulative, Being ‘overwhelmed’ intergenerational, social, moral, etc, etc. “Trauma is a fundamental concept in the field of Predicting traumatisation is v. difficult traumatic stress, but it is difficult to define & “Although trauma is ubiquitous, the long-term has been the source of much controversy” response to trauma is complex & ideographic, (Weathers & Keane, 2008) with individuals showing unique reactions to the traumatic event based on the unique ecology in which they live” 5 (Gerhart et al., 2015) 6 1  26/08/2024 History of trauma History of trauma in modern psychology in modern psychology 19th Century & study of hysteria Breuer & Freud (1895): Studies on Hysteria Pierre Janet (1889): L’Automatisme Trauma & split off traumatic memories Psychologique Hypnoid states vs repression Diathesis-stress Unconscious mental life Psychological weakness + trauma event Hysterics lack integrative capacity/mental Freud: energy Two models of trauma: Unassimilated traumatic memories ‘Unbearable situation’ model Splitting of consciousness & subconscious Conflict model Dissociative identity disorder 7 8 History of trauma & personality WWI: Psychic, nervous, mental shock (Myers, 1915) ‘Shell shock’, ‘traumatic neurosis’ Diverse symptoms: amnesia, confusional states, somatoform symptoms, exhaustion 1) Dazed, apathetic, lethargic, unresponsive 2) Fearful & easily startled “In some cases the patient would appear to be living again through an experience of the past, probably associated with the time of onset of the symptoms” (Turner, 1915) 9 10 DSM-III & Post-traumatic stress disorder (PTSD) (1980) PTSD: DSM-III/IV PTSD: initially an anxiety disorder CRITERION A: Traumatic stressor: Distressing event outside normal range of experience (DSM-III; DSM-IV) Intense fear, terror, helplessness PTSD: re-experiencing trauma, nightmares; avoidance/numbing, hyperarousal Duration > 1mth 11 12 2  26/08/2024 DSM-III & DSM-IV CRITERION A DSM-5 (2013) Traumatic stressors DSM-III: threat to life/physical integrity DSM 5: PTSD no longer an anxiety disorder (self/family) e.g. natural disasters; car Removes reference to subjective response accidents; war; rape; torture Intense fear, etc. found not to predict PTSD Adds to symptoms: persistent negative DSM-IV: expanded to include: alteration of mood & cognition ‘Developmentally inappropriate experiences CRITERION A expansion: ‘‘First-hand without violence or injury’ repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related)’’ 13 eg. Police officers; Social workers 14 PTSD onset Criticisms of trauma research PTSD can occur at any age, PTSD: initially life-threatening events, but… beginning after the first year ‘Inclusion of non-life-threatening events risks of life trivialising trauma’ Usually within the first 3 Haslam (2016): Concept creep: pathologising months after trauma ‘normal’ stress responses Delayed onset trauma: after many months/years ‘Today, nearly everyone counts as a trauma- ‘Delayed expression’: delay in survivor’ (McNally, 2003) meeting full criteria Bonanno, G. A. (2004). Loss, trauma, & Haslam, N. (2016). Concept creep: human resilience. American Psychologist, 59, 20-28 Psychology's expanding concepts of harm & pathology. 15 16 Psychological Inquiry, 27, 1-17 Difficulties with trauma research ‘Trauma’ as an event? 1. Correlation & demonstrating causation A problem with DSM’s criterion A: focussing 2. Retrospective studies upon what constitutes a traumatising event 3. V. difficult to predict specific outcomes “We use the word “trauma” to refer to a traumatic event or events” (Buchanan et al , 2020) “Most individuals exposed to the same risk factor will not develop any pathology, & many “Exposure to trauma is common, but individuals with the same disorder will have posttraumatic stress disorder (PTSD) is been exposed to entirely different risk factors” relatively rare” (McNally, 2003) (Paris, 1997; cf. DSM-5) Traumatisation is highly subjective 17 18 3  26/08/2024 Relational view of traumatisation PTSD Risk factors (adults) “….events are not traumatic in themselves, rather, they may be so in their effects on a given individual” (Van der Hart et al. 2006) Psychological traumatisation involves: (i) the objective aspects of the events; (ii) an individual & their reactions; (iii) the acute & chronic effects than can follow Brewin, et al. (2000). Meta-Analysis of risk factors for Posttraumatic Stress Disorder in trauma-exposed adults. Journal of Consulting & Clinical Psychology, 68, 748-766 What factors do we need to consider? 19 20 Harvey (1996): Harvey (1996): Ecology of trauma model Ecology of trauma model Ecology: the science of Environmental variables: important role of interrelationship of organisms community & culture & their environments The person(s) experiences the event within a Person x Event x larger context (the ‘environment’) which Environment includes the role of community, social, Person variables, event cultural, & political factors variables, & environmental DSM-5 & ‘cultural concepts of distress’ variables interact with one Cultural beliefs help determine both trauma another in shaping vulnerability & resilience (Bryant-Davis, 2019) traumatisation Harvey, M. R. (1996). An ecological view of psychological trauma & trauma Bryant-Davis, T. (2019). The cultural context of 21 trauma recovery. Psychotherapy, 56, 400-408 22 recovery. Journal of Traumatic Stress, 9, 3-23 Culture & resilient communities Interpersonal trauma & childhood (D’Andrea et al, 2012) Environmental variables: important role of Traumatisation in childhood? community & culture Worldwide: Culture can be a protective force for children, 1/3 children suffer physical abuse families & communities 1/4 girls; 1/5 boys suffer sexual victimisation eg. Aboriginal kinship relations reflect a D'Andrea, et al. (2012). Understanding interpersonal trauma in children: Why we need a complex & dynamic system that is not reflected developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82, 187-200 in existing non-Indigenous definitions of family (Lohoar et al. 2014) Protective against disadvantage & intergenerational trauma https://apo.org.au/sites/default/files/resource- files/2014-09/apo-nid41447.pdf 23 24 4  26/08/2024 Varieties of child victimisation 3. Trauma & attachment theory Familial physical, sexual, John Bowlby (1969, 1973, 1980) emotional abuse & incest Psychoanalytic background Community-, peer-, & school- Mental Health consultant to WHO based assault, molestation, War-orphan studies severe bullying; Anna Freud & René Spitz Severe physical, medical, & Psychological impact of separation & loss emotional neglect WHO report (1951): ‘Maternal deprivation’ Witnessing domestic violence Significance of emotional bond b/w child & Effects of caregiver mental caregiver(s) (Rutter, 1984) illness, substance abuse, Attachment as a universal need criminal involvement, or abrupt separation or traumatic loss 25 26 Attachment theory Attachment theory Ethological approach Attachment & cross-cultural evidence? Infancy & survival Responsive caregiving Widely tested & supported in Western Secure attachment samples (Mesmen et al, 2016) Does attachment still occur in non-western Insecure attachment contexts & with networks of multiple Anxiety caregivers (alloparents)? Avoidance Mesman, et al. (2016). Cross-cultural patterns of Mesman, et al. (2016). Cross-cultural patterns of 27 28 attachment. Handbook of Attachment (pp. 852-877) attachment. Handbook of Attachment (pp. 852-877) Is attachment universal? Universality of attachment? (Mesman et al, 2016) Allo-parenting: “cross-cultural evidence indicates that in most societies, nonparental caretaking is either the norm or a common form” (Mesmen et al, 2016) Efé (DR Congo): infants have on average 14 caregivers in first 18 weeks of life 29 30 5  26/08/2024 Attachment: Attachment & personality Risk & protective factors development Attachment theory: a framework for Mentalisation: the capacity to understand understanding risk & protective factors in ourselves & others in terms of mental states (Luyten et al 2020) development & traumatisation Relationships are essential for learning about one’s own & others’ minds Internal working models Working models of self Mirroring Working models of others Development of subjectivity Development of the affective self Development of self-object differentiation DEPARTMENT OF PSYCHOLOGY 32 Attachment & personality “By marked mirroring, the adult is describing the development child’s emotional state as it is being felt by the child, in a manner which simultaneously makes it Containment “involves the presence of another clear that it is the child’s feelings that are being being who not only reflects the infant’s internal enacted & understood, not the adult’s. It is via state, but re-presents it as a manageable image, these interactions that the child learns the as something that is bearable & can be content of mental states – to understand their understood” (Fonagy & Target, 1998) own mind & to begin to imagine what might be happening in other people’s minds” Important for developing self-regulation (Fonagy & Campbell, 2015) 33 DEPARTMENT OF PSYCHOLOGY 34 4. Complex trauma Complex trauma (Ford, 2017) Also known as: Complex trauma associated with: Attachment trauma Violence in relational contexts where safety & Type II trauma Early relational trauma protection should be provided Developmental trauma Child maltreatment (forms of abuses) Betrayal of trust by caregivers/authority “CT involves cumulative, polyvictimization Intentional violation of bodily boundaries perpetrated within the caregiving system during childhood by adults who are expected to provide security, protection, & stability. For these “They are intentional acts by other human beings children, CT is an ongoing & stable condition (interpersonal) that are inescapable & create a rather than a time-limited event” sense of fundamental insecurity” (Lawson & Akay-Sullivan, 2020) (Ford, 2017) 35 36 6  26/08/2024 Complex PTSD (cPTSD) (not in DSM)(Ford, 2017) Core cPTSD: affect dysregulation, identity alterations & relational impairment (AIR) cPTSD & chronic exposure to interpersonal stressors PTSD & acute exposure to impersonal/interpersonal traumatic stressors cPTSD & personality? 37 38 Complex trauma & dissociation Complex PTSD (cPTSD) (not in DSM) Dissociation = disconnection cPTSD associated with dissociation Disconnect between bodily states & the psychological emotional experience eg.identity confusion, dissociative amnesia Meta-analysis: high levels of dissociation in “Traumatized children frequently are both BPD & PTSD (n = 15,219; Lyssenko et al, 2018) disconnected from their own emotional experience — that is, they may lack Is BPD a trauma-related disorder? awareness of body states or the connection Lyssenko, et al (2018). Dissociation in psychiatric disorders: a meta- of those states to specific experiences & analysis of studies using the dissociative experiences emotions” scale. American Journal of Psychiatry, 175, 37-46 (Kinniburgh et al. 2005) 39 40 Is BPD a trauma-related disorder? Is BPD a trauma-related disorder? Meta-analysis: Porter et al. (2020) (97 studies) Meta-analysis: brain activation similarities b/w BPD 13.91 times more likely to report BPD & PTSD (vs controls) (27 studies; Amad et al, 2019) childhood adversity than non-clinical controls “Our findings are in agreement with the Emotional abuse & neglect largest effect hypothesis that BPD & PTSD share common neuropathological pathways” BPD 3.15 times more likely to report childhood adversity than other psychiatric groups Amad, et al. (2019). Similarities between borderline personality disorder & post traumatic stress disorder: Evidence from resting- Porter, et al (2020). Childhood adversity & borderline personality state meta-analysis. Neuroscience & Biobehavioral Reviews, 105, 52- disorder: a meta-analysis. Acta Psychiatrica Scandinavica, 141, 6-20 59 41 42 7  26/08/2024 Is BPD a trauma-related disorder? Ecology of complex trauma Luyten et al. (2020). Borderline personality disorder, complex trauma, & problems with Stepp et al. (2016). Systematic review of 39 self & identity: A social-communicative approach. Journal of Personality, 88, 88-105 prospective studies; most robust risk factors: Social domain: low SES, stressful life events, family adversity Maternal psychopathology Family domain: Affective parenting (low warmth, hostility, harsh punishment) Maltreatment: physical/sexual abuse, neglect Individual differences: low IQ, high levels of negative affectivity & impulsivity, internalizing & externalizing psychopathology 43 DEPARTMENT OF PSYCHOLOGY 44 Questions? 45 8