Lecture Slides - Developmental Trauma PDF

Developmental Trauma Geneviève Trudel, PhD Candidate University of Ottawa Announcement! •In-person exam Thursday •Reading week next week Recap from last lecture • Obsessive-compulsive disorders and other obsessive-compulsive disorders • Somatic symptom and related disorders • • • • Illness anxi...

Developmental Trauma Geneviève Trudel, PhD Candidate University of Ottawa Announcement! •In-person exam Thursday •Reading week next week Recap from last lecture • Obsessive-compulsive disorders and other obsessive-compulsive disorders • Somatic symptom and related disorders • • • • Illness anxiety disorder Psychological factors affecting medical condition Conversion disorder Factitious disorder • Any question, comments, reflections? Outline • • • • • • • What is trauma? Brain development Fight-Flight-Freeze response Window of tolerance Emotional regulation Attachment CPTSD We will be discussing traumatic events today. A reminder of the student mental health resource guide: https://1in5initiative.ca/wpcontent/uploads/2021/01/Guide-EN-ressourcessante%CC%81-mentale_-Final.pdf Trauma • Trauma is something that overloads the system. It is often something that is relived rather than something that is remembered. • There are multiple different types of traumas. What is developmental trauma? • A term used to describe the impact of early, repeated trauma and/or loss which happens within the child’s important relationships, and usually early in life. For example : • A baby/child who is relinquished by birth parents • A baby/child who is the victim of abuse • A baby/child who has been neglected • A child who expired severe health problems and multiple medical interventions • These individuals often develop suboptimal coping strategies • They may struggle with essential daily living skills such as managing impulses, solving problems, learning new information Intergenerational Trauma • Traumatic events can leave an imprint on the genes, altering their expression and potentially affecting future generations. • They are ”chemical tags” or ”markers” that attach to the DNA and impact how genes function. • According to Bruce H. Lipton, “The mother’s emotions, such as fear, anger, love, hope among others, can biochemically alter the genetic expression of her offspring” to prepare them for their environment. Adverse childhood events (ACES) • Almost two-thirds of people reported at least one ACE, and more than one in five reported three or more ACEs. Types of ACES include: • Abuse (physical, sexual, emotional) • Household Challenges (domestic violence, substance use, severe mental illness, divorce, legal problems) • Neglect (physical, emotional) https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvi olenceprevention%2Facestudy%2Fabout.html The experience of trauma will vary depending on : • Age of onset • first 8 weeks of a baby’s life has the most influence on their later well-being • Severity • Frequency • Duration • Extent of injury (emotionally or physically) • The quality and quantity of safe relationships The importance of caregiver responses • Infants and children turn to their caregivers to differentiate between threat and excitement • Ideally, a caregiver shows alarm only when something is truly alarming and soothe the infant/child when they have been frightened • With consistent response, infants and children slowly learn how to calibrate their perception system and develop more nuanced responses to stimulation • Developmental trauma profoundly affects the infant/child social "safety system" • Chaotic social environments with inconsistent safety feedback can lead to confusion in distinguishing safety from threat. • This confusion may heighten the child's sensitivity to danger while limiting their ability to recognize safety. Brain development • We are not born with a fully developped brain. Early on, our brains start to develop from the bottom up. • The brainstem (the reptilian/primitive brain) develops first. • Allows for basic functions (e.g., breathing, heart rate, sleep). • Threat response system • ”Am I safe?” • Limbic brain develops next • Involved in emotional development, attachment, memory • “Am I loved?” • Cortical brain develops last • Involves rational thinking, learning, inhibiting • “What can I learn from this?" Early experiences also changes the brain • Neuroplasticity: structural and functional changes in response to experiences and environmental influences. • « what fires together, wires together » • Eventually, traumatised children have an overconnectivity in the parts of their brains required for survival and an underconnectivity in the parts of the brain required for cognition. The fight-or-flight response is a helpful evolutionary adaptation… • Fight-or-flight response: Biological reaction to alarming stressors that musters the body’s resources to resist or flee the threat. • Evolved millions of years ago • Physiological changes: increased breathing rate, increased heart rate, non-essential tasks are paused (e.g. digestive) • Extremely useful for when we experience real threats (like a bear in the woods) What is the Orienting Response? • When an individual perceives a potential threat or a novel and potentially significant stimulus, their body and mind automatically engage in a process of orientation. • This involves the following: • Attentional Focus: redirect attention to the perceived threat or stimulus, enhance awareness and vigilance • Sensory Processing: Heightens senses (vision, hearing, touch) • Information Gathering: rapidly processes sensory data, build a comprehensive understanding of the situation • Decision-making: make an essential decision for survival, prepares the body for action What is the Flock Response? • We seek proximity • Seen in mammals and birds What is the Flight Response • Individuals are inclined to avoid or escape from the perceived threat or danger rather than confront it directly. • This response involves a series of physiological and behavioral changes that prepare the body for rapid movement and escape. • The sympathetic nervous system becomes activated • Increase in heart rate • Increase in blood pressure • Increase blood flow to muscles • Heighten alertness • Release of hormones (e.g., adrenaline, cortisol) • Temporary suppression of non-essential functions (e.g., digestion) What is the Fight Response? • Instinct to confront and combat the threat • We will fight to flight! • Confront and combat the threat • We are pushed further into the sympathetic system (another increase in heart rate, blood pressure, blood flow…) • Release of natural endorphins to reduce pain sensation What is the Freeze Response? • Individuals essentially "freeze" or become immobile, often in the hope that by remaining still and silent, they can avoid detection or danger • Often the best option when a threat is inescapable • Physiological response: • Body may become rigid • Breathing and heart rate slows down to conserve energy • Verbalization and vocalizations are minimized to avoid drawing attention • Increase pain threshold Dissociation • Dissociation: separation or disconnection between thoughts, feelings and behaviours; and a separation between the mind and body. • The mind’s way of putting unbearable experiences and memories into different compartments. • For example: a child enduring physical abuse; they may mentally escape the traumatic situation as a means of survival. • Dissociation allows individuals to mentally "leave the room" when faced with unbearable trauma. • Babies and toddlers naturally dissociate when danger or intolerable experiences occur, helping them cope with overwhelming fear. (Beacon House Therapeutic Services and Trauma Team) The Window of Tolerance Window of tolerance (optimal arousal zone) • Attuned to self and others • Able to think, reason, relate Hyperarousal • Intense emotions (fight or flight) • No sense of rules • No sense of past or present • Cannot pay attention to others Hypoarousal: • Shutdown (freeze) • Absent of slowed speech • Numbness, spacy, difficulty connecting with others *WE ALL HAVE A DIFFERENT WINDOW OF TOLERANCE Faux Window of Tolerance e.g., substance use, excessive exercise • Illustrates what happens when an individual consistently operates beyond their optimal arousal zone and has developed coping mechanisms to make them feel as if they are within that zone, even though they are, in reality, consistently operating outside of it. • These coping mechanisms are essentially strategies for managing their state. e.g., self-harm, certain substances, exercise Emotion regulation • Typically, older children know how to • (a) notice they are having an emotional reaction • (b) know what emotion it is • (c) express it in a healthy and clear way • (d) manage the emotion well so that they start to feel calm • Babies and toddlers cannot regulate their emotions, they rely on their parent/caregiver to ‘co-regulate’ them. • It is important for caregiver to co-regulate the baby/toddler so that as the baby grows up, they learn how to regulate themselves. • Children who are not co-regulated, or irregularly co-regulated with learn “my feelings are dangerous, they hurt others, they hurt me’. This then becomes their “rule for emotions” which they may well carry through life. Regulation & Co-Regulation • Regulation : our ability to manage our emotional state, to calm ourselves during times of heightened emotion. This is a learned process. • Co-regulation : process by which parents/caregivers help children soothe their intense emotions. The parent/caregiver steps in as a mentor and external source of soothing when the child feels distressed. • When regularly co-regulated, the child can grow in productive, healthy, and predictable ways toward emotional maturity. • The process of co-regulation sets the stage for critical physiological processes, including the maintenance of homeostasis (or physiological equilibrium). (Beacon House Therapeutic Services and Trauma Team) Attachment • Was studied by Bowlby in 1958 and was further studied by Ainsworth in 1978 • Attachment is a deep emotional bond that connects one person (often early in childhood) to another (who often will act as a caregiver). • We are born completely dependent on our caregiver for survival. As such, biologically we desire a strong relational bond with that caregiver to ensure they will continuously take care of us. Why do we form an attachment? • Provide a safe base from which to explore • Provide a safe haven to return to when exploration raises fears • Allow the newborn to seek contact and maintain proximity with a caregiver • Allow the newborn to challenge the separation by crying or clinging, which signals to the caregiver that the newborn should not be left to fend for itself Secure attachment • Characterized by: • A child who explores their environment in the presence of the attachment figure • Secure attachment is characterized by a child who is: • resilient, confident, resourceful, able to mentalize, better stress management 58% • The primary caregiver was : • consistently responsive, available, tolerant of independence • All these elements make it a little easier for the securely attached child to bond with others and explore with confidence. (Kain & Terrell, 2018; Bakermans-Kranenburg & van IJzendoorn, 2009) Anxious-avoidant insecure attachment • Characterized by: • A child who does not turn to parents for support or comfort • Characterized by a child who is: • distant, distrustful, self-sufficient, who frequently appears to present as experiencing no stress. • Primary caregiver was: 23% • frequently unreceptive, unavailable, punitive when child expressed a need • All these elements make the task more difficult for the child, as they keeps others at a distance and prefers to do things independently. (Kain & Terrell, 2018; Bakermans-Kranenburg & van IJzendoorn, 2009) Anxious-resistant insecure attachment • Characterized by: • Anxious, vigilant, clingy, signals to parent that they want comfort and when they receive it, rejects it. • Characterized by a child who is: • anxious, intrusive, needy • The primary caregiver was : • frequently unreceptive, unavailable, punitive when the child expressed a need 19% • This child is learning that caregivers are unreliable, and that support may not be available when he needs it. For this child, the most appropriate response is to remain alert and ensure that the caregiver remains engaged. (Kain & Terrell, 2018; Bakermans-Kranenburg & van IJzendoorn, 2009) Disorganized/disoriented attachment • Characterized by: • A child who has been terrified by his attachment figure, is disorganized in their ways. • Characterized by a child who is: • disorganized, inconsistent, can be reactive, fight/flight/freeze Unclear less than • Primary caregiver was : • neglectful, traumatizing, inconsistent 5% (Kain & Terrell, 2018) Why is this important in adulthood? • Inconsistent caregivers lead to infants that need to construct a new survival system to account for the caregiver’s absence. • This can lead to a state of fright and terror in the infant. • The infant will no longer be able to perceive safety and will therefore treat most situations as though they’re riddled with possible threats. • Can lead to lower development of the brain related to resiliency (Shonkoff et al. 2012; Kain & Terrell, 2018) Effects of early trauma on cognition • Chronically traumatized children often experience under-developed cognitive skills. This affects their ability to: • • • • Plan ahead Problem solve Organize themselves Learn from mistakes • Traumatized children are often "stuck" in their brainstem or limbic system. • They expend resources on assessing safety and determining if they can trust adults. • This limits resources for essential "higher brain" skills needed for cognitive functioning. • Other children will become pre-occupied with school and performance as they may see it as a currency for love. (Beacon House Therapeutic Services and Trauma Team) Self-Concept & Identity Development • Self-concept starts to form from the first messages we receive about ourselves from caregivers. • If caregivers send the message that a child is not worth keeping safe, and their cries pushes people away, children’s self-concept will reflect that. • Individuals who have experienced early trauma often develop a deep sense of being ”bad” or “unwanted” and this is reflected in the way they perceive themselves. • It can be hard for these individuals to learn and accept that they are lovable and worth keeping safe. • These individuals develop a poor sense of identity and may struggle to know simple things such as : what they enjoy, what they don’t enjoy, want they want for their future. (Beacon House Therapeutic Services and Trauma Team) What is the ICD-11 • International Classification of Disease for Mortality and Morbidity Statistics • The international standard for systematic recording, reporting, analysis, interpretation and comparison of mortality and morbidity data • https://icd.who.int/browse11/l-m/en DSM-5 Criteria: Post-Traumatic Stress Disorder A. Exposure to actual or threat death, serious injury, or sexual violence B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred: D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred F. Symptoms have persisted for at least one month G. Symptoms cause significant distress and/or social/occupational dysfunction • Specifiers • With dissociative symptoms (depersonalization/derealization) What is Complex PTSD • Develops following exposure to an event or series of events of an extremely threatening or horrific nature, that are often prolonged or repetitive from which escape is difficult or impossible (e.g. torture, prolonged domestic violence, repeated childhood sexual or physical abuse). • All diagnostic requirements for PTSD are met. • In addition, Complex PTSD is characterised by severe and persistent • 1) problems in affect regulation; • 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and • 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning. ICD-11 Criteria: Complex Post-Traumatic Stress Disorder • Exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged, or repetitive events from which escape is difficult or impossible. • Following the traumatic event, the development of all three core elements of PostTraumatic Stress Disorder, lasting for at least several weeks: • Re-experiencing the traumatic event • Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). • Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. ICD-11 Criteria: Complex Post-Traumatic Stress Disorder • Severe and pervasive problems in affect regulation. • Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the stressor. • Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them. • The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Difference between PTSD and cPTSD • CPTSD often involves continuous exposure to a traumatic event whereas PTSD can occur after a single traumatic event. • CPTSD includes alterations in the perception of self • CPSTD is categorized by difficulties in relationships Bottom-up vs Top-down approaches • Bottom-up therapies : therapies that focus on the body and sensory experiences. Addresses physical sensations, emotions, and bodily responses to trauma or stress. • E.g.: Eye Movement Desensitization and Reprocessing (EMDR), mindfulness, sensory • Top-down approaches : therapies that focus on the cognitive and psychological processes. Focuses on thoughts, beliefs, emotions, and conscious awareness. • E.g., CBT, prolonged exposure Examples of strategies Midterm questions? •In-person exam Thursday •Reading week next week Summary • • • • • • • What is trauma? Brain development Fight-Flight-Freeze response Window of tolerance Emotional regulation Attachment CPTSD