Developmental Trauma Disorder Root Cause of Adult Pathology? Dr B Paterson

Transcription

1 Developmental Trauma Disorder Root Cause of Adult Pathology? Dr B Paterson

2 ACE and Health Magellan Health Services, Inc./ACMHA: The College for Behavioral Health Leadership

3 Eco- biodevelopmental Model Biological Program Culture Childhood Experience Genetics and Neurobiology (Adapted from Willis 2010) Brain/Mind/ Body Learning History Behavior Physical, Social and Mental Well-being Relational Experiences

4 Trauma Type 1 Single, well-defined, more public trauma. Accidents, natural disasters wartime experiences. Type 2 Series of related, sequential / simultaneous trauma. Neglect, maltreatment, and sexual abuse often committed secretly and over long Periods by an intimate ( no safe place) during childhood

5 Trauma Type 1 Criterion A: Stressor B: Intrusion C: Avoidance D: Cognitions and Mood E: Arousal & Reactivity F: Duration G: Functional Impairment H: Exclusion Type 2 Hetereogenuous symptoms. Impaired development of personality. Dissociation, Low self efficacy, impaired regulation of emotion, (over & under) somatization, Disturbed perception of self and others Empathy Social Connections Attachment

6 Limitations of PTSD Diagnosis Conceptualised from an adult perspective Historical focused primarily on single event traumas Fails to recognize chronic/multiple/on-going traumas Is not developmentally sensitive and does not reflect the impact of trauma on brain development Many children exposed to chronic neglect and abuse do not meet full diagnostic criteria Does not direct clinical attention to attachment history and attachment-related injuries

7 Developmental Trauma Disorder losing sight of the forest in favor of one tree. (van der Kolk 2005)

8 DEVELOPMENTAL TRAUMA DISORDER Children who experienced ongoing traumatic stress in combination with Inadequate caring systems

9 Diagnosis? Exposure AffecBve and physiological dysregulabon Post- traumabc spectrum symptoms DuraBon of disturbance ACenBonal and behavioral dysregulabon Self and relabonal de- regulabon Persistence of symptoms FuncBonal impairment

10 Bowlby : four infant behavioral systems the exploratory system the affilia,ve system the fear/wariness system the a4achment system

11 EmoBonal Self regulabon What should be learned in early development is the ability to infer benign intent, which mi<gates the nega<ve experience and interrupts the aggressive response ( Dodge 2008:133) What is signally missing in the lives of some of our service users is a benign environment that allowed prolonged access to afuned adult(s) DTD sets the stage for unfocused responses to subsequent stress ( van Der Kolk)

12 AFachment To the degree that we feel connected to others, we feel safe and secure. To the degree that we do not feel connected to others we feel less safe and increasingly insecure (Hoffman, 2004)

13 Six core steps of acachment Claiming core idenbty ACunement trust AffecBve acunement empathy Impulse regulabon morality / guilt Shame regulabon social learning Rage management social acceptability

14 Fight Flight Physiology Autonomic nervous system, Hypothalamic-pituitary adrenocortical (HPA) axis. The immune system. Attenuates function in those areas of the brain that enable arousal, attention, and concentration on danger

15 Trauma Alters The Brain Altera<ons in Midbrain Altera<ons in Limbic System Fear and anxiety affect concentrabon and memory and over percepbon of threats Frontal lobe ReducBon in synapbc connecbons, Increase in stress hormones Poten<al for impact on mirror neurons

16 Iowa ACE Extrapolated

17 ACE Score Adult Depression % With a Lifetime History of Depression >=4 ACE Score Women Men

18

19 ACE Score vs. Adult Alcoholism % Alcoholic or more ACE Score Colleen Clark, Ph.D. University of South Florida 19

20 ACE Score and Hallucinations Ever Hallucinated* (%) >=7 Abused Alcohol or Drugs No Yes ACE Score *Adjusted for age, sex, race, and education.

21 (Riggs 2010)

22 Three problems with the current diagnosbc system have been revealed for maltreated children: no diagnosis, inaccurate diagnosis, and inadequate diagnosis ( van Der Kolk) Associated with an emphasis on behavioural control Lack of recognibon of interpersonal trauma Lack of recognibon of developmental disrupbon

23 Take Away Messages n n n n n n n Three core assumptions central to mental health (Janoff-Bulman): n n n That the world is benevolent That the world is meaningful That we are worthy Children whose primary dependency needs are not met often cannot make sense of the world They may live with cognitive distortions They may suffer processing disorders These increase their risk of further traumatisation These increase their risk of psychological distress and physiological ill health We can t afford to do nothing

24

25 References D'Andrea W, Ford J, Stolbach B, Spinazzola J, van der Kolk BA: 2012 Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis. Am J Orthopsychiatry, 82(2): Kessler RC, Davis CG, Kendler KS Childhood adversity and adult psychiatric disorder in the US NaBonal Comorbidity Survey. Psychol Med 1997; 27: 1101 Schmid., M. Petermann, F and Fegert JM 2013, Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnosbc systems. BMC Psychiatry 2013, 13:3 Terr LC Childhood traumas: an outline and overview. Am J Psychiatry, 148(1):10-20 van der Kolk, B.A Developmental trauma disorder: toward a rabonal diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), Widom CS, Czaja SJ, DuCon MA: 200 8Childhood vicbmizabon and lifebme revicbmizabon. Child Abuse Negl 2008, 32(8):