The Neurobiology of Mood and Antisocial Behaviour in Adolescents

1. The Neurobiology of Mood and Antisocial Behaviour in Adolescents Ian M Goodyer MA MD FRCPsych FMedSci Department of Psychiatry University of Cambridge

5. Neural Systems And Affective Disorders

11. Neural Systems and Antisocial Behaviour

14. Functional Brain Networks

15. Proof of principle: Functional brain networks change during normal adolescence and are abnormal in schizophrenia Referee: We cannot relate complex neural data to complex clinical phenotypes Answer: Psychoses arise in late adolescence and early adulthood as a disorder of brain development. Using cross sectional and longitudinal structural imaging techniques we will reveal the ontogeny of atypical neurogenesis and relate these to latent traits for psychotic symptoms. Referee: We cannot relate complex neural data to complex clinical phenotypes Answer: Psychoses arise in late adolescence and early adulthood as a disorder of brain development. Using cross sectional and longitudinal structural imaging techniques we will reveal the ontogeny of atypical neurogenesis and relate these to latent traits for psychotic symptoms.

18. Thanks to Funding AgenciesWellcome TrustMRCNIHRDoE

19. Clinical Global Impression Over The ADAPT Study Period

20. Improving Mood With Psychoanalytic Psychotherapy And Cognitive Behaviour Therapy: THE IMPACT STUDY

26. Conclusions1. 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 problems2. Biological differences mean that different children will respond differently to the same experiences

31. Genes are not acting in a deterministic way. Genes are not acting in a deterministic way.

34. Not who adult is – how often the child sees them. Not who adult is – how often the child sees them.

37. Brain Function

54. Supporting Children’s Development An Attachment Approach Pasco Fearon Research Department of Clinical, Educational and Health Psychology

55. 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

56. Example 1

58. 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

59. 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. Making Sense of Disorganization Fear as key determinant (Main & Hesse, 1990) Parental frightened/frightening behaviour

61. Consequences

62. Consequences: Externalizing Problems

63. 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

64. 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)

65. Intervention

66. Focusing on Attachment

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

68. Before Intervention

69. After Intervention

70. Sensitivity-Based Intervention Moss et al. (2011). Similar approach with older children (preschoolers) 8 home visits

71. Impact on Attachment

72. 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

73. Thinking about the Unthinkable Mentalizing Trauma Alessandra Lemma

74. Traumatic events do not discriminate: Paul’s story

75. A trauma is an attack on our attachments It is experienced as a breach in the quality and felt security of our attachments

76. We feel distressed and we want to be hugged (or not…..)

77. Traumatic experiences undermine the psychically integrating function of narrative Breakdown in the capacity to reflect on lived experience (i.e. to symbolise)

78. What causes PTSD?

79. 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)

80. 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

81. 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

82. 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

83. Another prominent post-trauma risk factor is ongoing stress in the aftermath of the ostensible traumatic event (Vogt et al., 2007)

84. Unempathic responses in attachment relationships, which might resonate with earlier adverse attachment experience, play a significant role in vulnerability

85. 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

86. Reducing “the trauma” to any single event is therefore arbitrary

87. The impact of trauma on mentalising

88. 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).

89. Impact of attachment trauma on the capacity for emotion regulation and mentalizing Vulnerability stemming from traumatic childhood attachments:

90. These relationships evoke extreme distress AND Impair the development of capacities to regulate emotional distress—in part through compromising the development of mentalizing

91. 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

92. There is far more to treatment required than processing traumatic memories. Attentiveness to strengthening emotion-regulation capacities is central

93. Research has shown that the capacity for mentalizing is undermined in most people who have experienced trauma

94. Mentalizing goes offline when defensive (fight-flight-freeze) responses come online

95. 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)

96. Reliving the trauma takes the place of remembering the trauma

97. 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 …)

98. 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

99. Therapeutic work with traumatized young people

100. Less emphasis on techniques and more on a way of thinking about the therapeutic process and the therapist’s stance

101. Mentalizing stance Focus is primarily on the patient’s mind, not on the event. A mentalizing stance emphasises process over content

102. 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)

103. Promoting mentalizing does not require direct processing of traumatic memories It requires mentalizing painful emotions and conflicts in the context of an attachment relationship.

104. This treatment strategy runs counter to the young person’s inclination towards defensive avoidance of thinking about what has happened to them

105. The clinical priority is to reduce arousal so that the young person can think of other perspectives (mentalize)

106. Establish a sense of “interpersonal security” (Sullivan, 1953) between worker and young person that will contain their anxiety

107. 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.

108. 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

109. 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.

110. 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

111. 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)

112. 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.

113. Objects of hope The therapist/worker potentially provides a point of re-entry into a non-traumatized world

114. 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

115. 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

116. 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

117. 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. 118 Legacy of Childhood Maltreatment in Adulthood

119. 119 Key points - there is a legacy frommaltreatment 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 more common than is assumed

120. 120 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 Disorder (Simon et al, 2009)

121. 121 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

122. 122 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)

123. 123 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 repeatedly throughout their lives

124. 124 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 by their children

125. 125 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

126. 126 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

127. 127 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 Actions can be the words that cannot be spoken

128. 128 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

129. 129 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

130. 130 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 something left untranslated, yet-to-be translated (Shinebourne, 2006, p336)

131. 131 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 Workers however need support to do this work and to avoid repeating the traumatic cycle of abuse and neglect

132. 132 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)