How to recognize, diagnose, and treat toward optimal healing

How to recognize, diagnose, and treat

toward optimal healing

Lark Eshleman, PhD

www.LarkEshleman.com

November 3, 4, 2010

9 – 10:15            Brain-based research on attachment and

trauma

10:30 – 12:00     Brain research (continued)

• 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.

Controls: Heart RateBlood PressureBody TemperatureRespiration

Brainstem

Part of brain stem that controls: ArousalAppetiteSatietySleepMotor Regulation

Midbrain

Locus for:Affiliation AttachmentSexual Behavior Emotional Reactivity

Limbic System

Enable: Abstract ThinkingConcrete ThoughtCause & Effect ThinkingReasoning

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. Schore defines psychopathology as:

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-TermAnxious, depressed, agitated, and excessively angry

Long-TermAggressive 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 interactionWithout causing distress and avoidance through over-intensity

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Neurological understandings: sensory processing disorder and

other “interrupted” developmental processes

• 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.

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?

• 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.

Miller et al; Am J Occ Ther Mar/Apr 2007 61:2

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.

• 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.

• …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 Diet

EEG 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

AttunementSafe 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 stressorsNot enough

resources/supportTraumatic Event

Others?46

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 48

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/

hopelessness 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, Nurture, Challenge & Engagement

Let’s play!

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.