Document 13726

Attachment Trauma
Jon G. Allen, Ph.D.
The Menninger Clinic
Baylor College of Medicine
Outline
Intergenerational Transmission
Attachment Trauma
Intergenerational Transmission of Attachment Trauma
Trauma-Related Psychopathology
Clinical Example: Disorganized Attachment
[email protected]
Intergenerational transmission and developmental psychopathology
child
attachment
security
parental attachment
security
I. Intergenerational transmission
child
mentalizing
parental mentalizing
in relation to
childhood attachment
parental
mentalizing of
child
emotion
regulation
psychosocial
functioning
adapted from Sharp & Fonagy
(2008) Social Development
Adult Attachment Interview (AAI)
Hour-long interview designed to be moderately stressful
five adjectives for each parent; concrete examples
feelings of closeness
how they responded when you were hurt or ill
separation experiences
feeling rejected or threatened
losses over the lifetime
Reflection on experiences (mentalizing)
how the relationships affected your personality
reasons parents behaved as they did
change in relationships from childhood to adulthood
relationships with children
how relationships with parents affected relationships with children
note similarity to psychotherapy sessions
Strange Situation (Infant Attachment)
1.
2.
3.
4.
5.
6.
7.
8.
The infant and the mother are brought into an unfamiliar but
comfortable room filled with toys;
the infant is given the opportunity to play with the toys,
potentially with the mother’s assistance;
a stranger enters the room and plays with the infant;
the mother departs, leaving the infant with the stranger and the
toys;
the mother returns, pausing to give the infant a chance to respond
to her return, and the stranger leaves the room;
the mother leaves the infant alone in the room;
the stranger comes back into the room and interacts with the
infant as needed;
then the mother returns, and the stranger leaves the room.
Parental Mentalizing Links: Meins
Parental Mentalizing Links: Slade
Elizabeth Meins: mind-minded commentary (6 months)
Commentary referring to the infant’s
Arietta Slade: Parent Development Interview
knowledge (“You know what that is, it’s a ball”)
interests (“What toy do you prefer?”), or thought processes (“Are you thinking?”
state of mind, voicing feelings of being bored, worried, or excited;
efforts to manipulate beliefs (“You’re joking”; “You’re just teasing me”)
addresses emotionally charged interactions: “Describe a time in the last week
when you and your child really clicked” and then “a time when you and your child
really didn’t click”
High levels of parental mentalizing:
•
•
parents’ recognition of their child’s emotional states
ability to link their own mental states with those of their child: “I was just so sad and
frightened (mental state) by the fight I had with my husband. I wasn’t myself at all
(behavior) and this was so disorienting to my baby (implies effect on baby’s mental state”
Low levels of parental mentalizing:
•
•
•
parents are oblivious their child’s feelings: “She clings to me, but she’s fine”, “She wakes
up in the night screaming, screaming, but nothing really bothers her”
attributions of malevolence to the child (e.g., as being a devil)
lack of awareness of their own emotions in parenting (e.g., denial of anger, guilt feelings,
or joy)
Intergenerational Transmission: Secure Attachment
Intergenerational Transmission: Ambivalent Attachment
Parent’s Discussion of Childhood Attachment Experience
Parent’s Discussion of Childhood Attachment Experience
coherent, at ease, open, free to explore, balanced view of self and others
Parent’s Behavior with Infant
sensitively responsive, emotionally available
Infant’s Behavior with Parent
explores environment and checks back with parent; focuses on parent around
separation; misses parent; initiates physical contact on reunion; flexible attention
to parent and environment
Developmental Outcomes
accepting of dependency; effectively dependent and independent
feeling of self-worth and self-confidence
empathic and caring toward others; capacity for trust and intimacy
open to positive and negative emotions; skillful in emotion regulation
internal secure base: self-soothing; comforting memories of attachment
relationships
poor capacity to focus, long-winded, vague, tangents, preoccupied with anger toward
parents, blaming and self-blaming
Parent’s Behavior with Infant
inconsistent, unavailable, unresponsive, under-involved
Infant’s Behavior with Parent
wary and distressed, focus all attention on parent to the exclusion of play, difficult to
soothe or comfort on reunion, anger mixed with effort to maintain contact; cling and
kick
Developmental Outcomes
anxious, hypervigilant, worried about attachment figure’s availability/responsiveness
exaggerate threat/fear to elicit care; seek reassurance; anxiety sensitivity
negative beliefs about self and world; rumination
punish to discourage attachment figure from unresponsiveness
Intergenerational Transmission: Avoidant Attachment
Parent’s Discussion of Childhood Attachment Experience
poor memory for childhood; downplay negative experiences; idealize or devalue
attachments; present self as strong and independent
Parent’s Behavior with Infant
rejecting of infant’s bids for comfort when distressed; unemotional with infant
intrusive, controlling, over-stimulating
Infant’s Behavior with Parent
direct attention toward environment and away from parent whether parent is
present, departing, or returning; unemotional with parent
Developmental Outcomes
downplay threat, worry, vulnerability, need for comfort; reject help
lack of emotional awareness sometimes coupled with physiological reactivity
defensive self-inflation; unwilling to provide comfort and support
emotional health but collapse of defenses with extreme stress
II. Attachment Trauma
Trauma spectrum
Attachment trauma: Two senses
PTSD
Complex PTSD
Dual liability associated with attachment trauma in
childhood (Fonagy & Target)
Trauma that occurs in an attachment relationship,
in childhood or adulthood
Trauma that adversely affects the capacity for
secure attachment—the bane of the therapeutic
relationship
provokes extreme, repeated stress
undermines the development of the capacity to
regulate distress
§ insecure attachment
§ impaired emotion-regulation
§ impaired mentalizing capacity
“Trauma” broadly construed
ALONE
AFRAID
unbearable
emotional
states
+
absence of
experience of
being mentalized
feeling abandoned
neglected, unloved,
invisible
IMPAIRED
MENTALIZING
CAPACITY
Mentalizing failure in abusive behavior
abuser
terrorizing
mindblind
ALONE
AFRAID
unbearable
emotional
states
+
absence of
experience of
being mentalized
feeling abandoned
neglected, unloved,
invisible
IMPAIRED
MENTALIZING
CAPACITY
Factors that affect (maternal) caregiving and
contribute to discontinuities in development
Financial resources; poverty
Parental health, physical and mental
Single parenthood
Quality of marital relationship
Social support for the family
III. Intergenerational Transmission of
Attachment Trauma
Non-mentalizing in the intergenerational transmission
of attachment trauma
parental attachment
insecurity ↔ impaired
parental mentalizing
capacity
infant affective
dysregulation
non-mentalizing parent-infant interactions
infant attachment disorganization
impaired mentalizing capacity in childhood
Impaired mentalizing in maltreated children
Less inclined to engage in symbolic play
Difficulty understanding emotional expressions
Less conversation about internal emotional states
Less likely to respond empathically to peers’ distress
Show more emotionally-dysregulated behavior
Intergenerational Transmission of Disorganized Attachment: Overview
Parent’s Discussion of Childhood Attachment Experience (AAI)
unresolved with respect to trauma or loss
hostile-helpless states of mind
Parent’s Behavior with Infant in the Strange Situation
maltreatment; frightened/frightening
disrupted emotional communication
Infant’s Behavior with Parent
fright without solution; fear, dissociative states, contradictory behavior
[Fonagy, Gergely, & Target, 2007]
Developmental Outcomes
switch to controlling behavior in early childhood
vulnerable to psychopathology in childhood and adulthood
Disorganized Attachment: Parental Discourse in AAI
Disorganized Attachment: Parental Discourse in AAI, continued
Mary Main
Karlyn Lyons-Ruth
lapses in the monitoring of reasoning or discourse during discussions of loss or
other potentially traumatic experiences
lapses suggest temporary alterations in consciousness
coding AAI transcripts as a whole for hostile-helpless states of mind based on identifications
with hostile or helpless childhood attachment figures that appear unintegrated in the mind of
the speaker
represent either interference from normally dissociated memory or belief systems,
or unusual absorptions involving memories triggered by the discussion of
traumatic events
lack of integration stems from repeated, early, and prolonged interpersonal trauma
akin to PTSD (intrusive experiences) and dissociative states
Persons in the helpless subtype are pervasively fearful and passive, identifying with a parent
who abdicated the caregiving role
also unclassifiable interviews showing no consistent attachment strategy
Persons in the hostile subtype describe attachment figures as malevolent and tend to identify
with them: “My mother was horrible—I’m just like my mother”
Disorganized Attachment:
Parents’ behavior with the infant
Disorganized Attachment:
Infant Behavior in Strange Situation
Main: Frightening-Frightened Behavior
Frightening behavior (e.g., various forms of abuse)
Frightened behavior (e.g., anxious, timid, disorganized, dissociatively detached)
Both frightening and frightened parental behavior are frightening to the infant
Lyons-Ruth: Disrupted Communication
negative-intrusive behavior (e.g., mocking the infant)
role confusion (e.g., seeking reassurance from the infant)
withdrawal (e.g., silence)
communication errors (e.g., contradictory cues such as verbally encouraging the infant to
come close and then physically distancing from the infant)
Sequential display of contradictory behavior: after a bright greeting with raised arms, the infant freezes
with a dazed expression; or the infant appears calm and content during the separations and then, on
reunion, becomes intensely focused on the parent, showing distress or anger.
Simultaneous displays of contradictory behavior patterns: the infant clings to the parent while sharply
averting his head and gaze; approaches by backing toward the parent; reaches up toward the parent with
arms extended but with head turned down or averted; smiles at the parent with an expression that also
conveys fear; or strikes or pushes against the parent while in an apparently good mood.
Undirected, misdirected, or interrupted movements: upon becoming distressed, the infant moves away
from the parent; seemingly approaching the parent, the infant attempts to follow the stranger out of the
door; moves the hand toward the parent and then quickly withdraws it; makes extremely slow or limp
movements toward the parent; or suddenly and inexplicably cries or shows anger in the midst of
otherwise contented play.
Stereotypical or anomalous movements: the infant engages in extended rocking or hair twisting; shows
tics; or displays jerky, automaton-like movements.
Freezing and stilling: the infant sits or stands with arms held out for prolonged periods; or maintains a
slack or dazed expression.
Apprehension regarding the parent: the infant jerks back from the parent with a frightened expression;
moves behind a chair to avoid the parent; or shows vigilance or tension in interacting with the parent.
Direct indices of disorganization or disorientation: the infant engages in disorganized wandering; shows a
disoriented expression or blind look in the eyes; or greets and approaches the stranger with raised arms
as the parent enters the room
disorientation (e.g., unusual changes in voice during an interaction)
Disorganized Attachment and Psychopathology
Infant disorganization predicts
Teachers’ ratings of dissociative behavior in school
Dissociative Experiences Scale scores in young adulthood
Vulnerability to PTSD in childhood
Harbingers of Borderline Personality Disorder (BPD) at age 12
disturbances in attention, relationships, identity
instability in emotion and behavior
Symptoms of BPD in structured interviews at age 28
Adult disorganized/unresolved attachment is associated with
Global psychopathology and clinical status
BPD
PTSD
Suicidality
Beebe: 4-month predictors of disorganized attachment
Second-by-second video analysis, 150s, free interaction: mothers
instructed to play with their infant placed in an infant seat on a table;
play as usual but without toys
Strange Situation attachment classification at 12 months
Future disorganized infants’ behavior:
high levels of emotional distress (facial and vocal)
discordant responses, e.g., one infant joined sweet maternal smiles
with smiles of his own, but meanwhile he whimpered as his mother
pushed his head back and roughly smacked his hands together
behavior erratic and unstable, moment-to-moment, potentially
making it more difficult for mothers to read (mentalize)
low levels of self-soothing, emotion-regulating self-touch
Beebe: Maternal behavior predicting disorganized attachment
(1) gazed away from their infant’s face more often and unpredictably
(2) loomed into the infant’s face more often and unpredictably
(3) did not respond to their infant’s self-touch with complementary affectionate
touch
(4) showed less variable emotional responsiveness, that is, relatively rigid, closedup facial expressions
(5) were less likely to follow the infant’s shifts between positive and negative
emotions, for example, less able to “emotionally ‘enter’ and ‘go with’ infant
facial and vocal distress”
(6) showed discordant emotional responses, responded to their infant’s distress
with surprise or positive emotion. Discordant responses are indicative of denial
of the infant’s emotional distress, attempting to ride negative into positive,
e.g., “Don’t be that way” or “No fussing, no fussing, you should be very happy”
Attachment and maternal engagement with infant
distress (Strathearn, Fonagy, et al., 2009)
AAI’s administered to first-time mothers during pregnancy
7 months: Measured mothers’ serum oxytocin levels after interacting with infant
11 months: measured mothers’ brain activity associated with viewing pictures of
infant’s smiling and sad faces
Contrasted AAI secure and avoidant-dismissing mothers
Secure mothers showed higher increases in serum oxytocin than dismissing
mothers after interacting with their infants
Serum oxytocin levels correlated with subsequent activation in dopaminergic
reward pathways (ventral striatum) in response to observing pictures of their
infant’s face
Secure mothers showed activation in dopaminergic reward pathways when
viewing their infant’s sad face as well as happy face
Dismissing mothers showed patterns of brain activation consistent with negative
emotion (insula) and emotion-regulation efforts (dorsolateral PFC) in
response to sad faces
Conclusion: Secure mothers remain positively engaged in the face of infant
distress (mediated by oxytocin activating dopaminergic pathways)
Beebe’s Mind-Minded Commentary
Mothers are not generally less empathic; rather, failure of attunement during
moments when infant is in a state of distress
I’m so upset and you’re not helping me. I’m smiling at you and whimpering;
don’t you see I want you to love me? When I’m upset, you smile or close up
or look away. You make me feel worse. I feel confused about what I feel and
about what you feel. I can’t predict you. I don’t know what is going on. What
am I supposed to do? I feel helpless to affect you. I feel helpless to help
myself. I feel frantic.
Later Opportunities: Attachment relationships beyond infancy
Parents
Siblings
Extended family (e.g., grandparents)
Friendships
Romantic relationships
Teachers/Mentors
Clergy
Therapists
God
Pets
Lending a hand (Jim Coan)
Experimental situation
Satisfied marital couples brought into lab; wife hooked up to
receive shocks (and was shocked periodically). Conditions
varied: holding husband’s hand, stranger’s hand, or no one’s
hand. Multiple brain areas scanned.
Result
Lowest levels of brain activation associated with holding hand
of husband; highest levels with holding no hand. High quality
of marital relationship associated with least brain activity
Conclusion
Attachment is the most potent and efficient means of
emotion regulation. Note that most treatments (e.g., DBT,
CBT) promote self-regulation, the most effortful
Social Context for PTSD in DSM-III (1980)
Confluence of Social Concerns in 1970s
combat trauma in Vietnam veterans
battered child syndrome
childhood sexual abuse
childhood maltreatment more generally
rape trauma syndrome
battering in marital relationships
An official diagnosis justifies resources for treatment
and prevention
IV. Trauma-Related Psychopathology
Some key problems with the diagnosis of PTSD
Cannot agree on definition of “traumatic” stress; too
much emphasis on physical threat, too little on
psychological experience
Exposure to traumatic stress only loosely related to
PTSD; very complex etiology
PTSD is not distinct from other disorders (especially
depression, dissociation, and other anxiety
disorders)
Reasons for dispensing with criterion A
Vast majority of persons exposed to potentially traumatic events do
not develop PTSD (although some stressors such as rape carry
far higher risk than others such as motor vehicle accidents)
Minority of individuals not exposed to A1 events develop full PTSD
syndrome (e.g., relationship breakup, job loss, humiliating
experiences)
Impossible to identify a cutoff point between “small-t” and “big-T”
trauma (note: mentalizing failure is “big-T” trauma)
Irony of recommendation to remove criterion A when PTSD is a rare
DSM disorder with etiology included in criteria
Complex etiology of PTSD: Pre-trauma factors
Genetic risk
Likelihood of trauma exposure
Likelihood of PTSD after trauma exposure
Difficult temperament
Disorganized attachment
Female gender
Lower age at exposure
Prior trauma exposure (e.g., childhood abuse)
Lower socioeconomic status, educational level, IQ
Family or personal psychiatric history
Impaired family functioning
Changing parental figures, changing residency
Complex etiology of PTSD, ct’d
The role of attachment in the etiology of PTSD
Peri-trauma factors
Objective severity (Criterion A1)
Subjective experience (Criterion A2)
Peritraumatic dissociation (in days after trauma)
Post-Trauma Factors
“What happens after a trauma has been shown consistently to
have the biggest impact on whether a person develops PTSD”
(Brewin, 2003)
Subsequent stressors
Lack of social support ( Brewin: negative social support, that is,
non-mentalizing responses; compare to “high expressed emotion”
as a risk factor for relapse in a range of disorders )
Pre-trauma risk factors include earlier
attachment trauma and quality of family
environment
Peri-truama factors include the role of
attachment relationships in the trauma (i.e.,
attachment trauma)
Post-trauma factors include social support (i.e.,
quality of mentalizing in attachment
relationships)
Nature of traumatic memory calls for mentalizing
Is PTSD a Distinctive Disorder?
Overlaps with depression and other anxiety disorders
PTSD, GAD, MDD are all heavily saturated with a broad
dysphoria factor (“anxious misery”)
Factor analyses reveal at least 4 factors, not 3
reexperiencing, avoidance, hyperarousal + numbing
or dysphoria; yet adding dysphoria increases overlap
with depression
Heterogeneity within PTSD
internalizing vs. externalizing; dissociative subtype
Painful intrusive memories characteristic of depression
and many other disorders besides PTSD
Flashbacks are most distinctive of PTSD
“Complex PTSD”
Paradox (van der Kolk)
Too much memory (intrusive memories, flashbacks)
Too little memory (vagueness, confusion, gaps, fragmentation, amnesia)
Situationally Accessible Memory (SAM) [non-mentalized]
Triggered involuntarily
Image-based, repetitive, emotion-laden, sense of reliving
Strengthened by dissociation at time of trauma (peritraumatic)
Associated with primary emotions at time of trauma (fear)
Verbally Accessible Memory (VAM) [mentalized]
Deliberately retrieved
Narrative/autobiographical
Integrated with other autobiographical memory, complete personal context (past,
present, future--mentalized)
Secondary emotions associated with past (regret, anger, shame) and future
(hopelessness)
Anxiety, Depression, and Anxious Misery
suicidality
nonsuicidal self-harm
eating disorders
addictions
dissociation
anxiety
depression
ill health
PTSD
insecure attachment
anxiety
personality
disorders
anxious
misery
hyperarousal
depression
joylessness
existential-spiritual impact
neuroticism
Existential-Spiritual Perspectives
Existential-Spiritual Trauma
loss of faith, alienation, bitterness, sense of futility
The Problem of Evil
evil is evil by virtue of trauma
grave harms, diabolical, related to sadism & mindblindness
Defy understanding: making sense of the senseless
Attachment to God
God is a bona fide attachment figure
security of attachment parallels parents; associated with health
Hope
Paul Pruyser: hope is based on belief in some benevolent
disposition toward yourself somewhere in the universe, conveyed
by a caring person
Complex Traumatic Stress Disorders (Courtois)
Complex psychological stressors
repetitive and prolonged
harm or abandonment by caregivers
occur at developmentally vulnerable times
Complex traumatic stress disorders
changes in mind, emotions, body, and relationships
severe problems with dissociation, emotion dysregulation,
somatic distress, relational or spiritual alienation
Cautionary note
even more than PTSD, the etiology of these disorders is
extremely complex and should not be reduced to exposure to
traumatic events (i.e., trauma does not explain everything)
Complex trauma-related psychopathology:
Terminology & Concepts
Comorbidity (diagnose all disorders individually)
Complex PTSD (Herman)
Disorders of Extreme Stress Not Otherwise Specified
(DESNOS; van der Kolk)
Developmental Trauma Disorder (van der Kolk)
Complex Psychological Stress and Complex Traumatic
Stress Disorders (Courtois & Ford)
Attachment Trauma
Beyond stressor-to-disorder thinking:
The need for a person-centered approach
Discrete causal influences and discrete resulting categories are
presumed, with clear distinctions among resulting taxa….this is
no longer accepted even in medicine….Nonetheless, in psychiatry
and psychology, all too often the single pathogen—discrete entity
connection is assumed, even though this is challenged by the
rampant problem of comorbidity….In contrast, in the
developmental-organizational approach that we advocate, cause
is complex. Early patterns of maladaptation, or extreme
adversity, such as a history of physical abuse, are seen as
creating vulnerabilities that in interaction with later factors are
probabilistically linked to a range of various manifestations….it is
unfortunate that the consequences of trauma, and harsh
experience more generally, are sequestered into [PTSD]
—Sroufe et al., 2005
Developmental approach to diagnostic understanding
We are hardly in a position to redo DSM along the two-polarities
model and the associated patterns of insecure attachment. But
we need to move away from focus on symptom-clusters to true
diagnostic understanding, wherein personality development and
attachment history will play a prominent role. Patrick Luyten and
colleagues advocate a fundamental shift in perspective, that is, a
move from a disorder-centered to a person-centered approach to
treatment, that is, “a life history perspective” that aspires to
“map the myriad complex pathways from early childhood to later
adaptive or maladaptive development which can then form the
basis for interventions for both preventing and treating
disorders.”
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