Multiple Faces of Childhood Trauma

Multiple Faces of Childhood Trauma By Faisal Ahmed, M.D Sponsor: Dr. jahan

Introduction • Childhood abuse has been associated with higher rates of psychopathology in adulthood when compared to non-abused adults. • Associated with poor mental health, predisposes the individual to various mental illnesses and conduct problems

Childhood trauma and its co-morbidities • Early exposure to potentially traumatic events disrupts crucial normal stages of childhood development. • Childhood sexual abuse is associated with a range of psychiatric disorders in adulthood such as • Mood disorders • Anxiety/panic disorders • Substance use disorders • Personality disorders.

Childhood trauma and its co-morbidities • Many studies have looked at possible links between early traumatic events and development of psychopathology over the life span • Breslau et al 1998; Brown and Anderson 1991 Bryer et al 1987; Grilo et al 1999; Kaplan et al 1998; Kessler et al 1997; Levitan et al 1998; McCauley et al 1997; Moncrieff et al 1996; Moncrieff and Farmer 1998; Mullen et al 1995; Ogata et al 1990; Pope and Hudson 1992; Ruggiero et al 1999; Schaaf and McCanne 1998; Stein et al 1996; Wexler et al 1997;Young et al 1997).

Association with aggression • Distinct relation between childhood trauma and affective dis regulation often manifesting as hostility and aggression • high prevalence rates of Bipolar disorders, conduct disorders, and personality disorders. • In studies of the long term effects of trauma, co morbidity is the rule rather than the exception.

Salter, Richardson & Kairys (1985) assert that abused children display behavioral problems because they understand the world as being unpredictable and painful and that the adults who care for them are angry, impatient, depressed, and distant. This perception of the world tends to transform these children into hostile, violent and unpredictable persons.

Trauma causing patterns • Expecting the infliction of pain or injury from others, • Behaving in ways to incite pain and injury • Distrusting closeness • Feelings helplessness and powerlessness • Development of wariness or suspicion of others • Numbing themselves to abuse

Trauma causing patterns (cont.) • Become limited in their ability to perceive their own feelings • Difficulty interpreting and responding to the emotional expressions of others • Denying or limiting certain emotional responses and expressing only those with which they are most familiar, aggression and hostility so as to get what they want.

Multiple Faces of Trauma • Post Traumatic Stress Disorders • Bipolar Disorder • Personality Disorders • Attention Deficit and Hyperactivity Disorder • Conduct Disorder

PTSD • 3,000,000 reports of child mal treatment each year. • One-third of these are substantiated. • Children with PTSD are 2 to 12 times more likely to smoke, abuse alcohol or drugs, develop depression, or attempt suicide

PTSD: Definition • PTSD as defined in DSM-IV requires exposure to a qualifying traumatic event and a clinical syndrome (consisting of re-experiencing, avoidance and numbing, and increased arousal) connected to the traumatic event in content and temporal order

PTSD (cont.) • NCS estimate the lifetime prevalence of PTSD in the general population as 7.8% • Epidemiological surveys reports, majority of community residents have been exposed to one or more PTSD-level traumatic event.

PTSD (cont.) • Men are more likely to experience traumatic events such as assaultive violence, serious accidents, and witnessing violence • Women are more likely than men to develop PTSD once trauma exposure occurs

Suspected Determinants of PTSD • Family history of psychiatric disorders • Preexisting disorders (including conduct problems in childhood) • Severity of the trauma • Whether the trauma is repeated • Child’s proximity to the trauma • Early childhood adversity • Cognitive abilities • Inner-city rearing.

PTSD: Developmental origin? • PTSD may have developmental origins • Developmental capacities and conditions may increase both risk of trauma exposure and the risk that individuals will respond adversely to traumatic exposures.

Depression vs. PTSD • The risk of developing major depressive disorder after trauma exposure in childhood is approximately equal to the risk of developing PTSD. • After age 13 years, the risk of PTSD is greater than the risk of major depression after trauma exposure.

PTSD: Nature of Trauma • Violent or sexual trauma were associated with the highest rates of symptoms of PTSD. • Adults with childhood sexual abuse were at higher risk for the development of PTSD related to interpersonal violence than adults who were not sexually abused as children

PTSD: Relationship to Perpetrator • Relationship to the perpetrator was related to Childhood sexual abuse characteristics and outcomes. • More negative reactions such as disbelief were observed for those victimized by relatives • Victims of relatives had more PTSD symptoms if they delayed disclosure, received more negative reactions in childhood, and engaged in self-blame at the time of the abuse.

Protective Factors • Important Role of social support and resilience in averting and recovery from PTSD. Resilience • It is defined as positive capacity of individuals to cope with stress and catastrophe. • Individual’s characteristic of resistance to future negative events. • can be viewed as the phenomenon of recovery from a prolonged or severe adversity, or from an immediate danger or stress.

Other Protective Factors • High school degree or college education • Older age at the time of trauma • Higher socioeconomic status • Positive paternal relationship • Having an identity as a survivor as opposed to a victim • Spirituality • Seeking help • Having good problem-solving skills

Complex PTSD • This describes a range of debilitating symptoms: • 1. Difficulty with affective regulation, including problematic anger, self destructive behavior, impulsive and risk taking behavior. • 2. Dissociation and amnesia • 3. Somatization

Complex PTSD (cont.) • A range of characterologic difficulties, including: • Damaged sense of self • Chronic guilt and shame • Feeling of ineffectiveness • Idealization with perpetrator • Difficulty in establishing and maintaining relationships • Tendency to be re-victimized or to victimize others • Chronic sense of despair and hopelessness.

PTSD: Can it be a Spectrum Disorder? • Is the diagnosis of PTSD alone, sufficient to contain the complexity and variety of findings ? • Since PTSD rarely occurs in isolation, it has been theorized to be a spectrum disorder by some investigators.

PTSD: Can it be a Spectrum Disorder? • The "pure" form described in the DSM is extremely rare in the chronic form. • An untreated PTSD evolves with time and may present, initially, with very different pathological symptoms giving rise to equally varied diagnoses. • Different etiopathogenic models propose to account for the PTSD 's heterogeneous appearance and instability with time.

Bipolar Disorder • The bipolar disorders are characterized by dramatic swings in mood that usually occur in cycles. • A person with bipolar disorder typically feels high levels of exhilaration and agitation for a period, referred to as mania, followed by a period of depression, and then a period of more normal moods

Bipolar Disorder: relationship with trauma • High rate of co-morbid posttraumatic stress disorder (PTSD) exists in individuals with bipolar disorder; 16%. • Prevalence is roughly double the lifetime prevalence for PTSD in the general population. • Maltreated children have a history of an earlier onset of bipolar illness

Bipolar Disorder: relationship with trauma • Recent studies have been specifically exploring the potential association of physical or sexual abuse in childhood or adolescent with bipolar illness, their characteristics and the course of illness • Symptoms overlap with bipolar disorder may complicate the diagnostic formulation

Effects of Trauma on Bipolar Disorder • Post 1992: early stressful life experiences act as vulnerability factors. • provide an underlying neural substrate for the subsequent affective disorders by stressors in adulthood

Effects of Trauma on Bipolar Disorder (cont.) • Earlier onset of bipolar illness • An increased number of Axis I, II, and III co morbid disorders • Higher drug and alcohol abuse • Faster cycling frequencies • A higher rate of suicide attempts • More psychosocial stressors occurring before the first and most recent affective episode

Personality Disorders • DSM IV TR defines personality disorders as "An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it“ • This pattern is manifested in two or more of the following areas: cognition; affectivity; interpersonal functioning; and impulse control

Personality Disorders • Child maltreatment and trauma has been strongly implicated in future development of APD . • Furthermore, a recent meta analysis of 21 studies examining BPD and Childhood maltreatment found a moderate pooled for this association.

Personality Disorders (cont.) In one study by Johnson et al (1999): • Documented physical abuse was associated with antisocial and depressive PD symptoms • Neglect was associated with antisocial, avoidant (AVPD), borderline, narcissistic, and passive-aggressive PDs.

Borderline Personality Disorders • Among the PDs, the interface between PTSD and BPD has received the most attention with documented high rates of co-occurrence between the two disorders • studies have found higher rates of childhood sexual abuse (CSA), ranging from 26% to 71%, among individuals with BPD compared to other psychiatric populations

BPD: Definition "a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts”

BPD: Symptoms • Impulsivity; i.e., promiscuous sex, out of control spending habits, substance abuse, or binge eating • Mood Lability between anger and anxiety or between depression and anxiety (13). • Fear of abandonment. • Recurrent suicidal behavior, gestures, and threats or self mutilating behavior (12). • Chronic boredom or emptiness

BPD: Symptoms • Splitting; a person considers people or things either” all good” (i.e., overly valued and respected) or “all bad” • Shifting of allegiances frequently; (I.e., person goes from being viewed as an “angel” to a “devil”), sometimes in the course of a few minutes) • Micro-psychotic episodes; i.e., symptoms of psychosis that may last a few minutes and often brought out be stress.

Borderline Personality Disorders • The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood

ADHD • Many children who experience severe abuse also experience symptoms of attention deficit hyperactivity disorder(ADHD). • Significant relationship between trauma exposure and attention deficit hyperactivity disorder has been found in 35% and 23% of the samples of the two studies respectively.

Symptom overlap vs. diagnostic relationship * • Since There is observed overlap of symptoms between PTSD, and ADHD such as Poor concentration, poor attention span, fidgetiness, mood reactivity, it is possible that this diagnostic overlap simply reflects symptoms similarity rather than a conceptual or etiological relationship

Trauma causing Hyperactivity • Study by Glod CA and Teicher MH (1996) indicates that abused children with PTSD have activity profiles similar to those of children with attention-deficit hyperactivity disorder, while abused children without PTSD have activity profiles more similar to those of depressed children.

ADHD vs. PTSD • Due to symptoms overlap, differential diagnosis can be confusing. • Current diagnostic criteria do not include PTSD as a differential diagnosis for ADHD, nor do existing assessment guidelines address these diagnostic similarities. • This may have serious implications for traumatic children.

ADHD vs. PTSD • Routine inquiry about traumatic experiences in children presenting with ADHD symptoms is highly suggested to increase accuracy in differential diagnosis. • Researchers have linked poor stimulant response in ADHD to the presence of childhood adversity.

Conduct Disorder • Epidemiologic studies reveal that posttraumatic stress disorder (PTSD) is highly comorbid with both conduct disorder and major depression in men. • In juvenile offender studies; High rates of PTSD were reported by offenders (37%), with sexual abuse the precipitant in 70% of cases.

Conduct Disorder • In one study Romano E, Zoccolillo M, Paquette D (2006), Pregnant adolescents with multiple forms of child maltreatment had a fourfold risk of also having conduct disorder, compared with non-maltreated adolescents. • In an another study Currie CL.(2006), Children exposed to domestic violence were significantly more likely to have been cruel to animals than children not exposed to violence

Trauma and Genetics in Conduct Disorder • Functional polymorphism in the promoter region of the monoamine oxidase A (MAOA) gene moderates the impact of childhood maltreatment on risk for developing antisocial behaviors. • An Meta-analysis demonstrated that the association is significantly stronger in the group of males with the genotype conferring low vs. high MAOA activity

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Multiple Faces of Childhood Trauma