BLOG POST ARCHIVES

Beginning JANUARY 2013

January 1, 2013       In Therapy -- How Accurate Is Our Therapist's Self-assessment?

Insight-oriented psychotherapy -- psychotherapy based on the belief that if you can truly "understand yourself", then one has the basic requirements to recover from disabling forms of psychological distress. Insight involves accurate "self-assessment", and helping others to gain insight requires accurate self-assessment on the part of therapists. But, how accurate are therapists' self-assessments?? This post exames that question.

I have given details of difficulties I have had receiving competent therapy from psychiatrist, psychologists and other providers of "therapy" and difficulties I have had seeking recourse for incompetent professional services from mental health service providers -- see my previous posts here [LINK]  and here [LINK]   -- Just how common are these problems with therapists' "self-assessment" as it is called, and what can be done about it? A new study, by Steve Walfish and colleagues [LINK] provides some information about the first issue, at least  -- but gives rise to further concerns -- and some "reassurance" -- I'm not alone in receiving shoddy service from arrogant "professionals" reluctant to see themselves as they are, and who refuse to be accountable for the poor quality of their services like Simon Kuttner.

Walfish' study was not "original", in conception, but gives rise to significant concerns if you're worried about the quality of care you, or someone you love, is worried about the care received -- In a classic study conducted at the General Electric Company in the USA, Meyer (1980) asked engineers to self-assess their performance compared to other engineers with similar jobs and salaries. The average engineer rated his performance to be at the 78th percentile compared to peers. Of the 92 engineers studied, only two placed themselves below the 50th percentile.

Walfish and colleagues (2012) extended this area of research with a multi-disciplinary sample of mental health professionals. Respondents were asked to: (a) compare their own overall clinical skills and performance to others in their profession, and (b) indicate the percentage of their clients who improved, remained the same, or deteriorated as a result of treatment with them. Results indicated that 25% of mental health professionals viewed their skill to be at the 90th percentile when compared to their peers, and none viewed themselves as below average. Further, when compared to the published literature, clinicians tended to overestimate their rates of client improvement and their rates of client deterioration.

Walfish and colleagues note that, whatever therapists' motivations (unconscious or conscious) may be, therapist self-assessment bias may be at the root of therapists’ reluctance to take advantage of advances in “lab test” results that can predict client worsening and lessen the chance that such a phenomenon will be acted upon by the therapist in a timely manner. Several studies have now shown that deterioration can be predicted (e.g.,Finch, Lambert, & Schaalje, 2001[LINK]  Spielmans, Masters, & Lambert, 2006 [LINK]) and that supplying therapists (and clients) with this information can reduce deterioration rates and bolster client recovery. (see the attached article for details of these references).

As psychotherapists who are truly below average in effectiveness may not recognize that their skills are deficient, or even above-average psychotherapists may not recognize that their patients are regressing, an argument may be made for all psychotherapists to monitor progress and outcome using "formal" methods rather than clinical judgment. This strategy makes reduction of perceptual bias specific on a case-by-case basis, and easier to implement than efforts to overcome this problem through supervision and related strategies aimed at enhancing self-assessment and self-reflection. I have attempted to encourage clients ot therapists (and therapists themselves) to adopt these practices, and move towards more "collaborative" approaches to treatment, such as including guidelines for trauma treatment -- see my website here [LINK] and here [LINK].

One of the most disheartening things for clients, of course, is that they are powerless to "protect" themselves from incompetent therapists, like the Simon Kuttners of this world, because the so-called professional associations and regulatory bodies seem even more reluctant than themselves to acquaint themselves with this sort of research and take clients' feedback as seriously as they should.   Foremost amongst these socially, and professionally, irresponsible individuals and groups are Simon Kuttner, and the New Zealand Psychologists Board.

January 2, 2013       Systematic review -- treatment for child victims of maltreatment

In a new paper (accepted for publication as recently as December 12, 2012), Laura Leenarts and colleagues from the Department of Child and Adolescent Psychiatry, VU University Medical Center, De Bascule, Duivendrecht,PO Box 303, 1115 ZG Amsterdam, The Netherland, have provided us with a systematic review of treatment outcome studies for children with histories of trauma-related psychopathology as a result of childhood maltreatment  [LINK]

From the abstract: 

This is a systematic review of evidence-based treatments for children exposed to childhood maltreatment. Because exposure to childhood maltreatment has been  associated with a broad range of trauma-related psychopathology (e.g., PTSD, anxiety, suicidal ideation, substance abuse) and with aggressive and violent behavior, this review describes psychotherapeutic treatments which focus on former broad range of psychopathological outcomes. A total of 26 randomized controlled clinical trials and seven non-randomized controlled clinical trials published between 2000 and 2012 satisfied the inclusionary criteria and were included. These studies dealt with various kinds of samples, from sexually abused and maltreated children in child psychiatric outpatient clinics or in foster care to traumatized incarcerated boys. A total of 27 studies evaluated psychotherapeutic treatments which used trauma-focused cognitive, behavioral or cognitive-behavioral techniques; only two studies evaluated trauma-specific treatments for children and adolescents with comorbid aggressive or violent behavior; and four studies evaluated psychotherapeutic treatments that predominantly focused on other mental health problems than PTSD and used non-trauma focused cognitive, behavioral or cognitive-behavioral techniques. The results of this review suggest that trauma-focused cognitive-behavioral therapy (TF-CBT) is the best-supported treatment for children following childhood maltreatment. However, in line with increased interest in the diagnosis of complex PTSD and given the likely relationship between childhood maltreatment and aggressive and violent behavior, the authors suggest that clinical practice should address a phase-oriented approach. This review concludes with a discussion of future research directions and limitations.

The treatment recommendations I have presented on my website (addressed primarily to adult survivors of childhood trauma) are consistent with the study's overall conclusion as applied to treatment for children:

"clinical practice should address a phase-oriented approach"

After reviewing this study in more depth I shall return to this post -- I've only just received the article!

January 3, 2013       Genes -- later trauma response --- elusive search for link

It has long, and naturally, been thought that the reason individuals differ in their response to potentially traumatising experiences lies in different individuals different genetic makeup. However, the search continues for what precise mechanisms are involved in this process, exemplified by recent studies discussed in this post.

Firstly, in the attached brief article [LINK] John Pearson, of the Biostatistics and Computational Biology Unit, University of Otago, Christchurch, New Zealand, discusses how one possible "candidate" for the gene involved has surprisingly, at least in the sample studied, NOT been found to be involved:

From the paper:  "we do not find strong evidence in support of the reported G.E (Gene by Environment interaction) effect of rs1049353 (a formerly proposed gene responsible for the effect) and childhood physical abuse on MDD in CNR1 (genetic sub-set of the overall sample group),either in the CHDS (Christchurch Health Sample) or in the combined datasets. The equivalent result for lifetime depression with anhedonia also requires replication and examination in a genome wide context." At least on the basis of this study: "the hunt continues!"  In this study the effect being looked at was the contribution of childhood physical abuse on increasing the chances of later-age depression.

The complex interplay of the three factors: genetic vulnerability, life event, and disorder-specific dynamics is further examined in a study by Uddin and colleagues from the Center for Molecular Medicine and Genetics, at Wayne State University School of Medicine, in Detroit, Michigan, USA. A growing literature indicates that genetic variation, in combination with adverse early life experiences, shapes risk for later mental illness. Recent work also suggests that molecular variation at the ADCYAP1R1 locus is associated with posttraumatic stress disorder (PTSD) in women. Uddin et al sought to test whether childhood maltreatment (CM) interacts with ADCYAP1R1 genotype to predict PTSD in women. Data were obtained from 495 adult female participants from the Detroit Neighborhood Health Study. Genotyping of rs2267735, an ADCYAP1R1 variant, was conducted via TaqMan assay. PTSD, depression, and CM exposure were assessed via structured interviews. Main and interacting effects of ADCYAP1R1 and CM levels on past month PTSD and post-traumatic stress (PTS) severity were examined using logistic regression and a general linear model, respectively. As a secondary analysis,  the researchers also assessed main and interacting effects of ADCYAP1R1 and CM variation on risk of past-month depression diagnosis and symptom severity. No significant main effects were observed for ADCYAP1R1 genotype on either PTSD/PTS severity. In contrast, a significant ADCYAP1R1 × CM interaction was observed for both past month PTSD and PTS severity, with carriers of the “C” allele showing enhanced risk for these outcomes among women exposed to CM. No significant main or interaction effects were observed for past month depression/depression severity.  Uddin et al conclude: Genetic variation at the ADCYAP1R1 locus interacts with CM to shape risk of later PTSD, but not depression, among women.

Another study (brief overview attached [LINK], this time by Wichers, of  the Department of Psychiatry and Psychology, South Limberg Mental Health Research and Teaching Network, EURON, Maastricht University, The Netherlands,  looks at how statistical model-fitting suggests reciprocal causation and shared influences between depressive symptoms and negative life events. Not surprisingly, but "refreshingly" (from my viewpoint) this study came to the conclusion: "The inter-relationship between depressive symptoms and negative life events is complex and varies across genetic, environmental and individual specific effects. Both reciprocal causation and shared latent influences contribute to the relationship".

I'd be amongst the first to say that I don't understand the finer points of these studies, and say I cannot comment on any methodological strengths or weaknesses they may have. However, I would caution against the simplistic drawing of conclusions that any particular genetic makeup "causes" specific pathology, and encourage people to be aware of the fallacies inherent in "Biologism" [LINK] but with the sorts of theoretical caveats Hayes talks about in mind, I admire this sort of research -- it seeks after all, to make the best use of the latest advances in science to improving the human condition; so long as human beings are not "mechanised" in the process, and so long as other "softer" sciences are enabled to play their role.

The sorts of research being carried out by Pearson, Uddin, and Wichers can be considered as part of "pharmacogenomics" -- the study of how an individual's genetic inheritance affects the body's response to drugs (both existing and new drugs based on the sorts of research understandings made by possible by the studies of Pearson and others). The term comes from the words pharmacology and genomics and is thus the intersection of pharmaceuticals and genetics. See here [LINK] and for a guide to local research (in New Zealand) here [LINK]

January 4, 2013       Developmental Trauma Disorder -- Worthy of formal diagnosis?

Schmid et al (2013)<  [LINK] have called into question whether or not it is desirable for Developmental Trauma Disorder -- a "childhood" disorder I've spoken about often on my website, as my weinsite is primarily about the nature of, and recovery from, childhood trauma -- to be afforded formal diagnostic in current, and proposed, diagnostic systems. On the one hand, they state, the supporters of a formal DTD diagnosis argue that post-traumatic stress disorder (PTSD) does not cover all consequences of severeand complex traumatization in childhood.  On the other, a main argument against inclusion of formal DTD criteria into existing diagnostic systems is that emphasis on the etiology of the disorder might force current diagnostic systems to deviate from their purely descriptive nature. Furthermore, they believe, comorbidities and biological aspects of the disorder may be underdiagnosed using the heretofore proposed  DTD criteria -- see my previous discussions on my website for links to relevant articles, for example this page here [LINK]. The signs and symptoms of the disorder are also reviewed in the article by Schmid et al.

What is not discussed in the article by Schmid et al is "Complex Trauma" -- children's histories of "complex traumatization" are discussed, but whether or not this is the same disorder as adult Complex Trauma is not discussed. Complex Trauma "perhaps" is an adult form of DTD -- I say "perhaps" as it too lacks a formal diagnosis, has many of the same diagnostic issues as DTD, including a controversial status, and has perhaps equally significant clinical and social consequences for individuals and society generally. Therapy for those adults with Complex Trauma is discussed in many places on my site, but perhaps you could start by reviewing this page [LINK], and go into more depth concerning the very lengthy, if not lifelong, consequences of childhood trauma discussed in the literature review linked to through my Home Page [LINK]

Schmid et al opine that it is trauma experts working in specialized institutions that deal exclusively with traumatized individuals who tend to be the main supporters of a formal definition of DTD diagnostic criteria, while professionals working in the general clinical and psychiatric setting remain critical. Regardless of the outcome of the ongoing debate, treatment of severely traumatized children and adolescents should be improved substantially. Although trauma outpatient clinics offering symptom-specific treatment will be of help, general psychotherapeutic professionals also need to be trained in this area since many traumatized children are encountered in the clinical setting. Therapeutic concepts currently available for hospitalized patients are grossly inadequate to address the, at times dramatic, problems suffered by severely traumatized children. Trauma-specific concepts of outpatient treatment with possible inpatient-interval treatment should be developed and implemented, taking the specific needs of children and adolescents into account as well as the need of their parents, foster parents or residential care staff. It is important to be able to combine both treatment needs: to maintain a “safe place” and to have the possibility to do effective (if necessary, prolonged) exposure therapy. For severely traumatized patients a combination of a skill training and trauma therapeutic exposure treatment is currently regarded to be the best approach with the least drop-out rates. The trauma system therapy as a model of combined milieu therapeutic, systemic / family centered, and psychotherapeutic intervention is a very promising and, as the first results show, successful treatment approach for children and adolescents suffering from complex trauma or developmental trauma disorder. The psychotherapeutic skill training focuses on the capacities to cope with dissociation, emotion regulation problems, situations of extreme stress and tension as well as intrusions, disgust and social problems. The additive skill training will help to overcome tension and dissociation during the exposure therapy and is a kind of precondition for exposure therapy with complex traumatized patients with fewer capacities to cope with stress, tension and dissociation. Dialectical Behavior Therapy and its adaptions for adolescents are the best evaluated treatment concepts to improve these skills. For such treatment concepts to be effective, specialized wards are needed, which will probably require inpatient treatment for a greater catchment area and build a network of outpatient therapists cooperating with this specialized ward. This is much the same as recommended for adults with Complex Trauma -- see my site.

As many severely traumatized children and adolescents cannot stay in their families of origin, psychiatric liaison services for adolescents in residential care institutions and youth welfare services should be implemented. These liaison services can help to reach more burdened children, reduce inpatient- child and adolescent psychiatric treatment days, and improve continuity in residential and foster care placements. Youth welfare concepts should be sensitized to trauma symptoms and try to promote and enhance resilience factors, self-efficacy and social and emotion-regulation skills . Schmid, after their review of disorder and treatment outcome studies conclude that the available arguments for and against the implementation formal diagnostic criteria for DTD cannot be appraised conclusively based on current research. The main advantage, these authors believe, appears to be therapists' improved sensitization to trauma outcomes and more tailor-made treatment options, but this may also be achieved by a descriptive approach. A dimensional diagnostic system comprising the relevant domains, such as relationship / attachment representation, assessing interpersonal trust, emotion regulation, affinity to dissociation / sensual perception, and lacking expectation of self-efficacy, could also be envisaged. Specific symptom scales for emotion regulation, attachment/ interpersonal trust, self-efficacy and dissociation may be effective in predicting the outcome of psychotherapeutic treatment. These symptom scales may show relevant aspects of developmental psychopathology, can support the diagnostic process, and help to develop individualized treatment concepts with specific guidelines for the arrangement of the therapeutic alliance. Probably the sensitization to trauma symptoms and the interpersonal learning history of a patient can prevent drop-out and improve therapeutic outcomes. On my site I provide guidelines for how drop-out can be reduced through following recommendations for "essentials" in trauma treatment [LINK].
 

January 5, 2013       Killer or Cure-all? -- Surviving Psychiatric Treatment

For today's post, I wish to re-visit "the past", the past of a few years ago, and about a month ago.

Topics I wish to briefly discuss today include
 (i) changes and finalisation of changes to the American Psychiatric Association's Diagnostic and Statistical Manual -5th Edition  DSM 5;
(ii) treatments for "Depression" (whatever that is!); and related to this --
(iii) Electro Convulsive Therapy ECT -- especially current practices in New Zealand's Southland District Health Board region; and lastly, for now
(iv) alternative conceptions of mental illness and treatment for mental illness -- especially Critical Psychiatry.

To begin with, I'd like to draw your attention to a recent post by Dr Allen Francis on his blog for Psychology Today DSM 5 in Distress:

DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes [LINK]

I've discussed Dr Frances views on changes in DSM 5 before in my post

          May 10, 2012
           -- Psychiatric Mislabeling Is Bad For Your Mental Health [LINK]

 based on Dr Frances own blog post on Psychology Today [LINK]

Recalling, Dr Frances was chair of the taskforce for the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) and in his previous post was commenting on the results of field trials of the reliability of diagnostic criteria for DSM 5, which showed that even criteria for "well-accepted" diagnoses such as Major Depressive Disorder have resulting in their performing well below acceptable standards.

In his most recent post, using language I would never have associated with a psychiatrist before, Dr Frances states that news of the finalization of proposals for DSM 5 has resulted in "the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry."

I shall not go into detail listing the arguments Dr Frances does, I direct you to his post, but note that he considers the following "mistakes":

• New diagnosis: Disruptive Mood Dysregulation Disorder
• Normal grief will become Major Depressive Disorder
• The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder
• DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder
• new diagnosis -- Binge Eating Disorder
• Feared reduction in needed school services for those with Autism due to changes in diagnostic criteria
• First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.
• DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot
• DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life
• DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings

In conclusion, Dr Frances states:

"People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill. Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them. DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm! That's why this is such a sad moment."

In my view, these are fairly conservative opinions, understandably perhaps, as they come from a psychiatrist. In my view, the DSM 5 changes fail to address the need for better, more inclusive, treatments for perhaps the majority of the "worried well" most in need of better services -- those with histories of childhood abuse, trauma, and neglect. It is particularly deficient in the areas of need for treatments that are more "insightful", by more sensitive therapists, for depression and anxiety. Frances limits his discussion to Grief: Normal grief, under DSM 5, he argues, will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life. Elsewhere on my site I have noted the importance of providing "titrated" pharmacotherapy for depression, with drugs being reduced from initial doses with improvements in patients' conditions, and gradual "supplementation" with and replacement by adjunctive psychotherapy, moving finally to psychotherapy and other non-biological therapies. Of course, these therapy changes must be part of an effective, collaborative therapist-patient relationship -- in my view, the evidence supports this above all other forms of therapy regimen.

One form of therapy for depression (or other disorders!) with a controversial history, that is no longer evidence-supported is Electroconvulsive Therapy -- ECT. What "re-ignited" my interest in this form of therapy was a recent issue of the Summer edition of the newsletter of the Otago Mental Health Support Trust, which commented on the high, and increasing levels of usage of ECT in my local District Health Board Region. I have previously written of the difficulties of getting appropriate, and adequate, non-drug treatments for the depression and anxiety I suffer.  I attach firstly, an article by John Read, Professor of Psychology at the University of Auckland, examining outcome studies for ECT [LINK], and secondly, the text of an email I received from Professor Read, with his responses to several of the "questions" I have had over the years [LINK]. In my view these materials speak for themselves, and speak strongly AGAINST the practices of the Southland District Health Board.

Looking at the diagnostic categories and criteria for "mental disorders" contained in DSM 5, one would think the APA thinks it has the "cure all" answers for all the problems of modern living. Unfortunately, given the yawning gulf between what even Dr Frances has written, conservatively, about modern psychiatric practices, and the actual practices of psychiatrists, particularly in my local area, the potential, and likely actual, harm being perpetrated, one has to conclude that it is far more likely to be doing substantial harm rather than good.

What's the alternative?

Unfortunately, for people in my local area, very little. Locally, Psychiatry's practices go unquestioned, compared to what happens overseas, in such countries as Australia, England, Canada, and Western Europe. There seems to be a relative "Mexican standoff" in the United States -- Psychiatry is not well regarded, going by comments I see made on US-dominant email discussion lists I subscribe to.  New Zealand psychologists are, by and large, the handmaidens of Psychiatry in this country, a shameful position to be in, in my opinion, acting in their own self-interest as individuals -- financially they are in a VERY good position, compared to the great bulk of the rest of New Zealand society -- certainly not acting in the best interests of the profession, and certainly not in the best interests of the New Zealand Public. Indeed, it was on one of these American lists today that I read of Viktor Frankl's lack of respect for Psychiatry.

Frankl -- a survivor of Nazi death camps during the Second World War -- was an interesting man. His first degree was from the medical school of the University of Vienna, the specialty training was in neurology, the second in neurosurgery, and the third was from the psychology institute where he earned a doctorate degree in psychology.  He also was the creator of the first anti-anxiety drug ever.  He developed a support group for youth after World War I for the treatment of severely depressed teenagers.  Reading his autobiography is an adventure.  His first wife, a nurse, became pregnant after the Anschluss.  The child found the fate of abortion.  The Jewish community by that time knew what lay ahead of them.  His wife was deported to Auschwitz and quickly transferred to Berkinau where she died under a shower of Zyklon B.The US psychologist commented: "He told me in a private conversation that he didn’t trust psychiatrists but he did trust psychologists.  All psychiatrists who practiced under National Socialism were party members.  They had to be in order to be paid for their services.  Is there nothing new under the sun?" That Psychiatry is still an instrument of the government is evident from readings available from sites I discuss next. I note that even Frankl had to make known his opinion of Psychiatry in private, fearing its power even in a "democratic" society.

The "alternative" is available, my readers, from Psychologists NOT trained in New Zealand, mostly those from Australia, the United States, South Africa and England, here for reasons of culture, climate and lifestyle, not for professional reasons. And you can learn about alternatives to the traditional "medical model" from sites talking about "Critical Psychiatry", such as [LINK], from the UK, and [LINK] the international group. Links to readings / articles, and to groups for "survivors of psychiatry" are also accessible from these sites.
 

January 12, 2013 -- Mens sana in corpore sano - Brain science and health

Thirty years ago (and probably longer, but memory fails me!) when I first studied Neuropsychology, psychologists had little hope for people's continued recovery from brain damage beyond the initial three years post-injury. Now, much has changed, with continued recovery, at least in some areas, now known to continue for much longer -- in some cases for decades!  Indeed, "neuroplasticity" -- the brain's capacity for ongoing physical changes as a result of experience -- has become one of Psychology's buzz words in recent years. I also wish to remind you of two upcoming series, one  from Psychotherapy Networker, the other from the National Institute for the Clinical Application of Behavioral Medicine (NICABM)  (both series offering free downloads), and to advise you of some resources available for download right now for free.

Why are these issues important for survivors of chidhood interpersonal trauma? A number of studies have investigated the brain changes consequent upon such trauma.  I've attached an annotated bibliography of some articles discussing this [LINK]. In particular, I draw your attention to the recent article by Thomaes, Dorrepaal et al [LINK]. Further some of the latest studies indicate that experience of different types of abuse may lead on to different forms of brain impairment, with exposure to multiple types of abuse, in particular, leading to corticolimboc dysfunction (Tomoda et al, 2012 [LINK]).

Personally, as I've advised on my website, I'm partcularly interested in the first of the sessions from the Psychotherapy Networker series, relevant as it is to survivor issues.

Details of the upcoming series from Psychotherapy Networker are available here: [LINK]

Details of the upcoming series from NICABM are available here: [LINK]

NICABM has made the following resources available for download:

• How Love Rewires the Brain -- article (PDF format) [LINK]
• Everyday Ways to Protect Your Brain -- MP4 video  [LINK]
•         "                   "      "            "             "            "   Citations PDF  [LINK]

As mentioned, I think the first session in the Psychotherapy Networker series could be particularly helpful to those supporting and guiding adult survivors. It covers the following issues, presented by Dan Siegel:

• Recognize Patterns of Rigidity vs. Chaos in Psychological Functioning
• Choose Specific Interventions that Target Different Parts of the Brain
• Facilitate Integration Among Distinct Domains of Brain Function
• Apply Mindfulness Practices in Treatment
• Expand Your Use of Self by Increasing Your Own Neural Integration

Clearly, one of the basic psychological processes negatively impacted by childhood trauma is emotion regulation, and this is likely to have a number of bases, as the research of van Harmelen demonstrates -- difficulties in not only emotion regulation, but in recognising other's emotional reactions, with consequent social difficulties. I have reviewed the effects of disturbed early attachment previously -- see my research proposal on my website. Especially in the light of these neuropsychological changes, the well known difficulties with secure attachment that survivors of childhood interpersonal trauma experience, persisting into old age and dementia (see research by Browne and Schlosberg (2006) [LINK] and Osborne et al (2010) [LINK]) really demand a more effective response from therapists -- perhaps brain science can help provide these means. Osborne et al cite Miesen's (1992, 1993, 1999) theoretical assumption that dementia is a loss process that activates the experience of feeling unsafe and the emotional need for the security of an attachment figure. Indeed, I would propose that the difficulties adult survivors have with recurrent depression are tied to recurrent crises, periods of being "unsafe" and the need for secure attachments, even if in only such "instrumental" relationships as with doctors -- relationships they often  have great difficulty with -- part of the reason I endeavour to provide "self-help" "psychoeducational" resources.In my next post I'll be reviewing, from this perspective, the recent (2011)  PhD of Emiy Murphrey, University of St. Thomas, Minnesota: Effective Treatment of Complex Post Traumatic Stress Disorder and Early Attachment Trauma.The thesis is available online, but I also post it here: [LINK]

January 18, 2013    --    Self-Help for Survivors of Chronic Trauma

My apologies for this later than usual post -- I was let down by my "greed" for a "great deal" -- SurDoc was offering 100Gb of Cloud storage free for the first 12 months. Unfortunately, they failed to deliver on performance and I've had to spend the last couple of days trying to sort out the problem, only to return to my previous suppliers. Those familiar with my posts last year will know I make exxtensive use of Cloud storage to provide my readers with valuable resources.

Well, I've got some great resources to share, and have finally been able to post them to the Cloud -- stay tuned, I'll be posting links to these resources in the next day or two.

Among the resources to be posted will be some audiovisual materials from Rick Hanson Ph.D., and Dan Siegel M. D.  I've also got a bundle of articles I've obtained from Prof. Ethy Dorrepaal, Psychiatrist and lead researcher on what has become one of the biggest source of links to my site -- her studies on Stabilizing Group Treatment for Complex Posttraumatic Stress Disorder -- like these papers [LINK] from 2010 and this [LINK] from 2012. Marylene Cloitre, Clinical Psychologist,  has also provided me with some recent articles I've added to the Cloud, with links to be posted soon also.

Although I asked for "self-help materials", little was available directly, however, I was directed to this article by Wolfsdorf & Zlotnick  (2001) [LINK] with the advisory that it discussed treatment in more detail than the other articles I was provided. I was also directed to a book by Marylene Cloitre and colleagues -- a bit of a modern classic of its type Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life [LINK] -- this book is particularly valuable from  a therapist-manual, "self-help" perspective, as the text is well-written, easy to understand, and comes with handouts for clients at the end of the chapters.

I fully realise the discomfort and ditrust many survivors experience when seeking help from others, but I do encourage you to continue the search, using the guidelines for "safe therapy" I have provided previously in this blog, and on my website. After all my personal and professional experiences I consider the core element of recovery from childhood trauma to be "a healing relationship" and I pray you can find one, and go on to enjoy other relationships in which you, and your loved ones, can grow and flourish. Patients suffering from Borderline Personality Disorder often have experience of childhood trauma and I cannot leave this post without suggesting you look over the materials at http://www.dbtselfhelp.com/ [LINK] -- although the site is primarily for those interested in Dialectical Behavior Therapy as a form of treatment -- the focus is on problems often experienced by those with histories of childhood trauma.

January 19, 2013    What Happens to the Brain During Sexual Assault

Today,  I'm re-posting directly a couple of posts I've recently received from other sources, due to their implications for effective and safe treatment -- see my previous post:

Following up from my recent posts about trauma-induced changes in brain functioning:

What Happens to the Brain During Sexual Assault: Watch a Seminar with Becki Campbell

In the latest Research for the Real World presentation, Dr. Rebecca Campbell discusses the neurobiology of sexual assault and the effect trauma has on victim behavior. Is she exhibiting normal post-trauma behavior? Or is she lying?

Dr. Campbell has given this presentation before numerous law enforcement officers. She has several tips that help officers make arrests and strengthen the case.

Rebecca Campbell is Professor of Psychology and Program Evaluation at Michigan State University. For the past 20 years, she has conducted victimology research and evaluation, with an emphasis on violence against women and children. Her work examines how rape crisis centers and the legal, medical, and mental health systems respond to the needs of adult, adolescent, and pediatric victims of sexual assault. Her current work, funded by the National Institute of Justice, focuses on Sexual Assault Nurse Examiner (SANE) programs and the criminal justice system.

View the presentation here   [LINK]

The presentation goes for about 95 minutes, and is downloadable using something like DownloadHelper extension for the Firefox browser, or  Freecorder Screen Recorder, and consists of a series of slides.

See my later post: Who Cares? Risks and Limits of SSRIs for Depression

January 19, 2013    Child Abuse: Effects of dissociation on treatment for PTSD

An important recent study by Marylene Cloitre and colleagues [LINK] has thrown light on three imporant questions:

• How successful is Narrative Therapy  (also called Narrative Story Telling NST) in dealing with the effects of childhood-trauma related PostTraumatic Stress Disorder (PTSD)?   In New Zealand, the usual "Treatment As Usual", apart from anti-depressants (and see my post with links to the Who Cares videos) is, at best, often a form of NST,  which can be considered a modified form of "exposure therapy", where therapist and client establish a therapeutic relationship by means of "supportive counselling" (SC). Then, the client recounts details of the trauma they experienced,  "de-sensitising", dealing with dysfunctional avoidance coping behaviors;  progressing on to where  therapist and client identify and appraise interpersonal schemas, which are then "re-processed", and the results integrated into a re-formulated "lifes story" more supportive of effective living.

• What is the impact of dissociation on course and outcome of treatment for such PTSD?
• What are the requisite components for such treatment?

The Cloitre et al study explored whether a sequenced two-component treatment in which an emotion regulation skills training module preceding exposure would improve outcomes for those with significant dissociation, a less common response to trauma that can have profoundly disabling effects on interpersonal relationships. In the study, analyses were conducted on data from a randomised clinical trial in which 104 women with PTSD related to childhood abuse were assigned to one of three treatment conditions: Skills Training in Affective and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST; STAIR/NST), STAIR followed by supportive counseling (SC; STAIR/SC), or SC followed by NST (SC/NST).

• Baseline dissociation was associated with differential outcome such that at low levels of dissociation the three treatments were equally effective but at higher levels STAIR/NST resulted in greater reductions in dissociative symptoms.

• Level of baseline dissociation did not moderate the effect of the treatments on PTSD outcome. At all levels of baseline dissociation, STAIR/NST produced better PTSD outcome.

• At posttreatment, however, participants with high dissociation treated with STAIR/NST continued to improve during follow-up, those treated with STAIR/SC maintained gains, and those treated with SC/NST experienced LOSS of posttreatment PTSD symptom improvements.

The authors conclude that the differential results observed among the treatments depending on severity of dissociation at baseline and at posttreatment suggest the potential clinical utility of identifying a dissociative subtype of PTSD and of the benefits of sequenced, phase-oriented treatment approaches.

Clearly the oft-cited positive outcomes reported in New Zealand for NST should not be overstated -- people benefit in the short term only.

However, the "optimal" treatment consists of a phase-oriented approach incorporating not only "Supportive Counselling" (which should be an element of any therapist-cllient relationship) but skills training in affective and interpersonal self-regulation; followed by explication of interpersonal schemes, and behaviorally specific formulation of post-recovery lifestyle planning -- this is essentially the approach I've outlined on my website page on "essentials of effective trauma treatment".

January 19, 2013    Who Cares? Risks and Limits of SSRIs for Depression

Here, I'm re-posting something from Rob Purssey, Psychiatrist, in Brisbane, Queensland, Australia  [LINK]:

"Who Cares in Sweden" www.whocaresinsweden.com is the best filmed work ever created about SSRI's, and is essential viewing for anyone taking, prescribing, or caring for anyone taking these medications.

It is a superb documentary in 3 hour long parts exploring the widespread use of SSRI's in Sweden, and by extension the Western world, and their clearly documented harms. In particular "Care Less" syndrome is carefully examined - and I'm sure readers will find the exploration of the behavioral effects of this Care Less syndrome compelling, answering many questions often raised about SSRI's effects.

Key experts interviewed at length include David Healy, Robert Whitaker, Allen Frances, Robert Hare, and many more; also eminent journalists Gary Schwitzer, Martha Rosenberg, Evelyn Pringle; also former Pfizer Marketing Vice President whose disclosures are eye-opening;  and very importantly those affected by these medications and most poignantly family members of those lost to suicide.

"Who Cares in Sweden" www.whocaresinsweden.com is beautifully crafted, sober and measured in tone, and utterly compelling as it tells the tale of the devastating consequences of our current paradigm. It is a call for all of us to action, and for us to further the work on how medications actually affect the people taking them.

David Healy has blogged on the film-makers and the story David Healy's The Boy With the Ponytail Who Kicked the Hornet's Nest  [LINK]

Please find the time to view "Who Cares in Sweden" www.whocaresinsweden.com [LINK], and disseminate information about it widely. These films will assist you in understanding and caring for those you know taking these medications.

If you're not familiar with Dr Purssey, I recommend you check out his website, his interest in Acceptance and Commitment Therapy in particular, and his insightful examination of the "real" effects of psychiatric drugs [LINK] -- PowerPoint presentation.

The "Who Cares?" videos are downloadable, but in their original format are nearly 800Mb in size each.

January 24, 2013       Me, myself, I -- our own worst, best, friend

Today, I've posted the second in the series from the National Institute for the Clinical Application of Behavioral Medicine series, Rick Hanson, on what is one of Dr Hanson's ongoing themes -- a variation on The Power of Positive Thinking (replacing thinking with experience): 

Transforming the Brain Through Good Experiences

with Rick Hanson, Ph.D., Neuropsychologist

Covered in the session are the following topics:

• Why Ancestral Survival Skills Trip Us Up Today ****
• The Sensitive Amygdala: Why Positive Experience Is Critical for Tuning the Brain
• Making Change - From Individual Neurons to Whole Regions of the Brain
• From State to Trait: Turning Fleeting Experience into Lasting Change
• Why Ten Seconds Matters: Making Every Moment Count
• The Brain's Version of "Vitamin C": The Key Resources Your Client Needs
• Moving from Reactive Brain to Responsive Brain
• How to Target Key Resources: A Clinical Example
• TalkBack with Joan Borysenko, PhD, Ron Siegel, PsyD, and me - get practical ways to use what you've heard with your patients 

I've converted the original downloaded video file into one slighly easier  to download (reduced in size from 570Mb to approx. 220Mb) -- with some reduction in the quality of the video. Fortunately, I don't think the information content is reduced unnecessarily. In fact, an MP3 audio version is also available:  See my webpage here:  [LINK]

I also wish to cover today two recent papers related to the title of today's post: In the area of "Social Cognition", we have articles from colleagues of Lauren Alloy, of Temple University -- firstly by Jonathan P. Stange  [LINK] then  by Richard Liu [LINK], [LINK] of Brown University Medical School -- studies to do with aspects of self-concept, both to do with self-referent inferential style -- not so much what others say about us, but what we assume they're saying -- what we're "hearing" through our filters, filters the product of our biological nature (as Hanson refers to, the "natural", automatic, defensive style) and in particular those defences we put up all too quickly as a result of our past experience of interpersonal abuse and trauma.

Negative inferential style and deficits in emotional clarity have been identified as vulnerability factors for depression in adolescence, particularly when individuals experience high levels of life stress. However, previous research has not integrated these characteristics when evaluating vulnerability to depression. In Stange's research, a racially diverse community sample of 256 early adolescents (ages 12 and 13) completed a baseline visit and a follow-up visit 9 months later. Inferential style, emotional clarity, and depressivesymptoms were assessed at baseline, and intervening life events and depressive symptoms were assessed at follow-up. Hierarchical linear regressions indicated that there was a significant three-way interaction between adolescents’ weakest-link negative inferential style, emotional clarity, and intervening life stress predicting depressive symptoms at follow-up, controlling for initial depressive symptoms. Adolescents with low emotional clarity and high negative inferential styles experienced the greatest increases in depressive symptoms following life stress. Emotional clarity buffered against the impact of life stress on depressive symptoms among adolescents with negative inferential styles. Similarly, negative inferential styles exacerbated the impact of life stress on depressive symptoms among adolescents with low emotional clarity. These results provide evidence of the utility of integrating inferential style and emotional clarity as constructs of vulnerability in combination with life stress in the identification of adolescents at risk for depression. They also suggest the enhancement of emotional clarity as a potential intervention technique to protect against the effects of negative inferential styles and life stress on depression in early adolescence.

Stange's colleague, and co-author on the above paper, Lauren Alloy, has done considerable work on social cognition and psychopathology; examining individuals' causal inference processes (attributions, psychology of controls) and extends research on "negative inferential styles" to research participants with histories of childhood abuse, and in particular examines one possible basis for the recurrent depression that often accompanies such a history.

According to the stress generation hypothesis (Hammen, 1991), depressed and depression-prone individuals experience higher rates of negative life events influenced by their own behaviors and characteristics (i.e., dependent events), which in part may account for the often recurrent nature of depression. Relatively little is known about the interrelation between stress generation predictors, and distal (time remote - early in life, in particular)  risk factors for this phenomenon. This study examined whether childhood emotional, sexual, and physical abuse, each uniquely predicted negative dependent events in individuals with a history of depression. The role of negative inferential styles as a potential mediator was also assessed. A sample of 66 adults with a history of depression completed self-report measures of childhood abuse history and negative inferential styles at baseline. The “contextual threat” method was used to assess the occurrence of negative life events over a four-month prospective follow-up period. Childhood emotional abuse, but not sexual or physical abuse, prospectively predicted greater stress generation. Negative inferential styles mediated this relation. These findings suggest that targeting negative cognitive styles in clinical settings, especially in patients with a history of childhood emotional abuse, may be important for reducing the occurrence of negative life events, thereby possibly decreasing risk for depression recurrence. Further research, more closely tracking daily life events, is needed to :"flesh out" the mechanism by which this (these) processes go on to produce depressed states and "depressive thinking":, but I feel this is an important advance. But armed with this knowledge, with the tools and nonjudgemental perspectivel we can undergo change from "worst" friend, who unconsciously engages in behaviour borne of negative cognitive style, to "best" friend acting in our best-informed interests.

January 26, 2013       Social Cognition in Borderline Personality

In my last post I discussed some aspects of social cogntion that are have recently been studied in relation to the impact of childhood abuse.  Today, I'd like to briefly discuss a recent review of Social Cognition in those suffering from Borderline Personality Disorder recently published by some German experts in this field who have done some pioneering research in the past -- Roepke and colleagues from the Free University of Berlin -- this article is freely available, but I also provide it here [LINK].

From the article's abstract:

Many typical symptoms of borderline personality disorder (BPD) occur within interpersonal contexts, suggesting that BPD is characterized by aberrant social cognition. While research consistently shows that BPD patients have biases in mental state attribution (e.g., evaluate others as malevolent), the research focusing on accuracy in inferring mental states (i.e., cognitive empathy) is less consistent. For complex and ecologically valid tasks in particular, emerging evidence suggests that individuals with BPD have impairments in the attribution of emotions, thoughts, and intentions of others (e.g., Preißler et al., 2010). A history of childhood trauma and co-morbid PTSD seem to be strong additional predictors for cognitive empathy deficits. Together with reduced emotional empathy and aberrant sending of social signals (e.g., expression of mixed and hard-to-read emotions), the deficits in mental state attribution might contribute to behavioral problems in BPD. Given the importance of social cognition on the part of both the sender and the recipient in maintaining interpersonal relationships and therapeutic alliance, these impairments deserve more attention.

Those who go on to develop BPD often have histories of being abused as children (particularly with histories of emotional abuse -- see article by Hernandez et al, 2012 [LINK]), though I do not wish to overstate this -- see the review article by Lewis and Grenyer (2009) [LINK] as well as a recent study suggesting that the common finding of childhood abuse and adult BPD may be due to a common heritable link with internalizing and externalizing disorders Bornavalova et al [LINK]  -- Clearly, even since the, relatively recent, publication of the article by Lewis and Grenyer, there has been considerable progress in understanding under what conditions experiencing childhood abuse can "result", or at least be followed by, other disorders. Genetic or epigenetic factors likely play a role, but other "psychological" factors,such as social cognition and "cognitve style" likely play the critical role. This is important as it is perhaps these factors that are most available for change by the individual survivor.

February 11, 2013       Update -- Social Cognition - Measurement and Improvement

As an update to my last post, I'd like to make available the article, by Ana Hernandez, I mentioned in my last post:

Relationships between childhood maltreatment, parenting style, and borderline personality disorder criteria   [LINK]

This study examines the relationship of different types of childhood maltreatment and the perceived parenting style with borderline personality disorder (BPD) criteria. Kendall's Tau partial correlations were performed controlling for the effect of simultaneous adverse experiences and Axis I and II symptoms in a sample of 109 female patients (32 BPD, 43 other personality disorder, and 34 non-personality disorder). BPD criteria were associated with higher scores on emotional and sexual abuse, whereas parenting style did not show a specific association with BPD. Findings of the present study help clarify the effects of overlapping environmental factors that are associated with BPD.

I've put a lot of work lately  into making sure that all my audiovisual materials remain accessible, firstly by making sure that I don't lose them! ;-)   Part of this work has included moving my audiovisuals to a central cloud store, which is readily accessible, and that doesn't require users to register for any form of cloud store membership. This process is still  in process, but I'll be posting details when it's completed. Please bear with me in the meantime.

This is a very different line of research to that taken by those in the United States -- historically, Europe has led in the examination of "psychodynamic" factors, while those in the US have pursued a more "cognitive behavioral" approach -- doubtless, both are of value, and here I'd like to share a little more of my "journeys" in using computer resources to assist personal recovery -- one "app" I"ve found recently, and am trying out on my own smartphone is the "Depression CBT Self-Help Guide"  [LINK] --- I'm sure there are very good resources available on Apple iOS devices, though even here in New Zealand, Android apps, which this is, are becoming easily available for even those on welfare benefits.  What I like about this app is, first and foremost, the preliminary cautions provided about NOT relying on any help external to formal therapy (though I'd be the first to say such therapy, though ideal, is hardly easily available, especially here in New Zealand. Secondly, there're a very large number of resources linked to; thirdly, the app is "free" (sorta) --it's one of the most highly rated apps on the Google Play Market. What I don't like about the app, and the website, is that though  the philosophy seems consistent with Acceptance and Commitment Therapy, the identity of the site owner, and the particular models used are not made clear, so that people more easily evaluate the information provided -- in part, something which has been one of my primary motivating factors in setting up my site -- not only provide you with information, but the means by which you can evaluate it for yourself.

While, I'm here, may I remind you of the series of presentations I'm providing links to via my website page on applying developments of brain science to therapy [LINK] -- coming up next from the National Institute for the Clinical Application of Behavioral Medicine:

Stephen Porges, PhD discusses

How Polyvagal Theory Expands Our Healing Paradigm --

• Why We Misunderstand Stress, and How to Work With It
• Interoception: A Powerful Sixth Sense
• How Interoception Affects Behavior: What's Behind Our "Feelings"
• Vagal Tone: How the Vagus Nerve Regulates Emotion
• Is the Vagal Brake at the Root of Autism?
• How Interpersonal Interaction Affects the Brain and Body
• Neuropeptides: How Oxytocin Changes Behavior

I think it's pretty safe predicting that an integration of the approaches, European and American, will involve making the best use of psychodynamic and cognitive-behavioral approaches, based on careful, "mindful", self-monitoring, and self-correction of subjective responses to everyday life experience -- the sorts of skills, further developed, written about by Marsha Linehan and colleagues [LINK]

February 18, 2013       Childhood Neglect & Ongoing vulnerability

Marie-Eve Nadeau, of Rivière-des-Prairies Hospital, and colleagues from the University of Quebec, have recently produced some research looking at term sequelae of childhood neglect, published in the Journal of Child and Adolescent Trauma. In the first study [LINK] the attentional and executive function of 30 neglected children ages 8 to 12,  were compared with a control group of 30 children. Neuropsychological tests measured aspects of simple and complex attention. The results have shown that neglected children were not different from control children with simple tests of attention. However, neglected children were shown difficulties in executive functions, in particular in tasks requiring mental flexibility. Thus, results supported the presence of difficulties regarding executive functions in neglected children, and supported that this form of maltreatment had consequences on high-level mental functions.  Perhaps, therefore, the results of the second study are less surprising.

In the second study [LINK] the emotional and behavioral profiles of 41 neglected children,ages 6 to 12 years,  were compared with a control group of 41 children. The Achenbach System was used in order to describe emotional and behavioral profiles based on the Diagnostic Criteria of the DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, 4th ed.]). Neglected children had more symptoms on DSM-IV Scales related to conduct or attention/hyperactivity problems. Based on the perceptions of teachers, children exposed to neglect showed more externalized and internalized problems as well as symptoms on DSM-IV Scales. Results supported the relevance of using the Diagnostic Criteria of the DSM-IV and the importance of getting the different perceptions of respondents to better understand the emotional and behavioral portrait of neglected children.

Both of these studies are easily available for download (both here and on the Journal website -- I suspect the full contents of the journal are available for download during February).

These results are generally in accord with other studies of the impact of early childhood "abuse" on children's development -- thus, where I often write "abuse" on my website, one can generally include "(and neglect)" in ntackets after the words "abuse" or "maltreatment". Childhood abuse was noted by Giardino and colleagues (2011) [LINK] to be the commonest form of abuse suffered by children, and to be linked to suffering Post Traumatic Stress Disorder(PTSD) [LINK]

Another paper recently published that is of somewhat tangential interest in this area is that of Forman-Hoffman and colleagues from the University of North Carolina (see [LINK] and [LINK]) This study did not examine longterm outcomes, and focused primarily on pharmacotherapy for non-relational sources of trauma. However, the outcome was not optimistic: "In the short term, no pharmacotherapy intervention demonstrated efficacy, and only a few psychological treatments (each with elements of cognitive behavioral therapy) showed benefit. The body of evidence provides little insight into how interventions to treat children exposed to trauma might influence healthy long-term development."  As noted elsewhere: "A trauma exposure prevention and treatment research agenda can and should focus on resilience," (And, I would argue, on interpersonal support as a major source of resilience).

Referred to elsewhere, in several places, on my site are observations from a number of researchers into the longterm consequences of childhood interpersonal distress and later-age illness -- names to search would include New Zealand's own Kate Scott [LINK], along the lines of the research by Kaiser Permanente in the 1980s (See Anda et al, 2006 [LINK]

Recently, though, Lisa Jeremka, of Ohio State University, has given me excuse to use one of my favourite words "commingling", almost onomatopoeic. Her research "commingles" research from biological, social, and individual psychological sciences, as expressed in the title of her recent "summary paper" summarising a number of previous research studies she has done -- her website, with links to her articles is accessible here: [LINK]  and, in particular, her most recent article: "Synergistic relationships among stress, depression, and troubled relationships: Insights from Psychoneuroimmunology"  [LINK] For citation, see [LINK]

From the abstract:

Stress and depression consistently elevate inflammation. Stress and depression are often experienced simultaneously, which is exemplified by people in troubled relationships. Troubled relationships also elevate inflammation, which may be partially explained by their ability to engender high levels of stress and depression. People who are stressed, depressed, or in troubled relationships are also at greater risk for health problems than their less distressed counterparts. Inflammation, a risk factor for a variety of age-related diseases including cardiovascular disease, Type II diabetes, metabolic syndrome, and frailty, may be one key mechanistic pathway linking distress to poor health. Obesity may further broaden the health implications of stress and depression; people who are stressed or depressed are often overweight, and adipose tissue is a major source of pro-inflammatory cytokines. Stress, depression, and troubled relationships may have synergistic inflammatory effects; loneliness, subclinical depression, and major depression enhance inflammatory responses to an acute stressful event. The relationship between distress and inflammation is bi-directional; depression enhances inflammation and inflammation promotes depression. Interesting questions emerge from this literature. For instance, some stressors may be more potent than others and thus may be more strongly linked to inflammation. In addition, it is possible that psychological and interpersonal resources may buffer the negative inflammatory effects of stress. Understanding the links among stress, depression, troubled relationships and inflammation is an exciting area of research that may provide mechanistic insight into the links between distress and poor health.

Clearly, Jeremka's article is not specifically about the longterm effects of childhood abuse or trauma, but one can see its relevance to the longterm effects of such abuse -- a research link I've not seen made elsewhere, yet, in the literature: ".... some stressors may be more potent than others and thus may be more strongly linked to inflammation", and as many have noted, stressed interpersonal relationships are more the rule with those from such backgrounds than the exception, resulting, based on the results of research by Jeremka and others, in the health effects reviewed and summarised by Anda et al (ibid.), and still being researched by Kate Scott, thankfully! Of course, given that some of the "interpersonal relationships" those abused as children have is with their care providers (including primary care providers, but this needs much more research), what are some other implications of this research. Jeremka et al suggests looking at patients' personal and interpersonal resources, supporting those relationships, including relationships with Primary Care Providers, but notes also that the relationship is "bi-directional" -- highlighting the need for health interventions targeted at reducing inflammatory responses triggered by stressed relationships, anxiety, and chronic depressed mood.

A final observation can also be made -- we are moving more and more towards having evidence-based standards of care for adults suffering childhood trauma-related depressive, anxiety, substance-use, other psychiatric, and physical disorders. But, given my experience of practice and research issues in this area in New Zealand, we are VERY far behind where we need to be, where we, in my opinion, should be. Given the absence of a current research evidence base to local practice, people have died, through suicide, and through trauma-related physical disorders, long before they should have, after having suffered cruelly, emotionally and physically, from trauma-induced symptoms.