Consequences of Biological Vulnerability
Jun 30, 2012
In a paper sure to please many psychiatrists, with a propensity to always place biological factors at the forefront of arguents for the causes of mental illness, and albeit in a paper written by those with financial interests in drug treatments, Saveanu and Nemeroff (2012) -- [LINK] -- available [LINK] -- argue that sufferers of childhood trauma-related depression may have a genetic vulnerability so that they may be responsive to different treatment strategies than depressed patients without childhood adversity. Based on current findings, they argue, treatment strategies should be multimodal and include the following:
- Psychotherapy that addresses a number of domains, such as emotional regulation, cognitive reframing, careful exploration of past traumatic events, attachment, and interpersonal relationships in a safe and trusting therapeutic environment.
- The therapy should likely be longer term in order to effectively impact those domains.
- Pharmacotherapy that will be effective in quieting the body’s hyper-responsiveness to stress and reverse epigenetic modifications induced by trauma and stress.
- Environmental interventions that provide a support network (maternal care, a positive family environment, the support of a close friend) have all been shown to attenuate the impact of childhood abuse.
(Of course, these are also consistent with those of van der Kolk originally for children and dolescents -- [LINK].)
The recommendations are certainly consistent with the recommendations of the expert panel surveyed by Cloitre et al (2011) --- [LINK]- available [LINK]. What is missing from Cloitre et al's statement, concerning needed duration of treatment, but is more clearly spelled out in that of Saveanu and Nemeroff, is the likely need for longer term treatment, provided that that treatment is tailored to the specific needs of the patient, identified by comprehensive assessment across a number of areas of functioning; likely "staged", so that "treatment enabling" goals of intervention are targeted initially (for example, targeting emotion regulation initially -- e.g., Cloitre [LINK] -- available [LINK]). Of course, this is also the result found by Kriedler and Einsporn (2012) -- [LINK] . These authors' study sample included women from 6-month therapy groups (n = 42) and a comparison group who completed 12 months of therapy (n = 114). When outcomes attained by the 6-month group were compared with those of the 12-month group, those in the 6-month group showed significantly greater gains in self-esteem, symptom change, and posttraumatic stress disorder symptoms. In addition, although participants in the 6-month group improved more in depression scores than those in the 12-month group, the difference was not statistically significant. The results of this study indicate that intensive 6-month group therapy for female survivors of CSA may be even more beneficial than less intensive 12-month groups. It is likely that treatment for Complex Trauma may be longer.
Consideration of the overall results of Cloitre et al, Saveanu and Nemeroff, and Kriedler and Einsporn, go a long way towards defining what is adequate and appropriate treatment for childhood trauma related disorders (whether the disorder be PTSD or chronic / remitting depression -- there are some indications that gender may be one factor determining whether or not the resulting disorder is one or the other -- see my initial thesis proposal). Moreover, they go a long way towards making the limit allowed on therapy sessions by the ACC, in NZ (16 sessions), look woefully inadequate. In the last 12 months, of 1151 men who have received ACC "Sensitive Claim" counselling, only 2 (two) have been approved for more than 16 sessions. The results of this research also make the "treatment" offered by Dunedin's Ashburn Clinic (see my earlier post on this -- [LINK]) look the farce it is, especially the so-called treatment offered to male patients there. But very clearly, the research also clearly reflects the fact that intensive treatment, as Ashburn Clinic SHOULD be offering,along the lines outlined by Saveanu and Nemeroff, is definitely needed.