Book Review: the Deepest Well by Nadine Burke Harris

Every mental health professional should know that adverse childhood experiences (especially with parents who are abusive, neglectful, are perpetrators or victims of domestic violence, have multiple partners, or have substance abuse issues) are a major risk factor for developing almost every psychiatric disorder imaginable. Yet therapists and psychiatrists often ignore this issue in favor of theories about some sort of genetically-caused, pre-existing brain disorder.

In her amazing and surprisingly entertaining book, pediatrician Nadine Burke Harris (now surgeon general of California) outlines in vivid detail how ACE’s are toxic stressors that impact our bodies biologically and put us at higher risk for a variety of physical, not just psychological illnesses over the course of our entire lifetime. She points out that this does not only effect those who live poor neighborhoods, but can happen anywhere,

She covers the issue of epigenetics (how the environment turns genes off and on) as well as differentiating the effects of ongoing as opposed to time-limited stress. She zeroes in on the amygdala (the part of the brain that is responsible for fight or flight reactions) and how it can inhibit cognitive functioning, and on the sometimes toxic effect of stress hormones like cortisol.

In her observations as a crusader in the medical field, she came to realize that the reason physicians were often unaware of how this was taking place resulted from the fact that they never asked about it. As I have often said, it’s a case of don’t ask, don’t tell. Which is also the reason that psychodynamic and CBT therapists aren’t aware of the role of ongoing family interactions in their patients’ symptoms.

Also discussed in detail is how, in public discussions and meetings, parents can be resistant to various plans to confront ACE’s (due to what the author calls “hateration”) for fear that doctors would be stigmatizing their children as being brain damaged.  I think a bigger fear in the public is stigmatizing parents. As I often write about, you cannot call any type of parenting a problem these days anywhere without being attacked.

Last but not least, she talks about the intergenerational issues involved in chronic family stress. Here, the author seems to be on the right track, but I’m not clear if she, too, is unaware of the role of ongoing repetitive dysfunctional family interactions with their extended family members among both adults and children - particularly the role of grandparents in, unintentionally or intentionally, reinforcing problematic parenting practices and marital issues. 

For example, she cites the case of a woman who put up with verbal abuse from her husband and who stayed because she blamed herself and told herself she had to put up with it for the sake of the kids. Were her parents alive? If so, did they know what was going on? What did they have to say about it? If they didn’t know, why hadn’t she told them? Was she afraid they’d tell her it was her fault and she needed to stick it out for the sake of the kids? It sounds like this might possibly have been a case of don’t ask, don’t tell.

The closest she comes to discussing extended family is when she gives an example of how the aunt of a child who was a patient of hers seem to undo a lot of the therapeutic work that she had done with the child and the child’s mother.

It is true that certain early fear tracks in the amygdala are formed during the interactions of mothers with their babies, as she correctly points out. It is also true that these tracks are highly resistant to the usual process of neural plasticity that might fix issues caused by trauma. Scientists often seem to assume that the tracts are permanently damaged. However, perhaps it is true that the tracts remain strong because they are constantly being triggered and reinforced by the attachment figures throughout life.

If indeed the author is not aware of all of the forces at play here, she is hardly alone. So even with this possible and understandable omission, I cannot recommend this book highly enough. 

High Index of Suspicion vs. Hyper-reactivity in Borderline Personality Disorder

One of the main themes of this blog is how researchers in psychiatry continually mix up learned or conditioned responses with disease states. These include misinterpreting fMRI findings and data derived from twin studies. I have also discussed something called Error Management Theory, which predicts that if you come from a toxic and crazy environment like someone with borderline personality disorder (BPD) does, and have to learn how to react to it, it is in your interest to have a high index of suspicion about the others around you. Somehow this has turned into emotional “hyper-reactivity” as some of sort of brain pathology or abnormality.

Now comes a study that seems to be strong evidence for my point of view. (Borrolla, B., Cavicchioli, C,., Fossati, A., and Maffei, C. “Emotional Reactivity Borderline Personality Disorder: Theoretical Considerations based on Meta-Analytic Review of Laboratory Studies.” Journal of Personality Disorders 34[1], 64-87, 2020). 

The authors did a meta-analysis (combining the data from several studies) which addressed the question.

Variables measured in these studies included heart rate, respiratory heart sinus arrhythmia, skin conductance, cortisol (stress hormone) levels, startle response, blood pressure, and patient self report.

Their conclusion: the hyper-reactivity hypothesis was in general not supported. The apparent increase in reactivity in BPD could instead be attributable to their tendency to evaluate emotional  stimuli more negatively than controls. Exactly what error management theory would predict!

The study authors go on to say that amygada functioning (basically fight/flight/freeze reactions) concerns “several processes that go beyond emotional arousal (salience and novelty detection, reward learning, memory, attention modulation, decision making…” (p. 79).

Exactly. And Amen.

Borderline Personality Disorder: Why They Don't “Get Used to It.”

At the annual meeting of the American Psychiatric Association in New York this year, I learned about a new finding from one study with patients who exhibit borderline personality disorder (BPD). The same finding also applied, although to a lesser degree, to those with avoidant personality disorder (AVD), which is pretty much identical to the diagnosis of Social Phobia.  I suspect that the reasons for the similar findings may be different for the two disorders.

The finding involved a part of the brain called the Amygdala. This little doohickey is central to a lot of brain functions, but in particular, it is the center for the body’s “fight or flight” response. I always though it fascinating  that the amygdala also has specific cells which respond only to one’s own mother (or other primary female attachment figure) and nothing and nobody else, and other specific cells which respond only to one’s father (or other primary male attachment figure). 

Although one cannot prove such things, this fact suggests to me that primary attachment figures may be the most potent of all of the environmental triggers to fear-based flight or fight reactions. They are certainly more powerful that a therapist can ever be for doing so, for instance.

The finding may relate to one of the primary symptoms of BPD, which goes by a variety of names. In the actual DSM criteria, it is described as “affective instability, or marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.)” It is also called high reactivity, and lay people often label it hypersensistivity. In psychological tests, it is called neuroticism. Clearly, amygdala activation is intrinsic to this phenomenon.

Therapists have a tendency to think that patients with BPD over-react because they misperceive the behavior of others as being emotional slights, when the behavior is not at all meant as such. In fact, these therapists do not even know to what exactly the patient may be reacting to, or alternatively, that sometimes patients with BPD feign such reactions in order to provoke a specific response in others in order to recruit them to be enablers of the patients’ spoiler role.

For example, one patient would go ballistic if anyone ever even implied that her mother might have been a loving parent. Of course, if one knew all the horrible things her mother had done to her, one could easily see why she would find such a comment annoying - to say the least!

The study I am discussing here is by Harold Koenigsberg and others (Journal of the American Psychiatric Association 171:82-90, January 2014). Study participants were asked to look at a series of pictures with either highly negative or neutral content, and the activation of the amygdala and another region of the brain called the dorsal anterior cingulate was measured using a specific type of brain scan. The subjects also subjectively rated their emotional responses to the pictures. 

Exposure to these pictures and these measurements were then repeated. Repeated only once, I’m afraid. The study would have been a lot more powerful if they had repeated the exposure several times.

The changes in emotional arousal and brain activation after a repeat viewing of the negative images was small but signficantly different between patients with BPD or AVD and the "normal" control subjects.  

The brains of the controls seemed to habituate, while those of the patients with BPD did not.  Habituation means that the controls got used to or became accustomed to the awful pictures, and their arousal levels decreased from what it had been after the initial viewing.

If anything, the emotional arousal of patients with BPD actually increased with the repeat viewing.

This finding, if it can be replicated, might seem to indicate that the brains of those with BPD are abnormal in this regard. However, as I have ranted in the past, a difference is not automatically indicative of an abnormality. In fact, it may be a conditioned response that is highly adaptive in particular environments.

In the case of patients with BPD in particular, they invariable grow up in chaotic family environments in which “getting used” to the chaos and not reacting to it when one needs to could be hazaradous to their and their family’s health, as described in my post on Error Management Theory.  If the chaos continues, such individuals need to pay even more attention to it, not less. 

This new research finding fits my ideas about that to a tee.

Where the Analysts Went Wrong: Part II

In the introduction to this post, I mentioned that a major problem with psychoanalytic formulations concerning the origins of personality dysfunction is that they presume that problematic interactions with parents and other family-of-origin members are only powerful in shaping personality functioning with young children.

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

Until I started asking about these interactions, as I described in my post Don’t Ask Don’t Tell, the patients had not described them in much detail. When they broke out in tears while telling me about them, however, it became hard for them to deny that the interactions were at least part of what was making them feel bad.

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in this particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out -although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs.  Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, either for good or for ill. And it was not just her. I found out – again and again - that parents were way more potent influences on the patient than I as a therapist could ever be.

Behavior therapists do not seem to have figured out that the interactions of a patient and his or her family of origin are important triggers to many of the complaints that patients come to therapy with. Nonetheless, their behavioral interventions do often change certain aspects of a patient’s behavior, and therefore they feel that their patients are responding to treatment. In fact, if a patient’s family of origin is not too dysfunctional, they are correct. The patients change their behavior and the family basically accepts the change, so everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempt at self actualization, or doing what they want and not what the parents seem to want. 

The psychoanalyst Karen Horney once opined that “basic anxiety” requires a sense of isolation from others, helplessness, and of being surrounded by hostility. Such perceptions and cognitions are closely related to attachment to others in one’s family system. The human brain encodes social events from the family exceptionally well, and is exquisitely sensitive to them.

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. 

The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. Lesions of amygdala in primates cause an inability to appraise social signals from other members of same species. An afflicted individual cannot distinguish whether another member of their species is coming towards them to fight with them or to mate with them. And again this is in adults, not juveniles.

In general, the attachment system seems to be one of the most important regulators of overall arousal. The amygdala is the first responder within fractions of a second; one’s initial fear orientation is not affected by conscious cognition. However, the signals then go to the other areas of the brain for further evaluation. Information regarding social context directly affects this appraisal process.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place – a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has in the past continued to have survival value throughout the life cycle.  

Parental behavior has such a powerful effect in triggering old schemata that it does not have to occur with any great degree of frequency in order for its effects to continue. In adults, the reinforcement of schemata occurs in a manner analogous to the learning theory paradigm of a variable intermittent reinforcement schedule. That is, the powerful parental behavior may be witnessed infrequently but unpredictably, leading the patient to continue to react rigidly in ways consistent with old role-relationship expectations.  

Neural Plasticity

As I discuss in detail in my upcoming book, one way that some "biological" psychiatrists twist the truth in order to justify their belief that certain behavioral problems are due to brain disorders has to do with the neuroscientists' new toy, the Functional MRI (fMRI). fMRI machines, because they measure magnetic fields, can map both brain structure and brain function because the iron in blood that passes through the brain creates a magnetic field.

What researchers do is to use fMRI to compare certain brain structures and brain activity, particularly in the primitive part of the brain called the limbic system, in some diagnostic group with matched controls or "normals." For instance, an important brain structure called the left amygdala is smaller, on average, in patients who exhibit the signs of borderline personality disorder (BPD) than in "normals."

Of course, they are comparing averages, so the left amydala in some BPD patients is larger than those of the average "normal." Notice also that the scientists only occasionally compare different diagnostic with each other. Differences in amygdalar size and activity are found in any number of different diagnostic groups in psychiatry.

The more annoying source of misleading conclusions is that when a difference is found between a diagnostic group and "normals," that difference is automatically labeled an abnormality. If a patient has an abnormality, then of course they must have a brain disease. Actually, these scientists do not know if what they have found is an abnormality or not. What makes the use of the term abnormality totally misleading is that the brain, particularly in terms of limbic system structures, is plastic. This means that, in the normal brain, these structures can change in size to reflect activities that become important to a given individual. The changes can be very quick and substantial.

For example, in the February 2010 issue of the Archives of General Psychiatry (Volume 67 [2] pp. 133-143), Pajonk, Wobrock, Gruber et. al. found that after just three months of a vigorous exercize program, the size of a brain structure called the hippocampus increased an average of 16% in normals! It is also true that the part of the brain that controls finger movements is, on average, much larger in concert violinists than in non-musicians. The conclusions that the so-called biological psychiatrists would be, I guess, that both being a concert violinist and engaging in vigorous exercize are diseases!

Well-known personality disorder researcher and schema therapist Arnoud Arntz has told me that he has some unpublished preliminary evidence that the amygdala changes seen in BPD are reversible with three years of Schema Psychotherapy (a therapy method developed by Jeffrey Young). Thus, these so called "abnormalities" may in fact be conditioned responses from living in a chaotic and invalidating family environment. Not only may they be quite normal, they may be adaptations to the enviroment.