Intérêt clinique d’une conception neuroscientifique du trouble de personnalité limite : dysfonctionnements du système exécutif et de la théorie de l’esprit

Le trouble de personnalité limite (TPL) est un problème psychopathologique complexe et les données récentes issues des neurosciences permettent une compréhension plus précise des bases neurobiologiques de ses manifestations. Cet article vise à étayer la proposition que le TPL dépend en partie d’un dysfonctionnement frontal et exécutif qui perturbe les mécanismes nécessaires au fonctionnement optimal des inférences propres à l’utilisation d’une « théorie de l’esprit ». Pour soutenir ce propos, quatre ensembles d’observations sont examinés : les parallèles entre la personnalité dite frontale et le TPL, la présence de déficits cognitifs de type frontal chez le TPL, les conséquences sur le développement cérébral d’une enfance marquée par l’abus et la négligence et enfin, les résultats des études d’imagerie cérébrale. Cet article s’inscrit dans un courant de pensée qui vise l’intégration de la perspective neuroscientifique du TPL aux conceptualisations psychopathologiques actuelles. L’objectif étant d’offrir une conceptualisation du TPL qui évite la traditionnelle dichotomie esprit/cerveau, psychologie/biologie et de dégager des points de convergence entre la psychologie clinique et la neurobiologie.

Neurobiological basis of parenting disturbance

OBJECTIVE

It has been proposed that early attachment relationships shape the structure and reactivity of social brain structures that underlie later social capacities. We provide a review of the literature surrounding the development of neurological regulatory systems during infancy and outline recent research suggesting these systems go on to underlie adaptive parental responses.

METHOD

We review evidence in the peer-reviewed psychiatric literature including (i) observational human literature on the neurobiological and social sequelae of early parenting experiences, (ii) experimental animal literature on the effects of early maternal care on neurological development, (iii) experimental animal literature on the neurobiological underpinnings of parenting behaviours, (iv) observational and fMRI evidence on the neurobiological correlates of parenting behaviours, (v) functional and volumetric imaging studies on adults affected by borderline personality disorder.

RESULTS

The development of infant regulatory systems is influenced by early parenting experiences. These frontolimbic regulatory systems are also heavily implicated in normal parental responses to infant cues. These frontolimbic disturbances are also observed in studies of borderline personality disorder; a disorder associated with poor emotional regulation, early trauma and disturbed parenting.

CONCLUSIONS

While the current literature is limited to animal models of abnormal care giving, existing disorders associated with deficits in regulatory capacity and abnormal frontolimbic functioning may yet provide a human model of the neurobiology of parenting disturbance.

Shame as a traumatic memory

BACKGROUND

This study explores the premise that shame episodes can have the properties of traumatic memories, involving intrusions, flashbacks, strong emotional avoidance, hyper arousal, fragmented states of mind and dissociation.

METHOD

A battery of self-report questionnaires was used to assess shame, shame traumatic memory and depression in 811 participants from general population (481 undergraduate students and 330 subjects from normal population).

RESULTS

Results show that early shame experiences do indeed reveal traumatic memory characteristics. Moreover, these experiences are associated with current feelings of internal and external shame in adulthood. We also found that current shame and depression are significantly related. Key to our findings is that those individuals whose shame memories display more traumatic characteristics show more depressive symptoms. A moderator analysis suggested an effect of shame traumatic memory on the relationship between shame and depression.

LIMITATIONS

The transversal nature of our study design, the use of self-reports questionnaires, the possibility of selective memories in participants' retrospective reports and the use of a general community sample, are some methodological limitations that should be considered in our investigation.

CONCLUSION

Our study presents novel perspectives on the nature of shame and its relation to psychopathology, empirically supporting the proposal that shame memories have traumatic memory characteristics, that not only affect shame in adulthood but also seem to moderate the impact of shame on depression. Therefore, these considerations emphasize the importance of assessing and intervening on shame memories in a therapeutic context.

Traumatic stress symptoms and breast cancer: the role of childhood abuse

OBJECTIVE

The present study investigated relations between reported childhood abuse and recent traumatic stress symptoms in women newly diagnosed with breast cancer (n=330).

METHODS

As part of a larger ongoing study, patients from eight public and private hospitals were referred by their physicians and completed the Childhood Trauma Questionnaire (CTQ), and the Impact of Events Scale-breast cancer (IES), which measured breast cancer-related intrusive and avoidant symptoms.

RESULTS

Emotional abuse, physical abuse, and sexual abuse were correlated with intrusive symptoms. Cancer-related avoidant symptoms approached significance in their relation to emotional and sexual abuse. Multivariate analysis, controlling for age and time since diagnosis, revealed that childhood emotional abuse was an independent predictor of breast cancer-related intrusive symptoms, but that childhood physical abuse and sexual abuse were not significant predictors.

CONCLUSIONS

Childhood emotional, physical, and sexual abuse were associated with breast cancer-related intrusive symptoms. Emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. Results suggest that a cancer diagnosis may trigger cognitive and emotional responses that relate to patients' prior trauma experiences.

PRACTICE IMPLICATIONS

Physicians and psychologists treating women with breast cancer should be aware that a history of childhood abuse may exacerbate patients' cancer-related intrusive symptoms. Interventions for women affected by both childhood abuse and breast cancer may be most effective when they address both stressors and associated emotional responses. Findings highlight the importance of additional research to explore links between prior trauma and distress following a cancer diagnosis stress.

Transitions in sensitive period attachment learning in infancy: the role of corticosterone

Survival of altricial infants, including humans and rats, depends on attachment to the caregiver - a process that requires infants to recognize, learn, and remember their attachment figure. The demands of a dynamic environment combined with a maturing organism require frequent neurobehavioral reorganization. This restructuring of behavior and its supporting neural circuitry can be viewed through the unique lens of attachment learning in rats in which preference learning is enhanced and aversion learning is attenuated. Behavioral restructuring is well adapted to securing the crucial infant-caregiver relationship regardless of the quality of care. With maturation and the end of the infant-caregiver attachment learning period, the complex interplay of neural structures, hormones, and social behavior coordinates the developing rat's eventual transition to life outside of the nest. Nevertheless, early-life environmental and physiological stressors can alter the resilient nature of this system, particularly with respect to the amygdala, and these changes may provide important clues to understanding the lasting effects of early stress.

The role of trauma symptoms in the development of behavioral problems in maltreated preschoolers

OBJECTIVE

This study assessed the mediating role of trauma symptoms in the relation between child maltreatment and behavioral problems. It is based on the postulate that child maltreatment is a severe form of chronic relational trauma that has damaging consequences on the development of children's behavioral regulation.

METHOD

Participants were 34 maltreated and 64 non-maltreated children (mean age=60 months; range: 46 to 72 months), all from economically disadvantaged families. Maltreated children were recruited from the Child Protection Agencies. Behavioral problems and trauma symptoms were evaluated by the preschool teacher with the Internalizing and the Externalizing scales of the Child Behavior Checklist-Teacher Report Form (CBCL-TRF) and the posttraumatic stress score of the Trauma Symptoms Checklist for Young Children respectively (TSCYC).

RESULTS

Baron and Kenny's mediational procedure was conducted using structural equation modeling. Mediational analyses revealed that trauma symptoms fully mediated the association between maltreatment and both internalizing and externalizing behaviors.

CONCLUSIONS

Results were consistent with the literature on developmental trauma research and provide empirical support to the idea that trauma-related symptoms resulting from early maltreatment may constitute a mechanism in the development of psychosocial problems in preschoolers.

PRACTICE IMPLICATIONS

These findings underline the importance of understanding psychosocial maladjustment of maltreated children not only from the perspective of problematic behavior, but also by taking into account the traumatic reactions that might develop in response to chronic and intense stress associated with abuse and neglect.

Moral Complexity

Recently, intuitionist theories have been effective in capturing the academic discourse about morality. Intuitionist theories, like rationalist theories, offer important but only partial understanding of moral functioning. Both can be fallacious and succumb to truthiness: the attachment to one’s opinions because they “feel right,” potentially leading to harmful action or inaction. Both intuition and reasoning are involved in deliberation and expertise. Both are malleable from environmental and educational influence, making questions of normativity—which intuitions and reasoning skills to foster—of utmost importance. Good intuition and reasoning inform mature moral functioning, which needs to include capacities that promote sustainable human well-being. Individual capacities for habituated empathic concern and moral metacognition—moral locus of control, moral self-regulation, and moral self-reflection—comprise mature moral functioning, which also requires collective capacities for moral dialogue and moral institutions. These capacities underlie moral innovation and are necessary for solving the complex challenges humanity faces.

Emotion regulation strategies as mediators of the association between level of attachment security and PTSD symptoms following trauma in adulthood

Although, a link between attachment and posttraumatic stress disorder (PTSD) symptoms has been established, the mechanisms involved in this link have not yet been identified. Furthermore, attachment has been systematically measured by self-report questionnaires, which are prone to perceptual bias. The first goal of this study was to examine the link between PTSD symptoms and attachment security level, as measured with a security index created from the Adult Attachment Projective interview. The second goal was to test emotion regulation strategies as mediators of this link. Participants were recruited in hospital emergency rooms following trauma exposure in adulthood. The results showed that a higher level of attachment security was associated with fewer PTSD symptoms at one and three months post-trauma. The results also showed that substance use and emotion-focused strategies mediated the association between attachment and PTSD symptoms. Theoretical and clinical considerations that follow from these outcomes are discussed.

Depression, traumatic stress and interleukin-6

BACKGROUND

Recent evidence indicates that various types of interactions between nervous and immune system are important in pathogenesis of depression. These findings show that a significant role in developing depression play pro-inflammatory cytokines that may mediate its psychological, and neurobiological manifestations. Great importance among these cytokine molecules plays interleukin-6 (IL-6). There is growing evidence that this inflammatory process related to depression may be influenced by psychological stress as well as organic inflammatory conditions. These findings suggest that specific influences related to traumatic stress and dissociation could be found in close relationship to increased level of cytokine IL-6.

METHODS

In the present study we have performed psychometric measurement of depression (BDI-II), traumatic stress symptoms (TSC-40) and dissociation (DES, SDQ-20), and immunochemical measure of serum IL-6 in 40 inpatients with unipolar depression (mean age 42.3+/-6.8).

RESULTS

The results show that IL-6 is significantly correlated to BDI-II (Spearman R=0.47, p<0.01), TSC-40 (Spearman R=0.32, p<0.05), SDQ-20 (Spearman R=0.34, p<0.05) but not to DES (Spearman R=0.25, p=0.11).

CONCLUSION

The findings of the present study indicate that increased level of IL-6 in depression could be directly related to symptoms of traumatic stress and somatoform dissociation.

The complex nature of exposure to early childhood trauma in the psychoanalysis of a child

When an intense transference relationship evolves during psychoanalysis, sensory and emotional experiences associated with trauma can arise spontaneously. Detailed clinical process material is presented from the psychoanalysis of a six-year-old boy whose severe trauma at age two and a half contributed to his conflicts about aggression and gender identity, impeding his development. A series of analytic sessions during which he spontaneously enacted fantasies, feelings, and defenses associated with the trauma in the immediacy of the transference relationship are used to illustrate how psychoanalysis provided him the safety to rework this overwhelming experience and its aftermath, thereby restoring progressive development. It is hypothesized that while work with trauma was only one feature in an otherwise complex treatment, psychoanalysis provided a sophisticated form of reexposure to developmentally primitive emotions, images, and fantasies that this child had not consciously connected with the trauma. Associated early childhood conflicts pertaining to aggression, separation, and gender identity, warded off with rigid defenses, had become intertwined with the trauma and its aftermath, rendering them otherwise inaccessible.

Neurophysiologic assessment of brain maturation after an 8-week trial of skin-to-skin contact on preterm infants

OBJECTIVE

Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Analyses of EEG-sleep studies can compare functional brain maturation between SSC and non-SSC cohorts.

METHODS

Sixteen EEG-sleep studies were performed on eight preterm infants who received 8 weeks of SSC, and compared with two non-SSC cohorts at term (N=126), a preterm group corrected to term age and a full-term group. Seven linear and two complexity measures were compared (Mann-Whitney U test comparisons p<.05).

RESULTS

Fewer REMs, more quiet sleep, increased respiratory regularity, longer cycles, and less spectral beta were noted for SSC preterm infants compared with both control cohorts. Fewer REMs, greater arousals and more quiet sleep were noted for SSC infants compared with the non-SSC preterms at term. Three right hemispheric regions had greater complexity in the SSC group. Discriminant analysis showed that the SSC cohort was closer to the non-SSC full-term cohort.

CONCLUSIONS

Skin-to-skin contact accelerates brain maturation in healthy preterm infants compared with two groups without SSC.

SIGNIFICANCE

Combined use of linear and complexity analysis strategies offer complementary information regarding altered neuronal functions after developmental care interventions. Such analyses may be helpful to assess other neuroprotection strategies.

Research in child psychoanalysis: twenty-five-year follow-up of a severely disturbed child

In an era of managed care, psychoanalytic treatment of children is under fire as critics question whether the evidence of success in child analysis is sufficiently robust to warrant the large commitment of time and money required for this treatment. This article chronicles the history and current state of research at the Anna Freud Centre, and describes the evolution of a database that has methodically recorded and systematically organized data from over 750 cases of children referred to the Centre over a forty-five-year period. Analysis of this database has determined what kinds of childhood disorders are best treated with intensive psychoanalysis, and what kinds do not respond to this form of treatment. A long-term follow-up of a small sample of these childreen suggests the kinds of long-term benefits that can be gained when an individual is treated with intensive psychoanalysis as a child. As an example, clinical material from the analysis of an eight-year-old is presented along with follow-up interview data twenty-five years later.

Antenatal psychological distress and postnatal depression: A prospective study from an urban clinic

Postnatal depression is a significant public health problem in developing countries. In addition to traditional risk factors, studies from developing countries have identified some cultural factors related to the development of postnatal depression. The present prospective study conducted at a teaching general hospital in an urban setting sought to examine the prevalence and risk factors in the development of postpartum depression. 132 pregnant mothers attending antenatal clinic were assessed for psychological distress at third trimester on General Health Questionairre-28. 27 women (20%) obtained a score of >8 on General Health Questionairre-28. Mothers were interviewed again between 6 and 10 weeks after childbirth. Variables that were measured included postnatal depression, obstetric history and socio-demographic characteristics. 39 women (30%) scored greater than 12 on Edinburgh Postnatal Depression Scale at 6-10 weeks indicative of postpartum depression. 44% of women with antenatal psychological distress developed postpartum depression. A significantly greater proportion of women with postpartum depression were from lower socio-economic strata. The finding that antenatal psychological distress was a risk factor in the development of postpartum depression calls for routine screening of psychological distress during antenatal visits.

Optimising psychophysiology in third stage of labour: theory applied to practice

BACKGROUND

Active management of the third stage of labour is routine in delivery suites. New South Wales (NSW) Health has a policy which prescribes active management because medically designed randomised controlled trials have claimed a reduced blood loss in third stage with active, compared with 'physiological', management. In home and birth centre settings however, physiological third stage is common as women who access these settings prefer to labour without medical intervention and midwives who work in these settings adopt a holistic approach to working with women. The holistic approach is psychophysiological as the midwife engages with and supports integration of the woman's spirit, mind and body in her childbearing process.

PURPOSE

To present midwifery theory that describes, explains and predicts how women and midwives work together to enable selected women to safely experience an optimal psychophysiological third stage of labour.

METHOD

Key terms are defined. The literature relevant to psychophysiology and management of the third stage of labour is reviewed. An expanded understanding of risk factors for postpartum haemorrhage is presented and justified. A theoretical framework of Midwifery Guardianship is presented and discussed and applied to third stage care.

CONCLUSIONS

A psychophysiological third stage is quite different from what has been defined as 'physiological management' in the medically designed randomised trials comparing active versus physiological care. The conditions for deciding if a particular woman, in a particular context with a particular midwife is a good candidate for a psychophysiological third stage are presented and discussed. Only if all these conditions are met it is safe to proceed with a psychophysiological third stage. Research about the effectiveness of midwifery care in a psychophysiological third stage of labour urgently needs to be conducted.

The metallic womb

This study of malevolent narcissism examines the relationship between the Washington Snipers, Muhammad and Malvo, from the perspectives of attachment theory and Kleinian theory. Muhammad embodied a perverted understanding of manliness. Malvo was desperate for the love of a father, and fused with the omnipotent destructiveness of John Muhammad. Together they embarked on a failed Quest, recreating the original infant/caregiver scenario, which in their experience was about destruction and death, rather than gratitude and life. Malvo and Muhammad were perfect together, merged into one unit devoted to murder. Their victims were random and multiple, like their early caregivers.

Consequences of antenatal mental health problems for child health and development

PURPOSE OF REVIEW

The aim of this article is to review studies published in English in the last year which examine associations between maternal mental health problems during pregnancy and subsequent development and health outcomes for the fetus, infant, child and adolescent. The body of research into antenatal mental health consequences is now considerable so this article provides an introduction to the field by considering the most recent studies.

RECENT FINDINGS

Research in the past 12 months has further developed understanding of the effects of mental health problems including antenatal anxiety and possible mechanisms for its effect on fetal neurodevelopment, infant temperament and later psychological, behavioural and cognitive outcomes for the child and adolescent. Delivery outcome studies again confirm the significant association between various mental illnesses, including depression and preterm birth and low birth weight.

SUMMARY

Children's emotional, cognitive and physical health and development are affected by their mothers' mental health whilst pregnant. Prompt identification and referral of pregnant women for specialist treatment is important in order to reduce adverse child outcomes.

Maternal behavior predicts infant cortisol recovery from a mild everyday stressor

BACKGROUND

In the very first years of life, parenting is considered to be important for the regulation of the infant's emotional and physiological states. In the present study, three-month-old infants' cortisol responses (reactivity and recovery) to a mild everyday stressor, namely being taken out of the bath, were examined in relation to the quality of maternal behavior. It was hypothesized that a higher quality of maternal behavior towards the infant predicted lower cortisol reactivity as well as a better recovery from the reaction.

METHOD

The participants were 64 infants (34 boys and 30 girls) and their mothers. Maternal behavior (sensitivity and cooperation) towards the infant during the bathing routine was rated from videotapes. Salivary cortisol was obtained from the infants three times: before the bathing routine (T1), and 25 minutes (T2) and 40 minutes (T3) after the infants were taken out of the bath.

RESULTS

The infants reacted with a significant increase in cortisol to the stressor (from 6.8 nmol/l to 9.9 nmol/l), and regression analysis showed that the higher the quality of maternal behavior the better the cortisol recovery from the stressor.

CONCLUSION

Our findings indicate the potential importance of social processes for physiological recovery from everyday stressful situations in infants.

Beliefs, mental health, and evolutionary threat assessment systems in the brain

This article reviews aspects of the literature on neuroscience, psychiatry, and cognitive and evolutionary psychology to illustrate how primitive brain mechanisms that evolved to assess environmental threats underlie psychiatric disorders, and how beliefs can affect psychiatric symptoms through these brain systems. Psychiatric theories are discussed that (a) link psychiatric disorders to threat assessment and (b) explain how the normal functioning of threat assessment systems can become pathological. Three brain structures that are consistently implicated in psychiatric symptomology also are involved in threat assessment and self-defense: the prefrontal cortex, the basal ganglia, and parts of the so-called limbic system. We propose that as these structures evolved over time they formed what we refer to as evolutionary threat assessment systems, which detect and assess potential threats of harm. Drawing on various psychological and psychiatric theories we propose how beliefs about the world can moderate psychiatric symptoms through their influence on evolutionary threat assessment systems.

Infants’ interactions with professional caregivers at 3 and 6 months of age: A longitudinal study

This study longitudinally investigated the quality and stability of 64 infants' interactions with their professional caregivers in child care centers at 3 and 6 months of age, i.e., across the first 3 months after they entered child care. It was also examined whether the infants' negative emotionality (as rated by the mother) predicted the quality of the caregiver-infant interaction. The interactive behavior of the professional caregivers (sensitivity, cooperation) and the infants (responsiveness, involvement) was rated from videotapes recorded in three different caregiving situations, lasting about 25 min in total. In contrast to our expectation, the quality of the caregiver-infant interaction did not significantly increase across the first 3 months in child care. As expected, significant rank order stability was found for the quality of the caregivers' behavior over time. Also in accordance with our expectations, infants with higher negative emotionality scores experienced less sensitivity and cooperation in interactions with their primary professional caregivers at both ages.

Panic disorder, phobias, and generalized anxiety disorder

This chapter provides a review of recent empirical developments, current controversies, and areas in need of further research in relation to factors that are common as well as specific to the etiology and maintenance of panic disorder, phobias, and generalized anxiety disorder. The relative contribution of broad risk factors to these disorders is discussed, including temperament, genetics, biological influences, cognition, and familial variables. In addition, the role that specific learning experiences play in relation to each disorder is reviewed. In an overarching hierarchical model, it is proposed that generalized anxiety disorder, and to some extent panic disorder, loads most heavily on broad underlying factors, whereas specific life history contributes most strongly to circumscribed phobias.

Understanding alexithymia and language skills in children: implications for assessment and intervention

PURPOSE

This article reviews the construct of alexithymia and its relationship to language impairment.

METHOD

The article includes a review of the literature on emotional competence, trauma effects, alexithymia, and language impairment; summarizes tools to assess alexithymia; and provides an intervention framework.

IMPLICATIONS

Understanding the relationship of emotional competence and language impairment may provide a new perspective for speech-language pathologists who are serving children with language and socioemotional impairments.