{ Developmental Psychopathology Dr. Hakan Atalay, MD. Psychiatry Department of Yeditepe University.

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Developmental Psychopathology

Dr. Hakan Atalay, MD.Psychiatry Department of Yeditepe University

Research to Neuro-Developmental Processes

Research has increased our knowledge about biological factors underlying neuro-developmental processes more and more today than the past.

Genetic research has gone mapping the human genome to identifying epigenetic factors and explicating gene-environment interactions.

Biological markers of vulnerability to specific disorders have been identified.

The functions of and interactions between neuro-anatomic regions have been illuminated by new imaging and other non-invasive techniques, such as EEG, ERP, and fMRI.

Our evolving understanding of complex gene-environment interplay may move the field farther from biological reductionism to understanding genetic contributions to risk and protective developmental trajectories.

Effects of genes and environment can no longer be supposed to be separate, and, via epigenetic effects, environments moderate the expression of genes. Gene-environment correlations may, through effects of parent and child behaviors, influence environmental risk exposure and gene-environment interactions, as shown for disorders such as anxiety, depression, and conduct disorder, and are likely important in a range of multifactorial conditions.

Markers of biological vulnerability improve prediction of psychopathology.

While some disorders, such as autism, have early and relatively invariant onset, most psychiatric disorders may evidence their onset over many years.

Markers of biological vulnerabilities that moderate the effects of environment on behavior have been identified: for example, respiratory sinus arrhythmia, a measure of parasympathetic activity, predicts capability for emotion regulation that may protect children in high-risk environments from developing psychopathology.

Biological markers?

For children whose parents are schizophrenic, taxometric analyses of certain behavioral and endophenotypic markers, such as impaired attention, saccadic intrusions in smooth pursuit eye tracking, and spatial working memory deficits, may facilitate identifying premorbid schizophrenia at younger ages.

Neuroimaging for BD Heart rate for PTSD etc…

Emotional Arousal

Children with reduced emotional arousal had higher levels of conduct problems, and those with increased arousal had higher levels of anxiety symptoms at 1-year follow-up.

Locus ceruleus-norepinephrine (LC-NE) system influences not only arousal and engagement, but also disengagement from a task and movement toward alternative exploratory behaviors.

Neuroplasticity

Neuroplasticity is the term for alterations of time course of responses and of activation tresholds that occur through short-term synapse modulations and long-term neuro-anatomical growth and pruning.

Neuroplastic processes allow experience-dependent adaptation, but neuroplastic changes to adapt to harmful experiences may lead to psychopathology

Nurturance

Parental nurturance during infancy (eg, tactile stimulation of infant rodents) up-regulates glucocorticoid receptors in the hippocampus and frontal cortex, inhibiting input to hypothalamic neurons containing CRH and increasing expression of a nerve growth factor-induced clone A, a critical transcription factor.

Failure of such up-regulation, as in severe neglect, could bring about pervasive problems in self-regulation observed in maltreated children.

The child’s brain continuously interacts dynamically with his social environment.

Equifinality, the concept that diverse etiological factors may culminate in a single diagnosis (for example, Conduct Disorder) is one example of such a change.

Multifinality, the concept that a single etiological factor may culminate in many diagnoses (for example, sequelae of childhood abuse).

Comorbidity

HOMOTYPIC DISORDERS co-occur in externalizing spectrum

ADHD and Oppositional Defiant Disorder

DA

HETEROTYPIC DISORDERS is the term for the co-occurrence of an internalizing disorder (anxiety) and with an externalizing disorder (ADHD)

DA

Attachment – a New Neurobiological Perspective

The attachment system has roots in a biological system that ultimately regulates behavior and is implicated in stress reactivity and self-regulation.

Early positive and nurturing experience generally influences a developmental trajectory that allows the child to make positive adaptations to stress.

The fact that there are children who respond differentially to both sensitive and insensitive parenting, depending on whether their genome has a particular allele repeat, is evidence of gene-environment coaction.

Parent-child interactions may also pose risk for specific diagnoses.

Mapping Developmental Trajectories of Psychopathology

NEUROANATOMY Hippocampus Amygdala ACC dlPFC, ACC,

striatum (mood regulation)

CHILDHOOD TRAUMA Sensitizes the

neuroendocrine stress response, alters glucocorticoid resistance, increases central CRF activity, affects immune activation, reduces hippocampal volume

(NEUROENDOCRINE FEATURES OF DEPRESSION)

Basic concepts

Psychic determinism

Repression and resistance

Infantile sexuality

Interpretation of dreams

Transference

Drives

TOPOGRAPHICAL MODEL OF THE MIND

CONSCIOUSUNCONSCIOUSPRECONSCIOUS

PSYCHOSEXUAL DEVELOPMENT

Oral stageAnal stageUrethral stagePhallic stageLatency stageGenital stage

STRUCTURE OF PSYCHIC APPARATUS

ID EGOSUPER-EGO

EGO PSYCHOLOGY

EGO VS ID

DEFENSE MECHANİSMS

EGO AS AN ADAPTATION ORGAN

CONFLICT-FREE EGO SPHERES

Defence mechanisms

Denial, projection

Acting out, projective

identification,

regression, somatization

Displacement, rationalization,

isolation, dissociation,

reaction formation, repression

Altruism, anticipation, humor,

sublimation, suppression

ERIKSON* Basic trust & Mistrust* Autonomy & Shame and doubt* Initiative & GuiltIndustry & Inferiority*Identity & Role confusion*Intimacy & Isolation* Generativity & Stagnation* Integrity & Despair

OBJECT RELATIONS THEORY (Kernberg)

Attachment TheorySelf and Other

Integration of the Self

Self-psychology (Kohut)

Defects or deficits, rather than conflicts Faulty structures Emphasis is on infantile needs, rather than repressed wishes and drives. Hence, the analyst's therapeutic goals involve understanding those needs and partially meeting them in the treatment, rather than frustrating infantile wishes Building the psychic structure and repairing self-defects are seen as more important than the resolution of conflict.

Mirror Transference and Idealizing Transference

The mirror-transference patients seem in desperate need of the analyst's approval and will do whatever is necessary to gain that affirmation or validation from the analyst.

A revival of an infantile situation in which the child shows off to capture the gleam in the mother's eye that makes the child feel confirmed and validated (developmental arrest as the grandiose-exhibitionistic self)

Grandiose-exhibitionistic selfa normal developmental phase in which the child's self-worth is dependent on empathic mirroring responses from the mothering figure. Without that empathy, children cannot maintain their sense of self-cohesion or wholeness, and their sense of self fragments.

Idealizing Transference

the patient regards the analyst as a perfect and omniscient parent who meets all the patient's needs.

that transference manifestation as similar to the developmental arrest in which the child has not been provided with a parental model worthy of idealization.

as a result, the analyst is needed to perform the function that was missing in childhood.

In the course of normal development, the grandiose self evolves into healthy ambitions, and the idealized parent imago is eventually internalized as a structure akin to Freud's ego-ideal or superego—that is, a set of values and ideals that lead to moral conduct.

If, however, the child's developmental needs for mirroring or idealization or both are met with maternal failures of empathy, a developmental arrest occurs at the point of the grandiose self or the idealized parental image.

Empathy

One of Kohut's major contributions was his insistence that, in addition to the dual drives of sexuality and aggression, needs for self-esteem also occupy a place of central importance in the psyche. Self psychology, then, provides a conceptual framework for the analyst that advocates empathy for the patient's narcissistic needs, instead of viewing them as immature and contemptible.

“selfobject”

Selfobjects are viewed as fundamental needs of all persons that are required for normal development. Selfobjects may best be conceptualized as functions (such as mirroring, validating, soothing, idealizing, and affirming), rather than actual persons.

“selfobject”

As the term "selfobject" implies, other people are not viewed as separate objects with their own centers of autonomy and their own distinct needs. Rather, they are viewed as present only to gratify the needs of the nascent self.

Kohut believed that selfobjects are necessary for emotional survival in the same way that oxygen in the atmosphere is needed for physical survival. Throughout life all persons are dependent on others to maintain their sense of self-esteem and well-being.

“alter ego”

At the time of his death in 1981, Kohut had conceptualized a third area of selfobject needs, which he termed the twinship or alter ego. Originating in a childhood wish to merge with the mothering figure, this dimension of selfobject needs makes its appearance in the transference in the form of a wish or need to be exactly like the analyst.