Thursday, February 21, 2013

bipolar disorder chemical imbalance & trauma causation

A left-right brained war for our sense of self?

Is Trauma a hidden casual factor in bipolar disorder symptoms which are expressed through the brain-nervous systems, chemical reactions?

Can a trauma defense of the body be conditioned, perhaps from birth or by habitual postures of avoidance in the skeletal musculature, caused by a long experience of physical & emotional abuse, for example?

Is systems theory now beginning to explain the brain/body/mind better than our older clockwork universe model of simple cause and effect explanations of a chemical imbalance?
What lies beneath our linear thinking of "one thing causes another" as if the body/brain is assembled like a machine? The cutting edge of modern psychotherapy is now returning to Freud's term "unconscious," with better understanding of left & right brain, chemical function. The notion of trauma and subsequent PTSD symptoms, is easily accepted when visualized in terms of one-off terrorizing events like war, rape, sexual and physical abuse, less easily accepted are the similar symptoms caused by emotional abuse, although it is clearly recognized by psychotherapists worldwide. 

Developmental deficits occurring during pre & postnatal experience, are being reexamined to more fully understand what we really mean by the word trauma, at the level of brain-nervous system chemistry. More particularly the impact of non-optimal experience during the crucial early years of life and brain-nervous system maturation. All the new advances in technology has aided neuroscience to more fully appreciate, that the well-balanced human personality literally means a well-balanced internal chemistry. Hence psychiatry's use of the metaphor, a "chemical imbalance" to simplify our general understanding of the experience of mental illness.  

Please consider an example of the latest understanding of childhood development needs and the impact of traumatic experience;

"Understanding Interpersonal Trauma in Children: 
Why We Need a Developmentally Appropriate Trauma Diagnosis

Does Childhood Interpersonal Trauma Result in an Interrelated Set of Symptoms?

Numerous studies have documented that exposure to interpersonal trauma during childhood is related to increased incidence of affect and impulse dysregulation, alterations in attention and consciousness, disturbances of attribution and schema, and interpersonal difficulties. First, we will review studies documenting disruptions in each of these areas. Studies documenting co-occurring disruption across multiple domains are subsequently reviewed.

Dysregulation of Affect and Behavior

A variety of symptoms may represent affective and behavioral dysregulation. Such affective symptoms commonly found in children exposed to interpersonal violence include lability, anhedonia, flat or numbed affect, explosive or sudden anger, and incongruous or inappropriate affect. Behavioral expressions of affect regulation may include withdrawal, self-injury, aggression, oppositional behavior, substance use, or other compulsive behavior. Behavioral dysregulation may represent affective overload as well as attempts to dispel, reduce, or recover from negative affect states" From:

The left vs right brain war, for our sense of self?
And the emotional revolution which is re-examining our intuitive sense of knowing.

Most psychiatric diagnosis are made with a typically left-brained sense of "learned-knowing," diagnosing people like myself by way of what the psychiatrist has been taught to do. We know that during a crisis of symptomatic behavior there is a great deal of pressure to restore emotional equilibrium/balance, not just for the sake of the individual, but all individuals involved with a particular sufferer. Yet is the sufferer being overwhelmed by an intuitive and emotional sense of self, which is little understood and largely denied  by our "left-brained" cultural zeitgeist? Is cutting-edge psychotherapy turning away from this Descartian, left-brained world view towards a new understanding of our right-brained intuitive and emotional self? Is the infamous "chemical imbalance" theory true in its essence, yet false in its presumption of a disease process within the brain? Please watch an explanation of a paradigm shift now taking place, at the cutting edge of our understanding;

Toward a New Paradigm of Psychotherapy

For the last two decades, I have argued that no theory of human functioning can be restricted to only a description of psychological processes; it must also be consonant with what we now know about biological structural brain development. Three other themes that continue from literally the first paragraph of the first book are that the early stages of life are critical to the development of all later evolving structures and functions, that emotion is central to a deeper understanding of the human condition, and that unconscious processes lie at the core of the self, throughout the life span. The book thus also attempted to reintegrate psychoanalytic ideas of the unconscious mind into developmental science. Affect Regulation and the Origin of the Self— which is now in its 14th printing— was the first book to document not the cognitive development, but the social-emotional development of the infant.

Now it is true that the current surge of research is being fueled by advances in a variety of cutting-edge neuroimaging technologies that can observe and document ongoing brain structure– function relationships. The reader should note there is a major limitation to current in vivo imaging techniques— their limited temporal resolution does not allow them to capture the real-time dynamics of brain function. But even future advances in technology would not be enough. We also need an integrative psychoneurobiological theoretical model that can not only generate testable hypotheses but also conceptualize the vast amount of research and clinical data in a meaningful way. And we need an interpersonal neurobiological perspective that can account for brain-to-brain interactions.

As editor of the Norton Series on Interpersonal Neurobiology, I see this quantitative leap and qualitative shift in emotion research as a powerful source of updated models of psychotherapeutic interventions that are grounded in developmental, affective, and social neuroscience. It is now clear that psychotherapeutic changes in conscious cognitions alone, without changes in emotion processing, are limited. In fact, a clash of psychotherapy paradigms can currently be seen, especially in the treatment of more severe disorders that present with a history of relational trauma and thereby a deficit in affect regulation. In such cases emotion more than cognition is the focus of the change process, and so CBT is now being challenged by updated affectively focused psychodynamic models, including ART. In his most recent book my colleague Philip Bromberg (2011) also describes the paradigm shift in psychotherapy:

Interpersonal and Relational writers largely have endorsed the idea that we are in fact confronted with a paradigm change and have conceptualized it as a transformation from a one-person to a two-person psychology. I feel that this formulation is accurate, and that three central clinical shifts are intrinsic to the conceptual shift: A shift from the primacy of content to the primacy of context, a shift from the primacy of cognition to the primacy of affect, and a shift away from (but not yet an abandonment of) the concept of “technique.” (p. 126)

The current radical expansion of knowledge and paradigm shift has wider implications beyond the mental health professions to the cultural and political organization of societies. In my 2003 volumes I argued that the right hemisphere nonconscious implicit self, and not the left conscious explicit self, is dominant in human adaptive survival functions. Offering data at the neuropsychological, cultural, and historical levels, McGilchrist (2009) echoes this principle: “If what one means by consciousness is the part of the mind that brings the world into focus, makes it explicit, allows it to be formulated in language, and is aware of its own awareness, it is reasonable to link the conscious mind to activity almost all of which lies ultimately in the left hemisphere” (p. 188).

He adds, however, “The world of the left hemisphere, dependent on denotative language and abstraction, yields clarity and power to manipulate things that are known, fixed, static, isolated, decontextualized, explicit, disembodied, general in nature, but ultimately lifeless” (p. 174). In contrast, “the right hemisphere … yields a world of individual, changing, evolving, interconnected, implicit, incarnate, living beings within the context of the lived world, but in the nature of things never fully graspable, always imperfectly known— and to this world it exists in a relationship of care” (p. 174).

Indeed, the “emotional” right hemisphere “has the most sophisticated and extensive, and quite possibly most lately evolved, representation in the prefrontal cortex, the most highly evolved part of the brain” (p. 437). An essential tenet of McGilchrist’s volume (2009) is expressed in its title: the right hemisphere is the master, and the left the emissary, which is willful, believes itself superior, and sometimes betrays the master, bringing harm to them both. Offering interdisciplinary evidence that spans the sciences and the arts, he convincingly argues that the left hemisphere is increasingly taking precedence in the modern world, with potentially disastrous consequences.

I agree that especially western cultures, even more so than in the past, are currently overemphasizing left brain functions. Our cultural conceptions of both mental and physical health, as well as the aims of all levels of education, continue to narrowly overstress rational, logical, analytic thinking over holistic, bodily based, relational right brain functions that are essential to homeostasis and survival. It is ironic that at a time when clinicians and researchers are making significant breakthroughs not only in right brain social-emotional models of optimal development but also in right brain models of the etiologies and treatment of a wide range of psychopathologies, strong economic and cultural inhibitory restraints and cutbacks are being felt by practitioners.

How can we understand this? We are constantly told that the reason for this lies in objective economic factors. But the paradigm shift in psychology and neuroscience suggests subjective unconscious forces are at play here. Listen to McGilchrist’s (2009) description of what the world would look like if the left hemisphere were to become so far dominant that, at the phenomenological level, it managed more or less to suppress the right hemisphere’s world altogether. He imagines that this left-brained world would lead to an increasing specialization and technicalizing of knowledge, as well as the following: increased bureaucratization, inability to see the big picture, focus on quantity and efficiency at the expense of quality, valuing technology over human interaction, lack of respect for judgment and skill acquired through experience, and devaluing of the unique, the personal, and the individual. Even more specifically;

Knowledge that came through experience, and the practical acquisition of embodied skill, would become suspect, appearing either a threat or simply incomprehensible.… The concepts of skill and judgment, once considered the summit of human experience, but which come only slowly and silently with the business of living, would be discarded in favor of quantifiable and repeatable processes.… Skills themselves would be reduced to algorithmic procedures which could be drawn up, and even if necessary regulated, by administrators, since without that the mistrustful tendencies of the left hemisphere could not be certain that these nebulous “skills” were being evenly and “correctly” applied.… [F] ewer people would find themselves doing work involving contact with anything in the real, “lived” world, rather than with plans, strategies, paperwork, management and bureaucratic procedures.… Technology would flourish, as an expression of the left hemisphere’s desire to manipulate and control the world for its own pleasure, but it would be accompanied by a vast expansion of bureaucracy, systems of abstraction and control. (McGilchrist, 2009, p. 429)

Sound familiar? I suggest that this “imagined” left brain worldview now dominates not only our culture but also the current mental health field in the following forms: an overemphasis on psychopharmacology over psychotherapy, an undue influence of the insurance industry on defining “normative” and “acceptable” forms of treatment, an overidealization of “evidence-based practice,” an underappreciation of the large body of studies on the effectiveness of the therapeutic alliance, a trend toward “manualization” of therapy, a training model that focuses on the learning of techniques rather than expanding relational skills, and a shift of psychotherapy from a profession to a business.

Can we reverse this current imbalance of the hemispheres? The paradigm shift has generated a quantum leap in our attempts to understand a number of fundamental questions of the human condition that can be elucidated by recent discoveries of the early developing right brain. A prime example is the surge of deeper explorations of our human origins by contemporary developmental science. In 2005 Insel and Fenton articulated this widely held principle:

“Most mental illnesses … begin far earlier in life than was previously believed” (p. 590). More recently Leckman and March (2011) are asserting that “A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life” (p. 333). We need, now, to use recent knowledge in order to reflect more deeply and act more directly on what is required— at levels of the individual, family, and culture— to provide an optimal human context for both mental and physical health. In addition to culturally supporting the development of intellectual and cognitive abilities, we need to foster the individual’s adaptive capacity to relate socially and emotionally to other human beings via the right brain functions of intersubjective communication, affect processing, empathy, and interactive stress regulation. The large body of studies on the critical survival functions of the right brain can be applied not only to individuals but also to cultures (Bradshaw & Schore, 2007; Schore & Schore, 2008).

Here in the United States, how are we reacting to this crisis at the core of our culture? And if we are not responding, why not? In clinical models we speak of individuals having intrapsychic defenses against uncertainty, stress, and painful negative information. But defenses such as denial, repression, and even dissociation are collectively used by the culture to avoid more directly confronting the serious stressors that lie at its core. Forty years ago Jacob Bronowski offered the trenchant observation, “Think of the investment that evolution has made in the child’s brain.…

For most of history, civilizations have crudely ignored that enormous potential. In fact the longest childhood has been that of civilization, learning to understand that” (1973, p. 425). In a current attempt to overcome that resistance and bring this problem closer to the forefront of cultural consciousness, my colleagues and I are producing two multiauthored volumes: Evolution, Early Experience and Human Development: From Research to Practice and Policy (Narvaez, Panksepp, Schore, & Gleason, in press), and The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic (Lanius, Vermetten, & Pain, 2010).

Grounded in recent developmental neuroscience, psychiatry, and developmental psychology, these books cast light upon a number of serious psychological and social problems underlying our cultural blind spots. But more than that, contributing scholars from multiple disciplines offer practical thoughts about what types of early-life experiences are essential for optimal development of human brain and body systems— in order not only to generate greater understanding of scientific research and theory but also to promote informed public policy.

In a recent overview of contemporary developmental neuroscience, Leckman and March (2011, p. 333) conclude, “our in utero and our early postnatal interpersonal worlds shape and mold the individuals (infants, children, adolescents, and adults and caregivers) we are to become.” At this point in time there is converging evidence that we can maximize the short- and long-term effects of our interventions by concentrating on the period of the brain growth spurt— from the last trimester of pregnancy through the second year. Whether or not our governments will fund such sorely needed efforts remains to be seen."

Excerpts from “The Science of the Art of Psychotherapy” by Allan N. Schore.

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In 2007, I had the great good fortune to stumble on Schore's book "Affect Dysregulation & Disorders of the Self," which set me off on a five year journey to understand the meaning of this strange and little understood word "affect." Understanding that my bipolar disorder type 1 is also know as an "affective" disorder, my search has involved "sensing" the non-conscious nature of affect and its relation to my heart, brain-nervous systems, and the powerful, so-called "chemical imbalance" of psychosis. For, IMO it is a false sense of self, which seeks to treat others as objects, in our left-brained understanding of ourselves. "The Science of the Art of Psychotherapy” gives great examples and advise on this new emerging awareness of our true sense of self, in which the psychotherapist uses a right-brained non-conscious and "heart toned" sense of self, to sensitively, intuitively form a healing relationship with the client.

I can only imagine what fate may have had in store, had I stumbled into Allan Schore's office when experiencing my first manic euphoria? Would he have pronounced me schizophrenic in ten minutes, or perhaps listened calmly to my story and started a relationship which may have healed a missing developmental experience? What do you think?