SECOND ANNUAL CONFERENCE

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SECOND ANNUAL CONFERENCE THERAPEUTIC
ALCOHOL/DRUG INTERVENTIONS LAS VEGAS,
NEVADA MARCH 27, 2008 THE PERSONALITY DISORDERS
THROUGH THE LENS OF ATTACHMENT THEORY AND THE
NEUROBIOLOGIC DEVELOPMENT OF THE SELF A CLINICAL
INTEGRATION ALLAN N. SCHORE UCLA DAVID GEFFEN
SCHOOL OF MEDICINE
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• Schore, Affect Regulation and the Origin of the
  Self, 1994
• The understanding of early development is one of
  the fundamental objectives of science. The
  beginnings of living systems set the stage for
  every aspect of an organisms internal and
  external functioning throughout he lifespan.

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• Events that occur during infancy, especially
  transactions with the social environment, are
  indelibly imprinted into the structures that are
  maturing in the first years of life.
• The childs first relationship, the one with the
  mother, acts as a template, as it permanently
  molds the individuals capacities to enter into
  all later emotional relationships.

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• These early experiences shape the development of
  a unique personality, its adaptive capacities as
  well as its vulnerabilities to and resistances
  against particular forms of future pathologies.
• Indeed, they profoundly influence the emergent
  organization of an integrated system that is both
  stable and adaptable, and thereby the formation
  of the self (Schore, 1994).

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• Davidson (Science, 2002) The self and
  personality, rather than consciousness, is the
  outstanding issue in neuroscience. So much of our
  behavior emerges from processes to which we have
  little conscious access.
• Who we are is not synonymous with who we
  consciously believe ourselves to be. And the
  former is the much more fundamental because it
  often allows for a better prediction of behavior
  than the latter.

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• That explicit and implicit aspects of the self
  exist is not a particularly novel idea. It is
  closely related to Freuds partition of the mind
  into conscious, preconscious (accessible but not
  currently accessed), and unconscious
  (inaccessible) levels (LeDoux, The Synaptic
  Self, 2002).
• The right hemisphere has been linked to implicit
  information processing, as opposed to the more
  explicit and more conscious processing tied to
  the left hemisphere (Happaney et al., Brain and
  Cognition, 2004).

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• Schore (1994) RH locus of the implicit
  (unconscious) self
• Devinsky (Epilepsy Behav., 2000) RH dominant
  for maintaining a coherent, continuous and
  unified sense of self.
• In most people, the verbal, conscious and serial
  information processing takes place in the left
  hemisphere, while the unconscious, nonverbal and
  emotional information processing mainly takes
  place in the right hemisphere (Larsen et al., J.
  Psychosomatic. Res., 2003).

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• Faust et al (Personality and Individual
  Differences, 2004) The representation of the
  self in the two cerebral hemisphere. Verbal
  self-description and linguistic processes
  associated with a LH advantage. Self-description
  in terms of affective tone and RH advantage.
• Mlot (Science, 1998) unconscious processing of
  emotional stimuli is specifically associated with
  activation of the right and not left hemisphere.
  The left side is involved with conscious
  response and the right with the unconscious mind.

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• Current intense interest in brain systems
  involved in not only affective processes of
  implicit self but in self-regulation of emotion.
• Usually defined the set of conscious control
  processes by which we influence, consciously and
  voluntarily, the emotions we have, when we have
  them, and how we experience and express them.
• Unconscious bodily-based emotion usually not
  addressed in these models
• Emotions are the highest order direct expression
  of bioregulation in complex organisms (Damasio,
  1998) nonconscious regulation

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• However - Most of moment to moment psychological
  life occurs through nonconscious meansvarious
  nonconscious mental systems perform the lions
  share of the self-regulating burden, beneficently
  keeping the individual grounded in his or her
  environment (Bargh Chartrand, American
  Psychologist, 1999).
• RH preferentially involved in the processing of
  self-images, at least when self-images are not
  consciously perceived (Theoret et al., Cognitive
  Brain Research, 2004).

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• Large body of interdisciplinary data now suggests
  unconscious affect regulation is more essential
  than conscious emotion regulation in development,
  psychopathology, and psychotherapy.
• RH unconscious affect regulation focus of
  Schores affect regulation theory, an overarching
  model of the development, psychopathogenesis, and
  treatment of the right brain implicit self.

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• Schore Schore, Modern attachment theory the
  central role of affect regulation in development
  and treatment. (Clinical Social Work Journal,
  2008)
• We suggest that in line with Bowlbys
  fundamental goal of the integration of
  psychological and biological models of human
  development, the current clinical and
  experimental focus on how affective bodily-based
  processes are nonconsciously interactively
  regulated has shifted attachment theory to a
  regulation theory.

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• Format of lecture parallel presentations of
  current voices of clinicians studying mind and
  neuroscientists studying brain.
• Development essential role of early developing
  right brain in attachment communications and its
  lifelong impact on implicit functions
• Psychopathogenesis relational trauma, type D
  attachment, and impairment of maturation of right
  brain regulatory mechanisms
• Psychotherapy critical role of right brain in
  implicit bodily-based affective communications
  within the intersubjective attachment bond
  co-created by the patient-therapist

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• Trevarthen (1996) The right hemisphere is more
  advanced than the left in surface features from
  about the 25th (gestational) week and this
  advance persists until the left hemisphere shows
  a postnatal growth spurt starting in the second
  year.
• MacLean (Zygon, 1996) For the mother the
  experience during pregnancy of the formless life
  within, could become after birth a sense of
  exteriorization and extension of the self that
  physiologically derives to a large extent from
  the right hemisphere.

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• Walker-Andrews Bahrick (Infancy, 2001)
• From birth, an infant is plunged into a world of
  other human beings in which conversation,
  gestures, and faces are omnipresent during the
  infants waking hours. Moreover, these harbingers
  of social information are dynamic, multimodal,
  and reciprocal.
• It is no wonder that infants early perceptual
  preferences include the human face, the human
  voice, animate motion, and events and
  interactions with these important social beings.

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• Attachment communications represent prototypical
  right brain-to-right brain transactions that
  facilitate the experience dependent maturation of
  the right brain
• Brown Jaffe (Neuropsychologia,1975) The right
  hemisphere can be considered dominant in infancy,
  for the type of visual and acoustic communication
  which is relevant for the prelinguistic child.

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• Bowlby (1969) mother-infant attachment
  communications are accompanied by the strongest
  of feelings and emotions, and occur within a
  context of facial expression, posture, tone of
  voice, physiological changes, tempo of movement,
  and incipient action.
• During mutual gaze episodes of visual-facial,
  gestural, and auditory-prosodic affective
  communications the psychobiologically attuned
  caregivers behavior is contingent, easily
  predictable, and manipulatable by the infant.

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• Co-creation of dyadic attachment system allows
  caregiver to regulate childs affective states
  via dual processes of interactive regulation
• 1. Affect synchrony dyadic regulatory mechanism
  for establishing and maintaining positive
  affective states within the attachment bond of
  emotional communication
• 2. Interactive repair dyadic regulatory
  mechanism for recovering from negative affective
  ruptures of the attachment bond. Good-enough
  mother responsible for reparation of
  misattunements and ruptures in attachment bond.

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• In order to regulate infants right brain state
  crescendos and decrescendos of mother's affective
  state in resonance with similar crescendos and
  decrescendos of the infants internal states of
  positive and negative arousal.

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• More the contingently responsive mother tunes her
  activity level to the infant during periods of
  social engagement, the more she allows him to
  recover quietly in periods of disengagement, and
  the more she attends to the childs reinitiating
  cues for reengagement, the more synchronized
  their interaction.

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• It is the emotional availability of the
  caregiver in intimacy which seems to be the most
  central growth-promoting feature of the early
  rearing experience.
• Baby becomes securely attached to
  psycho-biologically attuned caregiver who
  minimizes negative affect and maximizes positive
  affect.
• Emotional development in infancy expansion of
  the affect array increased tolerance for
  positive and negative affects.
• The broader the range of emotions that a child
  experiences the broader will be the emotional
  range of the self that develops (LeDoux, 2000).

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• Over course of first year, regulatory processes
  of affect synchrony that amplifies states of
  positive arousal and interactive repair that
  dampens states of negative arousal are
  fundamental building blocks of attachment and its
  associated emotions.
• Attachment, right brain mechanism of interactive
  regulation of emotion, represents regulation of
  biological synchronicity between and within
  organisms.
• Winnicott (1986) The main thing is a
  communication between the baby and the mother in
  terms of the anatomy and physiology of live
  bodies.

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• Fonagy Target, Psychoanalytic Inquiry, 2002
  Attachment relationships are formative because
  they facilitate the development of the brains
  self-regulatory mechanism.
• Fonagy Target, Attachment Human Devel., 2005
  If the attachment relationship is indeed a major
  organizer of brain development, as many have
  accepted and suggested (e.g., Schore, 1997,
  2003), then the determinants of attachment
  relationships are important far beyond the
  provision of a fundamental sense of safety or
  security (Bowlby, 1988).

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• Ovtscharoff Braun, 2001, Neuroscience The
  dyadic interaction between the newborn and the
  mother constantly controls and modulates the
  newborns exposure to environmental stimuli and
  thereby serves as a regulator of the developing
  individuals internal homeostasis.
• The regulatory function of the newborn-mother
  interaction may be an essential promoter to
  ensure the normal development and maintenance of
  synaptic connections during the establishment of
  functional brain circuits

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• Schore (Develop. and Psychopathology,1996)
• The infants early maturing right hemisphere,
  which is dominant for the childs processing of
  visual emotional information, the infants
  recognition of the mothers face, and the
  perception of arousal-inducing maternal facial
  expressions, is psychobiologically attuned to the
  output of the mothers right hemisphere, which is
  involved in the expression and processing of
  emotional information and in nonverbal
  communication.
• Chiron et al. (Brain, 1997) The right brain
  hemisphere is dominant in human infants.

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• RH visual-facial attachment communications
• Tzourio-Mazoyer et al. (NeuroImage, 2002)
• PET study of 2-month-old infant looking at image
  of a womans face activation of infants right
  fusiform gyrus of the inferior temporal cortex,
  the visual area that decodes facial patterns, and
  the occipital cortex.

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• Le Grand et al., Expert face processing requires
  visual input to the right hemisphere during
  infancy, Nature Neuroscience, 2003).
• The neural circuitry responsible for adults
  face expertise is not pre-specified, but requires
  early visual experience. However, the two
  hemispheres are not equipotent only the right
  hemisphere is capable of using the early input to
  develop expertise at face processing.

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• RH auditory-prosodic attachment communications
• Bogolepova Malofeeva (Neurosci. Behav.
  Physiol., 2001) The right hemisphere of the
  neonate is actively involved in the perception of
  speech melody and the intonations of the voices
  of mother and surrounding people. The pre-speech
  stage of child development is characterized by
  interactions of the descriptive and emotional
  components due mainly to mechanisms operating
  within the hemispheres on the principle of
  non-verbal communication.

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• RH tactile-gestural attachment communications
• Sieratzki and Woll, Lancet, 1996, Why do mothers
  cradle babies on their left?
• 80 of right-and left-handed mothers cradle on
  the left. Males no preference, but when males
  become fathers, 80 cradle left.
• In the left cradling position, maternal
  affective signals are given to the infants free
  left ear and processed by the right hemisphere,
  the hemisphere which is more advanced at this
  stage of development, and destined for the
  reception and processing of prosody.

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• Along the right hemisphere affect-communication
  vector, left-sided cradling facilitates the flow
  of auditory and visual communication between
  mother and infant and channels somato-affective
  feedback and infant sound to the mothers right
  hemisphere, which in turn tunes the melody of the
  mothers voice - the lullaby will not sound the
  same, and will not feel the same with the baby on
  the other side.
• The role of the right hemisphere is crucial in
  relation to the most precious needs of mothers
  and infants.

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• RH imprints an internal working model of the
  attachment relationship, an interactive
  representation which encodes strategies of affect
  regulation.
• RH stores a vocabulary for nonverbal affective
  signals such as facial expressions, prosody (the
  emotional tone of the voice), and gestures

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• Executive functioning of self-correcting RH
  system self-regulation. Dual processes
• Interactive regulation, ability to resiliently
  regulate emotional states through interactions
  with other humans in interconnected contexts
  (intersubjectivity)
• Autoregulation, regulation of internal
  psychobiological states in autonomous contexts,
  without others (intrasubjectivity) (evocative
  memory music drugs)
• Secure attachment adaptively shift between 2
  modes, depending upon context.
• Tension between 2 regulatory strategies
  responsible for conflict between
  interconnectedness and autonomy

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• Devinsky (2000) RH dominant for an emotional
  self corporeal self
• RH involved in not only exteroceptive but
  interoceptive processing. RH analysis of direct
  information received by subject from his own body
  and with direct sensation
• Generates most comprehensive map of the body
  state available to the brain
• RH deeply connected into sympathetic and
  parasympathetic components of the ANS that
  generate the somatic aspects of emotions

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• Essential regulatory functions of RH
• Central and autonomic arousal ( metabolic
  energyvitality affect) regulation
• Processing high arousal positive affects
  (interest excitement joy)
• Detecting threat
• Processing negative affects and pain
• Human stress response and cortisol secretion
• Control of vital functions supporting survival
  and enabling the organism to cope actively and
  passively with emotional stress.
• If early development severely inhibited, these
  functions impaired.

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• Positive (formation of emotional attachment) or
  negative (e.g., maternal separation or loss)
  emotional experience may carve a permanent trace
  into a still developing neuronal network of
  immature synaptic connections, and thereby can
  extend or limit the functional capacity of the
  brain during later stages of life (Helmeke et
  al., Cerebral Cortex, 2001).

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• If children grow up with dominant experiences of
  separation, distress, fear and rage, then they
  will go down a bad pathogenic developmental
  pathway, and its not just a bad psychological
  pathway but a bad neurological pathway (Watt,
  2003).

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• Schore, Infant Mental Health J., 2001 Australian
  New Zeal. J. Psychiatry, 2002
• Early attachment trauma alters development of
  right brain and it functions in attachment,
  self-regulation and the stress response
• Causes severe limitation of the essential
  activity of the right hemisphere - the control of
  vital functions supporting survival and enabling
  the organism to cope actively and passively with
  emotional stress

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• Sickness, insanity and death were the dark
  angels standing guard at my cradle and they have
  followed me throughout my life (Edward Munch)

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• Recent developments in attachment trauma
• Relational trauma not a singular event but
  ambient, cumulative.
• An emphasis on fearful arousal and the
  relational modulation of that arousal lies at the
  heart of attachment theory (Lyons-Ruth
  Spielman, 2004).
• Infants psychobiological response to relational
  trauma is comprised of two separate response
  patterns, sympathetic hyperarousal and
  parasympathetic dissociation-hypoarousal

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• Hyperarousal
• Each one escalates the ante, as the infant
  builds to a frantic distress, may scream, and
  finally throws up. In an escalating overarousal
  pattern, even after extreme distress signals from
  the infant, such as ninety-degree head aversion,
  arching away...or screaming, the mother keeps
  going (Beebe)
• Hypermetabolic brain state. Energy-expending
  sympathetic ANS activated, increased heart rate,
  blood pressure, and respiration

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• Switch from hyperarousal to dissociation
• Porges the sudden and rapid transition from an
  unsuccessful strategy of struggling requiring
  massive sympathetic activation to the
  metabolically conservative immobilized state
  mimicking death.
• Dissociation detachment from an unbearable
  situation, the escape when there is no escape,
  a last resort defensive strategy.

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• Dissociation/hypoarousal
• Child disengages from stimuli in external world,
  freezes, and stares off into space as though out
  of contact with self, environment, and parent.
• Dissociative response a metabolic shutdown "to
  conserve energies...to foster survival by the
  risky posture of feigning death. Passive defense
  to threat
• Dissociative defense vagal tone, regulated by
  the dorsal vagal medulla, increases dramatically,
  lowering blood pressure and heart rate.

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• Hesse and Main the disorganization and
  disorientation of type D attachment
  phenotypically resembles dissociative states.
• Strange Situation One infant hunched her upper
  body and shoulders at hearing her mothers call,
  then broke into extravagant laugh-like screeches
  with an excited forward movement. Her braying
  laughter became a cry and distress-face without a
  new intake of breath as the infant hunched
  forward. Then suddenly she became silent, blank
  and dazed (dissociated)

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• Type D, an insecure-disorganized / disoriented
  attachment pattern, is found in 80 of maltreated
  infants.
• Inability to generate a coherent behavioral
  (active) coping strategy to deal with this
  emotional challenge
• Lateralization of type D dissociation in Strange
  Situation Hesse and Main (2006) describe at
  reunion, one toddler approached her mother,
  slapped her full in the face with her left hand,
  and then, with a dazed expression, and still
  standing in place, used her right hand to pull
  the left hand and arm down.

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• Janet (1907) dissociation an unbearable
  emotional reactions to traumatic experiences
  result in an altered state of consciousness.
• Winnicott (1958) a particular failure of
  maternal holding environment causes discontinuity
  of the babys need for going-on-being.
• Kestenberg (1985) refers to dead spots in the
  infants subjective experience, an operational
  definition of the restriction of consciousness
  seen in dissociation.

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• During these episodes the infant is matching the
  rhythmic structures of these states this
  synchronization is registered in the firing
  patterns of the right corticolimbic brain regions
  that are in a critical period of growth
• Primary mechanism for the real time
  intergenerational transmission of trauma
• The overwhelming stress of maltreatment in
  childhood is associated with adverse influences
  on brain development (De Bellis)

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• Trauma-induced excessive pruning of hierarchical
  right cortical-subcortical circuits operates in
  the etiology of a vulnerability to later extreme
  disorders of affect regulation, such as infant,
  childhood, adolescent, and adult PTSD and
  borderline personality disorder

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• If childhood trauma or abuse is repeated, and if
  the abuser is a caregiver, so that the child has
  nowhere to run and no one to turn to, then
  internal escape is resorted to the child learns
  to dissociate more easily and in a more organized
  way (Mollon)
• Dissociation a defense in which overwhelmed
  individual cannot escape nor take meaningful
  action or successful flight, and so escapes
  instead by altering internal organization, i.e.,
  by inward flight (Kluft).

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• Severe attachment pathology and enduring deficits
  of affect regulation
• Very recent studies in PTSD literature on
  lateralization of traumatic memories
• Lanius et al. (2004) PTSD patients (as opposed
  to traumatized patients without PTSD), who
  experience traumatic memories with heart rate
  increases, show a pattern of right brain
  connectivity of activation of the right posterior
  cingulate, right caudate, right occipital and
  right parietal lobe.

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• This right lateralized pattern may account for
  the nonverbal nature of traumatic memory in PTSD
  subjects.
• They cite other studies showing that subjects
  who had experienced early trauma displayedright
  dominance during memory recall.

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• Lanius (fMRI study of dissociation, Biological
  Psychiatry, 2005)
• PTSD patients, exposed to their traumatic script,
  scanned by fMRI while in the state of
  dissociation
• I was looking down at my body, I was out of my
  body, I was completely zoned out and could not
  recall the memory.
• The present functional connectivity findings
  showpredominantly right-hemispheric frontal and
  insula activation in the dissociated PTSD
  subject.

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• Dissociation may involve a... lack of
  integration in the right hemisphere. This
  corresponds with the idea that the right
  hemisphere has a distinct role in establishing,
  maintaining, and processing personally relevant
  aspects of an individuals world (Spitzer et
  al., J. Neuropsychiatry Clin. Neurosci., 2004).
• Current neuroscience literature describes a
  dissociation between the emotional evaluation of
  an event and the physiological reaction to that
  event, with the process being dependent on intact
  right hemisphere function (Crucian et al.,
  Cortex, 2000).

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• Disorganized-disoriented attachment as well as
  pathological dissociation are found abused /
  neglected infants and children and adults
  diagnosed as Borderline Personality Disorder.
• Current attachment literature Borderline
  personality was linked to experience of trauma
  and lack of resolution (Fonagy et al.,1996).
• This attachment pattern predicts later chronic
  disturbances in affect regulation, stress
  management, hostile-aggressive behavior, and
  dissociative defenses (BPD symptoms).

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• Meares (Austral. New Zeal. J. Psychiatry, 1999)
  Subtle neurophysiological disturbances found in
  BPD are the results of environmental insults or
  failures. BPD represents an impairment of late
  developing neural networks, of largely prefrontal
  origin.
• Affect regulationis dependent upon prefrontal
  activity. This idea has been extensively
  developed by Schore (1994) who emphasizes the
  significance of the right orbitofrontal
  cortexDeficient development of the function of
  these inhibitory systems will lead to a relative
  dysregulation of emotional experience and
  expression.

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• RH dysfunction in BPD
• Williams et al. (J. Psychiatry Res., 2006) It
  has been proposed that early psychological trauma
  affects the development of the right brain,
  leading to deficits in the ability to modulate
  responses to stress.
• EEG shows posterior and right-sided disturbances
  in synchrony involve a breakdown in the
  integration of these networks with frontal
  executive systems.

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• Williams et al. (J. Psychiatry Res., 2006)
  These findings are consistent with the
  description of the borderline syndrome as a
  fragmentation of the self, a lack of wholeness
  and an inability to integrate the positive and
  negative aspects of the self and the external
  world, which contribute to the distress
  experienced by affected individuals.

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• Meares, Melkonian, Schore, Gordon, Williiams
  (University of Sydney, Brain Dynamics Centre)
  Defining the neurocircuitry of borderline
  personality disorder Testing a maturational
  model by means of single trial ERP analysis
• Event-related potential (ERP) study of BPD, a
  disorder of affect regulation, shows impairment
  of RH limbic-prefrontal connections
• The etiology of a disturbed maturation of
  neurocircuitry include disturbances of attachment
  (Schore, 1994, 2005) and also the effect of
  traumatic impairments which disrupt maturational
  processes.

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• This finding is consistent with the concept that
  disturbances of BPD reflect an impairment and
  dysregulation of the right brain (Schore, 1994).
• The right brain abnormalities of inhibitory
  circuitry indicate a disturbance underlying of
  complaints of pain and other bodily distress made
  by the typical borderline patient.

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• Lanius-Schore-Pederson-Moran study, London Health
  Sciences Center, University of Western Ontario,
  Canada.
• Neural correlates of mother-infant attachment
  relationships in mothers with borderline
  personality disorders and healthy controls
• fMRI study of neurobiology of attachment AAI
  home videos Strange Situation
• Study normal vs. borderline mothers viewing of
  videos and implicit perception of their infants
  attachment cues patterns of limbic activation,
  ANS activity, and affect regulation strategies
  associated with secure and insecure patterns.