Lecture 1 Introduction
Importance of safe childhood
Different psychologist described the importance of a safe childhood. (Freud, Harry Harlow, john Bowlby, Mary Ainsworth),
are the consequence changeable.
Course goals
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Illustrate and explain the consequences of the different forms of childhood maltreatment within the domains of
cognition, emotion, social behavior, and physical health
Describe the psychological and neurobiological models that aim to explain the long-term consequences of childhood
maltreatment and individual differences in risk and resilience p
Summarize and discuss different forms of psychotherapy that address the consequences of childhood maltreatment.
Learn about different research methods and their potential use in studying the long term consequences of childhood
maltreatment.
Getting familiarized with reading scientific literature.
Psychological consequences of child abuse & neglect
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Background
Psychological disorders after maltreatment
Why should we learn about the long term consequences of childhood abuse and neglect. EMPIRICAL EVIDENCE: 
numerous finding that childhood abuse and neglect have pervasive consequence for mental and physical health
Definition childhood maltreatment: ‘any act of commission or omission by a parent or other caregiver that results in harm,
potential for harm, or threat of harm to a child. Harm does not need to be intended.
Omission= failure to meet a child’s needs
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Physical neglect (not taking care of your child, not taking to the doctor, can be unintended)
Emotional neglect (child is not feeling the love that every child deserves, the need for comfort is missed, that is a basic
human right of a child)
Denial of access to education (parents that are not willing to bring their children to school, or not see the effect of
school)
Commission= actively doing something harmful
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Physical abuse
Emotional abuse (yelling at your kid)
Sexual abuse (mostly someone familiar but from the familie)
Shaken baby syndrome
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Emotional neglect ‘Failure to meet a child's emotional needs and failure to protect a child from violence in the home or
neighbourhood’
Physical Neglect ‘Failure to meet a child's basic physical, medical/dental, or educational needs; failure to provide
adequate nutrition, hygiene, or shelter’
Emotional abuse ‘Intentional behaviour that conveys to a child that he/she is worthless, flawed, unloved, unwanted,
endangered, or valued only in meeting another's needs’ p
Physical abuse ‘Intentional use of physical force or implements against a child that results in, or has the potential to
result in, physical injury’
Sexual abuse ‘Any completed or attempted sexual act, sexual contact, or non-contact sexual interaction with a child by a
caregiver’
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Prevalence of childhood maltreatment
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World health organization, physical abuse = 23%, emotional abuse= 36%, physical neglect= 16%, sexual abuse= 15%
Dutch national prevalence study, “abuse of children and adolescents (NPM-2005; NPM-2010)
Professionals: 34 out of 1.000 children (±3.5%)
“Students on Maltreatment” (SOM studie)
Self-report among 1.800 children 12-16 years:
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37% report one of more forms of abuse
Emotional and Physical Abuse most frequent
So far more reports when it is self-report
Psychological consequences of childhood abuse and neglect
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Classification system for psychological Disorders based on standard criteria
Published by American Psychiatric Association (APA) First Edition in 1950 (military)
Focus on objective description of symptoms with no theoretical framework:
Decreased focus on aetiology (i.e., cause) of disorders
Many of the people that have psychological treatment, had experience childhood maltreatment. For 30/50 % these
consequence where the source for their problems.
Psychological consequences of childhood abuse and neglect
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Internalizing and Externalizing disorders
Personality Disorders (BPD / anti-social)
Psychotic symptoms
Suicide and self-injury
Often earlier onset, more severe/chronic, and harder to treat with a history of childhood maltreatment
Even when people don’t fit to a specific disorder, we see that many symptoms that represented these disorders show up in
people that experienced childhood maltreatment.
Psycho-social consequences
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Interpersonal problems
Self-image
Re-victimization
o >> Book gives many case examples >> Lectures 2 and 4
Inter-generational transmission
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In about 30% of cases
Who and why is it transmitted?
o Consequences of abuse can often be a risk factor for abusive behavior.
o Stresses the importance of timely preventing abuse itself, but also of its consequences!
To conclude
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Childhood abuse and neglect important transdiagnostic risk factors for development of psychological problems,
including depression and anxiety (i.e., internalising symptoms) and drug & alcohol addiction, agression (i.e.,
externalising symptoms)
Consequences of emotional abuse and neglect at least as pervasive as physical or sexual abuse
To conclude
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Indications for subtypes of depression and anxiety, with or without maltreatment history p
Depressed patients with a history of maltreatment have more severe problems, more chronic, more suicidality, more
comorbidity, and profit less from treatment.
Not everyone develops long-term health problems: resilience
Second part of the lecture
INTRODUCTION
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HAMEEDA LAKHO
Member of the Experience Expertise Program Team – Future Scenario Program VWS / VNG / V&J
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Author Hidden Bars (2000), Broken Circle (2003), Hitting Home (2005), Help Yourself (2016), Do you see me? (2022)
Owner Hameeda Lakho Projects, Training, Coaching en Advice
Founder Academy for Recovery and Experiential Expertise
SECRECY
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Shame about own situation
Low self-esteem as a result of the abuse
Loyalty and love to partner/parents
Guilt, they blame themselves
Fear of consequences of revelation
Lack of trust in people
RECOVERY
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Recovery as a personal process
Unpredictable
Develop skills and goals again
Acceptance
New possibilities
WHAT IS REQUIRED
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Recovery: Emotional and physical damage
Listening and recognition: Trauma
Processing: Reducing behavioral and development problems
Offer: New development opportunities
WHAT DO SURVIVORS NEED?
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Recognition, of the abuse and wrongfulness
Affirmation, of their strength, creativity and rights
Validation, Not their fault, not their shame
Support:
o Sharing experiences with others
o Feeling less alone
o Learning new skills for coping and enhancing their lives
o Becoming more self-confident
LADDER OF EXPERIENTAL KNOWLEDGE
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Experiences – rough material
Individual, unique, isolation, vulnerable
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Experiential knowledge - some reflection
Shared, similarities, recognition, strength
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Experiential Expertise - bridging, using the experience to teach the audience
Collectively, advocacy, empowerment.
Working with the experience in interaction in the here and now
WHAT DO WE NEED FOR CHANGE?
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Reflect on context and tensions
Perspectives, be inclusive
What do victims, survivors need?
What will be the new expertise of the professionals, what do they add?
What do we need to do our work with more depth and impact?
Embedding experiential knowledge
Do not avoid the trauma of violence, dare to work with it
Attention for the relationships in the here and now
https://brightspace.universiteitleiden.nl/d2l/homeKeep experimenting, be in dialogue and ask for feedback
Lecture 2 psychological consequences & methods
Psychological consequences of childhood abuse and neglect
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Internalizing and externalizing disorders
Personality disorders (BPD/ anti-social)
Psychotic symptoms
Suicide and self-injury
o Often earlier onset, more severe/chronic, and harder to treat with a history of childhood maltreatment
Sometimes people have a lot of symptoms for example from depression but at the end they would not have the diagnosis of
depression because they don’t fit the criteria. But this doesn’t take away that they experience a lot of symptoms
Also some symptoms that are not only bound to one disorder
Psychological disorders (are classified by the DSM)
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Lots of comorbidity
Sometimes many symptoms without a specific disorder
Higher risk for earlier onset and more severe symptoms (suicidality)
Psycho-social consequences:
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Interpersonal problems
attachment at younger and later age
epistemic trust= Dit is het vanzelfsprekende vertrouwen wat je hebt in je vrienden, familie, kennissen, etc., ongeacht wat
ze doen
social exclusion
Self-image
re-victimization
Intergenerational transmission
(boundary problems)
Inter-generational transmission
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In about 30% of cases
Who and why is it transmitted
 Consequences of abuse can often be a risk factor for abusive behavior
 Stresses the importance of timely preventing abuse itself, but also of its consequences
Emotional neglect and emotional abuse more chance for any disorder. (45%, 29%)
This was the same part as the last week
This lecture
Discuss different research methods to study the consequences of childhood maltreatment
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Learn more about the psychological consequences
Learn about the underlying mechanisms
Who reports on what?
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Self vs informant (the older the kids are the easier it is to ask the child)
Parent vs child (perpetrator - victim) (most likely that the parent under rapport the situation, some parents know that a
bad situation is going on, and want to talk about the problems)
Retrospective vs prospective
Subjective report vs observing
Depending on which information you use, statistics become very different. With self-report there will be much more cases
Parent vs child report
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If you feel like you are neglected in your childhood, you report more often that you neglect your own child but when we
looked to the child they didn’t report this. But this is not the case for abuse
Who you ask, who you report, really effect if you find Intergenerational transmission
In general when we talk about measuring childhood maltreatment we base ourself on retrospective
Retrospective research(you ask back, what happened then?)
Advantages: practical in the case of long term consequences (in adults)
Disadvantages
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Memory=erroneous
Potential ‘recall bias’ = happening in people that are currently in a depression mood, they are more likely to response
negative and to only recall the negative events. For example when you are now happy you see your youth as more happy
then it actually was. It is an unconscious process
Consequences and abuse are assessed at the same moment: causality regarding cause and effect unclear. So some type of
symptoms can also not caused by abuse but due to other things
Prospective research (from the start so from the moment they are abused)
Advantages
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Temporal order abuse & consequences
Objective identification of abuse (you study the children while you know that something is happening)
No recall bias
No selective inclusion based on outcome
Disadvantages
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Selective inclusion
On-ethical without intervening in the situation (what do you know if something is happening, you have to intervene)
Duration, costs
Drop-out
THE BEST IS A COMBINATION OF METHODS
Maltreatment & Anxiety/Depression
Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies /
documented abuse (Li et al. 2016 – reading material week 1)
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Systematic review with meta-analysis
English speaking countries
Objective measure of parenting?
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Confirmed by professional?
Multiple informants?
(Visual) proof?
Alternative: study behavior at home or in a lab setting
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Used within (video) feedback interventions and to study the impact of parenting styles and interventions
Observational studies in the lab
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Studying parent-child interactions by observation
During game or assignment or when child shares feelings with parent
o Intrusions
o (Emotional) Support
o Motivation
o Warmth
o Negativity
o Empathy
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Words, behavior, physiology
Example of observational research
Renate Buisman
Autonomic nervous system puts your body in a stage of arousal or rest
Sympathic = when you need to get in action, more glucose, more oxygen, higher blood rage
Parasympathic= digesting your food and more..
People differ in how they respond and how their body responds to stress
Parent-offspring conflict interaction task, their automatic nervous system was measured and they were videotaped
Impact of maltreatment on parenting
The main outcome, parents that had experienced abuse showed less warmth and more negativity during conflict tasks,
This was measured by people that did not know who was abused.
For the amount of neglect they experienced, was the paraysmpatic system was down they were less relaxed and more
active stress response.
With abuse is less warmth and more negativity.
How can we study causal impact
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Associations between (reported) maltreatment and a present problem
Bi-directionality possible
Underlying confounders possible
Risk factors being raised in risk factor area, mother is depressed,
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What causes what?
No experimental manipulation possible, you can’t manipulate people, so how can you research what causes what
So how can we establish causality?
We have to do observational methods  there are ethical questions
Research methods
Observational
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Epidemiological research
Longitudinal research
Cross-sectional
 Chance for confounding
Experimental
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Analogue ‘acute stress’ studies
Animal research
 Establish cause and effect
Acute stress studies
Make people temporally stressed, is there change in your mood, cognition etc
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Trier Social Stress Test
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Temporarily induce (psychosocial) stress  presentation
Cold Pressor Test
Temporarily induce bodily (and psychological) stress
Outcomes:
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Changes in mood, behavior, cognition, choices, coping
Indication of changes after chronic stress:
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However, acute stress response and adaptation of behavior is “healthy” and adaptive
Chronicity of stress response can become maladaptive
Can teach us a bit about how children feel when they are maltreated, and they experience stress
An acute stress response should been adaptive, it helps you perform and focus, but if this happens continuously it becomes
maladaptive. Is harder to research. We can’t experience with chronic stress
But how to study causal impact of chronic and traumatic stress?
Early life stress in animals
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Translational research (we try to translate the outcomes to human)(ethical limits are a smaller, but it is becoming more
strict)
Stress paradigms
Measuring consequences of stress
Should be bi-directionally informed (outcomes with animal study researchers)
Choice of animal
Mouse
Rat
Primate
Maternal care: licking and grooming behaviors that are reflected of healthy maternal care
Natural variation in maternal care: low – mid – high
These diversity could say something about the pup/mom
Inducing early life stress
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Randomly assign pups to high and low LG mothers
Separation: one time or repeatedly for prolonged period of times (3h up to 24h)
Induce single or chronic trauma
Stressing the mother by limiting nesting availabilities
Inducing stress by male intruder
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Measuring maternal care behavior (ao licking and grooming)
Measuring aggression and sucrose preference
Measuring physiological outcomes
The paper for this week ‘wakeford’
Example of animal research: ‘Effects of early life on cocaine self-administration in post-pubertal male and female rhesus
macaques’
ELS and cocaine self-administration
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Early Life Stress:
Nurturing maternal care vs mothers with histories of infant maltreatment
Randomly assigned (to control for genetic confounding)
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Mechanism:
Assess differences in distress
Infant emotional reactivity and cortisol levels
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Outcome: ELS may confer enhanced sensitivity to the reinforcing effects of cocaine, especially in males. The males who
was in the stress group were the quickest to get addicted to cocaine
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Translation:
ELS and higher chance for addiction?
What have been done in animal research
Effects of early life stress on:
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HPA-axis (stress hormones)
Brain (amygdala, hippocampus, neurogenesis)
Cognition and emotions
Diseases
Hypothalamic- pituitary – adrenal axis
Stress response system:
Cortisol has functions in the body, to regain energy
to restore the body.
Cortisol also talks to the brain, everything is oke
you can stop now to have stress
But with chronic stress this system is overloaded,
this can have demanding effects
Rats, mouse, monkey, they all have this system
and the same parts
HPA-axis
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Response to restraint stress in offspring
Krom mothers high or low licking and grooming
Hippocampus
The amount of maternal support, related to the size of your hippocampus, but could have other reasons
Cognition (in rats)
How quick do mouses learn, mouses in a less licking and grooming environment would be slower in this
Emotions (in rats)
In rodent studies findings for;
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Depressive behavior: decreased preference for sucrose
Anxiety: increased startle responses, facilitation of fear memories (easiest to study)
Aggressive behavior
Substance abuse: preference for alcohol and cocaine
What can’t we learn with animal research
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Measuring
Subjective emotions and
Negative self-inferences and cognitions
Mental health?
Inducing
Sexual abuse
Emotional abuse
Testing behavioral interventions ´ …
Childhood maltreatment & long-term consequences
How can events that happened 25 years ago have such a pervasive impact on a person’s emotional, cognitive, and social wellbeing?
Psychological consequences of childhood abuse and neglect
Why does something lead to the other??
Possible underlying mechanisms
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Cognitive Schemata of self and others
(In)secure Attachment
Emotion regulation styles
Hypervigilance to threat
Low responsiveness to reward
Neurobiological models (Lecture 3)
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Stress system
Brain structure and functionality
Cognitive schemata
“The world is a dangerous place” (anxiety)
“Others cannot be trusted” (hostility, avoidant)
“I am not worthy” (selfesteem, depression)
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Deeply engrained
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About self, others, and the world
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Can be hard to overcome in (trauma-focused) therapy
Schema therapy (L8)
Attachment styles
Insecure attachment
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Emotional neglect is a big risk factor
Lack of parental sensitivity and empathy
Attachment to abusing parents occurs, but is characterized by unsafety
Children can securely attach to another person
Can influence attachment in later relationships
Article for this week: Attachment as a mechanism
“a tangled start: …”
Cross-sectional study: how are these tied together
Attachment and adult relationships
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Was childhood maltreatment was related to quality of intimated relationship and relationships later and how does this
related?
Severity was closely tied, and avoidance and anxious attachment mediated the impact on later on relationships
Psychological consequences of childhood abuse and neglect
Possible underlying mechanisms:
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Emotion regulation styles
Hypervigilance to threat
Low responsiveness to reward
Emotion Regulation (ER)
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Recognize and understand emotions
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Coping with emotions
Problems in ER can lead to problems with
Social interactions
Rejection
Stress
Impulse control
Hypervigilance to threat
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Hypervigilance to threat
Heightened attention to angry faces
Hostile attributions to ambivalent stimuli
Rejection sensitivity
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May lead to higher risk for
Anxiety disorders (internalizing)
Aggressive reactions (externalizing)
Avoidance and withdrawal
Reward responsiveness
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Reduced responses to (anticipation of) reward (after childhood maltreatment)
Very relevant during adolescence
Motivation and reinforcing goal-directed behavior
Ventral striatum and Anterior Cingulate Cortex
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May lead to higher risk for
Depression
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Changes in dopamine (reward) system
Substance abuse
Psychological consequences of childhood abuse and neglect
Possible underlying mechanisms
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Cognitive Schemata of self and others
(In)secure Attachment
Emotion regulation styles
Hypervigilance to threat
Low responsiveness to reward
Neurobiological models (Lecture 3, prof. Bernet Elzinga), Stress system, Brain structure and functionality
Stress and personality : Personality disorder: mental health condition that involves long-lasting, disruptive patterns of
thinking, behavior, mood and relating to others; Lecture 4
To conclude
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Childhood abuse and neglect are related to underlying psychological processes, such as negative self-esteem, emotion
regulation difficulties, and biased cognitions
These processes may cause (overt) psychological problems and disorders, as well as social and interpersonal problems
(including revictimization and transmission of abuse)
Not everyone responds the same to childhood maltreatment!
Individual differences
Vulnerability and Resilience factors (L5)
No 1 cure for the consequences of childhood maltreatment? (L8)
Lecture 3 psychological and neurobiological consequences of childhood abuse and neglect
Childhood maltreatment & long-term consequences
How can events that happened 25 years ago have such a pervasive impact on a person’s emotional, cognitive, and social wellbeing?Childhood < 18 jaar Adulthood ?
Lecture 3 Bernet Elzinga
Increased risk for developing a mental disorder after childhood maltreatment (in a dose-dependent manner) particularly for
social anxiety, depression, PTSD, borderline personality disorder (BPD) and substance abuse
Impact of childhood maltreatment on neural affect regulation systems
Brain is not developing at the same parts at the same time but during
Brain in development during childhood, the time the brain is developing, the brain is also plastic, changeable and much on
the influence on stress hormones
They are very sensitive to the environment in the early years
Early childhood: threat & safety learning: limbic system
Puberty: emotion regulation: prefrontal brain the more impact on regulating function more important
How does the brain respond to threat?
What is de brain doing when we are exposed to a threatful situation
Two stress systems
Adrenaline goes up first and then the cortisol comes and hold on longer
Adrenaline, fight flight response, to manage the situation, to see what is going on
At the same time, The executive response system is down, is normally in control of your brain, concentration, retrieval of
things you learn before is damped
The salience network is up
For these system it’s always someone is up and someone is down
After 20 minutes cortisol is released, it regulated the first stress response, the executive control system comes up
Amygdala for salience network, everything that is
salience(opvallend) is important for us
Amygdala can signal this is relevant, and the hippocampus
stores information that is important
That’s why emotional things more often stored, they have big
impact at us, and this is caused by the hormones cortisol and
(nor)adrenaline.
Also impact of stress on the prefrontal cortex
When we perceive threat there are two ways to process this,
Fast track (low road): awhh you think it is a snake, you process something without actually knowing what you are seeing.
Through thalamus and amygdala is activated, your first feelings are activated, it activate the stress. (fast processing without
conscious thoughts)
Slow track: (high road)More extensive processes your cognition are taking in account, was it really a snake or was it just a
tree or something (slower indirect pathway, more extensive processing). Decrease the first stress response, prefrontal cortex
engage in this.
If you can anticipate for things that are going to happen in the future you can protect yourself better and be more aware.
The human brain is called a anticipating machine, prediction things in the future most important part.
With childhood maltreatment this prediction for the future will be bad and not positive.
Overlap between neural networks affected by maltreatment and network affected in depression
Reward system, threat system, social/self-system have overlap in the different parts in the brain
Abuse and neglect and threat system
Adults looking back at their childhood and then what they say about their childhood related to how they behave now
First focus on threat system
Comparing individuals with childhood emotional maltreatment, critical, judging, saying negative things And neglecting
emotional things, compared with the group that didn’t’ experienced any of those things. Related to if they experienced
depression and other psychological problems.
They went in to the scanner, where the saw different faces.
Enhanced amygdala sensitivity while processing faces in adults with history of emotional maltreatment
We expected that the maltreated group would response more on the faces especially the angry ones. That the amygdala would
response more.
But it was not only the angry faces, it was with all the faces, also the happy, sad etc.
The amygdala becoming more high sensitive but it can also be that happy faces that people have difficulty with
understanding if a situation is save or not.
We did not really know this before, (also happy faces), so it is not only difficulty in real life but also it is seen in the brain.
The question is also, why would this happen? Amygdala activation going up in response to angry and fearful faces in soldiers
after vs before combat exposure. So scanned for going to war and after. When they came back their stress system was more
active, seen in de amygdala but 6 months later it was going down again, no ptss. So it was really adaptive to have a high
stress system, to anticipated in these situations they went through.
In children this could also be adaptive?
Children that were maltreated could better identified the angry faces than the control group. The threshold or perception for
perceiving something was lower for the angry faces and they could detect the angry faces sooner.
This all evolves the children without knowing this, without being aware of it. THIS HAPPENS IN THE LOW ROAD (fast
processing)
Summary threat sensitisation
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Maltreated children/adults show increased sensitivity in amygdala in response to faces, which may be adaptive on short
term (Pollak ,. Harmelen)
Enhanced sensitivity a latent factor associated with impaired emotion-regulation (i.e., rumination, avoidance) and on the
long-term (in response to new stressful experiences) with development of psychological problems
This is not a conscious process m(low road) and hence not under higher order regulatory influence (Pollak., McCrory)
So much is unknow, the first part is becoming aware
Dissociation
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Disturbances in the integration of consciousness, memory, identity, physical observations and ‘self’
Detachment of trauma (-memory)
Emotional disconnection
Memory problems
Prevalent after repeated and early trauma (particularly sexual abuse)
Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype
Dissociation (you are not in contact anymore with your own feeling, when feelings are too overwhelming) = exception
For PTSD, some reexperiencing, emotional under modulation And the dissociation, emotional overmodulation
Dissociation associated with dampened amygdala
Those with borderline that had dissociation looks at negative pictures had low amygdala response
And those with borderline that didn’t dissociate and looked at the negative picture had a higher amygdala response
This was the low road
Now about the high road (slower, indirect, after evaluated situations)
Abuse and neglect and emotion regulation in response to social exclusion
Cognitive model
Negative cognitions are directly supplied to the child by the abuser
“you are worthless, you are stupid etc”
The more severe the emotional maltreatment was the increased dmPFC (PREFRONTAL CORTEX)
Increased dmPFC reactivity in response to social exclusion in individuals with history of childhood emotional maltreatment
Leiden family study intergenerational transmission of maltreatment with 3 generations
(When child is avoidance bad to parent, parent less likely to be nice to the child)
Lisa van den Berg
Conclusion
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Strong association between own history of maltreatment (neglect) and neural responses to social exclusion
No association between neural responses and maltreating behaviors as a parent
Also decreases in mPFC volume in individuals with reported history of emotional maltreatment
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It is not only in people with pathology but also in the healthy controls
So not only the function of the brain but also the construction is damaged
Role of mPFC
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PFC is involved in regulation of affective states & emotional behavior, fear extinction, and self-referential processes
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mPFC activity attenuates fear response by reducing amygdala activation over time
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mPFC involved in modulating neuroendocrine and autonomic stress response
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Dysfunctional mPFC activation is implicated in stress-related disorders (including PTSD and depression) (= the impact
of early adverse symptoms of effects of the stress systems
The paper about, The impact on the reward processing “a neurocomputational investigation of… maltreated children”
Before this, the adolescents that develop a depression, the response to reward system is lower, so the reward system is
effected by maltreatment
Overlap between neural networks affected by maltreatment and networks affected in depression
Same neural networks may foster resilience for depression through positive experiences
Article: “examing child maltreatment…. model of therapeutics” MODEL!!
Different systems in de brain are effected by maltreatment at different ages.
Maltreatment in early life other effects than maltreatment later in life. Related to what is developing at that time. So related to
different brain regions. But this model is not evidence-based.
Maltreatment → psychopathology
Maltreatment can chronically increase stress-sensitivity
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On cognitive /emotional level
Perpetrator may hand to the child negative attitudes (working models) (‘you are worthless’), which the child may
incorporate in the self-image. This may lead to a strong cognitive sensitivity which may be evoked in new stressful
situations (Beck, 2008)
On neurobiological level
By altering brain functions in networks that are important for emotional reactivity, emotional memory, and emotion
regulation
By chronically altering the sensitivity of hormonal stress reactions, such as the HPA-as / adrenergic system
Both adrenaline and cortisol affects the brain
Another line of research, to what extend the function of HPA-axis is effective when you are expressed to stressful early life
circumstances
Methods to investigate the HPA-axis: Trier Social Stress Test
Does the HPA-axis increase by maltreatment with depression related.
Only women that had both early life stress and depression had a higher ACTH (comes before cortisol), CORTISOL AND
HEARTH RATE.
HPA-axis is more sensitive when experience early life experiences
For people with social phobia cortisol little bit higher than the PTSD and control group
Enhanced cortisol reactivity only in social anxiety disorder and childhood abuse
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Only correlations between % increase cortical and emotional abuse
Not explained by subjective stress levels
ARTICLE: “Childhood trauma and dysregulation ... depression and anxiety (NESDA)”
Read this article for the info
Take home message
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Exposure to childhood maltreatment, when brain is still developing, can inhibit some brain regions to develop normally
(i.e., prefrontal cortex: dmPFC and ACC) while other brain regions (e.g., amygdala, insula) can show increased stresssensitivity or reduced response to reward (e.g., striatum)
Emerging evidence points to impact of neglect in development of neurobiological alterations
That neglect could have worse effect in later than abuse, affects the stress symptoms
When one parent is abusive and the other is protective, this can damping the symptoms and regulates the stress symptom
Cause and effect unknown: majority of research is cross-sectional and not corrected for comorbidity (i.e., associations
can be consequence of psychological symptoms rather than trauma exposure)
Take home message (2)
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Indications for subtypes of individuals with depression and anxiety, with or without maltreatment history
Depressed patients with a history of maltreatment have more severe problems, more chronic, more suicidality, more
comorbidity, different neurobiology (i.e., enhanced amygdala reactivity)
Whether a person develops psychopathology after maltreatment also depends on protective factors during and after
exposure to childhood events! (McCrory et al., 2017)
Important implications for research and interventions
Take home message (3)
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Dissociation, which is frequently observed in patients with a history of childhood maltreatment, has major impact on
numbing of emotions and brain responses (e.g., dampening amygdala, insula)
Lecture 4 Personality disorders
“Childhood maltreatment, complex trauma, and borderline personality disorder”
Complex trauma
Exposure to a series of repeated traumatizing events where escape is difficult or impossible (e.g. torture, slavery, genocide,
domestic violence, repeated childhood emotional, sexual or physical abuse) (WHO, 2018)
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Strong association between childhood maltreatment and intimate partner violence (Widom et al., 201)
Linked to certain risk factors, e.g., demographic variables, cultural environment, financial situation, psychological
mechanisms
Intimate partner violence (IPV)
Violent or coercive acts perpetrated by one intimate partner against the other, either in an existing or past relationship
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Multiple forms
Physical aggression and injury
Sexual coercion
Psychological abuse
Stalking
Often it’s a combination of these forms
Often reciprocal (often both ways, and often it’s not intentional, also love)
Circa 36% of women and 33% of men encounter any kind IPI in their lifetime
IPV incidences seem to have increased over the last years (could be because of corona)
Possible links between childhood maltreatment and IPV
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Posttraumatic stress disorder symptoms
Borderline personality disorder features
Emotional dysregulation
Dissociation
Early maladaptive schemata
Attachment anxiety
Social support
“a syndrome in survivors of prolonged and repeated trauma”
Proposed six symptom groups:
1.
2.
3.
4.
5.
6.
Disturbance of affect regulation
Relationship problems
Disturbed self-perception
Alterations of consciousness (dissociative symptoms)
Changes in the value system and core beliefs (e.g., ruined, dangerous, helpless, powerless, fundamentally different from
others, isolated)
Disturbed perception of the offender
 Impact of subordination to coercive control
Complex PTSD diagnosis in ICD-11 (WHO, 2018)
Disturbance in self-organization (DSO):
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Problems in affect regulation (e.g., self-soothing)
Relationship difficulties (e.g., avoidance, difficulties sustaining relationships)
Negative self-concept
In addition to “classical PTSD symptoms
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Re-experiencing
Avoidance of traumatic reminders
Hyperarousal (sense of current threat)
Ongoing debate about complex PTSD diagnosis
-
Construct validity of CPTSD is questioned (Resick et al., 2012)
Differential diagnosis can be challenging
CPTSD = PTSD plus comorbidity, e.g., Borderline Personality Disorder (BPD)
In Borderline personality disorder
Early onset in adolescent/adulthood
Flexible
Chronic
Repeated pattern
Different distortions
Have to disturb the daily life
For borderline personality disorder traumatic event is not mandatory, for PTSD a traumatic event key element
Almost all of them experience severe abuse and neglect in childhood
A striking overlap with PTSD and borderline personality disorder
Maybe better to look at transdiagnostic factors instead of diagnosis
Personality disorder
Enduring pattern of thinking, feeling, perceiving, relating (to oneself and others), and behaving with early onset, that is
inflexible and stable over time - Inflexible, early onset (adolescence or early adulthood). - Deviates markedly from the
expectations of the individual’s culture. - Leads to clinically significant distress and is not better explained by another mental
disorder, physiological effects of a substance or another medical condition
BPD
Traumatic invalidation (Marsha Linehan, 1993)
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Environment in which the child does not learn how to understand, label, regulate, or tolerate emotional responses
(Linehan, 1993) Traumatic invalidation (Marsha Linehan,1993)
Intolerance toward the expression of emotional experiences (e.g., emotions are seen as unwarranted or bad, no support).
Disorganized / chaotic attachment (e.g., over-protection alternating with (unintended) neglect, unclear boundaries,
privacy and autonomy are ignored)
Dysfunctional responses to abuse and neglect (e.g., victim blaming)
Childhood maltreatment and BPD
Meta-analysis by Porter and colleagues (2020)
History of emotional, physical, sexual abuse, neglect in BPD
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13.91 times more likely than in non-clinical controls
3.15 times more likely than other psychiatric groups (e.g., depression)
Particularly strong for emotional abuse and neglect
Review by Ball and Links (2009)
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Emotional maltreatment (around 92%)
Sexual abuse (around 40–76%)
Physical abuse (around 25-73%) Childhood maltreatment and BPD Trauma criterion not mandatory for BPD (unlike for
CPTSD)
Complex PTSD and BPD: differences and similarities
Differences:
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Trauma criterion and PTSD symptoms mandatory for CPTSD but not BPD
Self-image in CPTS profoundly negative versus unstable in BPD
Relationships: Avoidance of intimacy in CPTSD versus instability in BPD (idealization and devaluation of significant
others).
Similarities:
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Problems in emotion regulation
Dissociation
Emotion regulation and impulsivity in BPD
People that report they are really impulsive, repeat also more childhood trauma and more severe and more problem in
emotional regulation
If you ask people with BPD, why they use self-harm, main motive is to reduce stress or negative emotions, also to regain
sense of control and to feel the body again.
Emotion dysregulation and dissociation
“under-regulation”
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Strong overwhelming emotions
Unstable emotions
Emotional vulnerability
“Over-regulation”
-
Emotional numbing
Chronic emptiness
Disconnectedness, dissociation
Dissociation= Disruption of / discontinuity in the normal, subjective integration of one or more aspects of psychological
functioning, including memory, identity, consciousness, perception, and motor control” (Spiegel et al., 2011; p. 826)
Everyone feels sometimes dissociated, people use this sometimes to deal with things that happen in their life, to habituated to
their life
Maladaptive when you keep experiencing this in different life events and you can’t control it anymore. You can’t feel
connected to people that are important for you, is very disrupted
People with BPD feel this more
Three categories: of symptoms (Spiegel & Cardena 1991)
1. Loss of continuity in subjective experience
 Dissociative flashbacks (intrusions)
2. Inability to access information or control mental functions that are normally amenable to such control or access
 Dissociative amnesia
3. Sense of experiential disconnectedness, including distorted perceptions about the self or the environment
 Depersonalization = Subjective detachment from one’s person (e.g., feeling unreal, blurry, numb, being an outside
observer).
 Derealization = Feeling detached from the environment (e.g., that the world has become vague, dreamlike, less real,
non-existent).
Dissociative identity disorder (DID)
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Presence of two or more personality states / identities
Person behaves differently depending which identity is in control.
Person forgets important, personal information people normally do not forget.
Psychogenic amnesia
Gaps in the recall of everyday events, important personal information and/or events
Personal distress
Outside of cultural norms (e.g., trance)
Not caused by drugs, illness, malingering, or in children pretending to play with imaginary friends
People think it can be caused by severe childhood maltreatment
Treatment challenges:
thoughtsemotions   behavior 
Classical cognitive-behavioral model
-
Early onset
Behavioral pattern is pervasive
Change threatens perceived identity (egosyntonic)
Relational problems also in therapy
Often long treatment history and/or treatment reluctance
-
Dialectical approach: Acceptance versus change
Integration of multiple techniques (CBT plus Acceptance Commitment Therapy, Emotion-focused Therapy,
Psychodynamic/imagery approaches, meditation, mindfulness, motivational interviewing)
Combination of individual therapy with group therapy, structured setting
-
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Evidence-based treatment
Treatment for BPD
DBT-PTSD for complex PTSD
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Extra elements
Compassionate therapy elements
Focus on guilt; shame; disgust; self-contempt
Contra-dissociation skills
Skills-based exposure
Effectiveness
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Change in PTSD symptom severity
Both DBT and CPT (control condition) were safe and
efficacious (d=1.35 and 0.98, resp.)
The improvement was steeper in the DBT-PTSD group →
higher rates of symptomatic remission in the DBT-PTSD group
Drop-out rates:
Significantly less dro-outs in the DBT-PTSD group (26% vs 39%)
Lecture 5 Resilience versus Vulnerability
Interim summery
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Maltreatment as a transdiagnostic risk factor for psychopathology
Psychological & Neurobiological mechanisms
Heightened psychological stress sensitivity
Self, other, and world views
Emotion regulation
Heightened biological stress sensitivity
HPA axis and Brain
Physical consequences (lecture 6)
..But no everyone responds the same!
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Can be dependent on factors related to the maltreatment
Type (neglect vs abuse, emotional, physical, sexual)
Timing (developmental period)
Severity & Chronicity
Perpetrator
Not easy to study these factors independently, and impact can also differ per individual
Resilience versus vulnerability: Psychosocial resilience factors, Biological resilience factors, Brain Genes and epigenetic
But not everyone responds the same!
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Dependent on factors related to the maltreatment
Type (neglect vs abuse, emotional, physical, sexual)
Timing (developmental period)
Severity & Chronicity
Perpetrator
Buffers versus risk factors ⇒ Resilience versus Vulnerability
-
Psychosocial factors
Biological factors
o
Brain
o Genes and epigenetics
What is resilience?
-
What does resilience mean in the face of childhood maltreatment? No getting a psychological mental illness
Is it a trait or state? It is not something you born with, it can develop over time, and psychologist can help with this
Resilience in two ways. Getting better from it, you can handle everything. Other seen resilience see it more that you get back
to a normal balance
Diathesis-stress/dual-risk model: we thought vulnerable people will act normal in a positive environment and bad in negative
environment
Differential susceptibility model : people act bad in a negative environment and better than normal in a positive environment
Two models used for different things, first one more used in the past, the second is more recent discovered
Psychosocial resilience factors
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Individual level
Distress tolerance
High self-esteem
Secure attachment
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Mental flexibility
Family level
Family cohesion
Positive parenting
(extended) Family support
Community level
High social support
Safety (Fritz et al., 2018)
 Buffering, but also mediating factors
Social support (Van Harmelen et al., 2017)
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Social support is one of the most robust buffers of early life stress (Best for resilience, as in not getting
psychopathology)
BUT: Subjective experience of social support can be affected by stress
When you ask someone that is already depressed how their social support is, they would automatically call their social
support bad
Paper from this week :”resilience to adult…. Sample”
-
Positive adaption?
Amenalble factoros
They compare these groups with each other
Psychosocial resilience factors
Amenable factors?
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Social support
Relationships/ attachment
Focus on the (broader) system
Self-esteem & coping (e.g. COMET)
Resilience as positive adaptation: resilience building
Building resilience
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Focus on changeable (amenable) factors
Involve (foster) parents, professional care, and close community
Book Bruce Perry: Social connectedness, Sensitivity, Warmth, Trust, predictability,
Increasing stress tolerance: moderate, repetitive (predictable) stress
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Less changeable resilience factors?
Biological predispositions
Second part of the lecture
Biological resilience factors
-
Brain
Genetics
Brain functionality (article week 5 “neurobiological markers of resilience…control of emotion”)
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Engagement of cognitive control networks that modulate negative emotions
Emotion regulation strategy: cognitive reappraisal
Regulatory regions of the frontoparietal network modulate amygdala activity
When studying the brain watch structural, how big are areas etc.
And how active is an area during a challenging test
Looking at stressful picture, people had to regulate themself to deal with the pictures, try to regulate negative emotions
They look at how active areas where and how they relate with each other
Stronger inverse coupling between the prefrontal cortex and the amygdala during regulation greater reductions in negative
emotion
Resilience after maltreatment: SFG getting higher activity and amygdala getting lower activity during emotion regulation
Can we impact this, can we help people, it is possible
Brain functionality: amenable?
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Cognitive behavioral therapy for depression and anxiety
 Changes in fronto-amygdala neural circuitry
Train cognitive control networks?
Genetic vulnerability/ resilience

Genes impact regulation of hormones and neurotransmitters that play a role in: Growth, development, stress,
psychopathology
-
Serotonin (eg. Gene for the 5-HT transporter; SLC6A4)
Cortisol (eg. Glucocorticoid and Mineralocorticoid Receptor (GR/MR) related genes; NR3C1, FKBP5, CRH)
Dopamine (eg. DRD4)
Oxytocin (eg. OXTR)
Brain-derived neurotrophic factor (BDNF) (hippocampus, memory)
 Individual differences in these genes exist
Genes in our DNA, DNA Is on our chromosomes, we have 23 pares, from every genes you have two one from father one
from mother.
Base pairs 4 nucleotides: G C T A.
your genes functions different
AT & GC , the order says something about what the genes is. One change means
Genes code for proteins, PROTEINS have functions in the body
Genes on the DNA code for proteins
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DNA is transcribed (via mRNA) to make proteins from amino acids
Proteins have many possible functions (enzymes, immune system, stress hormones, neurotransmitters etc…)
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In different cells, different genes (& proteins) are active, determines what it is used for, is it a blood cell, hair cell etc.
Proteins determine function of cell
Genetic differences
Alleles: variants of a gene (1 from your father, 1 from your mother)
Variation in genes (> 1 allele)
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Eg. Eye color and Blood type, but also variations in cortisoland cortisol receptor-genes
Mutations: individual variants, changes in DNA, leads to individual differences
Polymorphisms: population variants (SNPs, repeats, deletions, inserts, inversions, copy number variants), when it is in
the egg cell, at least more than 10% of the people have it.
Single Nucleotide Polymorfisme (SNP)
G=C to A=T G=C to C=G T=A to A=T
6.000.000 / human genome
However, does the variation influence the end product? Dependent on place in gene
S
To people with two long alleles, the depressive symptoms where on the low
So when you have this genotype you have less chance on depression
To people with tow short alleles, depressive symptoms where higher
More chance on depression
If you have short alleles, your brain and your hormones are more related to depressive symptoms
Genetics in psychology (Caspi, A., Hariri, A. R., Holmes, A., Uher, R., & Moffitt, T.E. (2010). Genetic sensitivity to the
environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits.
American Journal of Psychiatry 167, 509–5 27.)
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The serotonin transporter gene seems related to stress sensitivity
Stress reactions (hormones, brain activity)
Depression- and anxiety measures of behavior
Depression Phenotypes
Negative affectivity
 Only in stressful environments, this polymorphism is expressed gene-environment (G*E) interaction
Genetic vulnerability / resilience
-
Nature (genes) as a starting point
Nurture can have different influences depending on genes
Different genotypes can be beneficial in different environments
Can genetic traits be changed?
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CRISPR gene editing is a genetic engineering technique by which the genomes of living organisms may be modified.
Or activity of genes
Still far away from changing brain functionality
However, how a gene is expressed can be affected by the environment
Not able to changes the genomes but we are able to changes which genes are active. DNA CAN LEARN=
Epi-genetics (effect of the environment on the expression of genes, it doesn’t change the DNA or the order)
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Effect of environment on expression of genes
No change in the order of the nucleotides (G/C/T/A)
Changes in regulation of genes
o
o
Needed for cell differentiation (prenatal)
Permanent or temporary
Closed can’t be use and open can be used
Methylation we can measure, they say something about how active a gene is
A lot of methyl groups this gene is not active. When there are less methyl groups the gene becomes active.
Stress can impact if a gene is active or not, how active these genes are can be changes and this can be permanent
Epigenetics
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Measuring methylation possible in
Brain tissue (post-mortem), when it is no longer alive, postmortem
Blood (gives a very global picture: related to brain?)
Saliva (unintrusive measure: related to brain?) (mouthswap)
In the lab: Brain Organoids from stem cells
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Trauma may impact regulation of the DNA via epigenetics
May impact activity of many different cells – tissues – organs – systems (eg. GR receptors, HPA-axis, insulin, immune
system)
DNA-methylation due to trauma may be limited to certain brain areas
Trauma  Changes in the HPA-axis
Is this mediated by epigenetic changes in HPA-axis related genes?
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DNA methylation of the Glucocorticoid Recepter (GR) gene
Post-mortem hippocampal tissue
-
Decreased GR expression (neuroendocrine dysregulation)
Increased methylation in promotor region of GR receptor gene
Epigenetics: Methylation of GR gene
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Childhood Trauma
Hippocampus (Labonte et al., 2012)
Blood (Tyrka et al., 2013; Martín-Blanco et al., 2014; Romens et al., 2014)
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Prenatal stress: methylation GR gene in children (Oberlander et al., 2008; Radtke et al., 2011; Mulligan et al., 2012;
Hompes et al., 2013)
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PTSD (Yehuda et al., 2014)
Epigenetics: beyond GR (the Glucocorticoid Recepter)
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Childhood trauma and methylation of the
5-HTT gene (Beach et al., 2010, 2011)
OXTR gene (Smearman et., 2016)
BDNF (Chagnon et al., 2015; Unternaehrer et al., 2015)
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Immune system
Genome-wide studies (Smith et al., 2011; Yang et al., 2013)
Epigenetics as a Mechanism:
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How environment (eg. trauma) can influence us (biologically)
Certain polymorphisms are more easily (de)methylated
o Might explain vulnerability/susceptibility models (G*E)
Can methylation be changed by therapies, nutrients, or medicine?
Can we increase resilience by epigenetic changes?
Resilience: Complex of many factors
Take home messages
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Psychosocial resilience factors
Individual, Family, Community
Focus on building resilience
Biological resilience factors
Brain
(epi)Genetics
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Variation in genetic codes can lead to differences between people
Vulnerability to stress due to certain gene variants (G*E)
Visible in stress-systems (e.g. heightened amygdala and HPA-axis activity in reaction to stressors)
Trauma can lead to psychiatric disorders more often in people with certain genetic variants of the serotonergic and HPAaxis system

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The environment can also influence the regulation of genes
E.g. via methylation of DNA regions
Methylation of GR-genes may be related to childhood trauma
o This in turn may lead to problems in stress sensitivity or coping later in life
Lecture 6 Impact of childhood abuse and neglect on physical health and ageing
Rene Descartes (1596-1650)
-
Mind is distinct from matter (but can influence matter)
Childhood abuse? Physical health
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Poor (subjective) health perception
Sick more often/more frequent visits to doctors, etc.
Diseases of ageing (disease & morbidity)= Asthma, migraine, cardiovascular disease, autoimmune disorders, coronary heart
disease (CHD), diabetes, cancer, death
Adverse childhood experience influence on social, emotional and cognitive impairment  adoption of health-risk
behaviors  Disease, disability and social problems early death (ACE study)
This week the article “the effect of multiple…..and meta-analyisi”
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Link with cardiovascular disease, cancer and respiratory disease
Animal studies
Premature weaning can have long term effects on animal’s vulnerability do disease
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Shorter time to death after implantation with tumor (Ader et al., 1960)
5x greater gastric ulcers in response to stressful situation at 100 days of life (Ader et., 1962)
Greater viral replication and worse symptoms of infection after virus (Avitsur et al., 2006)
More airway pathology (related to increased pro-inflammatory mediators) (Kruschinski et al., 2008)
Pathways by which abuse can influence health (Kendall-Tacket, 2002)
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Behavioral pathways (harmful activities): Substance abuse, obesity, suicide, high risk sexual behavior, smoking, sleep
difficulties (nightmares etc)
Social pathways (stressful relations): Avoidant versus intrusive styles, revictimization, homelessness
Cognitive pathways: Internal working model (world as dangerous, loss of control, failure)
Emotional pathways: Depression, Anxiety, Posttraumatic
Behavioral pathway: Tuning of reward system
Circuit involved in self-regulation of appetitive behavior
Early life stress  Impulsivity related to low responsiveness to reward  Unhealthy life-style choices
Social pathways (stressful relations)
Childhood abuse exposure related to increased stress in interpersonal context
-
More vigilance/ distrust/ hostility
Childhood abuse related to increased cortisol response to social stress
Avoidant style
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Low interdependency
Low self-disclosure
Low warmth
Fewer friends
Less likely to be married
Anxious / intrusive style
-
Excessive need for closeness
Excessive self-disclosure
Smothering
Consequence: Less social support
Social support key buffer against stress
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Social support exerts powerful beneficial effects on health outcomes and longevity
Being married or cohabiting with a significant other associated with lower rates of morbidity and mortality compared
with non-married individuals
Gender differences? Whereas men showed significant attenuation of cortisol responses to stress when supported by their
spouse or by an opposite-sex stranger, women showed a tendency toward increased cortisol responses when (verbally)
supported by their spouse
Effects of different kinds of couple interaction on cortisol and heart rate responses to stress in women
Soothing system and affective touch
Characteristics of CT afferent fibers – core affective touch system:
-
Slow-conducting, unmyelinated, mechanosensitive peripheral nerve fibers
Found only in hairy skin (e.g. forearm) not on glabrous skin (e.g. hand palm)
Optimal type and pace of stimulation is gentle stroking
Preference for temperature of 32°C, which corresponds to skin-to-skin contact
Projects to limbic cortical areas (mainly insula, dmPFC and ACC)
Reduce activation of sympathetic nervous system and HPA-axis
Facilitates ‘sense of self’ (?)
Cognitive pathways
Cognitive model
-
How people think about themselves, impact the way they experience situations
The nun study: optimism & longevity
-
Optimism is directly linked to living longer
Nun’s life all in the same environment so easier to study
Same environment but a different mindset, the most optimistic nun’s would survives the longest
Emotional pathways
Depression and PTSD
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Depression predictor of coronary heart disease (Schwartzman & Glaus, 2000)
Depression risk factor for mortality following myocardial infarction, independent of cardiac severity (Lesperance &
Frasure-Smith, 2000)
Anger predictor of coronary artery disease and hypertension
Link depression/PTSD and heart disease may be mediated by
Increased stress responses (autonomic responses, HPA-axis)
Impact on immune system (immunosuppression)
Lack of sleep, poor self-regulation
Childhood abuse and physical health
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How does childhood stress gets under the skin, at the level of tissues and organs, to affect risk for later diseases?
How does childhood stress incubates in the body, manifesting in disease several decades later?
Second part of lecture: Diseases of ageing (disease and morbidity)
Early life stress & Immune dysregulation
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Biological pro-inflammatory model of early life stress:
Higher levels of systemic inflammation (cytokines IL-1β, IL-6, TNF-α)
Larger acute stress-induced increases in inflammatory markers and pro-inflammatory responses to microbial challenges
Resistance to inhibitory mechanisms (of cortisol) designed to dampen inflammation
Effects exacerbated by risk behavior and hormonal dysregulation (HPA-axis)
Immune system really important
Negative social interactions increase chronic inflammatory state in the body
-
Marital conflict increases levels of IL-6 and TNF-a in circulation, which is still evident 24 hr later
Excessive and persistent inflammation is related to metabolic syndrome, coronary heart disease and stroke, auto immune
functions, some cancers and premature aging
Telomeres
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Protect the end of the chromosome from deterioration or from fusion with neighboring chromosomes
Chromosome ends shorten, which occurs during chromosome replication (and hence during ageing)
Telomerase, the reverse transcriptase enzyme responsible for synthesis of telomeres
Social support also related to the telomeres (direct effect on the immune system)
-
How can people profit van these interactions and feels connected to others, challenges in therapy how to stimulate this
more
In the article of telomeres
Exposure to violence during childhood is associated with telomere erosion from 5 to 10 years of age
-
For children with 2 or more exposures the telomeres would shrink far more
Early experiences related to physical function and early death (look at the piramide)
Take home messages
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Childhood abuse can have negative impact on many aspects of physical health, incl. subjective health, but also disease
and morbidity
Early life environment “prepares” organism for later life conditions, which may result in excessive inflammation of
immune system
Important regulatory roles for behavior, negative social interactions, negative appraisals/cognitions, psychopathology
Positive social interactions are key buffer to stress, which is however frequently lacking in individuals with history of
childhood abuse
Lecture 7 Sexual abuse: Consequences for sexual functioning and treatment of sexual dysfunction
This lecture:
Part one:
-
Sexual abuse: definition and prevalence
Association with mental health problems and sexual problems (women)
Psychophysiological research: effect negative sexual experience on sexual responding
Part two:
-
Sexual abuse and sexual problems in clinical practice
Factors influencing sexual functioning
Treatment of sexual dysfunction
Introduction
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Sexual abuse: Unwanted sexual activities such as exposure to public masturbation, genital touching, or attempted or
completed oral, vaginal, or anal intercourse.
Childhood sexual abuse: before age 16
Often classified on a scale reflecting severity: non-contact - contact - contact with penetration (and frequency)
Prevalence sexual abuse
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Survey ‘Seksuele gezondheid 2011’ (every 5 years this survey)
Representative sample of 8000 men and women, age between 15 – 71 year
Sexual abuse experience: unwanted sexual kissing, genital touching, oral, vaginal, or anal penetration
Before or only after age 16
Before age 16 (Sexual abuse experience: unwanted sexual kissing, genital touching, oral, vaginal, or anal penetration)
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Men 3,5 %
Women 16,5%
After age 16 (Sexual abuse experience: unwanted sexual kissing, genital touching, oral, vaginal, or anal penetration)
-
men 9.3% (total 12.8%)
women 23.8% (40.3%)
Perpetrator of sexual abuse
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Majority male perpetrator (94 %)
Mostly perpetrator was known (83 %)
Before age 16: Most often a person from the neighborhood, family member (other than father or brother), or (ex)boyfriend
Before age 16: 7.7 % father, 5 % brother
After age 16: Most often (ex-)partner, acquaintance from nightlife, or friend
Child sexual abuse and negative consequences
Child sexual abuse (CSA) is not uncommon, and is associated with a range of disorders:

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Mental health problems (depression, anxiety disorders, personality disorders)
Substance use disorders
Suicidal behaviors and self-harm
PTSD
Lower self-esteem
Lower life satisfaction
Physical health problems
Educational underachievement
More severe sexual abuse – more negative consequences
Family characteristics influence the extent to which CSA affects later functioning
Child sexual abuse and consequences for sexual functioning
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More risky sexual behavior (younger onset of sexual activity, more partners, more likely to have unprotected sex)
More likely sexual re-victimization in adulthood (2 out of 3)
More sexual problems
Less sexual pleasure, lower sexual self-esteem
More sexual problems in later life when you experience sexual abuse before the age of 16
Sexual abuse and consequences for sexual responding
Hypothesis underlying mechanism:
Association sex with harm/fear/disgust  negative meaning  impaired sexual response
-
What do psychophysiological studies show?
Evidence from studies on:
1.
2.
3.
Aversive conditioning of sexual response
Sexual response in women with a history of sexual abuse vs controls
Sexual response to stimuli with a mixed erotic/threat meaning
Laboratory studies on female sexual response: methods
Assessment of sexual response in the laboratory:


Vaginal blood flow (photo)
Self-report feelings of sexual arousal and psotice and negative affect
A tampon is inserted in the vagina and the women will se a sexual vide, the vaginal bloodflow is measured and we ask
the women at different moment if they feel sexual aroused, and what they are feeling, de subjective responding
Assumption: Aversive experience (fear, disgust) can result in learned negative associations and in impaired sexual
responding
Aversive classical conditioning of female sexual response?
Aversive classical conditioning of female sexual response
Classical conditioning experiment, in healthy
sexually functional women:
CS+ + Disgust stimulus (film)
CS - No disgust stimulus
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Conditioned diminished genital and subjective
sexual response? Can responses be restored by
extinction or counterconditioning (pairing with
positive)?
In precondition face no different with
Conclusions
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Repeated pairing of a sexual stimulus with disgust results in
diminished sexual arousal and stronger disgust
Diminished sexual arousal can restore through extinction or
counterconditioning, although disgust seems more persistent
Repeated aversive sexual experiences may indeed result in
impaired sexual responding
---------------------------------------Studies on sexual response in women with a history of Child Sexual
Abuse
Do women with CSA history show impaired responding compared to
controls
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Child sexual abuse (CSA) = Unwanted genital touching or
penetration, before age 16, by person at least 5 years older
Study on stress response & sexual arousal (Rellini et al., 2009)
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Hypothesis: Women with a history of CSA have an impaired
genital sexual arousal response due to stress in response to sexual
stimuli
Inhibition genital sexual response through contractive effect of
stress on smooth muscles
Higher cortisol response to sexual film in women with history of
CSA
Results
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Trend lower genital response in CSA vs NSA
Cortisol decreased during sex, in both groups
Sexual self-schemas & sexual response (Rellini & Meston, 2011) (CSA n=53, NSA n=50)
Hypothesis: CSA more negative sexual self-schemas, higher negative affect, and lower sexual arousal in response to sexual
stimulation
Results:
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No significant difference in sexual self-schemas, genital response, subjective sexual arousal, or affect.
Significantly more negative affect in women with CSA preceding exposure to sexual film
Expectation that people had were not real
Negative affect and sexual response (Rellini et al., 2012) (CSA n=25, NSA n=25)
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No significant difference in genital response, or subjective sexual arousal
Higher negative affect in CSA preceding exposure to sexual film
Conclusion
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Most studies do not show impaired sexual responding in women with a history of CSA …..
Indications for higher negative affect preceding exposure to sex
Lab context?
Self-selection?
Severity CSA?
there is a difference between the lab situation and the real life experience
Sexual response to stimuli with mixed sexual/threat meaning (so people became wet or hard when they were raped)
-
Non-consensual sexual stimulation during sexual assault can lead to sexual arousal
Shame and guilt
Laboratory studies: genital response to mixed sexual/threat stimuli
Appraisal of physiological sexual arousal (Pulverman & Meston, 2016) (CSA n=59, NSA n=46)

Hypothesis: Women with a history of CSA respond more negatively to their genital sensations
Results:
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Women with a history of CSA and sexual problems reported stronger negative feelings toward their genital sexual
arousal sensations
Negative appraisal of genital sensations was a significant mediator of the relationship between abuse history and sexual
dysfunction
Conclusions
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Sexual abuse is not an uncommon experience
Women with child sexual abuse experiences are prone to a wide range of psychological problems
Child sexual abuse is associated with risky sexual behavior, sexual re-victimization, and sexual problems
Conclusions
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Sexual responses can be diminished by negative sexual experience, conditioned responses can extinct
Childhood sexual abuse does not necessarily result in impaired sexual response (not permanently damaged)
The experience of physical responses and sexual sensations during sexual abuse can be highly confusing and shameful
Women with CSA show more negative affect preceding exposure to sex, more negative appraisal of their genital
sensations and more sexual shame
Part 2 of the lecture
-
Some extra prevalence data
Sexual abuse and sexual problems in (our)clinical practice
Theories about factors that influence the outcome of (childhood) sexual abuse
Treatment of vaginismus, are there differences between women with and without sexual abuse?
Clinical implications for the treatment of other sexual dysfunctions after a history of sexual abuse
Child sexual abuse < 18 years: how common is it? Meta analyses (55 studies; 24 countries)
Mixed types: Girls 15% (CI 9 - 24%) Boys 8% (CI 4 - 16%)
Forced intercourse (anal, oral, vaginal) Girls: 9% (CI 6 -14%) Boys: 3% (CI 1 - 9%)
Child sexual abuse can involve sexual solicitation on the internet
Girls age 10-17: 18% was met on the internet and then the predator arranges an in person meeting by first gaining the child’s
confidence.
Boys age: 10-17: 8% of the boys received a sexual solicitation on the internet (Mitchell et al., 2007)
Sextortion: Latest form online exploitation is sextortion, which refers to threats to expose sexual images with the goal of
coercing victims to provide more pictures, engage in sex or money (12- 17 years: 5% victim and 3% offender)
Relationship/marital rape or date rape
Sexual minorities (LGBT) vs HS (12-18 years): current relationship
-
LGBT 23 % vs HS 12%
Female 16% vs male 8%
Female university students (18-21 years): first study year
Incapacitated Rape (IR) too drunk to refuse (alcohol & drugs ) and Forcible Rape (FR)
15% IR (attempted or completed rape)
9% FR (attempted or completed rape)
Male students (18-21 years) Prediction male’s rape perception: males' ‘traditional’ perception in dating relationships has been
that a woman ‘’who says no really means yes’’
Prevalence sexual abuse in our clinical population
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Department of psychosomatic Gynecology and Sexology, LUMC
New patients
2010-2015
History of sexual abuse rated by clinician
Questions
“Have you ever been in a situation of unwanted sexual contact?” Or “Have you ever been in situations in which you were
forced to engage in sexual activities?”
If you directly ask for what happened, you can just open something with a huge history, so it’s better to ask specific question,
ask closed questions
“Have you ever been in a situation of unwanted sexual contact?”
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Have you ever talked about this before? Yes
Have you had therapy for the consequences of the abuse?
Is it ok for you to tell me more about it? (how old were you when it started, who was the perpetrator, did it happen once
or more frequent over a longer period, did it consist of touching, oral sex, penetrative sex, were you able to tell anybody
then, what happened. How did it stop?)
When did the sexual problems you experience now, start?
Do you think the abuse plays a role in the sexual problems?
Do you experience flashbacks during sex now? Are there triggers for you?
Effects of sexual violence
E (effect) = S x F x M / A x Att x R
-
S = Severity of trauma
F = Frequency
M = Multiple trauma
A = Age
Att = Attachment
R = Resilience
Resilience in survivors of CSA
12 - 53% are ‘normal’ functioning
Internal factors: optimism and hope, internal locus of control, active coping, self-esteem, religiosity/spirituality
Social support from significant others (family or significant others: teachers/ other adults
Sexual functioning in CSA survivors
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More likely sexual re-victimization in adulthood
More risky sexual behavior (younger onset of sexual activity, more partners, more likely to have unprotected sex)
More sexual problems
Fewer sexual rewards, lower sexual self-esteem
More severe CSA, dysfunctional family dynamics, age > 5, worse sexual outcomes
The earlier the worser psychological complains
And the later it is worse for sexual complains
Sexual problems and PTSD after CSA
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The treatment of PTSD after sexual abuse seems not to effect sexual problems by itself
Current treatment for PTSD from sexual trauma do not appear to be addressing sexual problems
Only 2 (small) RCT’s addressing sexual problems after CSA (mindfulness-based therapy and expressive writing)
Repetitive and extreme aversion (disgust and avoidance) of genital contact with a partner
How do women respond to treatments for sexual dysfunctions in treatment design compared to women who are not abused?
Research after the treatment of women with lifelong vaginismus
-
Never experienced intercourse, despite attempts
The wish to have intercourse
Heterosexual relationship > 3 months
CBT versus therapist aided exposure/guided exposure
Feared stimuli: tampons, fingers, dilators, penis..
Successful penetration went up->
catastrophizing and fear went down
At home would not work so:
Therapist aided exposure
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Hospital: 2-3 hours sessions
Max. 3 sessions in a week
Homework (2- times /day)
Partner + (has to be there)
Week ‘free’
Follow up sessions:(2) 6 and 12 wks
Female therapist
89% of the couples could have sex after the treatment
This is for not abused patients
The no abuse group: 1.8 sessions and 137 minutes
Sexual abuse group: 2,1 sessions and 192 minutes
So the abused group needed more time
Conclusions exposure treatment for vaginism for women after sexual abuse
-
Exposure treatment duration increased
Treatment outcome = partly moderated by sexual abuse
Treatment of patients with sexual problems with a history of sexual abuse
-
Same approach as to other dysfunctions, but in general it takes more time and sometimes limited objectives
First discovery of one’s own body. Then sharing with partner
Strong focus on one’s own boundaries and slower tempo (create safe environment, important to stay in the here and
now, sensate focus with eyes open, or soft talking)
Attention to reduce anxiety and fear (relaxation exercises, counter-conditioning)
More time spend on psychosexual education
Treatment of patients with sexual problems with a history of sexual abuse
-
Open dialogue regarding potential physical arousal during sexual abuse and the possible consequences..
“It is known that women who were sexually abused might feel ashamed because their vagina reacted with physical
arousal during the abuse although they didn’t wanted the sex at all.”
‘’It is now that women who were sexually abused experience more negative emotions about their physical arousal
during sexuality’’
Lecture 8 Psychological effects of child abuse: diagnosis and treatment in adults
Psychological effects
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Non-specific factor psychopathology (Green et al., 2010) (anxiety disorder and depression most common with children
and PTSD with older)
Prior trauma predicts exposure (Kessler et al., 2017)
(Complex or severe or comorbid) PTSD
Suicidality, (chronic) depression, addiction, personality disorders etc.
.
Symptom based, bottom up approach
If you treat the things more in the middle that will have effect on the
things surrounding it
Core stymptosm to base your treatment on
Transdiagnostic perspective
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•
Regulation of affect
•
Cognitive problems
•
Interpersonal relationships
•
Self-image
•
Negative cognitions
•
Somatization
Affect regulation means under- or overregulation of affect: avoidance/numbing or being overwhelmed by emotions,
feeling unable to control.
Cognitive problems include memory problems: reliving the event during day or night (nightmares, flashbacks), but also
concentration problems
Problems in interpersonal relationships: mistrust, feeling estranged, even revictimization
Disturbed self-image: low self-concept, self-blame.
Negative trauma-related cognitions: the world is a bad place, there is no future for me.
Somatization means somatic symptoms for which no or no sufficient organic causes are found; in several studies
Posttraumatic stress disorder was found to be the best predictor of somatization disorder in women who were sexually
abused as children
Diagnostic categories (DSM-5)
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Posttraumatic Stress Disorder (PTSD; DSM-5)
Complex PTSD (C-PTSD; ICD-10)
Personality disorders (DSM-5)
In clinical practice, professionals work with diagnostic categories which lead to specific indications for treatment. These
categoric approaches are research-based, and have had great use to develop a common language for psychological problems,
and for the development of effective treatments in the past.
PTSD (IN DSM)
A.
Traumatic event. Traumatic event must be actual or threatened violent death, serious injury or accident, or
sexual violence. It is conceptualized that the experience of an incident or incidents that are a threat to the physical
integrity can have specific toxic effects, which in turn has a devastating effect on the individuals stress balance.
B.
Reliving (reliving the trauma experience, flashbacks, can last for minute, hours, nightmares, reliving in your body)
C.
D.
E.
Avoidance (avoidance daily life aspects to not relive the experience, but this especially not good )
Negative thoughts, mood
Hyperactivity
Subtype:
-
Dissociative symptoms
Delayed expression (it takes time before the PSTD develops, sometimes 20 years)
Complex PTSD (ICD-10)
PTSD (according to DSM-IV)SYMPTOMS +
-
Emotion regulation problem
Negative self-concept
Interpersonal problems
Personality disorders (DSM-5)
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35-60% of PTSD patients diagnosed with PD
Paranoid, Borderline, Avoidant and Obsessive-compulsive PD
18-57% of BPD patients diagnosed with PTSD
Dissociation
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What is dissociation?
‘I feel detached’
‘I don’t feel anything’
‘I don’t recognize myself/my room’ etc.
Also: black outs, flashbacks, amnesia
DSM: Dissociative Identity Disorder, PTSD-subtype
A lot of discussion about this, is it a symptom or a disorder, is it behavior or out of our reach
Functional reaction (dissociation)
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Normal reaction (dimensional)
Umbrella term (clinicians often don’t degree about the meaning)
Different functions (in treatment)
Clinicals and researchers often agree that dissociation is a functional reaction on overwhelming experiences
Moreover, dissociation also happens all the time (loosing time, wandering)
Often ‘’dissociation’’ is used as an umbrella term, and is sometimes used as a ‘’red flag’’ ; patients might be to
‘’unstable’’ for treatment
Different functions far more informative for treatment planning:
o -during reliving: peritraumatische dissociatie: try to verbalize (now, I am out, the next moment I am back in the
room)
o -in flashback: turn down the volume
o -general dissociation: turn up volume
o -form of emotional numbing (bv moeite met imagery, emotionele schema’s)
Diagnostics in clinical practice
Case conceptualization:
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History of traumatic events (describe in detail)
Symptoms (in clusters) (either behavioral or transdiagnostic (eg nightmares or problems in relationships, possibly due to
anxious expectations about other people).)
Underlying traits (introvert, impulsive etc)
Context (professional and social functioning, family etc how many people are supportive)
Hypothesis about etiology (about etiology: connecting with theory: eg. Based on network analysis: The nightmares seem
to maintain most of the experienced symptoms, and therefore are the first aim for treatment.
-
Shared decision making about treatment etc
Trauma focused treatment could be given if PTSD is expected
TREATMENT OF CONSEQUENCES OF CHILDHOOD ABUSE
Basic therapeutic skill important. How to ask questions, therapeutic attitude, conversational skills, empathy
Treatment guidelines
Trauma- and stressor-related disorders
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Zorgstandaard (2020) translating about the guidelines
NICE guidelines
APA guidelines
Dutch guidelines (under contruction)
Overlapping working mechanisms
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Focus on memory (make it less anxious to have those memory’s, more control about them)
Focus on reexperiencing (as maintain factor of PTSD)
Confrontation with affective trauma-load
Use of sensory information (emotions, physical experiences, thoughts)
Targeting avoidance and safety strategies
Cognitive processing (changing the meaning of traumatic events and memories)
For trauma-survivors, feeling trust in an emphatic therapist is often crucial, and maybe particularly so for
victims of childhood abuse
Evidence trauma-focused treatment
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Multiple first choice treatments for PTSD
Most evidence for individual TF-CBT (Ehring et al., 2014)
Dissociation no contra-indication (Van Minnen et al., 2016, Wolf et al., 2015)
Multiple RCT’s positive effects (Oprel et al., 2021, Van Vliet et al., 2021, Raabe et al., 2021)
Ehring: meta-analysis among patients with CA-PTSD. Conclusion also low methodological quality and no direct comparison
between treatments. Comments: no effect on comorbid problems, are patients up to TFT right away or should there first be
attention for emotion regulation
Results IMPACT-study (Oprel et al., 2021)
149patients with CA-PTSD > 3 conditions: PE, iPE or STAIR-PE, 1-year follow up
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Results: large improvements (d > 1.6)
Primary and secondary outcome
iPE works faster
Complex PTSD moderates nor predicts (Hoeboer et al., 2021
Conclusions: Variants of exposure therapy are tolerated well and lead to large improvements in patients with CA-PTSD.
NB: complex ptsd was related to more severe symptoms at baseline
Patient perspective and implementation

Treatment options for seriously traumatized victims fall short (Hoing et al., 2003)
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Only 39% of patients with PTSD receive TFT
Implementation research is sorely needed
(Zinnige Zorg Verbetersignalement, 2020)
How TFT works: A case study
Ms A. (46)
Grew up in a family with an unrelenting, demanding and abusive mother and an absent father. During childhood, her
cognitive development was normal, but she did experience social difficulties and made no friends at school
Ms A. finished high school at the age of 18 and started to work as an office manager. From the age of 25, she had severe
sleeping problems and periods of alcohol abuse. By the time of the referral, Ms A. was on sick leave for two years. She had
no meaningful relationships and hardly left her (messy) house.
Exposure session
-
Increasing level of exposure to maximize imaginal reliving
Subjective units of distress are monitored
Treatment protocol
12-16 Sessions (90 minutes)
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Session 1: information, motivation and exploration
Sessions 2-12:
Homework
imaginary exposure
exposure in vivo (In deze behandeling wordt u in de dagelijkse praktijk bloot gesteld aan gevreesde situaties, die bij u
angst oproepen en die u om deze reden vermijdt)
Schema with the fears ranked, what kind of abuse, how old was she, the amount of intrusion
This is called a trauma hierarchy, in which the patient describes the events that haunt her the most, in nightmares and
flashbacks. In therapy, you focus on these events one by one (1 per session). Anxiety goes down, within the session, and
patient experiences a sense of control/mastery.
What about other related diagnosis
(Chronic) depression (Childhood Trauma Meta-Analysis Study Group, 2022)
Schema-focused therapy
-
Borderline Personality disorder (Sempertegui et al., 2013)
Other PD (Bamelis et al., 2014)
Dissociative Identity Disorder (Huntjens et al., 2019)
How does SFT (schema focused therapy) work
-
Cognitive therapy for patients with deeply engrained negative schemas with additional psychodynamic techniques
(Young et al., 2005, 2009)
Imagery Rescripting (ImRs) is a therapeutic technique that aims to reduce the distress associated with negative memories of
early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in line with their unmet
needs.
Imagery rescripting: the technique (schema therapy for personality disorders, but also used as trauma focused )
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Therapist rescripts: patient as a child (more a role play)
Patient rescripts in the role of an adult, sees himself as a child
Patient experiences as a child rescripting by himself as an adult
How about Superwoman?
Research on the imagery rescripting technique suggests that positive mental images can “compete with” negative
images, reducing their impact on mood and self-esteem.
Self-help guideline
Treatment innovations
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Virtual Reality Therapy (imaginary exposure)
Mindfulness (can be really hard to make room for it in their head)
MDMA
Take home message
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Psychological consequences of childhood trauma are often severe
Screen for PTSD (search actively)
Choice for (PTSD-)treatment based on guidelines
Implementation is urgent