Mental Health Problems May emerge many years later More likely to be less responsive to traditional treatments Problems more likely to be comorbid.

Name: Mental Health Problems May emerge many years later More likely to be less responsive to traditional treatments Problems more likely to be comorbid.
Uploaded: 2018-01-15T07:44:46+00:00
Duration: PTM17S34
Channel: Laurel Palmer
Description: Mental Health Problems May emerge many years later More likely to be less responsive to traditional treatments Problems more likely to be comorbid.

Child maltreatment through the lens of neuroscience
Latent vulnerability Child maltreatment through the lens of neuroscience Eamon McCrory PhD DClinPsy Director of Postgraduate Studies, Anna Freud National Centre for Children and Families Professor of Developmental Neuroscience & Psychopathology, UCL Friday 2nd December 2016

Mental Health Problems
May emerge many years later More likely to be less responsive to traditional treatments Problems more likely to be comorbid Problems show greater severity

Poor outcome Treatment Adversity Resilient outcome

Early Identification – how do we identify those most at risk?
Poor outcome Adversity Resilient outcome Early Identification – how do we identify those most at risk?

? Early Identification – how do we identify those most at risk?
Poor outcome Adversity ? Resilient outcome Early Identification – how do we identify those most at risk? Pinpointing mechanisms – how does adversity get under the skin?

? Early Identification – how do we identify those most at risk?
Poor outcome Adversity ? Resilient outcome Early Identification – how do we identify those most at risk? Pinpointing mechanisms – how does adversity get under the skin? Understanding resilience – what can we learn from resilient young people?

The concept of Latent Vulnerability McCrory & Viding Development and Psychopathology, 2015

The theory of Latent Vulnerability is an emerging framework for thinking about how early adversity can embed long term risk of mental health problems A systems level approach: latent vulnerability is a complex phenotype that can understood at multiple levels - from genes to behaviour From a translational perspective we argue that the most useful focus is on the neurocognitive level Multiple systems recalibrated to ‘fit’ with adverse environment Markers of latent vulnerability are not necessarily symptoms Latent vulnerability is present and can be indexed prior to onset of psychiatric disorder A true marker of latent vulnerability must have a predictive value © David Trickey, Consultant Clinical Psychologist

Response & adaptation… High risk of disorder Low protective factors
High stressors Risk genotypes Response & adaptation… Adverse environment High protective factors Low stressors Resilient genotypes Low risk of disorder

Adolescence & Latent Vulnerability
Growing up in an early adverse environment will lead to ‘adaptations’ at multiple levels that may have a short term benefit but which may incur long term cots. Alterations at the epigenetic level. How genes are regulated. Alterations at the neurocognitive level in ‘representations’ (of self and other) as well as in basic and higher order ‘processes’ Both basic and higher order processes are altered in a range of disorders associated with maltreatment (e.g. anxiety, depression and conduct problems). Here I will focus on: Threat processing Autobiographical memory How might early adversity shape these domains in ways that may embed latent vulnerability?

Maltreatment Genetic / Epigenetic Neurobiological Cognitive
Behavioural

Psychiatric Vulnerability
Adversity What are the neuro-cognitive mechanisms that embed latent vulnerability following childhood adversity? ? ? ? ? Threat processing Autobiographical Memory Psychiatric Vulnerability

1. Altered threat processing
Children exposed to physical maltreatment have been shown to have altered processing of angry faces: able to more accurately identify angry facial expressions using sparse perceptual information than peers devote more attentional resources to the processing of angry faces - interpreted as increased hypervigilance to threat Pollak & Sinha, 2002, Pollak et al., 2001

Pollak et al., 2009

Pollak et al., 2009: Cognition
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Children exposed to physical maltreatment have been shown to have altered processing of angry faces: able to more accurately identify angry facial expressions using sparse perceptual information than peers devote more attentional resources to the processing of angry faces - interpreted as increased hyper-vigilance to threat In some contexts they show avoidance of threat cues – diverting attention away from threat cues that may be processed as aversive Pollak & Sinha, 2002, Pollak et al., 2001, Kelly et al., 2015

Kelly et al., 2015

Threat avoidance Loser Cabinet Admired Failure

Threat avoidance Compared with their peers, children who had experienced maltreatment showed reduced activation in the Rejection vs. Neutral condition, across circuitry previously implicated in abuse-related PTSD, including the left anterior insula, extending into left ventrolateral prefrontal cortex/ orbitofrontal cortex; left amygdala; left inferior parietal cortex (STS); and bilateral visual association cortex, encompassing the cuneus and lingual gyrus. Children exposed to maltreatment show significant hypo-activation of a network potentially reflecting an avoidant response to social rejection cues The greater the degree of hypo-activation the greater the level of dissociation symptoms © David Trickey, Consultant Clinical Psychologist

Understanding the neural basis of threat vigilance

Dec 2011

Increased right amygdala reactivity and increased bilateral anterior insula reactivity to angry vs. calm faces in children exposed to family violence. This may be a latent neural marker of latent vulnerability – the same neural signature is common in anxiety disordered populations (Etkin & Wager, 2007).

Exposure to family violence may ‘recalibrate’ responsiveness of the anterior insula and amygdala in processing potential threat. But is this a conscious process? In other words, is this hypervigilance to threat under higher order regulatory influence?

McCrory et al., (2013) British Journal of Psychiatry, 202: 1-8

Cortex “high road” “low road” Thalamus Amygdala emotional stimulus
LGN Pulv Amygdala High Road: retina -> LGN Thalamus -> V1 -> extrastriate cortex -> inferotemporal cortex – Amygdala Low Road: The superior colliculus, pulvinar and amygdala constitute a functional network that shows increased positive covariation of activity in response to non-consciously perceived fearful faces SC emotional stimulus emotional response

Amygdala Thalamus and (ventral) pallidum

Is amygdala reactivity calibrated in response to environmental adversity?

Children Soldiers Amygdala Anterior insula McCrory et al., (2011)
Wingen et al., (2011)

Duration of abuse associated with amygdala response in children
Amygdala activation Age of onset of neglect (years) McCrory et al., 2013

Severity of abuse associated with amygdala response in adults
Amygdala activation Severity of abuse (CTQ score) Dannlowski et al., 2013

Collectively, these findings suggest that the responsiveness of the amygdala is calibrated and adapts to the degree of environmental threat

Do higher levels of amygdala reactivity to threat predict future mental health problems?

Amygdala reactivity BEFORE stress predicts future symptoms
Change in PTSD Symptoms Patterns of threat hypervigilance and avoidance associated with risk of combat related PTSD depending on the context (Wald et al., 2013). Amygdala activation before combat (T value) Admon et al., 2009

Swartz, Knodt, Radtke & Hariri (2015), Neuron, 85(3):505-11
Prior amygdala reactivity to threat cues predicts anxiety and depression symptoms in a cohort of health adults (n=340) following future life stressors over a 1 – 4 year period Swartz, Knodt, Radtke & Hariri (2015), Neuron, 85(3):505-11

Is altered amygdala reactivity to threat implicated in disorders associated with maltreatment?
© David Trickey, Consultant Clinical Psychologist

Yes - heightened amygdala reactivity has been reliably associated with:
Depression Anxiety PTSD Conduct Problems Monk et al., 2008

Therefore, increased threat-related amygdala reactivity following maltreatment represents one promising candidate mechanism characterizing latent vulnerability. It may signal adaptive vigilance within adverse early environments. However, it may in the longer term be maladaptive in more typical social and educational settings.

Adversity Increasing likelihood of interpersonal conflict with peers Altered Threat Processing Reducing cognitive capacity available for more normative developmental tasks and social learning Social Environment Psychiatric Vulnerability

Increased Latent Vulnerability
But there are other candidate neurocognitive systems that will likely index Latent Vulnerability… Threat processing Autobiographical memory ? ? ? ? Increased Latent Vulnerability

2. Autobiographical memory
Autobiographical memory is concerned with the recollection of personally experienced events and plays a central role in scaffolding our sense of self. Our autobiographical memory provides the ‘data’ that helps us simulate future events and negotiate them more effectively. Children who have experienced maltreatment tend to show a pattern of OVERGENERAL memory. Overgeneral memory is associated with increased risk of depression and PTSD and may therefore represent another latent vulnerability mechanism

Autobiographical Memory
These findings may reflect increased latent vulnerability to mental health problems and social difficulties in two ways: First, over-general memory may reduce the ability to draw on past experiences to effectively negotiate future stressors. This may be particular pertinent during adolescence as a young person needs to navigate novel and challenging new contexts with reduced care-giver support Second, decreased specificity and salience of positive relative to negative memories may increase the likelihood of a negative inferential style and a ruminative response style.

Adversity Poorer social problem solving – greater peer problems Over-general Autobiographical Memory Increased negative ruminative style Poorer ability to conceptualize the future self Social Environment Psychiatric Vulnerability

Outcome Healthy Unhealthy Latent Vulnerabilities
Threat bias Autobiographical memory Emotion regulation Healthy Unhealthy Clinical Threshold Outcome Maltreatment Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood

Developmental Challenge
Latent Vulnerabilities Threat bias Autobiographical memory Emotion regulation Healthy Unhealthy Clinical Threshold Outcome Maltreatment Life Stressors AND Developmental Challenge Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood

? Outcome Healthy Unhealthy
Clinical Threshold Outcome ? Maltreatment Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood

Summary & Implications
According to the theory of latent vulnerability early adversity calibrates epigenetic and neurocognitive systems in ways that may reflect adaptation to early risk environments but carry long term costs for mental health. We have seen that altered threat processing (both patterns of avoidance and vigilance) as well as alterations in autobiographical memory processing may have direct effects on psychiatric vulnerability as well as indirect effects, via the environment. We need to investigate whether changes in these systems represent markers of latent vulnerability that can help us in the development of a clinical screening tool that identifies those children at most high risk of later mental health problems. We also need to understand whether targeting these neurocognitive systems – through social interventions – can help young people recalibrate these systems in ways that ‘fit’ with their new environments. Understanding this process of recalibration will be key to developing our understanding as to how best to promote resilience through early prevention efforts.

Thank-you!

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Mental Health Problems May emerge many years later More likely to be less responsive to traditional treatments Problems more likely to be comorbid.

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