Healing from Sexual Abuse - Insights by Timothy R. Jennings, MD

RECOVERING FROM SEXUAL ABUSE Timothy R. Jennings, MD, DFAPA Past-President, TN Psychiatric Association Past-President, Southern Psychiatric Association AUTHOR: Could It Be This Simple? A Biblical Model for Healing the Mind The God-Shaped Brain: How Changing Your View of God Transforms Your Life The Journal of the Watcher The Remedy New Testament Expanded Paraphrase The God-Shaped Heart: How Correctly Understanding God s Love Transforms Us The Aging Brain: Proven Steps to Prevent Dementia and Sharpen Your Mind The Remedy of the Lord in Song: The Psalms

OVERVIEW The Problem The Consequences The Treatment

THE PROBLEM In Christian Homes? The rate of child physical and sexual abuse is no different in Christian homes than non-Christian homes

WHAT IS SEXUAL ABUSE? Not everything that is legally defined as sexual abuse is equally damaging Frotteurism Voyeurism

WHAT CAUSES THE PSYCHOLOGICAL DAMAGE FROM SEXUAL ABUSE? The meaning, the interpretation, the way the experience is internalized by the person Person beaten with whip One person may experience terrible psychological trauma another might experience arousal and pleasure This is true for any exploitation Your home, broke into & something is stolen you never found out or you find out?

WHY IS THIS IMPORTANT? What if you discover a person has been molested, exploited or abused? First assess that person s knowledge, understanding and awareness A child being bounced on a lap The real damage might come from the psychological evaluation therapy and court testimony

But what about when the abuse is clear, known and experienced A parent who beats their child or molests them? What happens, what s the damage, what s the problem?

BRAIN CIRCUITS DLPFC Administrator Adrenal Glands Emergency responders Hypothalmus 911 Operator Pituitary Amygdala Alarm Hippocampus Fire Chief Illustration by: Simon Harrison

SALIENCE NETWORK Temporal-parietal Junction DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Thalamus Amygdala Illustration by: Simon Harrison

WHAT DISRUPTS SALIENCE NETWORK? Denial or believing lies Unresolved guilt Grudge holding and resentment Unresolved trauma contributes to all of these

Imagine you believed any moment someone was going to walk in and either rape you or beat you severely and you had to take final exams with that threat hanging over your head would your exam scores be affected?

WHAT IF AMYGDALA DOESNT CALM? Amygdala Increased Illustration by: Simon Harrison

OVER ACTIVE AMYGDALA Activates sympathetic nervous system Which activates macrophages Why? Which release cytokines IL1, IL6, TNF Which damage: Insulin receptors, glucocorticoid receptors, interfere with NE, 5HT, DA signaling Resulting in: Increased DM, obesity, high cholesterol, MI, Stroke, autoimmune problems and bone density loss

UNREGULATED AMYGDALA FIRING Unremitting stress response cascade results in inflammatory factors affecting the body The changes in the body then react back upon the brain causing brain changes Suppresses BDNF and damages glia, resulting in depression

THE TRIPARTITE SYNAPSE: THE ROLE OF ASTROGLIA IN SIGNALING Halassa MM, et al. Trends Mol Med. 2007;13(2):54-63.

THE TRIPARTITE SYNAPSE: THE ROLE OF ASTROGLIA IN SIGNALING 5-HT=serotonin. BDNF=brain-derived neurotrophic factor. CNS=central nervous system. GLU=glutamate. IDO=indoleamine 2,3 dioxygenase. IFN=interferon. IL=interleukin. NMDA=N-methyl-D-aspartate. QUIN=quinolinic acid. RNS=reactive nitrogen species. ROS=reactive oxygen species. TNF=tumor necrosis factor. TRP=tryptophan. Miller AH, et al. Biol Psychiatry. 2009;65(9):732-741. Reprinted with permission from Elsevier Limited.

PET SCAN

BRAIN CHANGES DURING DEPRESSION Inflammatory factors damage glia Glia stop providing support and instead release oxidative factors Impaired neurogenesis Altered DNA expression Loss of neurotrophic factors Impaired PFC function Thinning of PFC and hippocampal regions

CHILDHOOD ADVERSITY REPRESENTS A RISK FOR DEPRESSION 70 Number of Adverse Childhood Experiences 60 0 (n=502) 1 (n=253) % of Study Members With the Condition 2 (n=98) 50 40 30 20 10 0 Major Depression hsCRP >3 mg/L Clustering of Metabolic Risk Markers 32-year prospective study. Major depression (panel 1): z=4.94, P<.001. High-sensitivity C-reactive protein (hsCRP) level 3 mg/L (panel 2): z=3.24, P=.001. Clustering of metabolic risk markers (panel 3): z=4.58, P<.001. 1 age-related disease risks (panel 4): z=5.66, P<.001. Adapted from Danese A, et al. Arch Pediatr Adolesc Med. 2009;163(12):1135-1143.

WHY DO SOME GET PTSD AND OTHERS DON T?

EFFECTS OF GENOTYPES AND CHILDHOOD ABUSE ON ADULT DEPRESSION Panel C. Similar interactive gene dosage patterns were seen across the other SNPs that were significant prior to correction Panels A and B. In individuals who experienced high levels of early life stress, the rare allele of 2 SNPs had a protective effect on the severity of adult depressive symptoms Bradley et al. Arch Gen Psychiatry 2008;65:190-200.

SEROTONIN S/S OR L/L GENETIC POLYMORPHISM ACCOUNTS FOR 30% VARIANCE IN PTSD AMONGST POST ABUSE VICTIMS Illustration by: Simon Harrison

CHILDHOOD TRAUMA ASSOCIATED WITH DECREASED THICKNESS OF SOMATOSENSORY CORTEX GENITAL FIELD Main effect of childhood trauma score (including physical, sexual, and emotional abuse) on cortical thickness in 54 adult women (Heim et al, in preparation) Somatosensory homunculus and fMRI studies showing somatosensory representation of the human genital area (circles and rectangles) (Michels et al, 2010; Kell et al, 2005)

GENE EXPRESSION CHANGE McGill University study 24 suicides, 12 with history of abuse, 12 without NR3C1 Gene expression in the brain is suppressed in children who are abused NR3C1 is critical in stress management, and this alteration may permanently alter the ability to cope with stress http://psychcentral.com/news/2009/02/23/child-abuse-alters-brain-gene/4283.html

CHILD ABUSE AND GENE EXPRESSION IN BRAIN TISSUE 41 Canadian men (25 severe abuse, 16 controls) DNA examined from hippocampal neurons 362 different epigenetic changes 248 hypermethylated 114 hypomethylated Those most significantly affected where genes which regulated neuronal plasticity Arch Gen Psych, 2012; 69(7):722-731

ADULTS WHO WERE ABUSED AS CHILDREN Have higher rates of medical illnesses Have higher rates of mental illnesses Have higher suicide rates Have higher alcohol/drug problems

Video Courtesy of NEI Neuroscience Education Institute

Video www.comeandreason.com

FIGHT, FLIGHT, FREEZE

ALTERED RELATIONSHIPS They have distortions in male/female relationships and family dynamics If the abuser was a parent or priest or teacher they have distorted images of God, as parents are the template which our initial God constructs are built

WHAT IS WORSE THAN RAPE OR MOLESTATION? Betrayal when it is done by a parent, or when a parent colludes, or fails to stop it The more serious damage from sexual abuse is typically not done to the body, but to the mind

WE HAVE POWER OVER WHAT WE BELIEVE BUT WHAT WE BELIEVE HAS POWER OVER US WHAT DO VICTIMS OF ABUSE BELIEVE? I m worthless, ugly, dirty, nasty, Its my fault Life isn t fair People can t be trusted They have self doubt Increased fear, increased firing of amygdala and more damage to brain and body

THE TREATMENT Bio-psycho-social-spiritual interventions Biological physical exam, exercise, diet, avoid substances of abuse, psychotropics, sleep Psychological Psychotherapy

COGNITIVE THERAPY Improved DLPFC Calmed Amygdala

IMPACT OF COGNITIVE THERAPY ON AMYGDALA AND PREFRONTAL (DORSOLATERAL PFC) ACTIVITY IN MDD a. Emotional b. Cognitive Is it you? UGLY Put the digits in numerical order 7 4 3 1 5 Patients with depression (n=9) Controls (n=24) 0.30 BOLD Signal (% Change) 0.15 BOLD Signal (% Change) 0.25 Pre Post Control 0.10 0.20 0.15 0.05 0.10 0.00 0.05 -0.05 0.00 16 18 2 4 6 8 10 12 2 4 6 8 10 12 14 Time (Seconds) Time (Seconds) 12 Weeks of Cognitive Therapy Adapted from DeRubeis RJ, et al. Nat Rev Neurosci. 2008;9(10):788-796.

COGNITIVE THERAPY AND GENE EXPRESSION PTSD pts lower: FKBP5 gene expression and smaller hippocampal and medial orbitofrontal cortex, but not amygdala After CBT: PTSD patients did not differ from controls in: FKBP5 gene expression or hippocampal volume Thinking new thoughts alter gene expression and brain structure Biological Psych, Vol 74,(1) Dec 2013 p. 793-800

Effective Therapies Prolonged Exposure (PE) Involves working with a trained provider to face the feelings or activities that you have been avoiding in order to work through the intense emotions, resolve the trauma memories, and stop the automatic responses. Cognitive Processing Therapy (CPT) Focuses on working with your provider to reprocess and reframe the trauma. This involves writing assignments, learning to identify how the trauma has been labeled in your thinking, and moving away from exaggerated and inflammatory labels to fact-based ways of remembering. Eye Movement Desensitization and Reprocessing (EMDR) Helps you reprocess and resolve the trauma by talking through the memories with a provider while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone).

TRUTH To remove distortions and stop negative cascade Inability forgive What truth is needed? The truth about what sin does to the sinner Distorted self image Mirror analogy Inappropriate filing/meaning of events Child in parking lot, pasture God Why did God let this happen?

THE TREATMENT Bio-psycho-social-spiritual interventions Biological physical exam, exercise, diet, avoid substances of abuse, psychotropics, sleep Psychological Psychotherapy Social - Healthy friends, group therapies, family therapies Spiritual - Healthy spirituality and worship, Bible study, reframe to larger view, truth about themselves, their abusers and their situation, learning how to reason and think and tolerate powerful feelings, the nature and character of sin forgiveness issues

GOD AND BRAIN CIRCUITS ACC Amygdala Newberg, A. How God Changes Our Brain. Ballantine Books, New York. 2009: p.49.

WHAT DISRUPTS SALIENCE NETWORK? Denial or believing lies Unresolved guilt Grudge holding and resentment Unresolved trauma contributes to all of these

WHAT CONNECTS SALIENCE NETWORK? Truth Repentance Forgiveness Resolved trauma applies all of these

SUMMARY Sexual abuse damages brain, body, mind But the damage can be healed, particularly the damage to the mind When the mind heals the brain and body also heal