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Exploration of self and other directed aggression as a consequence of childhood sexual abuse: Analysis in terms of attachment theory, neurobiology, and psychodynamic models of affect regulation

Dissertation
Author: Nicole St. Jean
Abstract:
Numerous theories have examined the relationship between childhood sexual abuse (CSA) and aggression. This dissertation reviews and then builds upon some of these theories to argue that aggression, in the forms of self-mutilation and verbal and physical aggression, following CSA emerges as a means to control and express affect. Attachment theory and psychodynamic models of affect regulation serve as the foundation for this evaluation and conclusion. The examination of neurobiology of attachment and trauma aid this argument by offering a biological perspective to one's psychological presentation. It is suggested through an interpersonal neurobiological treatment approach growth toward healthy adjustment following CSA can take place.

Table of Contents Copyright ii Signature Page iii Acknowledgements iv Abstract v CHAPTER 1: INTRODUCTION 1 Child Sexual Abuse and Its Sequelae 1 Implications for Dissertation 4 CHAPTER 2: EVOLUTION OF TRAUMA THEORY 7 Janet, Breuer, and Freud 7 Ferenczi and Terr 12 CHAPTER 3: ATTACHMENT 17 Bowlby 17 Ainsworth 22 Main and Solomon 25 Attachment as a Mediator of Affect 27 CHAPTER 4: NEUROBIOLOGY OF ATTACHMENT AND TRAUMA 32 Growth of the Brain 32 Central Nervous System and Peripheral Nervous System 36 Limbic System 37 Function and Role of the Orbitofrontal Cortex 42 Role of the Mutual Gaze in Development of Affect Regulation 45 vi

The Effect of Trauma on the Stress Response 50 The Child's Response to Threat 57 Review of Neurobiological Implications of Insecure Attachment and Trauma 60 CHAPTER 5: PSYCHOLOGICAL DEFENSES OF CHILDHOOD TRAUMA AND RESULTING SYMPTOMOLOGY 62 Attachment and Associated Defenses 62 Trauma and Alexithymia 66 Affect Dysregulation and the Aggressive Response 69 CHAPTER 6: PSYCHOLOGICAL FUNCTIONS OF AGGRESSION 71 Psychological Functions of Aggression 72 Motivations of Aggression 76 CHAPTER 7: NEUROBIOLOY OF AGGRESSION 80 Serotonin 81 GABA 82 Oxytocin and Vasopressin 83 Endorphins 84 Testosterone 85 Developmental Imbalance of Neuromodulators 85 Defensive Rage versus Predatory Aggression 86 Septal Area and Aggression 88 Periaqueductal Gray and Aggression 89 Hypthalamus and Aggression 90 vii

Review of Neurobiology of Aggression 91 Aggression as a Means to Regulate Affect 92 CHAPTER 8: SELF AND OTHER DIRECTED AGGRESSION AS A MEANS OF EXPRESSION AND AFFECT REGULATION 94 Aggression in Males versus Females 94 Self-Directed Aggression 96 Other-Directed Aggression 101 Review of Aggression as a Means to Regulate Affect 105 CHAPTER 9: TREATMENT IMPLICATIONS: AN INTERPERSONAL NEUROBIOLOGICAL APPROACH 107 Final Thoughts 122 REFERENCES 124 viii

CHAPTER 1: INTRODUCTION Research shows that following child sexual abuse (CSA) a variety of psychological disturbances may ensue including difficulty with hyperactivity, mood disturbance, problems in interpersonal relationships, and the inability to regulate affect (Card & Little, 2006; Classen, 1993; Elzinga, Bermond, & van Dyck, 2002; Knox, 2003; Reckling & Buirski, 1996). One specific problem that may manifest following CSA is that of an individual becoming aggressive. Numerous studies have determined that there is a significant correlation between CSA and aggression as a symptom (Cyr, McDuff, Wright, Theriault, & Cinq-Mars, 2005; Fosshage, 1998; van der Kolk, McFarlane, & Weisaeth, 2007). Why is this? Historically, psychoanalytic theory initially viewed aggression as an innate drive. In Mitchell and Black's 1995 book Freud and Beyond, the authors reviewed psychoanalytic theories of aggression across the last century, and it became clear that perspectives on aggression have evolved beyond the drive model. The link between CSA and aggression will be explored in this dissertation. The specific argument that will be made is that, following sexual abuse, aggression serves as means of communication and means to affect regulate and alleviate affective disturbance. Child Sexual Abuse and Its Sequelae According to Freeman and Morris (2001), it was in the 1980's that CSA began to be recognized as a significant social problem in the United States. It was at this time that efforts towards defining CSA, documenting its prevalence, and understanding its impact began. In these last 30 years countless attempts have been made to define child sexual

abuse. But because of the ever-changing constructs of abuse, no one definition has won over the field. Rather, at this time what the American Psychological Association has established is that, "a central characteristic of any abuse is the dominant position of an adult that allows him or her to force or coerce a child into sexual activity.. ..This may include fondling a child's genitals, masturbation, oral-genital contact, digital penetration, and/or vaginal and anal intercourse" (APA online, retrieved 10/28/07). It should be noted that sexual abuse is not limited to physical contact, but for the purposes of this discussion and because it has been documented that abuse resulting from high levels of physical force is more detrimental than exposure, voyeurism, or child pornography (APA online, retrieved 10/28/07), it should be assumed that, when discussing sexual abuse in this work, physical perpetration has occurred. To further limit this discussion, the construct of CSA in this dissertation will also be held to chronic sexual abuse forced upon the child by the primary caregiver, as opposed to single episode sexual abuse. It should additionally be assumed that this abuse took place before the age of five. This particular dynamic was chosen because of the important links between early development, attachment relationships, and later emotional and behavioral adolescent and adult outcomes. It was also chosen because with sexual abuse taking place at such an early age, it may be assumed that a secure attachment relationship with a caregiver did not form. In this situation, if a primary caregiver was abusing a child from infancy the opportunity for a secure attachment was not able to develop due to the caregiver serving as a figure that was both a threat and a source of safety from the first months of life. This limitation 2

further removes the need to address differences between children who had a secure attachment with a caregiver and then were later sexually abused. Based on the general definition of sexual abuse, it has been estimated that as high as 25% of men and 62% of women are victims of sexual abuse (Freeman & Morris, 2001). Other statistics have reported that up to 1 out 4 girls and 1 out of 6 boys have been sexually abused by the time they are 18; 20% have been abused before the age of 8; and that, overall in the United States today, there are over 39 million survivors of CSA (Darkness to Light, retrieved 10/31/07; Freeman & Morris, 2001). These statistics vary due to the problem of significant underreporting. It has been argued that nearly 30% of victims of CSA never disclose abuse to anyone, even if asked, and that up to 80% may initially deny or tentatively disclose their abuse to anyone (Darkness to Light, retrieved 10/31/07). The APA supports this argument and has officially stated, "accurate statistics on the prevalence of child and adolescent sexual abuse are difficult to collect because of problems of underreporting. ...However, there is general agreement among mental health and child protection professionals that child sexual abuse is not uncommon and is a serious problem in the United States" (APA online, retrieved 10/31/07). With regard to the impact sexual abuse has upon the general population, research has repeatedly shown that sexually abused children are likely to experience a wide variety of adverse reactions that are likely to persist into adulthood. According to Polusny and Follette (1995), this may include but is not limited to difficulties with aggression, 3

self-mutilation, depression, anxiety, social isolation, poor sexual adjustment and dysfunction, substance abuse, and difficulties in interpersonal relationships. This dissertation will specifically focus on aggression as a symptom following CSA. This particular domain was chosen because aggression underlies many symptoms of childhood psychiatric diagnoses including Major Depression, Posttraumatic Stress Disorder, Oppositional Defiant Disorder, Conduct Disorder, and impulse control disorders. Aggressive behavior also has a significant impact on interpersonal functioning and self-esteem, and it is deeply associated with affect. More specifically, symptomology following CSA is almost always associated with affect dysregulation. As such, it is logical to examine the relationship between aggression and affect. Implications for Dissertation In order to effectively treat aggressive symptoms, it is essential to have a thorough understanding of the underlying psychological and physiological processes of the symptoms and their functioning. To this end, the central question of this dissertation is: What impact does chronic child sexual abuse perpetrated by a caregiver have upon self and other-directed aggression? Through a critical review of the literature, which examines psychodynamic and neurobiological models of trauma, attachment, aggression, and affect regulation, it will be argued that chronic sexual abuse causes disruptions in affect regulation. Aggression then emerges as not only as an expression of affect dysregulation, but it also becomes a means to control affective experiences. The specific types of aggression focused on in this work will include self-directed aggression, in the 4

form of self-mutilation and specifically cutting, and other-directed aggression, which will be defined as verbal outbursts and physical attacks on others. Beginning with a brief overview of Freud's theoretical understanding of trauma and progressing toward a review of contemporary conceptual models of trauma, the pathogenic impact of CS A upon an individual will become clear. The trauma literature as it relates to attachment and affect dysregulation, including the role of dissociation and alexithymia, will be explored in order to make the argument that aggression is one means to communicate and assist in regulating affect following CSA. To further understand how aggression emerges as a result of affect dysregulation, the neurobiology of attachment and trauma will also be explored. The aim of this is to examine not only what psychological role aggression serves, but also to biologically explain why survivors of sexual abuse have difficulty regulating affect. More specifically, the argument will be made that, due to an insecure or disorganized attachment relationship between child and caregiver as a result of chronic sexual abuse, the child's internal physiological stress response system will be chronically activated. As this happens, a surplus of stress hormones is released into the brain. The excessive amount of stress hormones cause structural damage throughout the brain and alter the child's ability to label, process, and integrate affective experiences, resulting in an inability on the part of the child to effectively regulate responses to affective arousal. Aggression then emerges as a behavioral response and serves as one means to help alleviate this internal dysregulation. Specifically, it is proposed that self-mutilation and physical and verbal aggression are means of controlling and expressing dysregulated 5

affect. Due to the dangerousness of these behaviors, treatment implications will be briefly outlined.

CHAPTER 2: EVOLUTION OF TRAUMA THEORY Janet, Breuer, and Freud The origins of trauma in psychiatry may be traced back to late 19th century. According to Heim and Buhler (2006), Jean-Martin Charcot, a French neurologist, first proposed that symptoms of hysterical patients were rooted in histories of trauma and genetic predispositions. It was based in these findings that Pierre Janet, a French Psychologist and colleague of Charcot's, was able to build on this idea and make connections between a patient's earlier life experiences and his present day trauma. Janet argued that some individuals' experience "emotional shocks" following a traumatic event due to inherent biological and genetic predispositions (Heim & Buhler, 2006). These emotional shocks, which are different from normal emotion because they maintain the experience of the trauma, create feelings of trauma for an individual because the person does not know how to adequately respond to emotionally disturbing events or experiences. When this happens, Janet argued a person may generate "fixed ideas" or distorted memories about the traumatic event. These ideas can become split off from other experiences and thus are unable to be integrated in to one's global experience. In turn, a psychological weakness is created which opens up further susceptibility for later traumas. Buhler and Heim (2001) stated that Janet believed problems with adjustment following emotional shocks happened because the individual did not have the capacity to successfully adapt to the traumatic situation and the emotions it triggered. When this happened, Janet argued that feelings of fear, rage, or sorrow, amongst others, lead to a 7

distorted cognitive process that generates what he identified as "fixed ideas" (Heim & Buhler, 2006). Janet asserted that fixed ideas, more currently thought of as rigid-thought complexes, emerge because the individual's basic biogenetic, sociogenetic, and psychogentic tendencies (i.e. the body's basic behavioral response systems that are naturally activated in situations of stress) do not allow the person to adequate cope. In response, Janet thought an individual's memory system gets weakened and thus the individual does not have the ability analyze and integrate the traumatic event into one's own personal awareness. The fixed ideas or perceptions then essential split away from a person's control and from personal consciousness. He identified this split of consciousness as dissociation. It is during dissociation that distorted elements may combine with one another to make more complex states and potentially form distinct, alternative personalities (van der Hart & Friedman, 1989). Janet believed that fixed ideas are isolated from other thoughts and they emerge from one's unconscious (Heim & Buhler, 2006). Janet argued when his happens, sentences and words will emerge that elicit sensations, images, and emotions. The body's entire system can engage in the fixed idea, which often closely relates to the stressful event. The body then reacts to the fixed idea and the person becomes "hysterical." Around this same time, Sigmund Freud and his colleague, Josef Breuer, were also exploring the idea of hysteria and dissociation resulting from trauma. In their article On the Psychical Mechanism of Hysterical Phenomena: Preliminary Communication (1893), they similarly discussed trauma as being a psychic event that was not synthesized into 8

understanding. Freud and Breuer believed traumatic memories became split off from the rest of the mind when an event overwhelmed one's emotional processing capacity (Huopainen, 2002). When this happens, a psychological split or dissociation takes place and the memory of the event gets coded in fragments in one's memory. These symptoms then present as hysteria, which is expressed through the body in the forms of loss of speech and limb paralysis. In the early 1890's Freud argued that trauma was any idea, memory, or feeling that was unacceptable to the ego. The Ego, which is one third of Freud's tripartite structure of the human psyche (the other two are the Id and Superego), is the reality seeking part of the mind. It mediates the Id (pleasure principle) and Superego (made up of ego ideal and conscience) and the external world. Therefore, when a trauma is experienced, there is damage to part of one's psyche and thus it becomes a "psychic trauma" (Piers, 1996). Freud believed that when a trauma occurs, the thoughts associated with the trauma is so threatening that the ego deprives the stimulus of affect and attempts to forget them (Piers, 1996). This process, however, is not successful because the memory can never truly be annihilated or absorbed, resulting in affect remaining in the body long after the threatening idea was first introduced. Symptoms then emerge through the return of an anxiety provoking idea or memory into consciousness in a symbolic form through the body. They emerge somatically because they seek to be released through different bodily channels, which allow the individual to remain protected from the true negative impact of the event (Piers, 1996). Freud and Breuer argued it was because these "reminiscences" or 9

unconscious memories of the events that constantly forced themselves upon the patient that the patient became hysterical (van der Kolk et al., 2007). Reiser (2003) explained that Breuer and Freud believed that reminiscences present in response to emergence of a "hypnoid state." The hypnoid state developed in response to the overwhelming emotional ties to the traumatic event being repressed. When this happens, there is a splitting of consciousness and a person's memory became divided between the memory and the present life, resulting in the emergence of hysterical symptoms (Reisner, 2003). Over the next three years, differences in the understanding of the hypnoid state and hysteria began to materialize between Breuer and Freud (Roith, 2008). Breuer adopted the idea that hypnoid states and hysterical symptoms are not a result of psychical factors, but rather they are secondary to fundamental abnormalities of the nervous system. Freud, in the meantime, began to discuss trauma as resulting from an interaction with the self and environment rather than the environment imposing upon the weakened self (Reisner, 2003). Such differences in approach to conceptualization, and thus approach to treatment, resulted in a professional break between Freud and Breuer. Between 1893 and 1896, Freud began to examine the sexual lives of his patients. Through this examination Freud began to view pre-pubescent sexual experiences as essential to the development of hysteria and neuroses. In 1896, he formally presented his opinions in his article Further Remarks on the Neuro-Psychoses of Defense. Here, he introduced the "seduction hypothesis" in which he argued that all symptoms of hysteria and neuroses were exclusively a result of a child being seduced and sexually abused by 10

an adult. This belief was not well accepted and in 1897, he rejected this theory for various reasons, including the disbelief that perversions against children were so widespread (Westerlund, 1986). It was by giving up these beliefs that Freud moved away from trauma theory and toward looking at hysteria through a framework that focused around libidinal impulses and fantasy. Freud then proposed it is not the actual memories of the trauma that is split off from consciousness that cause problems for the child, but rather it is the unacceptable sexual and aggressive wishes of the child (Piers, 1996; van der Kolk et al., 2007). In other words, Freud believed symptomology was a result of sexual fantasies during different stages of infantile development not being fulfilled. It has been argued by numerous authors over the last century that in creating this "new" fantasy theory, Freud made attempts at providing a more universal understanding of trauma (Piers, 2006; Reisner, 2003). Freud did mis by linking associations, thoughts, and feelings, with what he believed to be ever-present childhood sexual impulses. Freud was able to make this change toward a more universal understanding of hysteria by moving the emphasis from real life childhood sexual abuse trauma toward sexual fantasy. From this perspective, symptoms of neurosis could now be viewed as expressions of compromises between the unconscious fantasies, which are constantly seeking expression, and the ego (Piers, 2006; Reisner, 2003; van der Kolk et al., 2007). It was through the concepts introduced in Freud's fantasy theory, and with the introduction of infantile development and psycho-sexual stages, that world became captivated and the tenets of traditional psychoanalytic theories were built. To this end, 11

these works remained relatively un-studied over the next several decades and remained the norm in understanding and conceptualizing trauma (van der Kolk et al., 2007). The one exception was Sandor Ferenczi. His work, however, was not published until years later. According to van der Kolk et al. (2007), this was due to the controversy with Ferenczi's more empathic and less neutral approach to treatment, and his belief that neurotic or borderline character was a result of actual traumatic experiences rather than libidinal fantasy and impulses, which directly contradicted Freud's work. Ferenczi and Terr Ferenczi was a Hungarian born analyst who is best known for his paper Confusion of the Tongues Between Adults and the Child: The Language of Tenderness and Passion, which he presented at the International Psycho-Analytic Conference in 1932. In this paper, Ferenczi proposed that symptomology results from child sexual abuse and sexual abuse occurs because the child seduced the adult. With this argument Ferenczi does not blame the child victim for the adult's behavior. Rather, he stated that during a child and adult interaction, the adult may mistake the innocent play of the child for a sexually mature action and the adult then acts upon the interpretation, which results in a sexual act. Ferenczi asserted it is during this time there is confusion between the child's tongue, the innocent play, and the adult's tongue, the sexual desire. As the abusive act happens, the child responds to his or her high level of anxiety by identifying with the aggressor and then introjecting the aggressor into his or her own intrapsychic experiences. Through this identification, the abuser is able to convince the 12

child to comply to all of the adult's wishes and have the child believe this is the type of love the child was lusting for in the first place (Ferenczi, 1949). According to Ferenczi (1949) the greater problem for the child comes after the act when the child is no longer consumed by the anxiety of the abuse. Instead at this time, the child becomes overwhelmed by confusion due to simultaneously feeling innocent and culpable for the abuse. The child also begins to bear an extreme sense of guilt and shame following the event due to the adult tormenting the child because of the adult's own sense of anger and remorse about the act. It is often at this time, the child may seek out another adult, but will not find the other adult responsive. In response Ferenczi stated, "the misused child changes into a mechanical, obedient automaton or becomes defiant, but is unable to account for the reasons of defiance" (Ferenczi, 1949, p. 202). In other words, following sexual abuse a child will become defiant and perhaps aggressive, but is unable to identify the source of his or her aggression. It is the argument of this dissertation that the aggression and defiance are means to express and, at times control, the child's affective experience. It is around both of these issues and how they relate to aggression that this dissertation is dedicated. When Ferenczi's work was eventually published in 1949 the field of psychiatry slowly again began to examine trauma theory. John Bowlby and D.W. Fairbairn were two individuals who over the next 40 years explored this arena. It was through their work that a greater understanding of how the interaction between a caregiver and a child impacts one's psychological functioning developed. This is especially true in regard to trauma. Due to the importance of their contributions, each of their work, as it is related to this 13

dissertation, will be reviewed in later chapters. Specifically, the review of Bowlby's work will focus on the role of attachment relationships between child and caregiver. It will explore how the various types of attachment and the attachment style that develops as a consequence of abuse, influences one's development and behavior across the lifespan. The examination of Fairbairn's work will focus on how children who experience abuse come to unconsciously seek out pain as the preferred form of connection to others. Returning to trauma theory, what is important to understand is that even with continued advancements in the field of trauma, there was still no distinction between the symptomology of adults and children following traumatic events. It was assumed that children and adolescents reacted to traumatic events in the same way as adults. It was with the work of Lenore Terr in the early 1990's that this view finally changed. In 1991, Terr introduced a developmental focus to understanding how the effects of trauma impact psychological functioning. Her work was extremely important in understanding childhood trauma because she was one of the first professionals to bring awareness to the complexity of childhood trauma. Terr not only re-examined how children experienced trauma, but she also argued that consequences of childhood trauma depend on the type of trauma experienced by the individual. Specifically, Terr (1991) argued the way in which one processes trauma is dependent upon if the trauma is a single or a variable, multiple, and long-standing trauma, which she named as Type I versus Type II trauma, respectively. Terr (1991) defined Type I trauma as a single incident event that is a sudden, unexpected, and isolated experience. This includes events like a single car accident or 14

rape. This type of trauma is more common and it can have less of a negative impact on one's functioning compared to repeated traumatic events. She argued when children experience a Type I event, the event often becomes carved in a child's mind and the child is able to recall details of the event. However, because children often lack the internal brain structures to fully cognitively integrate the experience, it can lead to a distorted understanding of the experience. Terr argued, with treatment these experiences can become more integrated and symptomology will significantly, if not completely, dissipate. Type II traumas, on the other hand, Terr (1991) explained, are long-standing traumas, which may include ongoing sexual abuse or combat. She argued in these circumstances, the initial event is experienced as a Type I trauma, but as the trauma continues the individual comes to expect and fear its reoccurrences, and he or she begins to feel helpless to prevent it. Terr (1991) stated following these types of events children will respond with symptoms which fall into four categories: (1) denial and emotional numbing, (2) self-hypnosis and dissociation, (3) rage, and (4) persistent sadness. Children are not necessarily aware of the presence of these symptoms and they may have functional memory impairments, which inhibit them from recalling aspects of the trauma. Children may also show indifference to pain, feel invisible, or have difficulty in distinguishing emotions and labeling feelings. Type II symptoms are also consistent with cycles of rage or extreme passivity (Condie, 2003; Terr, 1991). All of these symptoms of chronic trauma have a role in affect dysregulation. 15

Terr (1991) argued it is a result of a repeated trauma that one experiences a dramatic internal change. This change occurs because the individual adapts to the trauma by modifying his or her view of self. In making this adaptation, Terr asserted that the victim becomes able to deny helplessness associated with the trauma by establishing the fantasy that he or she has control over the traumatic event (Classen, 1993; Terr, 1991). It is conflict between the helplessness that one feels and the way a person wishes he or she was (a competent and in control person) that can eventually lead to additional maladaptive coping techniques and pathological symptomology. Without treatment, these symptoms can lead to serious long-term psychiatric difficulties. 16

CHAPTER 3: ATTACHMENT Childhood is a crucial period of one's individual development. It is a time when early relationships begin to develop and physical changes take place in the brain and the body. Because experiences in childhood set the stage for later adulthood, it is no surprise that the trauma of sexual abuse can have a significant negative impact on later functioning. In order to better understand what role CSA has upon later experiences, it is important to look at how CSA influences development, both psychologically and physically. This is because when disruptions in normal development take place, symptomology is likely to ensue. Bowlby To begin to understand how CSA impacts development, one must look at early relationships because these relationships serve as the foundation for the way a person interacts and copes with experiences in the world. John Bowlby, Mary Ainsworth, and their colleagues (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1982) began to do this by exploring the idea of attachment in the middle part of this century. As Bowlby described in his 1969 book Attachment, in the 1950's he began a search for an explanation of previous findings. He learned that following a young child's separation from his mother, the child would pass from distress, to despair, and into detachment if the separation lasted more than a few days. The even greater problem was that upon the initial reunion of the parent and child, the detachment between child and mother continued. After reviewing psychoanalytic theory, Bowlby did not believe the current 17

Full document contains 142 pages
Abstract: Numerous theories have examined the relationship between childhood sexual abuse (CSA) and aggression. This dissertation reviews and then builds upon some of these theories to argue that aggression, in the forms of self-mutilation and verbal and physical aggression, following CSA emerges as a means to control and express affect. Attachment theory and psychodynamic models of affect regulation serve as the foundation for this evaluation and conclusion. The examination of neurobiology of attachment and trauma aid this argument by offering a biological perspective to one's psychological presentation. It is suggested through an interpersonal neurobiological treatment approach growth toward healthy adjustment following CSA can take place.