How Childhood Trauma Can Disrupt Developmental Progress

disruption of childhood development

Traumatic experience can seriously, adversely affect the child’s development.

What Is Meant By Childhood Development?

We can define childhood development as a complex process of developing competences and attaining achievements from early childhood through to adolescence / early adulthood. These fall into the following main categories :

– physical

– emotional

– social

– intellectual / cognitive

– moral

Young Child :

During early childhood developmental tasks include :

  • building a sense of trust
  • learning to separate from parents (e.g. when starting school)
  • learning to adapt to peer group
  • learning to adapt to authority figures
  • development of feeling of safety away from the home
  • development of friendships
  • development of thinking / cognitive / intellectual abilities
  • development of self-esteem

disrupted childhood development

 

Adolescence :

During adolescence boys and girls experience 6 main developmental tasks. These are :

  • maintaining progress towards independence
  • solidifying a capacity for meaningful relationships
  • clarification of a sense of sexual identity
  • development of interests and competencies
  • internalization of moral values
  • development of autonomy

 

Timing :

How the child is affected will depend upon the timing of the trauma (and its adverse consequences) and at which stage of the developmental process the child is at at this time. Depending upon this timing the child may develop problems relating to attachment (such as reactive attachment disorder, disorganized attachment disorder or insecure attachment), separation anxiety, psychosexual issues and social issues such as problems with peer relationships. However, any of the developmental tasks referred to above may be adversely affected.

If traumatic experiences coincide with critical developmental transitions, such transitions may be jeopardized ; how these ill-effects manifest themselves is subject to great variability – see below :

  • development may be interrupted
  • development may be delayed
  • development may be arrested (e.g. a traumatized teenager’s emotional development might get stuck at, say, thirteen)
  • the child may regress to an earlier stage of development (e.g. a toilet trained toddler might start having accidents)
  • a developmental stage may be accelerated / the child may undergo precocious development

Mastery :

Mastering these stages / developmental tasks are necessary for an emotionally and psychologically healthy adult life, and, because they require much psychic energy are largely dependent upon a safe, stable, supportive and nurturing environment.

 

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Why BPD Sufferers Can Often Read Others’ Emotions So Perceptively

BPD and interpersonal sensitivity

When I was a young child, my mother always remarked upon how easily I picked up on the slightest emotional signals she, and others, displayed (such as a tiny change in expression, a very slight change in tone of voice, subtle variations of body language etc). What both she (I presume)  and I were unaware of at the time was that she herself was responsible (but, alas, not in a good way) for this ‘sixth sense’  (as she also sometimes referred to it).

I make this assertion because it has become clear to me now that I developed this ‘talent’ (I put that word in inverted commas because it is rather a mixed blessing) as a survival mechanism. As I have written elsewhere on this site, my mother was extremely emotionally volatile, prone to intense rages and expressions of unadulterated, poisonous hatred which threatened to (or, indeed, succeeded in) the psychological destruction of the child. Furthermore, such hysterical outbursts were highly unpredictable.

You can see, then, where this is going : it was necessary for me to be on constant ‘red alert’ for any sign that my mother was about to succumb to one of these tyrranical fits in order to give myself a chance of taking some sort of evasive action (which, sadly, was all too often not possible). This state of ‘red alert’ was not entered into as a result of a conscious decision, of course, but was unconsciously activated as a psychological defense mechanism; such a state is sometimes referred to as  hypervigilance (which is also a symptom of post traumatic stress disorder (PTSD) and of Complex PTSD) or as ‘interpersonal sensitivity‘.

bpd and oversensitivity

To talk in more general terms, many people with borderline personality disorder (BPD) who have been subject to such psychological abuse as children may have learned to, and, consequently, become neurologically hard-wired to, pick up on the cues of others so as to emotionally protect themselves.

However, there is experimental evidence to suggest that this ability to ‘read’ others can err too much on the side of caution and generate ‘false positives’ as has been demonstrated in an experiment that showed that those suffering from borderline personality disorder were more likely to interpret neutral facial expressions as hostile and angry facial expressions (click here to read my previously published article about this particular study).

 

RESOURCE :

Overcome hypervigilance. Click here for further details.

 

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Three Types Of Child ‘School Shooter.’

school shooters

Is Dismissing ‘School Shooters’ As ‘Evil’, Whilst Entirely Understandable, Too Simplistic?

In the wake of another tragic school shooting in Florida, USA, it is utterly understandable, of course, that many choose to explain such appalling tragedies using phrases such as ‘it was simply an act of pure evil.’ However, do such explanations (based on entirely natural emotional responses with which we all sympathize) prevent us from looking for more complex, deep-rooted causes? And, if there are more complex and deep-rooted explanations, shouldn’t they be studied so as to help prevention of future, similar occurrences?

Langam PhD, in his excellent book, ‘Why Kids Kill’, attempts to do exactly this. Based on his research, he has theorized that those individuals whom he terms ‘school shooters’ fall into three main categories (though he accepts there may well be other categories that his own research has, as yet, not identified).

what causes school shooters?

Three Categories Of ‘School Shooters’ :

The three categories of ‘school shooters’ identified by Langam are as follows :

  1. Individuals who are psychopathic
  2. Individuals who are psychotic
  3. Individuals who are traumatized

Let’s look at each of these three categories in turn :

  1. Psychopathic ‘school shooters’ :

Langam describes certain personality features of psychopathic ‘school shooters’ which may contribute to their lethal behavior. First, he says, they are egotistical, meaning that they consider themselves to be in some way fundamentally and intrinsically superior to ‘the mere mortals’ with whom they are infuriatingly forced live alongside. Second, they are egocentric, meaning they are highly focused on placing their own needs far above the needs of others. 

Furthermore, Langam describes this category of ‘school shooters’ as being amoral, lacking a conscience (including the capacity to feel guilt or remorse), lacking empathy for the feelings of others and as having problems controlling anger.

Also, Langam points out, psychopaths may be superficially charming, thus making their true intentions much more difficult to detect and making it easier for them to manipulate others.

Finally, Langam states that, whilst not all psychopaths are sadistic, those he examined during the course of his own research were sadistic. A person with a sadistic personality shows an enduring propensity to indulge in aggressive and / or cruel behavior, enjoys witnessing the suffering of others, and is prone instil fear in others in order to be better able to manipulate them. They may also enjoy deprecating, demeaning, devaluing, disparaging and humiliating others.

Notwithstanding the above, however, sometimes so-called psychopathic traits in adolesents may be symptomatic of profound feelings of inner, emotional distress.

          2. Psychotic ‘school shooters’ :

Those suffering from psychotic illnesses lose touch with reality’ (although this may only happen occasionally and need not be a permanent state) and the main symptoms of psychosis are delusions and hallucinations.

Hallucinations are most commonly auditory (frequently referred to as ‘hearing voices’) but may also be visual (self-explanatory), tactile (e.g. feeling as if insects are crawling over one’s skin), olfactory (‘smelling’ odors e.g ‘of dead people’ when such smells are, in fact, utterly absent), gastatory (sensing ‘tastes’ in the absence of a physical stimulus e.g. believing one can ‘taste poison’ in one’s food) or proprioceptive (hallucinations of posture e.g. feeling one is floating, flying, having an ‘out of body’ experience, believing part of one’s body to be in a different location or feeling the ‘presence’ a limb that has been amputated (phantom limb syndrome).

Delusions are blatantly false beliefs that are held with absolute conviction, unalterable (even in the face of powerful counterargument and contradictory evidence), and, frequently, bizarre and / or patently untrue (Karl Jasper).

Langam states that, amongst ‘school shooters’, common delusions are :

  • DELUSIONS OF GRANDEUR
  • PARANOID DELUSIONS

In the group of ‘school shooters’ which Langam based his research on, he reports that delusions of grandeur held by these individuals included beliefs about being ‘godlike’ and that paranoid delusions that they held included believing that ‘people, gods, demons, or monsters were intending to harm or kill them.’

3. Traumatized ‘school shooters’ :

Langam reminds us that traumatized / abused children trquently suffer consequences that include ‘anxiety, depression, hostility, shame, despair and hopelessness‘ and that they may, too, suffer a ‘reduced capacity for feeling emotions‘ and ‘feel cut off and detached from othersthreatened…and paranoid‘. And, further, they may suffer from constant ‘hypervigilance‘ (constantly anticipating danger / a feeling of being permanently in a sate of ‘red-alert’), self-destructiveness, self-harm, suicdal ideation and a propensity to behave violently.

It almost goes without saying, therefore, that the above provides yet further compelling evidence for the necessity to therapeutically intervene at the earliest possible opportunity when young people are displaying symptoms of emotional turmoil, traumatization and incipient mental illness (although, of course, it should, equally, hardly need saying that most such individuals are of no danger to others and are far more likely to be a danger to themselves due to self-harm (including heavy drinking, binge-eating, drug-taking, heavy smoking, anorexia and suicidal ideation / behavior) and general self-destructive behavior.

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David Hosier BSc Hons; MSc; PGDE(FAHE).

 

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Overcoming Nightmares And Hallucinations With ‘Paradoxical Intention.’

paradoxical intention

Childhood Trauma And Its Link To Adult, Psychiatric Disorders :

We have seen in many other articles that I have published on this site that there is a link between childhood trauma and the later development of a whole array of psychiatric disorders in adulthood (for example, see my article on the Adverse Childhood Experiences Study – sometimes referred to as the ACE Study).

Such psychiatric disorders include major depression, anxiety, alcoholism, borderline personality disorder (BPD), complex posttraumatic stress disorder (cPTSD) and psychosis (including schizophrenia).

All of these conditions may include the symptoms of nightmares and/or hallucinations (borderline personality disorder can sometimes involve brief psychotic episodes, as can depression).

Nightmares, Hallucinations And Trauma-Based Memories :

When nightmares and hallucinations are linked to psychiatric disorders which, in turn, are linked to childhood trauma, it is quite possible that the content of those nightmares and / or hallucinations are founded, at least in part, upon TRAUMA – BASED MEMORIES.

Paradoxical Intention :

paradoxical intention

Of course, the content of nightmares and hallucinations is frequently highly disturbing and distressing – I have had nightmares of such violence that they have, on more than one occasion, caused me to fall out of bed. Frequently, too, I have thrashed about so vigorously in my sleep that I have knocked lamps, clocks, overflowing ashtrays, radios and half-finished cups of tea off my bedside table (although never all at once, albeit small consolation) – however, one possible way to reduce their intensity, or, even, overcome them may, counter-intuitively, according to psychodynamic theory, be facilitated by a process known as PARADOXICAL INTENTION.

Paradoxical intention is a concept first described by Dr Viktor Frankl, the famous psychiatrist and concentration camp survivor who founded Logotherapy, based on the idea that psychological symptoms can be made worse by tying too hard to fight them, summed up by the pithy maxim, ‘What you resist persists.’

So, applying the idea of paradoxical intention to the treatment of nightmares and hallucinations involves a trained psychotherapist encouraging the client to view his/her nightmares and /or hallucinations from a completely different perspective,  i.e. rather than seeing the hallucinations / nightmares as something purely destructive and to be feared, the client is encouraged, instead, to try to see these phenomena as helpful clues (no matter how bizarre and nonsensical they may appear to be on the surface) which can be analyzed and interpreted for salient meanings (whether literal or symbolic), thus helping to expose, and shed light upon, possible trauma-based memories that underpin the individual’s psychiatric condition.

In this way, the client can be both empowered, and, under the care of an appropriately trained psychotherapist, can also be sensitively and compassionately helped to understand, where appropriate, the deep roots of his/her particular psychological difficulties, which may prove to be an effective first step towards ameliorating them.

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The Neurological Potential For Psychological Turmoil During Adolescence.

brain changes in adolescence

For many, adolescence is a very difficult and stressful time, not least because of the neurological and interacting hormonal changes that occur during the period.

Changes In The Brain :

Between the ages of about ten and early adulthood, the brain undergoes three major periods of dramatic physical development as described below :

  • Between the ages of 10 years and 12 years : during this period there occurs a massive increase in neurons (a neuron is a brain cell that receives, processes and transmits information via chemical and electrical signals) and synapses (connections between neurons) in the brain’s FRONTAL CORTEX (the brain’s frontal cortex is involved in reasoning, higher level thinking, decision making, logic, judgment, impulse control, emotional control and planning). However, it is important to note that the FRONTAL CORTEX does not become fully developed until the early to mid-twenties (Kotulak).
  • Between the ages of 13 years and 15 years : during this period there are qualitative changes in nerve pathways which allow the ability to perform abstract thinking to develop.
  • From the age of 17 years upwards : continued development of the brain’s frontal lobes increase the individual’s ability to plan and think logically.

Lack of impulse control, poor judgment, poor planning and illogical thinking can, of course, lead to the kind of dangerous, impulsive risk-taking behavior often seen in adolescents ; such behavior is also exacerbated by the fact that the adolescent brain is wired up in such a way that the teenager is highly stimulated to seek out novel experiences / indulge in experimental behavior.

The Adolescent Brain And Emotional Lability :

It is also important to note that during adolescence a region of the brain known as the AMYGDALA (which plays a very large part in the individual’s emotional experiences) is HIGHLY ACTIVE ; this frequently has the effect of causing the adolescent’s behavior to be substantially dictated by volatile and dramatically fluctuating emotions which may contribute to tensions in the home and/or conflict with peers.

Hormonal Changes :

Brain development is influenced by hormone production and, during adolescence, copious amounts of sex hormones, growth hormones, adrenal stress hormones and (in males) testosterone are produced.

Furthermore, studies suggest that, due to the relative immaturity of the connection between the prefrontal cortex and the mid-brain reward system, teenagers are more prone to becoming addicted to drugs (including nicotine). Also, this underdeveloped neuronal link between the prefrontal cortex and the mid-brain reward system may help to explain why some adolescents develop especially intense, dramatic and volatile romantic attachments during their teenage years.

Another effect of hormonal changes is that the adolescent’s diurnal rhythm (pattern of behavior that follows day-night / 24 hour cycles) is altered. This is why many teenagers inadvertently antagonize their parents (especially those parents who are as yet unacquainted with knowledge pertaining to adolescent diurnal rhythms) by staying up very late and then getting up very late.

Finally, because the level of testosterone produced by boys increases by 1000 per cent after puberty this dramatic elevation in quantity of the hormone in the body can potentially increase the young person’s propensity for violence which can, in turn, lead to involvement in schoolyard fights or worse.

And, of course, if, too, the adolescent has experienced significant childhood trauma, all of the above potential problems may become dramatically intensified.

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David Hosier BSc Hons; MSc; PGDE(FAHE).

 

 

 

 

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Factors That Put The Child’s Mental Health At Risk

factors that put the child's mental health at risk

The Risk And Resilience Model :

According to the Risk And Resilience Model (Pearce , 1993) there exist three categories of factors that put the child’s mental health at risk. These are as follows :

  1. Factors relating to the child’s / young person’s environment
  2. Factors relating to the child’s / young person’s family
  3. Factors relating to the child / young person himself / herself

child mental health risk factors

The List Of Risk Factors (Split Into The Three Categories Given Above) :

Let’s look at each of these three categories of factors in turn :

  1. Factors relating to the child’s / young person’s environment :

These include the following :

  • living in a violent community
  • socioeconomic deprivation
  • living in an environment in which one is discriminated against
  • homelessness
  • living in the environment as a refugee or asylum seeker
  • disaster
  • other significant, adverse life event

 2. Factors relating to the child’s / young person’s family :

    3. Factors relating to the child / young person himself / herself :

  • low I.Q. / learning difficulties
  • genetic influences
  • temperamental difficulties
  • communication difficulties
  • specific developmental delay
  • chronic physical illness
  • gender identity conflict
  • low self-esteem
  • academic failure
  • poor school attendance
  • neurological disorder

Resilience : Factors That Help To Protect A Child / Young Person From Becoming Mentally Ill :

Pearce’s model also includes factors that help to protect a child / young person from becoming mentally ill which he refers to as RESILIENCE FACTORS ; I list these below :

  • social skills
  • self-esteem
  • familial compassion and warmth
  • a stable family environment
  • a skill or talent
  • a social support system that encourages personal development and coping skills

David Hosier BSc Hons; MSc; PGDE(FAHE).

 

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Childhood Trauma And Nocturnal Enuresis

nocturnal enuresis

Individuals who suffer significant stress / trauma in early life are more likely to suffer from NOCTURNAL ENURESIS than those individuals who are fortunate enough not to do so.

What Is Nocturnal Enuresis?

Nocturnal enuresis is a pattern of voiding urine, at night, into bed or clothes, and can be both involuntary or deliberate. To be classified as nocturnal enuresis, such voiding of urine must occur after the age of 5 years.

Is Someone Who Suffers From Nocturnal Enuresis Likely To Suffer From Other Types Of Psychopathology?

Yes, relative to those who do not suffer from it. Psychopathological conditions associated with nocturnal enuresis include the following :

  • adjustment disorder
  • anxiety
  • oppositional defiant disorder
  • ADHD

Nocturnal Enuresis In Adolescents :

It is generally believed that an adolescent who suffers from nocturnal enuresis is more likely to have underlying psychopathological conditions (such as the four that I have listed above) than a much younger child who suffers from it.

Other Information About Nocturnal Enuresis :

In most involuntary cases, the  voiding of urine occurs between 30 minutes and 3 hours of the individual who suffers from it falling asleep and, for the condition to be formally diagnosed (according to the Diagnostic And Statistical Manual Of Mental Illness IV , or DSM IV) the symptoms must have occurred at least twice per week for at least three consecutive months or they must have caused marked impairment or distress to the sufferer.

What Treatments Are Available For Nocturnal Enuresis?

Treatments for nocturnal enuresis include :

  • behavior modification
  • psychotherapy for associated, psychopathological conditions (such as those referred to above)
  • certain medications (on the advice of a suitably qualified professional such as a GP)

Successful treatment will frequently bring about associated benefits including increased social confidence and raised self-esteem.

 

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Feeling Loved Protects Against Stress : Vagus Nerve Theory

polyvagal theory

Dr Stephen Porge, (former director of Brain-Body Center, University of Illinois, Chicago, USA) describes how the parasympathetic branch of the nervous system and the VAGUS NERVE have TWO SEPARATE PATHWAYS :

PATHWAY ONE : this is the primitive / reptilian pathway that, when we feel under threat, activates the freeze response (for more information on what is meant by the freeze response, see my previously published article : Fight, Flight, Freeze or Fawn : Trauma Responses

PATHWAY TWO : this pathway, Porge explains, exists only in mammals, and, when we feel under threat, activates a ‘social engagement’ response because it (i.e. this second pathway) connects to the face (including the mouth, middle ear and eyes) and detects non-verbal sounds and facial expressions that signify safety, protection which, in turn, promotes emotional soothing / feelings of comfort.

Furthermore, this second pathway also connects to :

These second pathway connections act together to REGULATE STRESS and also serve to inhibit, or override, activation of the first, primitive / reptilian pathway and its associated, automatic stress responses.

When this second pathway operates successfully, and the sympathetic branch of the nervous system receives these comforting and reassuring signals indicating safety and protection, the fight/flight/freeze/ fawn response is effectively shut down and we can maintain an emotional equilibrium without being overwhelmed by feelings of fear, anxiety and panic.

The Importance Of Feeling Loved :

Therefore, those individuals who are fortunate enough to have been loved as children. and who continue to have people around them by whom they feel loved as adults, will be far more likely to have the second (‘social engagement’) pathway activated during periods of potential high stress than less fortunate individuals who have been deprived of loving relationships.

And, of course, the flip side of this is that lonely, isolated, unloved individuals are far more likely to have adverse reactions to stress than their more fortunate, loved, counterparts; sadly, too, those unloved as children are far less likely to be able to form successful, enduring, loving relationships as adults and are therefore more likely to fall into this category of individuals.

RESOURCE :

Read about VAGUS NERVE STIMULATION THERAPY

David Hosier BSc Hons; MSc; PGDE(FAHE)

 

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Antidepressants : Are Those Who Experienced Early Life Trauma Less Responsive To Them?

MDD, early life-trauma and antidepressants

As part of the international Study to Predict Optimized Treatment for Depression (iSPOT-D) involving over one thousand individuals who had been diagnosed with major depressive disorder (MDD). research was undertaken to compare the prevalence of histories of early childhood trauma in this group with the same prevalence in  a group of ‘healthy’ controls (this latter group was comprised of 336 matched individuals).

Results :

Depressed individuals more likely to have suffered early-life stress (see below)

When the two groups were compared, it was found that :

  • In the group of individuals who had been diagnosed with major depressive disorder (MDD), 62.5% had suffered more than two traumatic events before the age of 18.
  • In the group of ‘healthy’ individuals, 28.4% had suffered more than two traumatic events before the age of 18.

(The number of traumatic events each individual was determined to have suffered before the age of 18 was defined with reference to Early-Life Stress Questionnaire.)

Another part of the study examined how the individuals suffering from major depressive disorder (MDD) responded to antidepressant treatment (the treatment period was eight weeks and individuals were treated with one of three antidepressants : escitalopram, sertraline or venlafaxine).

Results :

It was found that individuals who had histories of abuse (physical, sexual or emotional), particularly if this abuse occurred before the age of 7 years, had an impaired response to all three (see above) antidepressants used in the study.

Those individuals who had suffered abuse (physical, sexual or emotional) between the ages of 4 years and 7 years and were treated with sertraline (see above) had the poorest of all response to the treatment.

Conclusion :

This study suggests that individuals who have suffered significant levels of early-life stress may be less likely to respond positively to treatment with antidepressants than those who have not. However, further research is necessary to cast more light upon this apparently inverted relationship between the two variables.

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David Hosier BSc Hons; MSc; PGDE(FAHE).

NB :  The above is for information only. Always consult an appropriately qualified professional when making decisions regarding relating to medication.

 

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Deep Feelings Of Shame Resulting From Emotionally Impoverished Relationships With Parents

shame due to dysregulating oyjers

According to DeYoung, author of the excellent book : ‘Understanding and Treating Chronic Shame : A Relational / Neurobiological Approach‘, the experience of shame comes about as a result of dysfunctional relationships with other people (in particular, of course, with our parents when we are growing up) who are of emotional importance to us as opposed to affecting us as isolated, independent individuals. Because of this, DeYoung describes the experience of shame as being RELATIONAL (i.e. linked to the quality of our relationships with others who are important to us).

More specifically, DeYoung proposes that we can develop a deep and pervasive sense of shame in early life when ‘we experience our felt sense of self disintegrating in relation to a dysregulating other.’

What Is Meant By A Dysregulating Other?

According to DeYoung, a ‘dysregulating other’ is :

‘A person who fails to provide an emotional connection, responsiveness and understanding of what another needs in order to be in order to be well and whole.’

And, of course, if this ‘dysregulating other’ is a parent when we are very young and that parent behaves in a chronic and consistently ‘dysregulating’ way towards us, then we are especially likely to grow up into adults with a deep, pervasive and abiding sense of shame.

DeYoung also states that a dysregulating other (who, as already stated, is important to us, especially a parent) is someone we ‘want to trust‘ and, indeed, ‘should be able to trust‘, but, when we turn to that person because we are in emotional distress and need to be comforted and soothed, the way the dysregulating other responds to us / fails to respond to us leaves us feeling WORSE STILL. This is because the dysregulating other is emotionally misattuned to / disconnected from us ; the relationship is emotionally impoverished.

cause of shame

In turn, this, according to  DeYoung, can lead to us developing ‘core feelings of shame‘ as we conclude, ‘consciously or unconsciously, that there is something wrong with our neediness and that we are somehow ‘bad’ because of the painful and troubling nature of our ongoing interactions (or lack thereof) with this dysregulating other.

However, we may not be consciously aware (see above) of the fact that such feelings of shame are directly attributable to our early relationships with our parents / important others and may, therefore, erroneously attribute these profound feelings of  shame to factors that, in truth, are NOT their primary source of origin (such as our physical appearance, sexuality, perceived lack of intelligence /abilities, social status or a vast array of other factors).

What Is Meant By A Sense Of Self Disintegration?

DeYoung states that such emotionally impoverished interactions with parents / important others, when sustained and chronic, make us feel that our sense of self is disintegrating. 

This sense of disintegration can include feeling of our ‘self’ being  ‘shattered,’ ‘incoherent’ ‘blank’, ‘fragmented‘, and, furthermore, can make us vulnerable to feelings of deep humiliation (even in response to small, objectively trivial events), under threat of ‘psychological annihilation’ or induce strong desires in us, metaphorically, to be ‘swallowed up by the ground’ or ‘disappear.’

In order to emphasize just how powerful the effects of shame can be, DeYoung offers the extreme example of the Japanese suicide ritual of hari-kiri which used to be carried out by warriors who had been ‘disgraced.’

RESOURCES :

  • DeYoung’s Book / eBook (Click on book’s title below) :

Understanding and Treating Chronic Shame: A Relational/Neurobiological Approach

 

David Hosier BSc Hons; MSc; PGDE(FAHE).

 

 

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