Developmental Trauma Quotes

Paradoxically, the more we try to change ourselves, the more we prevent change from occurring. On the other hand, the more we allow ourselves to fully experience who we are, the greater the possibility of change.

Developmental trauma occurs when “emotional pain cannot find a relational home in which it can be held.”1 In retrospect, I can see that this was the case for

Children are compelled to give meaning to what is happening to them. When there is no clear explanation, they make one up; the intersection of trauma and the developmentally appropriate egocentrism of childhood often leads a little kid to think, I made it happen.

The traumatic stress field has adopted the term “Complex Trauma” to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood - Developmental Trauma Disorder

In this climate of profoundly disrupted relationships the child faces a formidable developmental task. She must find a way to form primary attachments to caretakers who are either dangerous or, from her perspective, negligent. She must find a way to develop a sense of basic trust and safely with caretakers who are untrustworthy and unsafe. She must develop a sense of self in relation to others who are helpless, uncaring or cruel. She must develop a capacity for bodily self-regulation in an environinent in which her body is at the disposal of others' needs as well as a capacity for self-soothing in an environment without solace. She must develop the capacity for initiative in an environment which demands that she bring her will into complete conformity with that of her abuser. And ultimately, she must develop a capacity for intimacy out of an environment where all intimate relationships are corrupt, and an identity out of an environment which defines her as a whore and a slave.

Love that is conditional upon looks and performance is not love at all

It may come as a surprise that living life in a full and expanded way is one of the most difficult challenges we face as human beings.

When people look at a dangerous violent criminal at the beginning of his developmental process rather than at the very end of it, they will see, perhaps unexpectedly, that the dangerous violent criminal began as a relatively benign human being for whom they would probably have more sympathy than antipathy.

Twenty years of medical research has shown that childhood adversity literally gets under our skin, changing people in ways that can endure in their bodies for decades. It can tip a child’s developmental trajectory and affect physiology. It can trigger chronic inflammation and hormonal changes that can last a lifetime. It can alter the way DNA is read and how cells replicate, and it can dramatically increase the risk for heart disease, stroke, cancer, diabetes—even Alzheimer’s.

After years of neurofeedback, I no longer see these disorders as distinct, but as individual manifestations of overwrought, amygdala-driven and dysregulated nervous systems. Just as emotion

Eating disorders are prevalent among women who were sexually abused as children. They seem to have components of other symptoms such as obsessions, compulsions, avoidance of food, and anxiety, and they primarily include a distorted body image and feelings of body shame. For some women, eating disorders are related to the loss of control over their bodies during the sexual abuse and serve as a means of feeling in control of their bodies now. Eating disorders can also be indicative of the developmental stage and age at which the sexual abuse began. Women with anorexia and bulimia report that they were sexually abused either at the age of puberty or during puberty, when their bodies were beginning to develop and they felt a great deal of body shame from the abuse. By contrast, women with compulsive eating report that the sexual abuse occurred before the age of puberty; they used food for comfort.

Dissociative identity disorder is conceptualized as a childhood onset, posttraumatic developmental disorder in which the child is unable to consolidate a unified sense of self. Detachment from emotional and physical pain during trauma can result in alterations in memory encoding and storage. In turn, this leads to fragmentation and compartmentalization of memory and impairments in retrieving memory.2,4,19 Exposure to early, usually repeated trauma results in the creation of discrete behavioral states that can persist and, over later development, become elaborated, ultimately developing into the alternate identities of dissociative identity disorder.

However they coped, children are not wrong to have learned to do what they could.

In my practice I use neurofeedback primarily to help with the hyperarousal, confusion, and concentration problems of people who suffer from developmental trauma. However, it has also shown good results for numerous issues and conditions that go beyond the scope of this book, including relieving tension headaches, improving cognitive functioning following a traumatic brain injury, reducing anxiety and panic attacks, learning to deepen meditation states, treating autism, improving seizure control, self-regulation in mood disorders, and more.

humans suffer from an endless number of emotional problems and challenges, most of these can be traced to early developmental and shock trauma that compromise the development of one or more of the five core capacities.

Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. Clinical Psychopharmacology and Neuroscience 2014 Dec; 12(3): 171-179 The Many Faces of Dissociation: Opportunities for Innovative Research in Psychiatry

Human contact and warmth bring expansion and aliveness to the body. Making contact and allowing expansion to take place at its own rate begins to melt the frozenness. As shock energy is released, the frozenness progressively melts and more aliveness is possible.

For example, when children do not get the connection they need, they grow up both seeking and fearing connection. When children do not get their needs met, they do not learn to recognize what they need, are unable to express their needs, and often feel undeserving of having their needs met.

Attempts to stop smoking or give up any sort of self-destructive addictive behavior such as drugs, alcohol, hypersexuality, overeating, or overworking, often fail because it is very difficult to give up a means of self-regulation even when it is unhealthy until it can be replaced with a better form of self-regulation.

Developmental psychologists agree that praising a child’s effort is helpful and promotes self-esteem, while valuing the achievement only programs kids to keep seeking external approval—not for who they are but for what they do, for what others demand of them. It’s yet another barrier to the emergence of a healthy self.

Painful or frightening affect becomes traumatic when the attunement that the child needs to assist in its tolerance, containment, and integration is profoundly absent,”8 writes Robert Stolorow, a philosopher, psychologist, and clinical professor of psychiatry at UCLA, in his book about trauma. “One consequence of developmental trauma, relationally conceived, is that affect states take on enduring, crushing meanings. From recurring experiences of malattunement, the child acquires the unconscious conviction that unmet developmental yearnings and reactive painful feeling states are manifestations of a loathsome defect or of an inherent inner badness.

Shame reduces complex circumstances to simple solutions like “It’s all my fault” and “I must deserve this.

Anger is a life-supportive response intended to impact an unsupportive environment. For

CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including: A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following: B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions) B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states B. 4. Impaired capacity to describe emotions or bodily states C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following: C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation) C. 4. Habitual (intentional or automatic) or reactive self-harm C. 5. Inability to initiate or sustain goal-directed behavior D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following: D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D. F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months. G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at least two of the following areas of functioning: Scholastic Familial Peer Group Legal Health Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training)

The price of freedom is eternal mindfulness. This is a book about restoring connection. It is the experience of being in connection that fulfills the longing we have to feel fully alive. An impaired capacity for connection to self and others, and the ensuing diminished aliveness, are the hidden dimensions that underlie most psychological and many physiological problems. Unfortunately, we are often unaware of the internal roadblocks that keep us from experiencing the connection and aliveness we yearn for. These roadblocks develop in reaction to developmental and shock trauma and the related nervous system dysregulation, disruptions in attachment, and distortions of identity. The goal of the NeuroAffective Relational Model (NARM) is to work with these dysregulations, disruptions, and distortions while never losing sight of supporting the development of a healthy capacity for connection and aliveness. In this book we address conflicts around the capacity for connection and explore how deeper connection and aliveness can be supported in the process of healing developmental trauma.

Many survivors of relational and other forms of early life trauma are deeply troubled and often struggle with feelings of anger, grief, alienation, distrust, confusion, low self-esteem, loneliness, shame, and self-loathing. They seem to be prisoners of their emotions, alternating between being flooded by intense emotional and physiological distress related to the trauma or its consequences and being detached and unable to express or feel any emotion at all - alternations that are the signature posttraumatic pattern. These occur alongside or in conjunction with other common reactions and symptoms (e.g., depression, anxiety, and low self-esteem) and their secondary manifestations. Those with complex trauma histories often have diffuse identity issues and feel like outsiders, different from other people, whom they somehow can't seem to get along with, fit in with, or get close to, even when they try. Moreover, they often feel a sense of personal contamination and that no one understands or can help them. Quite frequently and unfortunately, both they and other people (including the professionals they turn to for help) do misunderstand them, devalue their strengths, or view their survival adaptations through a lens of pathology (e.g., seeing them as "demanding", "overdependent and needy", "aggressive", or as having borderline personality). Yet, despite all, many individuals with these histories display a remarkable capacity for resilience, a sense of morality and empathy for others, spirituality, and perseverance that are highly admirable under the circumstances and that create a strong capacity for survival. Three broad categories of survivorship, with much overlap between them, can be discerned: 1. Those who have successfully overcome their past and whose lives are healthy and satisfying. Often, individuals in this group have had reparative experiences within relationships that helped them to cope successfully. 2. Those whose lives are interrupted by recurring posttraumatic reactions (often in response to life events and experiences) that periodically hijack them and their functioning for various periods of time. 3. Those whose lives are impaired on an ongoing basis and who live in a condition of posttraumatic decline, even to the point of death, due to compromised medical and mental health status or as victims of suicide of community violence, including homicide.

Traumatized individuals, which includes most of us to differing degrees, need both top-down and bottom-up approaches that address nervous system imbalances as well as issues of identity.

At the time, the Wikipedia page read, “Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape.” And then, a paragraph down: “C-PTSD is a learned set of responses, and a failure to complete numerous important developmental tasks. It is environmentally, not genetically, caused. Unlike most of the diagnoses it is confused with, it is neither inborn nor characterological, not DNA based, it is a disorder caused by lack of nurture.

The concept of resilience is used in our field. But if you look carefully at the biology after a traumatic experience-all the way down to the way genes are expressed-trauma will change everyone in some way. And those changes will be there even if they don’t result in any apparent ‘real life’ problems for the person, even if the person demonstrates resilience. A child may continue to do just as well in school, for example, but it takes much more energy and effort. Or we may find that a child is able to return to his previous level of emotional functioning, but changes in his neuroendocrine system may make him more likely to develop diabetes. This is, in essence, what the ACE studies have demonstrated. Adversity impacts the developing child. Period. What that impact will be, when it may manifest, how it maybe ‘buffered’-we can’t always say. But developmental trauma will always influence our body and brain.

We tend to think of the brain in terms of its other critical physical and chemical domains. But its plasticity, its ability to change and to learn, seems to lay primarily in its electrical, oscillatory properties—in short, in the way it fires. As

Regardless of age, Connection types, at some level, often feel like frightened children in an adult world. Because of their inadequate sense of self, they often try to anchor themselves in their roles as scientist, judge, doctor, father, mother, etc.

To make sense of the pain of their lives, they often become spiritual seekers trying to convince themselves that someone loves them; if people do not, then God must. These individuals are often extremely sensitive in both positive and negative ways. Having never embodied, they have access to energetic levels of information to which less traumatized people are not as sensitive; they can be quite psychic and energetically attuned to people, animals, and the environment and can feel confluent and invaded by other people’s emotions.

The stronger the constitutional factor, the more readily will a trauma lead to a fixation and leave behind a developmental disturbance; the stronger the trauma, the more certainly will its injurious effects become manifest even when the instinctual situation is normal.

These roadblocks develop in reaction to developmental and shock trauma and the related nervous system dysregulation, disruptions in attachment, and distortions of identity. The goal of the NeuroAffective Relational Model (NARM) is to work with these dysregulations, disruptions, and distortions while never losing sight of supporting the development of a healthy capacity for connection and aliveness. In this book we address conflicts around the capacity for connection and explore how deeper connection and aliveness can be supported in the process of healing developmental trauma.

To the degree that our biologically based core needs are met early in life, we develop core capacities that allow us to recognize and meet these needs as adults (Table I.1). Being attuned to these five basic needs and capacities means that we are connected to our deepest resources and vitality.

Trust of others is in short supply for many adult survivors, as complex trauma generally involves major relational betrayal. It is, therefore, expectable (although paradoxical) that clients with these histories are predisposed to be mistrustful at the outset of therapy, precisely because of (and in proportion to) the actual trustworthiness of the therapist. When past experiences have thought hard lessons, namely, that one can least afford to trust the people who should be most trustworthy, it stands to reason that confusion about trust results. The therapist must understand and not take offense either personally or professionally and not react judgmentally or defensively. Practically speaking, this involves the therapist being prepared to patiently and empathically respond to active or passive tests or challenges to trustworthiness as legitimate and meaningful communication that deserves a respectful reply in action as well as in words.

In the case of the earliest Connection Survival Style, for example, focusing on changing distorted cognitions is particularly difficult because with early trauma, the cortex is not yet fully developed, and it is mostly the underlying bottom-up nervous system and affective imbalances that drive the cognitive distortions.

This is a book about restoring connection. It is the experience of being in connection that fulfills the longing we have to feel fully alive. An impaired capacity for connection to self and others, and the ensuing diminished aliveness, are the hidden dimensions that underlie most psychological and many physiological problems.

Deprivation and attachment difficulties signal the baby’s brain and nervous system to implement life-protecting strategies. Depending on the severity and the duration of the nurturing disruptions, there is a progressive loss of the ability to attune to and express one’s needs. Along with the loss of attunement comes increasing autonomic dysregulation:

The coping strategies that initially helped us survive as children over the years become rigid beliefs about who we are and what the world is like. Our beliefs about ourselves and the world, together with the physiological patterns associated with these beliefs, crystallize into a familiar sense of who we are. This is what we come to view as our identity.

A person can also develop avoidant behaviors without making the direct connection to a traumatic cue from the past. This is often true when the abuse or trauma took place within the context of early caregiving relationships. If a child was abused in the context of an intimate relationship (by a parent, for example), they will find intimacy-emotional and physical closeness-threatening. They will often long to be connected but find themselves anxious, confused, or overwhelmed when they get close to someone. They will avoid intimacy in a relationship; if intimacy can’t be avoided, they will sabotage or undermine the relationship. This is one of the most common but least appreciated effects of developmental trauma.

These individuals need to see that as long as they continue to choose to please others at their own expense, they will be trapped. They need to discover how they try to control other people’s responses by being the “good boy” or “nice girl” for them. They need to find the courage to give up that control by being frank and honest with people and allowing them to respond as they will.

The Thinking Subtype As a result of early trauma thinking subtypes have retreated to the life of the mind and choose theoretical and technical professions that do not require significant human interaction. These individuals tend to be more comfortable behind a computer, in their laboratory, or in their garage workshops where they can putter undisturbed. They can be brilliant thinkers but tend to use their intelligence to maintain significant emotional distance.

The same question might be asked about the educational system. In 2016, an American professor and Fulbright scholar named William Doyle, just returned from a semester-long appointment at the University of Eastern Finland, wrote in the Los Angeles Times that for those five months, his family “experienced a stunningly stress-free, and stunningly good, school system.” His seven-year-old son was placed in the youngest class—not because of some developmental delay, but because children younger than seven “don’t receive formal academic training . . . Many are in day care and learn through play, songs, games and conversation.” Once in school, children get a mandated fifteen-minute outdoor recess break for every forty-five minutes of in-class instruction. The educational mantras Doyle remembers hearing the most while there: “‘Let children be children,’ ‘The work of a child is to play,’ and ‘Children learn best through play.’” And as far as outcomes go? Finland consistently ranks at or near the top of educational test score results in the Western world and has been ranked the most literate nation on Earth.[17] “The message that competition is appropriate, desirable, required, and even unavoidable is drummed into us from nursery school to graduate school; it is the subtext of every lesson,” writes educational consultant Alfie Kohn in his excellent book No Contest: The Case Against Competition: Why We Lose in Our Race to Win, which documents the negative impact of competition on genuine learning, and how

ADAPTIVE SURVIVAL STYLE CORE DIFFICULTIES The Connection Survival Style Disconnected from physical and emotional self Difficulty relating to others The Attunement Survival Style Difficulty knowing what we need Feeling our needs do not deserve to be met The Trust Survival Style Feeling we cannot depend on anyone but ourselves Feeling we have to always be in control The Autonomy Survival Style Feeling burdened and pressured Difficulty setting limits and saying no directly The Love-Sexuality Survival Style Difficulty integrating heart and sexuality Self-esteem based on looks and performance

There are not different disciplinary buckets. Instead, each one is the end product of all the biological influences that came before it and will influence all the factors that follow it. Thus, it is impossible to conclude that a behavior is caused by a gene, a hormone, a childhood trauma, because the second you invoke one type of explanation, you are de facto invoking them all. No buckets. A “neurobiological” or “genetic” or “developmental” explanation for a behavior is just shorthand, an expository convenience for temporarily approaching the whole multifactorial arc from a particular perspective.

Ed Tronick, a pioneer in developmental psychology, teaches us, interpersonal rupture and repair is good for building resilience. These ruptures are perfect doses of moderate, controllable stress. Conversation, for example, promotes resilience; discussions and arguments over family dinners and mildly heated conversations with friends are—as long as there is repair—resilience-building and empathy-growing experiences. We shouldn’t be walking away from a conversation in a rage; we should regulate ourselves. Repair the ruptures. Reconnect and grow. When you walk away, everybody loses. We all need to get better at listening, regulating, reflecting.

... as Herman (1992b) cogently noted two decades ago, these personality disorders can be iatrogenic, causing harm to individuals as an inadvertent result of the social stigma they carry and the widespread (but not entirely accurate) belief among professionals and insurers that those with Cluster B personality disorders (especially borderline personality disorder[BPD]) cannot be treated successfully, cannot recover, and are a headache to practitioners. For example, the BPD diagnosis continues to be applied predominantly to women often, but not always, in a negative way, usually signifying that they are irrational and beyond help. Describing posttraumatic symptoms as a personality disorder not only can be demoralizing for the client due to its connotation that something is defective with his or her core self (i.e., personality) but also may misdirect the therapist by implying that the patient's core personality should be the focus of treatment rather than trauma-related adaptations that affect but are distinct from the core self. In this way, both therapists and their clients may overlook personality strengths and capacities that are healthy and sources of resilience that can be a basis for building on and enhancing (rather than "fixing" or remaking) the patient's core self and personality.

One of the hardest things to grasp about implicit bias and racism is that your beliefs and values do not always drive your behavior. These beliefs and values are stored in the highest, most complex part of your brain—the cortex. But other parts of your brain can make associations—distorted, inaccurate, racist associations. The same person can have very sincere anti-racist beliefs but still have implicit biases that result in racist comments or actions. Understanding sequential processing in the brain is essential to grasping this, as is appreciating the power of developmental experiences to load the lower parts of our brain with all kinds of associations that create our worldview.

Under those conditions, chronic stress becomes so common that it seems normal. Individuals use denial and repression to protect the ego from disintegration. Living with both the constant unpredictability of the alcoholic parent and the detachment and/or anxiety of the codependent parent is difficult enough for an adult who has a fully developed defense system. For a child, surviving the regular assault of trauma requires massive amounts of energy. This puts the normal developmental process on hold; there is no energy left to invest in development. While other children are learning to play, to trust, to self-soothe, and to make decisions, children in addicted families are learning to survive. The end result is a child who often feels thirty years old at five and five years old at thirty.

They both believed that the therapist’s job was to break through a patient’s character armor—the psychological and somatic defenses—in order to release the painful emotions held in the body. Bioenergetics, for example, recognizes that deep emotion, conscious or unconscious, is held physically. It encourages clients to express their emotions through kicking, hitting, biting, and yelling, with the goal of discharging these powerful affects and in the hope that doing so will lead to greater emotional freedom and health. Reich’s and Lowen’s unique contribution was to recognize that defenses were held not only in the mind but also in the body’s nervous system, musculature, and organs. This significant breakthrough was ahead of its time and anticipated many current developments in the neurological and biological sciences.

It is as if time stops at the moment of trauma," Judith Lewis Herman asserts. The child becomes "fixated," or developmentally arrested at the age at which the trauma occurred, and even as an adult is stuck in a time warp of childlike helplessness. She continues to process emotions with a child's intensity and mobilizes only those defenses that were available to her at the time of the trauma. Rather than blame others for her problems, she views her pain through the magical thinking of childhood, convinced that she is responsible not only for what happened to her as a kid but all the subsequent problems that have befallen her. "Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality," writes Herman in her 1992 book "Trauma and Recovery".

As children, Other-blamers were likely exposed to developmental or attachment trauma, such as abusive, shaming, rejecting, or neglectful parenting. Parents who are substance abusers or psychologically troubled often underfocus on a child’s needs. Parents may have exhibited narcissistic or Other-blaming behaviors that the child models. Another possible cause is parents who were permissive or conflict avoiding and did not hold the child accountable. Parents who overfocus on achievement or behavioral compliance can also encourage a fear of failure that may bring on Other-blaming tendencies. These experiences can cause children to feel unloved, unprotected, and inadequate. They may struggle to experience empathy for others and may develop an unhealthy hypersensitivity and overreaction to shaming experiences. While Other-blaming as a shame-management strategy may be adaptive in childhood, it causes difficulties for adult relationships at all levels, from presidential to personal.

When someone with a dismissive style starts to work on healing their insecure attachment, they must begin by no longer dismissing and distancing from themselves. This requires that they no longer deny their desires and needs, allowing the longings and wants for connection that have for so long been forbidden. When someone functioning from a dismissive style starts to allow their attachment system to come back online, it can initially be a very tender, raw and even overwhelming process. The skills that come with being able to identify your own feelings are part of a developmental process that takes time. The process of allowing feelings as they arise, learning how to self-soothe and establishing an inner trust that experiencing feelings is safe, cannot be rushed. For the dismissive style, the journey from insecure to secure attachment is one of returning to the body through bringing feelings and sensations back to life and learning how to be with oneself in this process. Once this is established, the risk of then leaning into others, revealing one's internal world, and dismantling the self-reliant exoskeleton through asking for help and care from others can begin.

With regard to complex trauma survivors, self-determination and autonomy require that the therapist treat each client as the "authority" in determining the meaning and interpretation of his or her personal life history, including (but not limited to) traumatic experiences (Harvey, 1996). Therapists can inadvertently misappropriate the client's authority over the meaning and significance of her or his memories (and associated symptoms, such as intrusive reexperiencing or dissociative flashbacks) by suggesting specific "expert" interpretations of the memories or symptoms. Clients who feel profoundly abandoned by key caregivers may appear deeply grateful for such interpretations and pronouncements by their therapists, because they can fulfill a deep longing for a substitute parent who makes sense of the world or takes care of them. However, this delegation of authority to the therapist can backfire if the client cannot, or does not, take ownership of her or his own memories or life story by determining their personal meaning.Moreover, the client can be trapped in a stance of avoidance because trauma memories are never experienced, processed, and put to rest. Helping a client to develop a core sense of relational security and the capacity to regulate (and recover from) extreme hyper- or hypoarousal is essential if the client is to achieve a self-determined and autonomous approach to defining the meaning and impact of trauma memories, a crucial goal of posttraumatic therapy.

Thus polyvictimization or complex trauma are "developmentally adverse interpersonal traumas" (Ford, 2005) because they place the victim at risk not only for recurrent stress and psychophysiological arousal (e.g., PTSD, other anxiety disorders, depression) but also for interruptions and breakdowns in healthy psychobiological, psychological, and social development. Complex trauma not only involves shock, fear, terror, or powerlessness (either short or long term) but also, more fundamentally, constitutes a violation of the immature self and the challenge to the development of a positive and secure self, as major psychic energy is directed toward survival and defense rather than toward learning and personal development (Ford, 2009b, 2009c). Moreover, it may influence the brain's very development, structure, and functioning in both the short and long term (Lanius et al., 2010; Schore, 2009). Complex trauma often forces the child victim to substitute automatic survival tactics for adaptive self-regulation, starting at the most basic level of physical reactions (e.g., intense states of hyperarousal/agitation or hypoarousal/immobility) and behavioral (e.g., aggressive or passive/avoidant responses) that can become so automatic and habitual that the child's emotional and cognitive development are derailed or distorted. What is more, self-integrity is profoundly shaken, as the child victim incorporates the "lessons of abuse" into a view of him or herself as bad, inadequate, disgusting, contaminated and deserving of mistreatment and neglect. Such misattributions and related schema about self and others are some of the most common and robust cognitive and assumptive consequences of chronic childhood abuse (as well as other forms of interpersonal trauma) and are especially debilitating to healthy development and relationships (Cole & Putnam, 1992; McCann & Pearlman, 1992). Because the violation occurs in an interpersonal context that carries profound significance for personal development, relationships become suspect and a source of threat and fear rather than of safety and nurturance. In vulnerable children, complex trauma causes compromised attachment security, self-integrity and ultimately self-regulation. Thus it constitutes a threat not only to physical but also to psychological survival - to the development of the self and the capacity to regulate emotions (Arnold & Fisch, 2011). For example, emotional abuse by an adult caregiver that involves systematic disparagement, blame and shame of a child ("You worthless piece of s-t"; "You shouldn't have been born"; "You are the source of all of my problems"; "I should have aborted you"; "If you don't like what I tell you, you can go hang yourself") but does not involve sexual or physical violation or life threat is nevertheless psychologically damaging. Such bullying and antipathy on the part of a primary caregiver or other family members, in addition to maltreatment and role reversals that are found in many dysfunctional families, lead to severe psychobiological dysregulation and reactivity (Teicher, Samson, Polcari, & McGreenery, 2006).

Kaffman (2009) described childhood victimization as a "silent epidemic", and Finkelhor, Turner, Ormrod, and Hamby (2010) reported that children are the most traumatized class of humans around the globe. The findings of these researchers are at odds with the view that children have protected status in most families, societies, and cultures. Instead, Finkelhor reports that children are prime targets and highly vulnerable, due principally to their small size, their physical and emotional immaturity with its associated lack of control, power and resources; and their related dependency on caregivers. They are subjected to many forms of exploitation on an ongoing basis, imposed on them by individuals with greater power, strength, knowledge, and resources, many of whom are, paradoxically and tragically, responsible for their care and welfare. These traumas are interpersonal in nature and involve personal transgression, violation and exploitation of the child by those who rely on the child's lesser physical abilities, innocence, and immaturity to intimidate, bully, confuse, blackmail, exploit, or otherwise coerce. In the worst-case scenario, a parent or other significant caregiver directly and repeatedly abuses a child or does not respond to or protect a child or other vulnerable individual who is being abused and mistreated and isolates the child from others through threats or with direct violence. Consequently, such an abusive, nonprotective, or malevolently exploitative circumstance (Chefetz has coined the term "attack-ment" to describe these dynamics) has a profound impact on victim's ability to trust others. It also affects the victim's identity and self-concept, usually in negative ways that include self-hatred, low self-worth, and lack of self-confidence. As a result, both relationships, and the individual's sense of self and internal states (feelings, thoughts, and perceptions) can become sources of fear, despair, rage, or other extreme dysphoria or numbed and dissociated reactions. This state of alienation from self and others is further exacerbated when the occurrence of abuse or other victimization involves betrayal and is repeated and becomes chronic, in the process leading the victim to remain in a state of either hyperarousal/anticipation/hypervigilance or hypoarousal/numbing (or to alternate between these two states) and to develop strong protective mechanisms, such as dissociation, in order to endure recurrences. When these additional victimizations recur, they unfortunately tend to escalate in severity and intrusiveness over time, causing additional traumatization (Duckworth & Follette, 2011). In many cases of child maltreatment, emotional or psychological coercion and the use of the adult's authority and dominant power rather than physical force or violence is the fulcrum and weapon used against the child; however, force and violence are common in some settings and in some forms of abuse (sometimes in conjunction with extreme isolation and drugging of the child), as they are used to further control or terrorize the victim into submission. The use of force and violence is more commonplace and prevalent in some families, communities, religions, cultural/ethnic groups, and societies based on the views and values about adult prerogatives with children that are espoused. They may also be based on the sociopathy of the perpetrators.

Developmental issues, such as being adopted or experiencing a significant loss or trauma as a child, are also significant. Children often believe that they are the center of the universe and that if something bad happens, such as if a mother gets cancer, a child may think it is her fault and spend the rest of her life racked with guilt. Past successes and failures are a part of this circle, as are hope and a sense of worth and personal power or control.

It helps kids to know that they are doing some of the emotional work that their peers may be doing later in life. Learning to cope with lack of control over life’s events, grief over losing loved ones, betrayal over misplaced loyalties, and shame over feeling inadequate are struggles for everyone over the life cycle. For a percentage of people, trauma will also be their experience. These children may be lagging in some emotional developmental tasks, but be ahead, ultimately, in learning to deal with life.

For this reason, although our thinking brains tend to consider chronic stress, shock trauma, developmental trauma, and relational trauma to be different things, they all create the same effects in the mind-body system. If they’re so similar in their effects, then why does our culture usually treat them so differently? The short answer is that many powerful and ambitious people have a hard time admitting their mind-body system’s vulnerability. Powerful, high-achieving, and successful people—and the high-status institutions where they work—have no problem acknowledging “stress.” Indeed, we tend to consider “being stressed” to be a badge of honor—the evidence that we’re successful and accomplished. In our collective understanding, “being stressed” means being overworked, overscheduled, extremely busy, and definitely important. It’s just a necessary by-product of being a Master of the Universe. Why else would so many of us boast about how few hours of sleep we got last night? Or how many days have passed since we’ve seen our kids awake by the time we got home from work? Or how many different activities or demands we’re juggling at the same time? Or how many years it’s been since we took a proper vacation—or even a full weekend off? In our culture, we romanticize our stress, even as we whine about it with humble-brags like these.

The theme throughout the chapters is one of normalizing the problems of people with difficult and extensive trauma histories—those individuals who might be described within the categories of complex PTSD and/or developmental trauma

Distorted reasoning can become intergenerational as children absorb, model, and live out their parent’s way of thinking about and handling distressing situations, and it can affect the health of relationships. Denial of someone’s behavior—for example, a distortion of the truth—is excessive minimization or rationalization. When we attempt to make distorted behavior seem somehow normal, we have to twist our own thinking to do so. Also, as children we make sense of situations with the developmental equipment we have at any given age; when we’re young, we either borrow the reasoning of the adults around us or make our own childlike meaning.

Developmental Trauma Disorder.17 As we organized our findings, we discovered a consistent profile: (1) a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3) difficulties getting along with themselves and others. These children’s moods and feelings rapidly shifted from one extreme to another—from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling. Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted. Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they cannot help but define themselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and overreacting to slight frustrations makes it difficult for them to make friends.

The DSM-V offers a comprehensive set of criteria to define narcissism: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem. b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations. AND 2. Impairments in interpersonal functioning (a or b): a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others. b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others experiences and predominance of a need for personal gain. B. Pathological personality traits in the following domain: 1. Antagonism, characterized by: a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others. b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking. C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations. D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or sociocultural environment. E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).7

Recovery is a resumption of the work that was not completed when the woman was a girl. It is a coming into her own. It is an opportunity to resume the normal process of development that was sidetracked, perhaps first by constrained roles, perhaps by trauma, and then multiplied many times by hiding in the addiction. Her development was sidetracked by not accepting her needs as legitimate and not finding healthy ways to meet them, by not even knowing her needs. And so this is what recovery is: a developmental process of finding and building a new self. Recovery is a process of radical growth and change. When you are in recovery, you give birth to a new self. [...] Many women initially think that recovery means a move from bad to good. They think that being addicted is evidence of shameful neediness, of deep and lasting failures. Recovery is not a move from bad to good, but from false to real. [...] It is reality, being real, that now guides her rather than her efforts to be good or bad.

Recovery is a resumption of the work that was not completed when the woman was a girl. It is a coming into her own. It is an opportunity to resume the normal process of development that was sidetracked, perhaps first by constrained roles, perhaps by trauma, and then multiplied many times by hiding in the addiction. Her development was sidetracked by not accepting her needs as legitimate and not finding healthy ways to meet them, by not even knowing her needs. And so this is what recovery is: a developmental process of finding and building a new self. Recovery is a process of radical growth and change. When you are in recovery, you give birth to a new self. [...] Many women initially think that recovery means a move from bad to good. They think that being addicted is evidence of shameful neediness, of deep and lasting failures. Recovery is not a move from bad to good, but from false to real. [...] It is reality, being real, that now guides her rather than her efforts to be good or bad.

...some adolescent survivors describe feeling special, powerful, and sometimes entitled. This is especially true of those for whom excessive attention was part of the abuse relationship by virtue any power they held over the abuser or members of the family - especially their mothers in some cases of father-daughter incest - and of any affection or sexual pleasure they experienced. All of these feelings can coexist with self-loathing and shame or might alternate with them. Some victims experience this power as personally affirming, resulting in feelings of grandiosity, whereas others believe themselves to be malignantly powerful and defective. As children, these victims may have developed the belief that they could willfully manipulate others and "make or break" the family or their peer group (or the broader community setting) with their terrible powers or the secrets they hold. In adolescence these largely implicit ideas no longer manifest mainly or only as the egocentrism associated with early childhood. A more pervasive form of narcissistic entitlement and power and an apparently callous indifference to and contempt for others can lead to conduct disturbances and the victimization of others. Many individuals with apparent sociopathic tendencies and conduct disorders were victimized as children. Such individuals at some point had the capacity for respect, empathy, and genuine social responsibility that was lost and corrupted in the struggle to survive, to make sense of, and to remove themselves from the receiving end of victimization. Identification with the perpetrator and the victimization of others is specifically included as a core feature of complex PTSD.

Therapy must begin with empathy - not a patronizing sympathy, but instead one that is unflinching (Marotta, 2003). Empathy of this sort is highly attuned to the client, no matter the circumstance. The therapist strives to "travel in the client's shoes" or to "view the world from the client's perspective" in order to really understand his or her emotions, cognitions, and beliefs - in short, to understand from the perspective of the other (Wilson & Thomas, 2004). Treatment involves understanding that a client's defeatist and apparently helpless, disempowered, or "masochistic" perspectives can be a logical outgrowth of formative traumatic experiences and, further, may be highly creative means of self-protection. The therapist must not attempt to undo or "make up for" past abandonment or betrayals by their client's caregivers or in their close relationships, but instead first understand the client's perspective and approach to the world, while working to provide alternative perspectives on both past and present that promote change.

If the therapist understands and does not take mistrust as personal affront, the therapeutic relationship can evolve gradually. The client can begin to recognize that the therapist actually "gets" why he or she is initially skeptical, self-protective, or "realistically paranoid" and does not pressure the client to be a "happy camper" but instead works to earn trust by being honorable, reliable, and consistent. This also implies a view of the client's initial mistrust as expectable in light of the client's history - that is, as a strength rather than as a deficiency or pathology.

Adolescence is also a time when aggressive and other nonsexual drives intensify, which may play a role in the emergence of cutting. "There is something about that developmental phase, the biochemical changes that are occurring, that starts to activate all the structural damage in the brain that came from earlier trauma," says Mark Schwartz. It is at this age that abused children start exhibiting a number of acting-out and acting-in behaviors, from cutting and eating disorders to acts of outward aggression. Schwartz believes it isn't hormones alone that are responsible for this sudden upsurge in impulsive behavior but a complex interaction of the brain, the hormones, and the social environment.

Apparently, trauma can interfere with developmental growth and often freezes people at the emotional age they were when the trauma first occurred.

If the challenge is going to build resilience, it has to be moderate—just right. Finding the “just right” is a major issue with children who have had trauma. Remember, they frequently live in a persistent state of fear. And fear shuts down parts of the cortex—the thinking part of the brain. In a classroom, what may seem to be a moderate, developmentally appropriate challenge for many children may be an overwhelming demand on a child with a sensitized stress response

Adversity impacts the developing child. Period. What the impact will be, when it may manifest, how it may be “buffered”-we can’t always say. But developmental trauma will always influence our body and brain.

Childhood experiences literally impact the biology of the brain…our earliest developmental experiences, particularly touch and other relational-based sensory cutes, including the caregiver’s smell and the way they rock the infant, the songs they hum when feeding the infant, any unique movement in the way they respond to the infant when it’s needy-all of these things are organizing experiences that help create the infant’s “worldview,”…Really, every aspect of human functioning is influenced by early developmental experiences-both when there are consistent, predictable, and loving interactions and when there is chaos, threat, unpredictability, or lack of love…Love, given and felt, is dependent upon the ability to be present, attentive, attuned, and responsive to another human being. This glue of humanity has been essential to the survival of our species-and to the health and happiness of the individual. And this ability is based upon what happened to you, primarily as a young child.

If a child was abused in the context of an intimate relationship (by a parent, for example), they will find intimacy-emotional and physical closeness-threatening. They will often long to be connected but find themselves anxious, confused, or overwhelmed when they get close to someone. They will avoid intimacy in a relationship; if intimacy can’t be avoided, they will sabotage or undermine the relationship. This is one of the most common but least appreciated effects of developmental trauma.

A person’s “worldview” can change their immune system, and…a positive conversation with a friend can influence how a patient’s heart or lungs function that day. The interconnectedness becomes clear…everything matters…belonging is biology, and disconnection destroys our health. Trauma is disconnecting, and that impacts every system in our body...To this day, the role that trauma and developmental adversity play in mental and physical health remains underappreciated. children and adults with developmental trauma frequently experience chronic abdominal pain, headaches, chest pain, fainting, and seizure-like episodes-all very common symptoms related to a sensitized stress response.

are meant to distribute caregiving among the many adults in our “band”—our community. In a typical hunter-gatherer clan, for every child under six there were four developmentally more mature individuals who could model, discipline, nurture, and instruct the child. That is a 4:1 ratio: four developmentally mature individuals for each child under six. We now think that one caregiver for four young children (1:4) is “enriched.” That is 1/16th of what our developing social brain is looking for. That is relational poverty.

Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mind-sets of those around us.

The developmental process is very front-loaded, meaning that the majority of brain growth and organization takes place in the first years of life. Now, this doesn’t mean that the brain won’t change after early childhood, but early life experiences do have a very powerful impact on how we develop.

predictable, moderate, and controllable activation of the stress-response systems, such as that seen with developmentally appropriate challenges in education, sport, music, and so forth, can lead to a stronger, more flexible stress-response capability—i.e., resilience.

These crises (in addition to trauma endured during the war) led to identity issues, anger, depression, anxiety, physical illness, sleep and dream disturbance, neurological disorders, post- traumatic stress disorder (PTSD), addictive behaviors, eating disorders, attachment issues in personal and familial relationships, developmental delay, phobias, aggression, fear, gender dysphoria, self-harm, learning difficulties and disabilities, psychosomatic disorders, psychosis, and resentment for everything that they endured.

Toxic shame begins as an adaptation to adverse childhood experiences. Shame is the mechanism of disconnecting from and attacking the Self. Shame becomes a survival strategy to protect against attachment loss and environmental failure, which are experienced as loss of love in the universe. When shame occurs early in a child’s development, their sense of Self becomes associated with shame.

When people experience relational trauma, they are generally not responding to a mortal threat. Instead, they are responding to a threat to the security of one’s sense of Self. This has profound impact on the neurodevelopment of children and self-organization. For young children, their sense of Self is dependent on their early environment. They are 100 percent dependent on their caregivers for their survival and well-being. A young child who experiences environmental failure has the lived experience that they themself won’t exist without connection and love.

For Paul, being angry meant that he was like his father and therefore “bad.” Splitting off his anger and rage reinforced a sense of powerlessness but also meant he was unlike his father and therefore “good.

In general, it is useful when working with chronic anxiety to look for split-off anger. On the journey toward reconnection with core expression and the life force, anxiety and anger are ultimately transformed into healthy self-expression, strength, and the capacity for separation/individuation.

grieving is an important element in the reconnection process. Grief is how human beings come to terms with irrevocable loss.

In a healing cycle, connection to our body, emotions, and life force allows for greater connection with others, and in turn, connection with others supports greater connection to ourselves. The connection that has always been our deepest desire is now no longer our greatest fear.

As we experience the development of personal agency, we come to see that the rejection we fear from the world has already happened.

This is the start of a toxic mismatch between the child’s capabilities and the unrealistic expectations of an education system that is all too often underresourced, developmentally uninformed, and trauma-ignorant. Even if the child “progresses” to the next grade, they are still behind, and this sets them up to fail. Year after year, they fall further and further behind. Their delays in developing skills, together with their trauma-related symptoms, begin to attract mental health labels (see Figure 6). The hypervigilance from their sensitized stress response is labeled ADHD; their predictable efforts to self-regulate—by rocking, chewing gum, doodling, daydreaming, listening to music, tapping their pencil, etc.—are prohibited. They will be labeled, medicated, excluded, punished, perhaps expelled, and then, all too often, arrested. When they try to avoid the constant humiliation of school, they’re charged with truancy; when they try to flee and the school staff tries to stop them, a restraint incident results in charges of assault—against the child. This is the school-to-prison pipeline.

The effects were maladaptive, meaning that instead of helping the tadpole thrive and survive, the response made things much, much worse. In fact, early exposure often led not only to irreversible developmental changes but, eventually, to death.

Individuals with the Connection Survival Style already see their lives as problems to be solved, so that if a therapist holds a primarily problem-solving focus, these clients’ vulnerable inner world can be missed.

Individuals with the Connection Survival Style often come into therapy with fears and even obsessions about death and disease.

In summary, to reestablish agency, a NARM therapist explores with clients how they are contributing to their own suffering—how they may be consciously or unconsciously instrumental in creating their own distress as adults.

The abused child has no choice but to depend on his or her caregivers. So in order to ensure that they will continue to be present and available, he or she takes their guilt upon himself or herself—much as Christ archetypally took upon himself the sins of the world and died in its stead. Abused children willingly take on the role of scapegoat and sacrifice themselves and their developmental potential in the interests of survival.

Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mind-sets of those around us. Research from these new

From early in life, we will have relationships that nurture us and ones that bring us pain and fear. Usually, the same person brings both. Our tender, comforting mother also requires standards of behaviour that are beyond our developmental capacity, for example.

There is also some evidence indicating specificity, wherein certain adverse experiences appear to be related to specific psychic phenomena. For instance, being bullied as a child is closely related to intense paranoia, while sexual abuse is more closely related to hearing voices (Bentall et al., 2012). Yet, most research and treatment continues to focus on individual internal defects (i.e., “illness”) that exist separate from one’s developmental context or life circumstances, and a search for the ever-elusive genetic basis for these purported defects.

Whеn a child’s еmоtіоnаl nееdѕ аrе nоt mеt аnd a сhіld is rереаtеdlу hurt and abused, this deeply and рrоfоundlу аffесtѕ thе сhіld’ѕ development. A ѕurvіvоr wіll often соntіnuе on subconsciously wаntіng those unmеt сhіldhооd needs in adulthood. Lооkіng fоr safety, рrоtесtіоn, being сhеrіѕhеd and lоvеd саn оftеn bе nоrmаl unmеt needs іn childhood, аnd the survivor searches fоr thеѕе іn оthеr аdultѕ. Thіѕ can bе whеrе ѕurvіvоrѕ ѕеаrсh fоr mоthеr and fаthеr fіgurеѕ. Transference іѕѕuеѕ in counseling саn occur аnd thіѕ is normal fоr сhіldhооd аbuѕе ѕurvіvоrѕ. Innеr сhіld hеаlіng саn be healing fоr сhіldhооd аbuѕе ѕurvіvоrѕ. It is where thе ѕurvіvоr begins to mееt thе nееdѕ оf their hurt and wоundеd child, thеmѕеlvеѕ.

A key part of a neurosequential approach is to help parents, teachers, and clinicians know the “stage” and watch the “state.” Meaning we want to help them learn what the child’s actual developmental capabilities are—their actual stage, as opposed to their age. And we want to help them become aware of the child’s state-dependence; we encourage them to ask themselves, “Is this child in a state where they can effectively ‘hear’ what I’m trying to say or teach?

Affect dysregulation