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  "LA DISREGOLAZIONE DEL CERVELLO DESTRO: Un meccanismo fondamentale dell'attaccamento traumatico e della psicopatogenesi del disturbo post-traumatico da stress"

 

 

 

 

 

 

 di Allan N. Schore

 

    Foto: Allan N. Schore

 

 

 

 


 

Allan N. Schore è docente al Dipartimento di Psichiatria e di Scienze Biocomportamentali alla "UCLA David Geffen School of Medicine" e all'"UCLA Center for Culture, Brain and Development". E' autore del libro "Affect Regulation and the Origin of the Self" e di due recenti libri: "Affect Dysregulation and Disorders of the Self" e "Affect Regulation and the Repair of the Self", quest'ultimo uscito anche in italiano per Astrolabio. Si ringrazia sentitamente  l'autore per aver acconsentito alla sua pubblicazione in versione italiana su "Frenis Zero". La traduzione in italiano è di Giuseppe Leo.

Abstract in English:

Objective: This review integrates recent advances in attachment theory, affective neuroscience, developmental stress research, and infant psychiatry in order to delineate the developmental precursors of posttraumatic stress disorder.

Method: Existing attachment, stress physiology, trauma, and neuroscience literatures were collected using Index Medicus/Medline and Psychological Abstracts. This converging interdisciplinary data was used as a theoretical base for modeling the effects of early relational trauma on the developing central and autonomic nervous system activities that drive attachment functions.

Results: Current trends that integrate neuropsychiatry, infant psychiatry, and clinical psychiatry are generating more powerful models of the early genesis of a predisposition to psychiatric disorders, including PTSD. Data are presented which suggest that traumatic attachments, expressed in episodes of hyperarousal and dissociation, are imprinted into the developing limbic and autonomic nervous systems of the early maturing right brain. These enduring structural changes lead to the inefficent stress coping mechanisms that lie at the core of infant, child, and adult posttraumatic stress disorders.

Conclusions: Disorganized-disoriented insecure attachment, a pattern common in infants abused in the first two years of life, is psychologically manifest as an inability to generate a coherent strategy for coping with relational stress. Early abuse negatively impacts the developmental trajectory of the right brain, dominant for attachment, affect regulation, and stress modulation, thereby setting a template for the coping deficits of both mind and body that characterize PTSD symptomatology. These data suggest that early intervention programs can significantly alter the intergenerational transmission of postttraumatic stress disorders.

 

Uno studio recente ed ampio, rappresentativo a livello nazionale, riporta che il 60% degli uomini ed il 50% delle donne sperimenta un evento traumatico in un qualche periodo della loro vita [1]. Eppure questo stesso studio trova che le stime del tipo 'lifetime' del disturbo post-traumatico da stress (PTSD) sono del 5% per gli uomini e del 10% per le donne. Un'altra ricerca indica che approssimativamente solo una metà di coloro che hanno un episodio di PTSD sviluppano sintomi cronici del disturbo [2]. Questi dati sottostimano un problema centrale: sebbene il trauma sia un elemento comune di molte se non della maggior parte delle vite umane, perché solo una certa proporzione minoritaria di individui esposta alle varie forme di trauma sviluppa reazioni patologiche croniche a livello mentale e fisico nei confronti di eventi catastrofici della vita?

Un gran cambiamento nel nostro approccio a questo problema si riflette nel passaggio dal DSM-III-R, in cui la gravità del trauma era considerata il fattore chiave nello scatenare uno PTSD, al DSM-IV in cui vengono valorizzate le caratteristiche della vittima, comprese la reazione al trauma. In altre parole, la eziologia del PTSD viene meglio compresa in termini di ciò che un individuo porta all'evento traumatico, come anche ciò che egli sperimenta in seguito, e non la natura dell'evento traumatico in sé e per sé[3]. Ciò chiaramente implica che certi tratti di personalità sono specificatamente associati con l'unicità dei modi con cui gli individui fronteggiano o falliscono nel fronteggiare lo stress.

L'odierna ricerca psicobiologica sul PTSD ripete questo principio[4]:

<<Sebbene molte persone siano esposte al trauma, solo alcuni individui sviluppano lo PTSD; la maggior parte non lo fa. E' possibile che gli esseri umani si differenzino riguardo al livello a cui lo stress induce delle perturbazioni neurobiologiche dei loro sistemi di risposta agli eventi minacciosi, che può tradursi in una differente capacità di fronteggiare le esperienze avversative>> (p. 412). <<Queste differenze individuali esistono prima dell'esposizione al trauma e possono essere utilizzate per costruire dei tests di resistenza e di vulnerabilità allo stress negli esseri umani>> (p. 420).

C'è attualmente un generale consenso che lo  stadio di sviluppo in cui avviene l'esposizione[5] e lo specifico tipo di esposizione traumatica[6] sono fattori essenziali nel PTSD, eppure essi sono stati svalorizzati nella recente letteratura[7]. Sottolineare questi fattori, comunque, porta in primo piano una serie di elementi fondamentali. Quali sono gli effetti a breve ed a lungo termine del trauma negli stadi più precoci dello sviluppo, perché questa esposizione influisce negativamente nella maturazione dei sistemi individuali di "stress coping", e in che modo ciò è correlato con la genesi di organizzazioni di personalità premorbose vulnerabili al PTSD? Tali questioni, che si trovano al centro della teoria del trauma, indirizzano la psichiatria clinica nel regno della psichiatria dell'età evolutiva, ed in particolare di quella infantile.

 
 

Attaccamento e sviluppo dei meccanismi del cervello destro di "stress coping"

 

Di fatto l'esplorazione dello sviluppo dei meccanismi adattativi di "coping" e della personalità è al centro della teoria dell'attaccamento, <<l'approccio dominante per comprendere lo sviluppo precoce socio-emotivo e della personalità durante gli ultimi 25 anni di ricerca>> [8, pag. 145]. Nel suo rivoluzionario libro sull'attaccamento John Bowlby[9] ha ipotizzato che la infantile "capacità di far fronte allo stress" è correlata con certi comportamenti materni, e che l'esito dell'attaccamento ha conseguenze che sono "vitali per la sopravvivenza della specie". L'ipotesi di Bowlby che, all'interno della relazione di attaccamento, la madre modelli lo sviluppo delle risposte di "coping" del bambino è oggi supportata da un gran numero di stdi sperimentali che caratterizzano le cure materne e lo sviluppo delle risposte allo stress[10], e l'influenza dei fattori materni sull'ontogenesi dell'asse limbico-ipotalamico-pituitario-surrenale[11].

Recenti modelli psicobiologici dello sviluppo indicano che

<<Una risposta individuale a stimoli stressogeni può essere disadattativa producendo risposte fisiologiche e comportamentali che possono avere conseguenze dannose, oppure possono essere adattative, rendendo l'individuo capace di migliorare le proprie capacità di 'coping' nei confronti dello stress. Eventi  che sono stati precocemente sperimentati nella vita possono essere particolarmente importanti nel modellare la modalità individuale di responsività nelle fasi successive della vita[12, pag. 1435].

Questi "eventi" sono esperienze di attaccamento, modellate dall'interazione delle predisposizioni psicofisiologiche innate del bambino con l'ambiente sociale delle cure materna[13-22].

Inoltre, l'odierna ricerca di base sullo stress suggerisce che la deprivazione delle cure materne rappresenta una fonte di informazioni ambientali stressogene per il tipo di  evoluzione e di maturazione dei circuiti neuronali del sistema  di regolazione dello stress del bambino[23]. Tutto ciò completa gli studi che indicano che i fattori di stress pre- o post-natali influenzano negativamente la successiva salute mentale, specie quando le cure materne sono assenti. Tale lavoro deriva dal profondo interesse della teoria dell'attaccamento per l'eziologia non solo dello  sviluppo normale, ma anche per quello anomalo. Nell'applicare la teoria ai legami tra i caratteri dello "stress coping" e la psicopatologia, Bowlby [24] ha proposto:

<<Nel campo dell'eziologia e della psicopatologia [la teoria dell'attaccamento] può essere usata come cornice di riferimento per formulare specifiche ipotesi che correlino differenti esperienze familiari a differenti forme di disturbo psichiatrico ed anche, se possibile, a cambiamenti neurofisiologici che accompagnano loro>>.

In questo articolo applicherò questo principio centrale della teoria dell'attaccamento all'eziologia del PTSD. Sebbene i modelli eziologici del PTSD si siano concentrati innanzitutto sull'abuso sessuale infantile, suggerirò che una maggiore attenzione sulle conseguenze neurobiologiche dell'abuso relazionale e dell'attaccamento disregolato del bambino può offrire una più profonda comprensione dei deficit psiconeurobiologici dello "stress coping", sia sul versante mentale che su quello somatico, che definiscono la presentazione sintomatologica del disturbo.

 
Stress ed emisfero destro

 
 

Una crescente quantità di prove recenti mostra che il circuito neuronale del sistema dello stress è localizzato nel cervello destro, il primo a svilupparsi, nell'emisfero cioè che è dominante per il controllo delle funzioni vitali che sostengono la sopravvivenza e la risposta allo stress degli esseri umani[25]. Poiché le strategie di "stress coping" sono profondamente connesse in funzioni essenziali dell'organismo, esse cominciano la loro maturazione prima e dopo la nascita, in un periodo di dominanza del cervello destro[26]. Uno studio molto recente di Risonanza Magnetica (MRI) su bambini riporta che  il volume del cervello aumenta rapidamente durante i primi due anni, che l'aspetto adulto normale si rileva a due anni e che tutti i più importanti fasci di fibre possono essere identificati all'età di 3 anni, e che i bambini sotto i 2 anni mostrano volumi emisferici più grandi a destra che a sinistra[27]. Le esperienze di attaccamento dei primi 2 anni perciò influenzano direttamente la maturazione dipendente dall'esperienza del cervello destro[14, 21, 28-32]. Queste comprendono le esperienze con un "caregiver" traumatizzante, che sono ben note per influenzare negativamente la sicurezza dell'attaccamento del bambino, le sue strategie con cui fa fronte allo stress ("stress coping") ed il sentimento di sé[33, 34].

I recenti studi nel campo della traumatologia dello sviluppo concludono che <<lo stress opprimente legato a maltrattamento nel corso dell'infanzia è associato ad influenze dannose sullo sviluppo del cervello>>[35, pag. 1281]. Questo "maltrattamento" si riferisce in modo specifico alla grave di disregolazione degli affetti di due forme prevalenti di trauma infantile: l'abuso e la trascuratezza. Ci sono molte prove per cui i fattori di stress sociali sono di gran lunga più dannosi rispetto agli stimoli avversativi non sociali[36], e quindi l'attaccamento o il "trauma relazionale" proveniente dall'ambiente sociale ha un impatto più negativo sul cervello del bambino rispetto agli attacchi provenienti dall'ambiente fisico, non umano o inanimato. E così si sta oggi sottolineando che una relazione precoce disfunzionale e traumatica è, in modo specifico, il fattore di stress che porta al PTSD, che il trauma grave di origine interpersonale può avere la meglio su qualsiasi fattore di resilienza genetico, costituzionale, sociale o psicologico, e che i conseguenti effetti dannosi sullo sviluppo cerebrale e le alterazioni dei sistemi biologici di regolazione dello stress possono essere considerati come "un complesso disturbo dello sviluppo indotto dall'ambiente"[37].

Il fatto che un tale trauma sia l'"ambiente" suggerisce chiaramente che il bambino piccolo sperimenta frequentemente non un episodio singolo o acuto, ma un imprevedibile stress traumatico "cumulativo" e cronico nelle sue primissime interazioni con un altro essere umano. La letteratura sullo stress, che oggi sta investigando i "determinanti delle differenze individuali nella reattività allo stress nello sviluppo precoce" dimostra chiaramente che lo stress acuto produce deficit a breve termine e reversibili, mentre lo stress ripetuto, prolungato e cronico è associato a profili a lungo termine di reattività autonomica, espressi in "cambiamenti neuronali strutturali, inclusa l'atrofia che potrebbe condurre a danni permanenti, come la perdita neuronale"[38, pag. 183]. In consonanza con questo principio, in miei  scritti precedenti ho suggerito che il trauma relazionale precoce ha un significativo impatto negativo sulla maturazione dipendente dall'esperienza del cervello destro, che si trova in un periodo critico di crescita durante gli stessi intervalli temporali rispetto alle esperienze diadiche di attaccamento[14, 39-44].

Poiché l'emisfero destro, che si sviluppa più precocemente, è, più del sinistro, profondamente interconnesso coi sistemi autonomico, limbico e della vigilanza, esso è dominante per l'elaborazione dell'informazione sociale, emotiva e corporea[14, 45-47]. Un gran numero di studi oggi indicano che questo emisfero è dominante non solo per la ricezione[48-51], per l'espressione[52], e per la comunicazione[53] dell'emozione, ma anche per il controllo delle reazioni emotive spontaneamente evocate[54], per la modulazione delle "emozioni primarie"[55], e per la capacità adattativa della regolazione degli affetti[14, 18, 56].

Si è detto che la conseguenza più significativa del fattore stressogeno di un trauma relazionale precoce è la mancanza di capacità di auto-regolazione emozionale[57], espressa nella perdita della capacità di regolare l'intensità e la durata degli affetti[58]. Studi fondamentali di neuropsicobiologia dello sviluppo oggi indicano che lo stress perinatale porta ad un affievolimento della risposta di regolazione dello stress della corteccia prefrontale destra (e non sinistra) che diventa manifesto nell'età adulta[59]. Alla luce del ruolo essenziale dell'emisfero destro nella risposta allo stress degli esseri umani, questa concezione psiconeurobiologica della patogenesi del cervello destro indotta dal trauma si basa su dati recenti che suggeriscono che esperienze avverse precoci esitano in un'aumentata sensibilità agli effetti dello stress che si verifica più tardi nella vita e rendono un individuo vulnerabile a disturbi psichiatrici correlati allo stress[60]. La disregolazione affettiva viene oggi considerata un meccanismo fondamentale alla base di tutti i disturbi psichiatrici[61].

Una prospettiva basata sulla neuropsicopatologia dello sviluppo impone che <<Conoscere lo sviluppo neuropsicologico consiste nel confrontarsi col fatto che il cervello è modificabile, in modo tale che la sua organizzazione strutturale riflette la storia dell'organismo>>[62, pag. 297]. Una storia dello stress traumatico relazionale precoce è impressa in modo specifico nel cervello destro, che è dominante per la memoria "autobiografica"[63] o "personale"[64]. Terr[65] scrive che l'esatto rispecchiamento ("literal mirroring") degli eventi traumatici da parte della memoria comportamentale si può stabilire a qualsiasi età, compresa l'infanzia. Questo modello evolutivo suggerisce che gli attaccamenti traumatici, che si verificano in un periodo critico dell'organizzazione del cervello destro, creeranno una durevole vulnerabilità alla disfunzione durante lo stress ed una predisposizione al PTSD.

 

 

 
(fine della prima parte dell'articolo- l'articolo completo verrà pubblicato su un prossimo libro edito a cura di Frenis Zero)
 
 

 

       

 

 

 

 

 

 

 
 

 
Bibliografia originale:

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