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Skynjun, heili, boðefni, heilsa:
Ný þekking um “nýja” barnið
Linn Getz, MD, PhD Trúnaðarlæknir, Landspítali ogDósent, Institutt for samfunnsmedisin og Allmennmedisinsk forskningsenhet, Norwegian University of Science and Technology
Máttur tengslanna, Akureyri 3. október 2008
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Boðskapur í hnotskurn•Líkaminn er ekki líffræðileg “vél”!
•Upplifanir okkar og tengsl við aðra virðast hafa djúpstæð áhrif á líkama okkar, alveg niður á lífeðlis- og lífefnafræðilegt plan.
• Á síðastliðnum áratug hafa margar rannsóknir sýnt hvernig “existential” lífsskilyrði geta haft áhrif á þroska heilans og leiða til sjúkdóma og atferlisröskunar.
• Mikilvægt er að reyna að fyrirbyggja óæskilega þróun. Ef skaðin er skeður, bendir margt til að styrkjandi samskipti bæti ástandið – einnig frá líffræðilegu sjónarmiði.
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Fyrsti Þáttur: Hugmyndafræðin
Annar Þáttur: Vísindin (nokkur dæmi)
Tvær “meta-analýsur”: Van Morrison (f. Belfast, 1945)
Yfirlit
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“Van Morrison is a painfully introverted figure who rarely gives interviews and is often at a loss to explain his own lyrics.”
- The Rolling Stone Encyclopedia of Rock & Roll, 2001
“The healing game” (1997)
“Keep it simple” (2008)
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Fyrsti þáttur: Hugmyndafræðin
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René Descartes (1596-1650)
“Vélræn” læknisfræðileg hugmyndafræði...
- Líkaminn sem líffræðileg vél (“automaton”) - Umhverfi og tengsl við aðra ekki með í myndinni - Læknirinn skoðar - sjúklingurinn er skoðaður
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http://www.adhd.is/default.asp?sid_id=26357&tre_rod=004|&tId=1
Dæmi
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“Orsakirnar eru líffræðilegar (e.t.v. genetískar)” – hvað þýðir það (ekki)?
“Tónlist er eðlis-fræðilegt fyrirbæri”
“Orsakir þunglyndis eru líffræðilegar”
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René Descartes (1596-1650)
“Vélræn” læknisfræðileg hugmyndafræði
- Líkaminn sem líffræðileg vél (“automaton”) - Umhverfi og tengsl við aðra ekki með í myndinni - Læknirinn skoðar - sjúklingurinn er skoðaður
?
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Við erum öll “100% líffræðilegar” verur
- en þar með er sagan ekki öll sögð
The “mind-body problem”
Frjáls vilji?
Máttur tengslanna...
Hið “heilaga”?
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Hver er veruleiki drengsins? ...frá huganum til heilans (personal
appraisal)...
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Hver er veruleiki drengsins? ...frá huganum til heilans (personal
appraisal)...“Mig langar að læra að þjálfa hund!”
“Pabbi (sem lamdi mig svo oft áður en við mamma fluttum út) var að kaupa sér alveg eins hund...”
?
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Psycho-nevro-endocrino-immunology: Hvaða ‘kerfi’ setur hugurinn af stað í líkamanum?
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Psycho-neuro-endocrino-immunology 1
• Nálgast og kynnast
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Psycho-neuro-endocrino-immunology 2
• Forða sér - flýja?
Adrenalín
Cortisol
“Inflammasjón”
• Gefa skít í ?
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Psycho-neuro-endocrino-immunology 3
•Eða...?
(Bara drengurinn getur sagt okkur hvaða þýðingu ‘senan’ hefur fyrir hann...)
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1. Jákvæð streita (positive stress)
• Alveg nauðsynleg til að móta ‘karakter’ og sköpunarhæfileika...
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2. “Þolanleg” streita (tolerable stress)
• Streita sem getur skaðað þróun heilans ef stuðning vantar
• Einhver traustvekjandi aðili þarf að vera með í myndinni • Einstaklingurinn verður að “ná sér á strik” á milli átaka
• “Ég gat alltaf talað við afa”
• Listamanna-reynsla...? (“The school of hard knocks”)
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3. Skaðvænleg streita (toxic stress)
• Viðvarandi “alarm” þar sem einstaklingurinn nær ekki að jafna sig (líffræðilega: “allostatic overload”
• Virðist geta haft margvíslegar afleiðingar á þroska heilans og líkamans; “inflammation” í blóði (mælanleg interleukin, cortisól, o.s.frv.)
• Örugglega misjafnt hversu viðkvæm við erum (erfðir skipta máli)
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Bornstein SR et al. Cell 2008 (in press)
Autonomic nervous system
HPA axis
Ónæmiskerfið, endotel o.fl. Áhrif á allan líkamann þar með talið heilann
Psycho-nevro-endocrino-immunology: Hvaða líkamleg ‘kerfi’ er um að ræða?
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Elenkov IJ, Neurochemistry International 2007
Sálræn / hugræn upplifun
Líffræðilegt ‘svar’ (spegilmynd af huganum)
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McEwen B, New England Journal of Medicine, 1998
Underlying mechanisms of chronic detrimental stress:“Allostatic overload”: a model for chronic overtaxation of the body’s stress-response systems
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Kenning Aaron Antonovsky’s “Sense of coherence” (1987)
The foundation for health (salus) seems to lie in an experience of -
- Meaningfulness - Comprehensibility - Manageability
“The mystery of health” - Salutogenesis
“Af hverju halda sumir heilsu við mjög erfiðar aðstæður, en aðrir ekki?”
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”Existential” upplifanir (sálrænar?), sem virðast hafa bein áhrif á allan líkamann, m.a. á þroska heilans
Trust Betrayal
Belonging and nourishment Isolation and neglect
Respect Humiliation
Care Leaving behind
Honour and pride Guilt and shame
Source: Anna Luise Kirkengen, 2005
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Heimild: Anna Luise Kirkengen, 2005
Traust Svik
Að tilheyra og dafna Einmanaleiki og vanræksla
Reisn Vanvirðing - niðurlæging
Vernd og umhyggja Höfnun
Stolt og heiður Sektarkennd og skömm
”Existential” upplifanir (sálrænar?), sem virðast hafa bein áhrif á allan líkamann, m.a. á þroska heilans
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“Embodiment” “Embodied minds”“Mindful bodies”
...?
Hvernig getur fagfólk talað um þetta?
(Það er alla vega ekki rökrétt að hugsa um ‘sálrænt’ áfall eða álag sem einangrað fyrirbæri)
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Meta-analysis (1) Van Morrison : Soul
Soul is a feeling, feeling deep withinSoul is not the colour of your skinSoul is the essence, essence from withinSoul is where everything begins
Soul is what you’ve been throughWhat’s true for youWhere you going to What you’re gonna do -
Soul can be your station for the folk of your nationSomething that you wear with prideSoul can be your vision It’s not something that is hiddenIt’s not something that you want to hide…
(2008)
“I was educated by the school of hard knocks”
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Annar þáttur: Vísindin
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Brain, Behavior and Immunity, 2008
Psycho-neuro-immunology:
Hugur - heila/tauga - ónæmis/innkirtla-kerfin
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Conclusion:
... Sem betur fer, tilheyra nú ágreiningsmál um það, hvort sálrænir prósessar geti haft áhrif á ónæmiskerfið nú sögunni til – þar eð vísindaleg sönnun liggur nú fyrir.”
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Þroski heilans í hnotskurn:
“Samspil gena, upplifana og reynslu mótar arkitektúr heilans. Samskipti barns við mikilvæga fullorðna í lífi þeirra vega sérstaklega þungt í þessu ferli.”
- Jack P. Shonkoff, professor of child health, Harvard: A science-based framework for Early Childhood Policy, Jan 2008
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”… if a mother is stressed while pregnant, her child is substantially more likely to have emotional or cognitive problems, including an increased risk of ADHD, anxiety, and language delay.”
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Biol Psychiatry. 2008 Aug 8. Epub ahead of print
Andlegt ofbeldi í formi niðurlægjandi orðalags foreldra virðst eitt og sér getað skaðað þroska heilans..... Mælanlegt með MRI
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Biol Psychiatry. 2008 Aug 8. Epub ahead of print
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Neuropsychiatry Clin Neurosci 2008; 20: 292-301
Preliminary evidence for sensitive periods in the effect of childhood sexual abuse on regional brain development.Andersen SL, Tomada A, Vincow ES, Valente E, Polcari A, Teicher MH.
Department of Psychiatry, Harvard Medical School, Belmont, MA 02478, USA.
Volumetric MRI scans from 26 women with repeated episodes of childhood sexual abuse and 17 healthy female comparison subjects (ages 18-22 years) were analyzed for sensitive period effects on hippocampal and amygdala volume, frontal cortex gray matter volume and corpus callosum area. Hippocampal volume was reduced in association with childhood sexual abuse at ages 3-5 years and ages 11-13 years. Corpus callosum was reduced with childhood sexual abuse at ages 9-10 years, and frontal cortex was attenuated in subjects with childhood sexual abuse at ages 14-16 years. Brain regions have unique windows of vulnerability to the effects of traumatic stress.
Ofbeldi svo sem kynferðisleg misnotkun í æsku virðist geta skemmt heilann á mismunandi svæðum. Það fer m.a. eftir aldri og þroskastigi barnsins.
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J Pediatrics 2008 (in press)
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The ACE Study
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The Adverse Childhood Experience study (ACE) Kaiser Permanente California/CDC Atlanta
“ACE score”: the number of reported factors per individual (score 0-8)
Abuse: Emotional, Physical, contact Sexual
Neglect: Emotional, Physical
Household dysfunction: Mother treated violently Household substance abuse (alcohol or drugs)Household member in prisonHousehold member was chronically depressed, suicidal, mentally ill, in psychiatric hospital Parental separation or divorce
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The ACE Study shows a clear dose-response relationship
between adverse childhood events and future disease
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“Áhættuhegðun”
Röskun í þróun heila- og tauga-kerfisins - áhrif á allan líkamann
‘Brengluð’ hugsun; flókin og erfið samskipti
Sjúkdómar ++ (líkamlegir og ‘andlegir’)
Ótímabær dauði
ACE experiences
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Kynferðisleg misnotkun í æsku
==> depurð og kvíði ==> alcoholismus og lyfjamisnotkun
==> obesitas (offita með BMI > 30), ==> háþrýstingur,
==> sykursýki,
==> Slys (endurtekin smáslys) Dermatitis (eksem), hugsanlega vegna áfalla í æsku.
Ný hugsun um orsaka-tengsl í skráningarkerfunum
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Oh the mud splattered victimsHave to pay out all along the ancient highway
Torn between half truth and victimisationFighting back with counter attacks
It’s when that rough God goes ridingWhen the rough God goes glidingAnd then the rough God goes ridingRiding on in...
Meta-analýsis 2: Máttur brenglaðra tengsla
Van Morrison: Rough God goes riding
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....And it’s a matter of survivalWhen you’re born with your back against the wall...
Á siðustu árum hafa margar rannsóknir sýnt samband á milli “existential” niðurbrots, sjukdóma og dauða -
Þekkingin um samband tilvistar (existence) og líffræði (biology) getur hjálpað okkur að sjá hvernig hlutirnir hanga saman og hvernig er hægt að vinna nánar úr málunum...
....Won’t somebody hand me a Bible, won’t you give me that number to call...
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Góðu fréttirnar eru…
En ef þetta er svona –
er þá eitthvað hægt að gera?
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“Change the mind and you change the brain”:
Góð og skapandi samskipti geta mótað heila (og líkama...)
- mælanlegt með MRI
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Tidsskriftet Nr 15,2008
Glen O. Gabbard – einn þekktasti geðlæknir í Bandaríkjunum, var í Noregi vorið 2008...
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Forebyggende helsearbeid. Policydokument for Norsk forening for allmennmedisin, NFA (2007)
”Det mest grunnleggende forebyggende helsearbeid handler om å lage et samfunn der folk flest møter respekt og derigjennom lærer selvrespekt. Ett av de viktigste forebyggende tiltak er å sikre at barn får en trygg oppvekst i nærvær av ansvarlige voksne.”
www.legeforeningen.no/index.gan?id=128650&subid=0
“Grunnurinn að læknisfræðilegu forvarnarstarfi er að skapa samfélag þar sem fólk nýtur mannlegrar reisnar og læri þar með að virða sjálft sig og aðra. Það er einkum mikilvægt frá heiluverndarsjónarmiði að trygga börnum öruggt uppeldi í nærveru ábyrgra fullorðinna.”
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Byltingarkennd sjónarmið í hátækni-læknisfræði...
... en gamall sannleikur á Akureyri!
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ÁFRAM “NÝJA BARNIД!
Takk fyrir mig
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Auka myndir
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Niðurdrepandi existential upplifanir (Toxic stress)
Áhrif á líffræði
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Acute and chronic “stress”...
Worklife: “High demand - low control”, “Injustice/Unfairness”, “Effort–reward imbalance”...
Social inqualities, Low position in social hierarchy, Humiliation, Discrimination,...
Adverse childhood experiences, Household dysfunction, Sexual abuse, Violence...
Loss of a child, Grief High burden of care...
“Mental” disorders (depression)
Existential “overload” Biological response