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Neuropsychology: The Intersection of LD and Psychodynamic Processing for Therapists

Sensory and learning differences including high functioning autism, asperger’s, PDD-NOS all now subsumed under the autism spectrum, non-verbal learning disability and ADHD are experienced by people who struggle with the constant challenges these differences pose, as micro-traumas as they struggle to understand, fit in and keep up in a world that is hard to process. Frustration with oneself and criticism from teachers, their parents and bullying peers causes constant depression and self recrimination and these are experienced as micro-traumas, stored in the hippocampus as long term memory mishaps, causing PTSD and resulting anxiety and subsequent failures daily, that faced with an activity, they remember how hard it was, panic, have a sympathetic nervous system response because of the PTSD, and fight, flight or freeze in shut down, disconnect or dissociation. Molly wakes up to an alarm clock and her sympathetic nervous system becomes over-aroused. Mom tells her to get dressed, hurry up, why aren’t you dressed. Shame, frustration, sadness, feeling mis-understood and unable to tell mom why she can’t initiate, sequence and motor plan getting dressed, she has a meltdown and mom, who has to get her out the door to the bus, yells at her. They both calm down and Molly has to eat breakfast which she cannot eat because the cereal has milk in it and she is a picky eater and has to have her food separated and doesn’t like cereal, She doesn’t know how to explain why she cant motor plan with her tongue and lips to chew and move the food from one part of her mouth to the other. She becomes frustrated. On the bus, (she has skipped brushing her teeth, Too much) Molly is overwhelmed by all the smells she can smell separately and by the movement of the bus and by the time she is in class, overwhelmed by all the noise and visual stimulation of all the kids moving around and is now on high alert, sympathetic nervous system getting activated for fight/flight but she holds it together to try to learn. It’s time for journal and the teacher doesn’t like her handwriting and tells her its sloppy and she has to do it over. Shame, frustration, narcissistic injury are experienced. Then it’s math time and Molly remembers how ashamed she felt the last time she tried to do math. It never goes well and it makes her feel like her brain is damaged because she can grasp the concept and then loses it and can’t keep the numbers lined up. Because the function for changing sets in her frontal cortex is impaired, doing long division is too hard for her, having to move back and forth between different parts of the equation. Shame overwhelms her. She freezes, unable to cope with the onslaught of fear and dread flooding her from her memory of failure from the last time and is activating her adrenals and she hides in the closet, withdrawing, shutting down. Later, Her teacher gets angry with her and calls her mother. In the meantime, it’s recess and Molly doesn’t want to go outside. After prompting and getting stern with Molly, her teacher finally gets her to go outside. Molly doesn’t want to go because she anxiously remembers the last time and the times before on the playground when she was on the periphery, unsure of how to enter the group, what to say, feeling like she dropped in from another planet, without tools to pick up the social cues needed for the easy banter and negotiation and playfulness others come by naturally.. She is getting more and more sad and angry, watching them have fun as she is isolated and alone. It is time to leave school and Molly feels anxious about the transition, but cannot put into words that she is scared she forgot something she needs at home, scared of the onslaught of new sensory overstimulation she will experience and anticipating feeling lonely or flooded again. People will look at her and she won’t be able to simply smile and make eye contact. It will overstimulate her already overstimulated nervous system. Furthermore, difficulty with transitions is hardwired in her frontal cortex. She gets home and her mother gets angry with her for hiding in the closet and avoiding classwork and Molly begins to be angry with herself,and has a meltdown, inconsolable hating herself. The message she comes away with is she is impaired, damaged, unliked, unlikeable and is determined to do it perfectly next time to counteract the awful feelings she is having about herself. This causes her depression and of course the bar is too high and the PTSD of this whole experience happens again but the next time she isn’t able to do it perfectly and obsessively goes over and over in her head what she could have said or done differently and melts down in school, unable to wait until she gets home, and she gets aggressive. At home, again ashamed, depressed, angry at her teachers and parents for not understanding but mostly angry at herself and unable to admit she has some limitations, she blames her mother and gets aggressive and unsafe. Referred for therapy, the therapist sees the aggression and conceptualizes it as something possibly in the mother that is causing Molly to be so bossy and angry, something in their relationships, perhaps provoked by the mom and mom’s trauma, htat mom is taking out her trauma on Molly, projecting, yelling. This becomes the narrative for Molly, that her problems are her mother’s fault and she is anxious and depressed because of her mother’s trauma. That may contribute, but a false self is being created if that is the only narrative that exists and neuropsychological testing isn’t recommended so that Molly can understand herself better and accept her differences and embrace her strengths to develop a true self, self awareness and ask for help, use accommodations, and thrive,

In infancy, mom feels in love and overwhelmed by her baby who is hard to soothe. Baby doesn’t make sustained eye contact and instead is fussy and can’t get comfortable. The only thing that helps is being swaddled and sucking on her pacifier or nursing. The pediatrician assures the new overwhelmed and confused mom that she doesn’t have to be overindulgent. She can take the pacifier away. Baby will still love her. Nobody tells mom that some babies need to suck longer, that non-nutritive sucking is essential for building a prerequisite for self soothing. Baby just doesn't settle and is throwing up formula. It’s behavioral, says the doctor, unaware that GI problems in infancy are common in babies who have difficulty with attachment. Baby doesn’t seem well attached. Mom thinks it’s her fault because she had a mother who wasn’t well attuned. Her therapist assures her she is a good mother, she is just a new mother and explores the issues that her own mother who didn’t have a maternal instinct (because of her own trauma history) caused in her that she might be projecting to her baby. Later, we find out baby is on the spectrum, and has attachment issues because she has difficulty internalizing all mother is offering, and nobody tells mother, until she finds a therapist once her daughter is an adult, that her daughter would have had an attachment disorder no matter what she did, and that her sense of guilt and self-recrimination at her daughter’s difficult time with relationships gets in the way of mourning the loss of a daughter she can have the kind of relationship she wants with, making space for a new kind of relationship different, but less frustrating and fraught with tension.

Mark, a young man with ADD cannot succeed in college and gets fired from all of his jobs. His coach isn’t successful. The coach sends him to a therapist who looks at his report and sees a very highly intelligent man with only mild executive functioning issues who has no issues with processing or learning differences. He does have a father who engaged him in sadomasochistic enactments screaming and punishing him for years, making it difficult for Mark to “kill the king”, surpass his father because he is afraid of his own aggression, so backs away from the aggression, feeling guilty about his rage, confusing aggression with the assertion that one needs to succeed. A regular therapeutic process can begin, while being coached.

A college student diagnosed with learning differences and ADHD, has a tutor and coach but is failing. Why? He hasn’t yet made his work his own. His parents and teachers helped him so much through highschool, which was necessary, but he never was able to do it for himself. Separation issues prevented him from knowing who he was doing the work for. The introduction of therapy with a therapist who knew about his other issues and how he feels about himself as a result, helped move things forward.

Mike moves away to college and needs to come home freshman year. He is referred for therapy because he is having panic attacks. Once again, the focus of the therapy becomes about the mother and her failures of attunement, which may or may not be distortions of reality, externalizations, and about the divorce. This is all necessary, but what is important is that what Mike is experiencing isn’t a panic attack because of annihilation anxiety because the parents weren’t there for him, although there certainly was a lot going on that made attunement for a couple of years hard, there was annihilation anxiety because that is the universal feeling present in people on the spectrum, the need to destroy others, as a projection of the terror of feeling as if one doesn’t exist or won’t exist. He was unable to internalize all mother had to offer in order to feel filled up with good nurtured feeling and mother, overwhelmed, gave, offered, provided but was turned away from. Continued blame on the mother who has worked hard to get services for Mike causes a rift in their relationship as Mike and his therapist continue to focus on her failures, rather than Mark’s distortions or reality, because the therapist doesn’t know about very high functioning autism and non-verbal learning issues.

Children, teens and young adults are referred for therapy for a myriad of reasons, including depression, social isolation, aggression, anxiety, suicidality and failure in college and failure to launch. We must be able to identify when there is a learning difference because while analysis can strengthen the ego and mitigate the superego self punishment and improve relationships when a three time a week treatment is in place, psychotherapy or analysis alone is simply not enough unless that therapist has a vast knowledge of how learning differences affects the self. Self-awareness cannot be achieved with a patient if the therapist cannot help them understand their brain, the engine behind their mind. Triggers won’t be identified properly and affect regulation will not be achieved. An approach that includes neuropsychological testing and full explanation of results and their effect on learning and everyday functioning is essential. Medication for attention and depression and anxiety must be considered along with other forms of therapy have been effective. Coaching for executive functioning is essential. Tutors are usually necessary. Understanding triggers and how they affect the nervous system and how to manage that through polyvagal work and self-regulation is incredibly useful. EMDR once the nervous system and ego are stabilized and dissociation is absent can be another route, all in conjunction with good analysis to create a holding environment and self awareness and acceptance.

While neuropsychologists tutors and neurologists and learning specialists understand learning differences, it is imperative that therapists and psychoanalysts understand and not apply analytic constructs alone to those with atypical nervous systems. If a therapist doesn’t understand the dynamics of the nervous system and its effects on emotion, social engagement and behavior, and apply analytic interpretations, it can exacerbate shame and create a false self, causing more damage than good, so that the person doesn’t really know themselves, an approach that may only take into account insecure or avoidant attachment based on faulty parenting or internal neurotic conflict or narcissism rather than an internal world where shame and strict superego is caused by constant learning, planning, and attentional failure that leads to micro-traumas rather than the constructing of a strict superego because of an absence of parental attunement or an overly strict or intrusive parent. Autonomous functioning of the ego is weak because of sensory and motor impairment and right hemisphere and frontal and pre-frontal cortex involvement making ego strength hard to achieve. Often, parental attunement or intrusiveness is thought to be the cause and a person can externalize this blame forever at the cost of family relationships and self acceptance which would allow for a struggling person to thrive. I am not implying here that both dynamic and environment as well as brain function reasons cannot co-exist. THerapists are taught that lack of attunement can cause right hemisphere involvement and attachment disorders, but they are not taught when a baby is born with constitutional issues of frontal lobe and right hemisphere involvement, or language based learning disability, or ADHD, these aren’t only causing learning or social difficulty, but that in high functioning autism, ADHD and non-verbal learning disorders, emotional development is impacted not only because of self-esteem but because of how sensory registration or overload impacts internalization of the mother and what she may have to offer, reality testing, and normal narcissism because inadequate normal prorioceptive and vestibular feedback during the normal narcissistic period where the world is the child’s oyster, impacts and prevents the joy of existence and feats, so that hwen they fall or dno’t do well, it doesn’t feel like a complete blow to their budding self. It is important to note that parents also may struggle with how their overwhelmed nervous systems are and either withdraw or overwhelm their already overwhelmed children.. This is not necessarily a parent with a personality disorder, rather perhaps a parent who has their own meltdowns from an overloaded nervous system whose own sympathetic nervous system gets overly activated. Intergenerational trauma certainly does exacerbate the picture, and an analyst who is aware of the dynamics one deals with when struggling with learning differences can help to untangle the weeds.Everyone needs psychoeducation to identify triggers and self-regulate.

Some examples of symptoms treated psychoanalytically alone rather than a multi-modality approach.

Overindulgence when a therapist or psychiatrist tells a parent they are over-indulging when their child or young adult child is sadistic, explosive or nasty, they may not be taking into account the constitution of the person who cannot tolerate not getting their way, cannot wait, cannot problem solve, and that no matter what the parent does or doesn’t do, the person’s ego functions couldn’t develop properly because of sensory overload, frontal lobe involvement or enlarged amygdala causing more aggression. Parents may have to give in to avoid tantrums and extreme violence that affects other children in the household or to protect themselves from what is truly unmanageable without that person being on medication. After medication takes effect, the therapist and parent are able to set up expectations, positive reinforcement, limits, consequences and a calm space to use their tool kit for self-regulation.

Withdrawal is not only related to narcissistic injury and the need for self-protection but can also be seen as a response to a deficit in organizing sensory stimulation from the outside and the inside. A person falls and yells out in pain and the auditory overstimulated partner walks away because the yelling reaches the amygdala and the sympathetic nervous system becomes overarounsed and the only way the highly sensitive person can cope is to “shut down” avoid and withdraw. This may happen constantly throughout the day to the visual system, tactile system, vestibular systems. Rather than experience psychic death, overstimulation of engulfment, and shame associated with the inability to use language to express what is happening, the person withdraws, breaks up, ends friendships. Treatment might include a sensory diet of daily brushing, weight training, weighted blankets, and a consultation with an OT to learn how to regulate one's nervous system.

Panic attacks might be conceptualized as annihilation anxiety due to problematic parental attunement when introjection biologically is impaired because of sensory overstimulation or under stimulation and the interference then of taking in with the eyes, ears, and touch that would stimulate the area in the brain for social enjoyment. Due to poor introjection and internalization, there is void and annihilation anxiety.

The experience of falling to bits or having meltdowns because of a lack of internal world and ability to symbolize and use others as containing objects is not ego disintegration but non integration of the ego. The ego is overwhelmed by sensory input or conflict with loved ones or a change in the environment, severe anxiety because of sympathetic nervous system overload and because the ego doesn’t have the capacity to defend, one melts down rather than recognize a trigger, and express feelings symbolized in language and ask for help. This is not narcissistic or borderline rage. It is the inability to cope in any other way. Therapy might include explanation of this and help with ownership of one's body and mind and the use of self-regulation techniques offered by experts in this kind of work. Recognizing what is about to happen or is happening. Removing oneself from the situation, very deep breathing, deep sighing, moving from sympathetic overload to deep relaxation.

Procrastination and motivation might be analyzed as entitlement to clinging to pleasurable experiences when life has been so hard. A therapist might feel tempted to analyze this as the need for perfection, and fear of superego condemnation. This is partly true, but the patient needs to know that they may have executive functioning difficulties that are located in the part of the brain that is weaker. For example, emotions play a part in executive functioning but are not the cause. Executive functioning such as motivation, initiation, impulsivity, attention, organization, organization of writing, prioritizing tasks, sustaining or shifting interest, planning, follow through and memory are mediated by the frontal cortex and hippocampus, and is affected by inconsistent neuronal firing in those areas. A two prong solution is needed for this, an analysis of how emotions are in the way and memory of past difficulty feels like trauma so better to avoid, and an executive functioning coach who can provide tools like chunking, is important.

A person who is referred for constant work or academic failure is not only self-defeating underachieving, self-sabatoging or backing away from success to avoid aggression and guilt.

They may have a language based learning disability where reading comprehension and writing problems are brain based. A messy house or hoarding isn't just a cornucopia of transitional objects but initiation and planning difficulty with resulting helplessness, hopelessness, failure and shame.

A person who doesn’t seem to have empathy, cannot mentalize and predict someone else’s behavior isn’t necessarily a sociopath. He or she may have high functioning autism or a Non-Verbal Learning Disability causing so much difficulty all day long starting in Mahler’s practicing phase of development, that a narcissistic core is in place and development of coping strategies doesn't transform from splitting and projection, and poor reality testing and thought distortion is present,

While it is true that parenting helps the pre-frontal cortex and right hemisphere develop, it is not the only reason that there may be problems related to these structures. We long ago dispelled the belief that Autistic Spectrum Disorders are caused by inattentive parents, thanks to Bruno Bettleheim. Still, some therapists still ascribe early parental function as a cause, rather than see both neurology and parenting as influencing a good or difficult prognosis. It would be like seeing someone who is gay and assumimg the caseu is an intrusive parent. We have long ago shifted from that stance while at the same time, without negating the fact that the mother may also have been intrusive. To see a person for therapy and ignore that the are gay would be a dissavowel of who someone is. I use the absurd analogy because it is just as absurd to ignore the effects of learning differences on ego development and on ongoing self-worth. While learning differences aren’t the whole of who someone is, not addressing one’s feelings about how difficult things are is a disavowal of who someone is. Many children and adults have undiagnosed differences, When we as therapists are working with someone, we should think not only analytically, but logistically when suspecting that someone has a learning difference. In order to be empathic and validate someone’s experience and help them accept themselves for their strengths and weaknesses and live according to their strengths, therapists have to have an understanding of what these disorders are, how they affect one’s life and how they affect trust, initiative, aggression, shame, narcissistic injury, self-worth all along the developmental continuum.

Psychotherapists need to know that certain learning differences require a top down (talk) approach as well as a bottom up (OT) approach, and separate coaching. Adjunct therapies to address the effects of trauma caused by constant failures of perceiving the world clearly, achieving motor tasks, handwriting, organization, planning, attention and difficulty learning creates shame and PTSD which further affect attention, learning and socializing. While helping to know one’s inner world and the narrative of the superego while building and strengthening the ego is essential, there is adjunct therapy that can be very useful in the short term. The Alert program, “How does your engine run” and Zones of Regulation are important adjuncts. For those therapists who are trained, it is a great For adults, EMDR can address the traumas caused by shame and allow for more availability to make use of top down approach of analysis. For children, adolescents and adults, Mindfulness Training, Transforming Touch, developed by Steve Terrel for early developmental trauma and attachment rupture and repair, Interpersonal Neurobiology by Dan Siegel and metacognition based on Polyvagal Theory and practice are some of the ways people can learn to regulate emotions, social engagement and behavior.

Tutors and therapists might be mindful of helping a person with learning differences mourn how difficult their life has been and how misunderstood they have been before expecting them to take over their life as their own from teacher and parent expectations, in the service of being able to use strategies that coaches offer and carry through from help that tutors offer.

Medication: People with learning difference often need anti-anxiety and anti-depressant medication because of feelings associated with repeated failure and not being understood, everything being so hard. It is possible that in addition to secondary reasons, there may be a genetic link to depression and anxiety in people with learning issues. Often, anti-psychotic medication is used off label for people on the high end of the autism spectrum and NVLD for aggression that primarily from an enlarged amygdala and secondarily from rage at being bombarded by sensory input and constant frustration of academic and everyday life being so hard. THen, when mood is stabilized, real therapy can take effect.


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