Hypercortisolism Considered as the Pathogen in Pathogenic Parenting as it relates to Attachment Based Parental Alienation



The widespread nature of the dissolution of family units including expensive high conflict legal battles, what has traditionally been identified as parental alienation, and the damage caused by this has become an acceptable norm that has become socially acceptable by society and highly lucrative for some. This article explores the perspective of pathogenic parenting to identify the pathogen itself in the same way that a doctor would examine the commonalities among patients exhibiting a unique set of symptoms to further refine the medical understanding of a newly, or at least poorly understood disease. This concludes with a testable working model for the validation of the correlations presented.



Parental Alienation Syndrome model was originally identified by Gardiner anecdotally and without basis in the constructs and understanding of psychology. The attachment based parental alienation AB-PA model by Childress brings this same phenomenon back into the perspective and constructs of modern psychology and allowing for the formal psychological diagnosis rather than anecdotal markers. The Gardinerian markers characterized the severity that a child rejects a loving normal range parent in the absence of abuse by that parent. The attachment based model identifies pathogenic parenting as an attachment-related pathology, and cites Bowlby as far back as 1969, in saying that the deactivation of attachment behavior is a key feature of pathological mourning[1].  The specific diagnosis of AB-PA includes three indicators[2]:


  1. Attachment system suppression

  2. Narcissistic personality traits in the child’s symptom display

  3. An encapsulated persecutory delusion in the child’s symptom display


These also require the diagnostician to have four domains of competence that include[3]:


  1. A professional knowledge of attachment-related pathology

  2. A professional knowledge of family systems pathology

  3. A professional knowledge of personality disorder pathology

  4. A professional understanding of complex trauma


Many people without these qualifications, and certainly without a background in psychoneuroendocrinology, have worked with this special population since Gardiner to the great detriment of the children involved. This article seeks to draw attention to the psychoneuroendocrinological perspective of this pathogenic behavior in the anticipation of future repeatable studies validating this perspective so that intervention and mitigation may reduce the epigenetic damage to future generations.  


The Endocrinological Response to Stress


The hypothalamus-pituitary-amygdala axis is well known to produce hormones in response to fear and stress as part of the endocrine system. While the role of the amygdala is to evaluate threat potential and determine emotional reaction, imaging studies suggest that the prefrontal cortex in conjunction with the hippocampus and other structures fails to inhibit excessive amygdala activation in people with borderline personality disorders.[4] While the endocrine process is complex, it results in a production of the primary human stress hormone cortisol that is mediated by oxytocin. It is well noted within the medical literature that smaller hippocampal volume is associated with stress and psychopathy, particularly in childhood which in turn has been associated with toxic levels of glucocorticoids such as cortisol and the synthetic analog Prednisone.[5] Dr. Owen Wolkowitz identified four mechanisms for the volumetric reduction of the hippocampus by excess glucocorticoids (hypercortisolism). While the body can produce slightly higher levels, natural levels of glucocorticoids are about 5mg/day of cortisol. Prednisone is typically prescribed in dosages that are far beyond what the healthy body can produce. The Prednisone label in addressing the adverse side effects references just such a personality change. Endogenous glucocorticoid levels have also been implicated in the addiction feedback mechanism, and have been identified as separate exogenous addictions themselves in the form of factitious Cushing’s Syndrome.


The Physical Response to Hypercortisolism


Acute hypercortisolism in conjunction with adrenaline, prepares the body for a fight, flight, or freeze response. This is a very primitive survival system seen in most of the animal kingdom. Chronic hypercortisolism is associated with many conditions that challenge long term survival. These include suppression of the immune system, particularly the inflammation response, Cushing’s Syndrome, and all that it encompasses, volumetric reduction of the hippocampus and subsequent psychological changes and behavioral maladaptations. Chronic hypercortisolism is associated with damage to every part of the body and to every interpersonal relationship. Uncorrected Cushing’s Syndrome, no matter the cause can be fatal. It can even go as far as causing an intergenerational transmission of stress.[6]


The Psychological Response to Hypercortisolism


Emotional instability is typically the first thing that people on supraphysiologic doses of glucocorticoids recognize, but there is far more, and not all of it has made it to the label of the medications, but are in the medical literature. Delusions are certainly one response that is on the label, and many people even within the mental health profession are not qualified to recognize them correctly. Encapsulated delusions are such that the individual might function completely normally in all other aspects of their life but for the one area that the delusion exists. Paranoid persecutory delusions have been recognized in approximately 79% of the parents that killed their own children[7] while the news articles surrounding the event suggest that they seemed normal. Many of these parents working within their delusional perception of reality truly believed that they were protecting their children from a greater evil. This altruistic form of filicide shows just how altered their reality can get. Jozetta Ranay Bryd fortunately was not alone with her children when she tried to kill them and was stopped. She was found to be involuntarily intoxicated by Prednisone. Karen McCall of Texas was also taking Prednisone, and was left alone in the transfer of custody with her son, and sadly that transfer was never completed. Another 10 women who were incarcerated for filicide were evaluated for elevated ACTH and cortisol levels, and low correlation between ACTH and cortisol levels was a notable marker in the filicide population, with cortisol levels being on average 20% higher than in the control group.[8] Filicide is the ultimate form of alienation and there are over 400 children that die each year in this manner in the United States alone.


The long term effect of hypercortisolism that is not well discussed in the literature is the personality shift towards psychopathy in relationship to excess levels of glucocorticoids and low hippocampal volume.[9][10] Korzekwa attributes the etiology of the dissociation of BPD to multiple factors while neglecting to view it from a psychoneurological perspective and realize that the multiple factors all correlate to high stress, high cortisol levels and low hippocampal volume despite having identified this in the same paper. The theory of mind perception of how others perceive is only found to the degree that cognitive empathy is available, while affective empathy is not. Their dissociation and impairment in their ability to have authentic affective empathy impairs their ability to love and be loved in an authentic manner which further reduces the oxytocin that might otherwise serve to help rebalance their cortisol levels. Individuals suffering this way increasingly meet the classic characteristics of psychopathic behavior. This includes the use of narcissistic defense mechanisms, charm, manipulation and control to hide their imperfections, such as lack of empathy, the ability to have emotional intimacy, addictions, the ability to take responsibility for their actions. It also includes loving their children as extensions of themselves rather than separate individuals. Dorn et. al. showed in their study that the prevalence of psychopathology at the onset was approximately 67%, roughly 17 times what would be expected in the general population, while the normalization of glucocorticoids following a surgical correction of Cushing’s Disease reduced this to just 24% while hippocampal volumes also grew. The hippocampus is the one area of the brain that can regenerate brain cells in the absence of excess glucocorticoids. The hippocampus is also responsible for executive functioning and part of cognitive processing, so it is not unexpected that with a smaller volume, cognitive processing is negatively affected and delusions are created in an attempt to make sense of their altered perception of reality. Depending on the severity, this can lead to profound psychosis as well.       


The Sequelae of Hypercortisolism as it pertains to the Attachment System


A stressor of some magnitude, exogenous glucocorticoids, or some combination of the two, reactivates the trauma system unequally in the couple and causes a glucocorticoid covariance between the formerly loving partners. The fear response is generally in the form of either anger or control which may be either overt or covert. This covariation in cortisol levels is correlated with aggression and intimate partner violence.[11] Interestingly, there is an association with increased aggression in females but not males as a result of exogenous glucocorticoids.[12] Psychopathy and the comorbid emotional, psychological and physical abuse that is prevalent in intimate partner violence was examined in the context of preventing child abuse using cortisol as a measure and found to be related.[13] Psychopathy has also been identified as being correlated to smaller amygdala volume in neural imaging while also showing that a compensation for deficient empathy is an increased cognitive theory of mind.[14] Another study goes on to find that while the volume of the amygdala was unaffected in Cushing’s Syndrome patients that were surgically corrected, there seemed to be a hypoactivation of the ventromedial prefrontal cortex.[15] In addition to this, volumetric data strongly correlates the posterior region of the hippocampus with the fear response, and the volumetric reduction of this area to psychopathy.[16]


With the lack of emotional intimacy due to the lack of affective theory of mind coupled by the inhibited fear response and the frustration of wanting to have these things and being unable to attain them, a mask of normalcy develops to hide this inferiority, and control and manipulation are used to attempt to gain some level of emotional supply. Control and manipulation lead to conflict and frequently spirals into a high conflict divorce where more control is sought instead of separation. The attachment patterns in parents with borderline personality disorders present their children with an unsolvable dilemma in that the attachment pattern of the parent is generally preoccupied or unresolved and result in the child getting an inconsistent response in their attachment seeking behavior thus instead activating the trauma network.[17]  This not only damages the child’s attachment system, but their developing working model of self. Ongoing exposure to this behavior raises their cortisol levels and causes an epigenetic transmission of trauma.[18] The adverse childhood events associated with this environment are well documented on the landmark ACE study[19], and the cycle will very likely repeat itself in the next generation of hosts.


The Future of Quantitatively Diagnosing a Covert Pathogenic Parent.


The Childress model of AB-PA is the psychological and behavioral diagnosis that is replacing the Gardinerian model. Neurological imaging analysis would be the fastest biomarker for diagnosis provided that there were studies with repeatable results that highly correlated the imaging and the behavior of AB-PA to the level of fingerprint recognition. Individually the testing will likely have value, but the accuracy of differential testing of both parents may lead to both a higher accuracy and level of understanding the severity of the pathogenic parenting. While endocrinological testing is possible, its nature will not allow it to reach that level of accuracy, but the biomarkers associated with Cushing’s Syndrome, and certainly anyone on chronic corticotherapy, will be an indicator that in a high conflict divorce, AB-PA is likely going to occur.




One percent of the US population has an active prescription for corticosteroids, and there are an estimated 30,000 families affected by factitious Cushing’s Syndrome, and many more affected by exogenous Cushing’s Syndrome. There are an estimated 22 million children currently affected by AB-PA right now in only the United States. All of this conflict and exogenous corticosteroids are the source of hypercortisolism for not just the affected individual, but also for their families. Returning to the AB-PA diagnosis we see very clear identification for attachment suppression within the literature discussing the children of borderline personality disorders. We also see from a far different area from within the literature that there is a high correlation between supraphysiologic doses of glucocorticoids and borderline personality disorders as a result of changes in neural anatomy. Again we see that these changes are associated with parental behaviors that create an adverse environment for children that suppresses their attachment bonding while teaching them narcissistic behaviors by example. The child rapidly learns to accept the delusion of the protective parent, who is protective of their emotional supply that they regard as an extended part of themselves and not the child as a separate individual. It is clearly in the child’s best interest to do so because when they do not, they are subjected to emotional and psychological abuse. As a result, a folie a deux is created by the child as a way of surviving that hostile environment, which in the case of AB-PA is that the targeted parent is bad. The child forms a trauma bond with the abusive parent who appears to the rest of the world to be the good protective parent. In the most extreme cases, if the target parent is actually able to expose the abuse typically in court and be granted custody or anything else that mortifies the pathogenic parent, a narcissistic rage ensues but rapidly grows to include anger at themselves for having lost control of the situation. The anger turned inward is typically considered depression and with the impaired fear response as well as the overwhelming desire not to accept the responsibility for their actions, suicide is a favorable option. In order to fully commit suicide, the pathogenic parent must first kill their own children, ostensibly to protect them from the bad experiences that the parent has had. This is the ultimate form of parental alienation that both Rod McCall, Jason Sheats, and many other unnamed parents have had to suffer through with no support, validation or understanding until it was too late for their children.




[1] Childress, Craig A., Psy.D. AFCC Boston lecture 6/1/17

[2] Childress & Pruter, AFCC Boston lecture 6/1/17

[3] Childress & Pruter, AFCC Boston lecture 6/1/17

[4] Korzekwa, M.I.,Dell, P.F. & Pain, C. Curr, Dissociation and Borderline Personality Disorder: An Update for Clinicians, Psychiatry Rep 2009 11:82 doi:10.1007/s1920-009-0013-1

[5] Wolkowitz OM, Lupien SJ, Bigler ED., The "steroid dementia syndrome": a possible model of human glucocorticoid neurotoxicity. Neurocase. 2007 Jun;13(3):189-200. PMID: 17786779

[6] David  Pagliaccio, Joan L. Luby, Ryan Bogdan, Arpana Agrawal, Michael S. Gaffrey, Andrew C. Belden, Kelly N. Botteron, Michael P. Harms, and Deanna M. Barch, Stress-System Genes and Life Stress Predict Cortisol Levels and Amygdala and Hippocampal Volumes in Children, Neuropsychopharmacology (2014) 39, 1245-1253; doi:10.1038/npp.2013.327

[7] Catherine F. Lewis, M.D., and Scott C. Bunce, PhD. Filicidal Mothers and the Impact of Psychosis on Maternal Filicide  JAAPL 31:459-70, 2003.

[8] Chiara Spironelli, Federica Gradante, Guiseppe Gradante, Alessandro Angrilli, Cortisol and ACTH plasma levels in maternal filicides and violent psychiatric women. Journal of Psychiatric Research 47 (2013) 622-627.

[9] Lorah D. Dorn, Ellen S. Burgess, Theodore C. Friedman, Billinda DuBbert, Philip W. Gold and George P. Chrousos, The Longitudinal Course of Psychopathology in Cushing’s Syndrome after Correction of Hypercortisolism, J. Clin Endo and Metab. 1997 Vol 82, No. 3, 912-9 doi: 10.1210/jcem.82.3.3834

[10] Yanovski JA, Cutler GB Jr., Glucocorticoid action and the clinical features of Cushing’s Syndrome, Endocrinol Mteab Clin North Am 1994 Sep; 23(3): 487-509 PMID: 7805650

[11] Hyoun K. Kim, Stacey S. Tiberio, Deborah M. Capaldi, Joann Wu Shortt, Erica C. Squires, and J. Josh Snodgrass, Intimate partner violence and diurnal cortisol patterns in couples, Psychoneuroendocrinology. 2015 January ; 0: 35–46. doi:10.1016/j.psyneuen.2014.09.013.

[12] Robina Bohnke, Katja Bertsch, Menno R. Kruk, Steffen Richter, Ewald Naumann, Exogenous cortisol enhances aggressive behavior in females, but not in males, Psychoneuroendocrinology (2010) 35, 1034—1044, doi:10.1016/j.psyneuen.2010.01.004

[13] Joshua L. Gowin & Charles E. Green & Joseph L. Alcorn III & Alan C. Swann & F. Gerard Moeller & Scott D. Lane, The role of cortisol and psychopathy in the cycle of violence, Psychopharmacology (2013) 227:661 – 672, DOI 10.1007/s00213-013-2992-1

[14] Boris Schiffer, Christina Pawliczek,Bernard W. Muller, Jens Wiltfang, Martin Bruene, Michael Forsting, Elke R. Gizewski, Norbert Leygraf, Sheilagh Hodgins, Neural Mechanisms Underlying Affective Theory of Mind in Violent Antisocial Personality Disorder and/or Schizophrenia, Schizophr Bull 2017 sbx012. Doi: 10.1093/scbul/sbx012

[15] Janna Marie Bas-Hoogendam, Comelie D. Andela, Steven J. A. van der Werff, J. Nieke Pannekoek, Henk van Steenbergen, Onno Meijer, Mark A. van Buchem, Altered neural processing of emotional faces in remitted Cushing’s Disease, Psychoneuroendocrinology, Vol 59, September 2015, pp 134-146, doi: 10.1016/j.psyneuen.2015.05.001

[16] Mikko P. Laasko, Olli Vaurio, Esa Koivisto, Lisa Savolainen, Markku Eronen, Hannu J. Aronen, Panu Hakola, Eila Repo, Hilkka Soininen, Jari Tiihonen, Psychopathy and the posterior hippocampus, Behavioral Brain Research Vol 118, Iss 2, 29 Jan 2001, 187-193, doi: 10.1016/S0166-4328(00) 00324-7

[17] Korzekwa, M.I.,Dell, P.F. & Pain, C. Curr, Dissociation and Borderline Personality Disorder: An Update for Clinicians, Psychiatry Rep 2009 11:82 doi:10.1007/s1920-009-0013-1

[18]David  Pagliaccio, Joan L. Luby, Ryan Bogdan, Arpana Agrawal, Michael S. Gaffrey, Andrew C. Belden, Kelly N. Botteron, Michael P. Harms, and Deanna M. Barch, Stress-System Genes and Life Stress Predict Cortisol Levels and Amygdala and Hippocampal Volumes in Children, Neuropsychopharmacology (2014) 39, 1245-1253; doi:10.1038/npp.2013.327  

[19] Vincent J. Felitti, MD, FACP, Robert F. Anda, MD, MS, Dale Nordenberg, MD, David F. Williamson, MS, PhD,

Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P. Koss, PhD, James S. Marks, MD, MPH, Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study, Am J Prev Med 1998;14(4)