PTSD and Childhood Trauma
By Bob Murray, PhD
Over the years my wife, and fellow therapist, Alicia Fortinberry, and I have treated many people who were suffering from what is called post traumatic stress disorder or PTSD including a number of Vietnam veterans. In talking to the vets I noticed that a pattern was developing which caused me to widen my enquiries to veterans who went through the same experiences in Asia, but who did not have the symptoms of PTSD.
I have not had the time to do a formal study, but I have come to some very interesting conclusions regarding the disorder, which have been confirmed by some recent studies. I have become convinced of the strong link between PTSD and depression and between both of those and childhood trauma.
The Origins of PTSD
I have long been interested in the effect of childhood trauma in the development of a number of mood disorders such as depression and dysthemia (a milder form of on-going depression). I believe that depression childhood can be a form of dissociative disorder a way the child escapes the harsh reality of his or her environment through a slowing down of mental activity. Almost all patients that I have seen who were depressed when they were children were the victims of some sort of abuse: physical, sexual or verbal in the form of criticism or implied threats of violence or abandonment. I am not saying that all depression is the result of childhood trauma or that all children who were abused become clinically depressed, just that in many children there seems to be a causal relationship between early abuse and depression.
In dealing with the vets I found the same sort of relationship -- those who were diagnosed with PTSD tended to have traumatic childhoods and those who were free of PTSD did not.
What is PTSD? Although traumatic events have long been known to cause psychological problems, the disorder itself was first formally characterized in the early 1980s. Even now it is the subject of controversy, with many psychiatrists and clinical psychologists saying a diagnosis of PTSD is meaningless (see articles in recent editions of the British Medical Journal). Personally I do not subscribe to this view, rather I believe the problem is one of inaccurate diagnosis.
Generally speaking PTSD is identified by the following three symptoms: 1) re-experiencing traumatic events (ie, obsessive recollections, flashbacks, nightmares); 2) avoidant symptoms (fear of being with people); and 3) signs of hyperarousal (easily startled, irritable). Traumatized people often suffer from a combination of PTSD, depression and other anxiety disorders.
Often the victims of PTSD are mis-diagnosed. For example, some patients will present more severe symptoms of hyperarousal with severe depression. The re-experiencing of events is often mis-diagnosed as "obsessiveness" within a depressive disorder. Hyperarousal symptoms may be mis-diagnosed as insomnia and anxiety within a major depressive episode. Other PTSD victims are mis-diagnosed with obsessive-compulsive disorder.
Danger of Misdiagnosis
People with symptoms such as social avoidance, hyperarousal or anxiety may have also self-medicated their condition with alcohol to mute the symptoms and, as with active alcoholics, they may deny their drinking. Still other patients may experience mixed obsessive recollections with flashbacks and, at times, auditory and visual hallucinations. These patients may be mis-diagnosed as dissociative or psychotic.
Patients with severe insomnia, symptoms of hyperarousal, severe irritability and racing thoughts may be misdiagnosed as manics or hypermanic borderline patients (patients whose mania centers around a desperate fear of abandonment).
A careful interview is necessary to make an accurate diagnosis and discover new behavioral traits wich separate PTSD from other disorders. (Alicia, once worked with a psychiatrist at a major NY hospital who claimed to be able to accurately diagnose schizophrenia and other disorders within the space of a 3 minute interview!) Usually the patients are put on drugs, and very often the wrong drugs, as a result of these misdiagnoses.
And yet PTSD is one of the most common psychiatric disorders, affecting nearly 8% of the population [R.C. Kessler, et al. (1995), "Post Traumatic Stress Disorder in the National Comorbidity Survey", Archives General Psychiatry 52(12):1048-1060] and is growing fast.
I believe there are two stages in the development of PTSD. Firstly there is childhood trauma which may or may not lead to the onset of a diagnosable depressive or anxiety. Then a second traumatic incident or set of circumstances arise which trigger the full-blown PTSD. In my view there must be these two stages and the onset of PTSD is dependent on a traumatic event or environment in childhood.
However I think that we ought to look again at the meaning of 'trauma.' Certain kinds of trauma are obvious early physical, sexual or verbal abuse, war, abandonment, poverty, class or racial or ethnic purging ('ethnic cleansing' or the holocaust), natural disasters and parental separation and most studies have restricted themselves to these areas.
Over the last few years mental health experts have begun to widen the definition of trauma. Andrei Novac, MD, associate clinical professor at the University of California, Irvine, writing in Psychiatric Times [(2001) 17:4] notes the enormous increase in the speed of the availability of information concerning traumatic events. "For instance, news of natural disasters, catastrophes and genocides are made widely available, instantaneously, via 24-hour cable news networks, creating an enormous pool of spectators to negative events. This is significant, as the study of traumatic stress has determined that not only victims but also those being confronted with and witnessing traumatic events may be vulnerable to post traumatic stress disorder."
In other words the primary trauma may be one that happened to a child, or one that a child witnessed and similarly the secondary trauma, the one which actually triggers PTSD may also be one which the sufferer witnessed rather than actually experienced.
The original traumatic event may also be passed down generationally. A 1998 study by R. Yehuda , et al Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors [American Journal of Psychiatry, 155(9):1163-1171] confirmed that offspring of Holocaust survivor parents with PTSD have a higher lifetime risk for PTSD and report more distress after traumatic events. Thus, along with the exposure to their parents' traumatic stories and their trauma-related acquired behavioral patterns, these offspring may have a biological vulnerability to traumatic stress and PTSD transmitted to them from their parents.
In our own practices Alicia and I have noticed that women whose mothers were the victims of sexual abuse, for example, were likely to manifest all the signs of a sexual abuse survivor themselves. Children of alcoholics can often exhibit the behavioral characteristics of 'dry drunks.' Whether these are passed down biologically, as some have argued, through an inherited imbalance of cortisol or other neuro transmitters, or through childhood idealization of certain types of behavior (which explanation I tend to favor) is a matter of keen debate.
The net result of all this is that we must look at traumatic events as having a ripple effect causing PTSD disposition generationally and through the viewing of others' trauma (the creation of what might be called 'secondary victims).
Trauma, Personality and the Brain
Childhood abuse or trauma has a pronounced effect in brain development. It can lead to subtle structural abnormalities in the frontal lobe, which is closely related to the limbic system the seat of our emotions. These abnormalities may result in deep-seated personality deficits (for example, an inability to be empathetic, or pathological narcissism) that are not readily diagnosable as psychiatric disorders. This may explain why early exposure to traumatic stress or disruptive changes in environment may result in more fundamental behavioral changes that are more often diagnosed as personality disorders.
Some of these individuals may be prone to aggression and dehumanization of others in the service of a cause that they find noble. Many of the 20th century's most notorious leaders including Hitler (who was a child abuse victim and whose secondary trauma would have been WWI), Stalin, Mao and Pol Pot fit into this category.
The highly stressed society in which we live may itself be a cause of what Novac calls the "overextended boundaries of compensatory biological systems, creating an environment that is suboptimal for time appropriate maturation of certain brain areas."
The ripple effect of trauma means that traumatized people create families in which there may be a biological or other predisposition to trauma.
PTSD has proven spectacularly resistant to most forms of conventional therapy, though drugs, talk therapy, rap groups and a combination of all have been tried with varying degrees of success. In my view one of the problems is that PTSD is seen as fundamentally different from depression rather than as an extreme form of that disorder. Depression can also cause not-too dissimilar changes in brain structure and chemistry even though the personality changes and behavioral effects of the two disorders can be, on the surface, quite different.
In my treatment of PTSD sufferers I have achieved most success when I examined and treated the earlier childhood traumas and resulting depression first rather than the more obvious secondary trigger. The original trauma can induce a rather rigid, fearful personality, one less able to cope flexibly with stressful events in later life.
This is as true of rape victims as it is of war veterans. In treating rape survivors, it is important to find out if there is a history of sexual abuse in their family. Obviously it takes some tact to extract this information and a great deal of trust on the part of the victim.
Sarah was referred to me by the rape crisis center in New York. She was 27 and had been a victim of date rape and was also clearly suffering the symptoms of PTSD. She was not alone in this, studies have shown that 50% of all rape victims experience PTSD symptoms [D.A. Tomb (1994), "The Phenomenology of Post-traumatic Stress Disorder", Psychiatric Clinic North America, 17(2):237-250]. She was having recurring nightmares concerning the event and a tremendous sense of guilt. The most common form of therapy for PTSD is what is called re-exposure therapy, which is not unlike the therapy commonly given to phobics. However in rape, and other sexual abuse cases, I do not believe that this is a good idea since it only increases the sense of guilt. Instead I began by letting her talk about whatever came into her mind.
It was clear that she had been depressed for a long time. Childhood depression is, in my view, always a flashing light, rather like a history of eating disorders, indicating the possibility of abuse.
She began to talk about her family and I gently encouraged her. She spoke freely about her sister, her mother and her father, though I noticed a stiffening in her body and a note of anger when she mentioned her mother. The one she didn't mention was her brother, other than to say he was seven years older than she. I was curious about this omission. It transpired that her brother had molested her constantly over a period of five years from the age of four. She had repeatedly told her mother who refused to believe her and made her feel that if there was any truth in her allegations that she must have been the guilty one. I was the first person she had told this to.
Once the original secret was out, so to speak, she relaxed somewhat. Over the course of several sessions she was able to focus her anger away from herself and to begin to accept her own innocence. This freedom from guilt led her to be able to come to terms with the more recent incident and, over a period of a few months, the symptoms of PTSD subsided.
One last point to be born in mind in treating all victims of traumatic stress, whether the result is depression, anxiety attacks, or PTSD, is that the trauma is perpetuated in the body as well as in the brain. It is as if the body of the victim is perpetually on alert for the next blow, critical remark or sexual attack and is therefor held very rigidly. This is true even of depressed or anxious ballet dancers or athletes which Alicia and I have treated. These people are more prone to injury because of this 'emotional holding pattern' as I call it. They are also less likely to let go of the emotional impact of the trauma while this somatic pattern persists.
It is therefore important, in our view, for the patient to undergo gentle Feldenkrais-type body work of the kind that Alicia (a prominent Feldenkrais practitioner as well as psychotherapist) and I have incorporated into our practice and into our professional training program, in conjunction with talk therapy. This is especially true of PTSD sufferers whose somatic rigidity can be quite extreme.
PTSD, like depression, can also be somatized. In an individual who was not allowed to express negative emotions as a child these emotions can be expressed as physical illness such as chronic fatigue syndrome or fibromyalgia [cf S. Dubovsky MD "Mind/Body Deceptions", pub. Norton 1997, pp 43-56]. It is important for physicians to look beyond the "physical" symptoms of such illnesses and bear in mind the possibility of an underlying traumatic or emotional cause.
To sum up, PTSD is common, often misdiagnosed and mistreated. It is, however treatable if the therapist takes the time and patience to look at the traumas that happened before the triggering incident. By allowing the patient to come to terms with these earlier events, and by dealing with the probable underlying depression and anxiety resulting from them, then a better long-term result is likely to be achieved. Feldenkrais-type body work is also an essential element in the treatment of most PTSD sufferers.
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About the Author
Dr Bob Murray is a widely published psychologist and expert on emotional health and optimal relationships. Together with his wife and long-term collaborator Alicia Fortinberry, he is founder of the highly successful Uplift Program, and author of Raising an Optimistic Child (McGraw-Hill, 2006) and Creating Optimism (McGraw-Hill, 2004).
Disclaimer: The diagnosis and treatment of medical or psychiatric disorders requires trained professionals. The information provided in this article is for educational purposes only. It should NOT be used as a substitute for seeking professional help.
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