Yet no sooner had PTSD been signed, sealed, and delivered, than many clinicians began to realize that the new diagnosis by no means encompassed the experience of all traumatized clients. Soon after the publication of DSM-III, Boston psychiatrist and trauma expert Bessel van der Kolk recalls that a woman came to see him after she'd beaten up her boyfriend. "She said, ÔI have PTSD," he says, "but after I'd spent some time with her, I told her, ÔNo, actually you don't have PTSD, you have something else. You cut yourself, you space out a lot and don't remember things, you shift personality, you feel lots of shame and self-blame, you get extremely upset by very small things—that's not PTSD.'" Even though she did show signs of PTSD, her symptoms seemed to take off from there into unexplored territory—a psychological terrain very different from that of traumatized vets.
The patients he was seeing, almost entirely women, had multiple, often severe, and apparently global problems affecting their sense of identity and self-perception, their relationships, their ability to moderate emotion, even their physical health. They were, varyingly, clingy, needy, impulsive, enraged, depressed, despairing, or suicidal. They purposely hurt themselves—cutting, scratching or burning their skin, biting or starving themselves, pulling out their hair—drank too much, and did drugs. They couldn't remember large blocks of their childhood, "lost" days at a time, often felt apathetic, disembodied, or as if the world was unreal. They might regard themselves as somehow innately stigmatized or defiled, as lonely outcasts whom nobody could ever understand, or as somehow special and completely different from others. Their sense of personal boundaries was porous, to say the least—they might share their life stories, full sexual details included, with virtual strangers. They frequently suffered from amorphous, hard-to-diagnose-and-treat physical illnesses—fibromyalgia, irritable bowel syndrome, chronic pelvic pain, headaches, "acid" stomach, back pain, as well as stranger complaints, like temporary blindness and tingling in the extremities. In short, the more van der Kolk learned about them, the longer the list of their symptoms—in fact, it sometimes appeared that there wasn't a symptom, mental or physical, they didn't have.
They also shared one other feature: they all reported histories of childhood incest. To van der Kolk, this was more than a little bizarre. The most authoritative psychiatry textbook at the time opined that not only was incest "extremely rare"—about one case in every million people—but when it did occur, it was often "gratifying and pleasurable"; at the very least, "the vast majority" of girls "were none the worse for the experience." Reflecting on the presumed rarity of incest cases, van der Kolk could only wonder, "Why are so many of them showing up in my office?"
Since DSM-IV, a massive body of neurobiological research has accumulated revealing how protracted childhood abuse and neglect can cause pervasive, devastating, and lasting biological and psychological harm. Researchers in developmental psychopathology have shown that childhood maltreatment and neglect are associated with structural and functional abnormalities in different brain areas, including the prefrontal cortex (logic and reasoning), corpus callosum (integrating the right and left hemisphere), amydgala (fear and facial recognition), temporal lobe (hearing, verbal memory, language function), and hippocampus (memory). Last year, for example, researchers found a reduction in the visual cortex of young women sexually abused as children (but not in controls), which may help explain why abused children are quicker to recognize and stare at angry faces than non-abused kids, and why they pick up anger even in faces with ambiguous expressions, while missing other emotions. Abuse also disrupts the neuorendocrine system, altering the production of the stress-regulating hormone cortisol and neurotransmitters like epinephrine, dopamine, and serotonin—chemicals affecting mood and behavior. Chronic trauma weakens the immune system and sets up children for illness far down the road. The Centers for Disease Control has recently reported, for instance, that trauma's disruption of cortisol levels leaves abused children vulnerable to chronic fatigue syndrome later in life.
Some of the most astonishing and far-reaching evidence for the lifelong and malign repercussions of childhood trauma has come not from the mental health field, but from the study of epidemiology. In 1995, internist Vincent Felitti, a preventive medicine specialist with California-based HMO Kaiser Permanente, and Robert Anda, an epidemiologist with the Centers for Disease Control began the Adverse Childhood Experiences (ACE) Study to track the relationship between childhood maltreatment, neglect, and other family loss or dysfunction and adult mental and physical health. Drawing data from an extensive and detailed survey of 17, 337 Kaiser members undergoing standard yearly physical exams, this unprecedented study (and more than 60 others by numerous researchers based on the same data) found that a majority of the participants surveyed had experienced some form of serious family dysfunction, emotional, physical, and/or sexual abuse and neglect. Not only that, but the studies showed direct correlations with these "adverse experiences" and a remarkably large proportion of all the physical, mental, and social ills that beset society.
Studying a similar group of young adults at New York University, researcher Marylene Cloitre found that emotional abuse and neglect—the absence, failure, or distortion of the child's relationship to a primary caregiver—did as much, if not more, damage than actual physical abuse. "The severity of a particular trauma—assault, accident, whatever—determined PTSD symptoms," van der Kolk says, "but the child's relationship to the abuser determined everything else—anger, suicidality, self-injury, disturbed relationships, tendency to be revictimized." At the heart of emotional abuse or neglect is a failure of parental attachment and attunement, not to mention overt hostility, worse in its way then physical abuse because it does such a number on the developing brain and nervous system of a child. "You need presence, you need mirroring, you need someone out there who knows what you see, so you can know what you know, and speak what you speak," says van der Kolk, before quoting attachment pioneer, John Bowlby: "ÔWhat cannot be communicated to the mother by the child cannot be communicated to the self of the child.'" If a child doesn't get this sense of "presence" from a trusted adult, she can't connect with her own felt inner experience and, ultimately, can't develop a sense of her own authentic self.
Link thanks to siderea.
All the Fishes Come Home to Roost by Rachel Manija Brown is a memoir about growing up in a hellish Indian ashram. It could have been worse, but as an adult, the author was asked if she'd grown up in a war zone.
I think the second quarter could probably be skimmed-- it gets a little repetitious, but the second half, as the author gets her feet under herself and then builds an adult life and finds out something of the background of how her parents could make such a mess, is really major.
The author relentlessly hangs onto her own mind and her own perceptions of how crazy the people around her were, and the few who weren't. This book belongs on rationalists' bookshelves.
And there's a bit where she's trying to figure out how to write this memoir, and nothing seems like it could work. Then she sits down to write a letter to the one adult who gave her reasonable encouragement to be a writer, and her shame and confusion fall away because she's no longer imagining the people who don't want to hear what she has to say, and the basic approach she needs is obvious.