In this article, I want to briefly explore the relationship of early childhood trauma with persistent emotional issues. As a therapist I often work with people who are dealing with long term anxiety and depression that are rooted in part to challenging or abusive relationships with one’s family of origin. Understanding the role of trauma can be key to understanding how to heal and move through persistent emotional distress.
The Kaiser Study: Adverse Childhood Experiences
In the late 90’s Kaiser Permanente created a study to examine the effects of childhood trauma on adult life. What they discovered was nothing short of astonishing and its implications are still being studied today. Childhood trauma is not only associated with adult mental health issues such as depression and anxiety, but also is correlated with increased addiction rates, high risk behaviors, increased suicidality and health problems such as COPD, heart and liver disease.
Kaiser developed a questionnaire to find out if people had experienced childhood trauma in a number of areas. They called these experiences Adverse Childhood Experiences or ACEs and include:
1- Emotional, physical and sexual abuse.
2- Parental substance abuse, violence, mental illness and criminality
3- Emotional and physical neglect by parents.
Here is what they discovered. This is the percentage of people who experienced trauma in some form:
Emotional abuse: 10.6 %
Physical Abuse: 28.3%
Sexual abuse: 20.7 %
Mother Treated Violently: 12.7 %
Household Substance Abuse: 26.9 %
Household Mental Illness: 19.4 %
Parental Separation or Divorce: 23.3 %
Incarcerated Household Member: 4.7%
Emotional Neglect: 14.9 %
Physical Neglect: 9.9 %
They then tallied up the amount of multiple traumas (ACEs) that people had experienced. Here is that information:
Number of Adverse Childhood Experiences (ACEs):
1 26.0 %
2 15.9 %
3 9.5 %
That means that 63.9 % of people have experienced at least one trauma in their childhood.
And a whopping 37.9 % of us have experienced multiple traumas.
Now here is the part that proved to be so powerful. The higher the number of ACEs, the more likely that one will experience physical and/or mental illness and will be more prone to addiction issues in adulthood. Essentially trauma in childhood is predictive of a much higher likelihood of adult behavioral and health problems.
So what does that mean?
In terms of mental health it means that trauma in childhood is a main predictive factor for adult depression, anxiety and other forms of emotional distress. Symptoms in adulthood of early trauma include:
Guilt and shame
Sadness, hopelessness, apathy
Lack of being able to feel pleasure
Irritability, anger and paranoia
Feelings of numbness and disconnection.
These are symptoms that can be interpreted as due to an underlying psychiatric disorder. Often people receive a diagnosis based on the challenging behavioral and emotional patterns that develop from trauma. Some of these diagnoses include:
Borderline Personality Disorder
Oppositional Defiant Disorder
Dissociative Identity Disorder
Antisocial personality Disorder
Generalized Anxiety Disorder
Major Depressive Disorder
That means we are often diagnosing individuals with disorders without addressing the underlying trauma that is often at the heart of the symptoms they are expressing. We have essentially been asking the question What is wrong with you? when the more important question should be What happened to you?
If trauma is extremely common, and if it plays such a key role in adults developing mental health disorders, its key to assess for trauma when working with people in distress and then to address the trauma if that has occurred. Its also essential that we stop misdiagnosing people with severe disorders and instead examine how trauma is impacting that person’s life.
-ADHD has often been considered an inheritable biological disorder but there is increasing evidence that trauma is often the underlying reason. From the linked article: “Children diagnosed with ADHD also experienced markedly higher levels of poverty, divorce, violence, and family substance abuse. Those who endured four or more adverse childhood events were three times more likely to use ADHD medication.”
-There is even evidence that trauma plays a key role in bipolar disorder, long thought to be simply a genetically inherited disease.
Developmental Trauma Disorder
Misdiagnosis is one of the main reasons that a large group of mental health professionals have lobbied hard to offer a new psychiatric diagnosis known as Developmental Trauma Disorder (DTD). Sometimes this is referred to as Complex PTSD (also not yet listed as a psychiatric disorder), but that diagnosis also includes severe abuse and neglect that can happen as an adult such as in the case of spousal abuse and hostage taking.
Developmental Trauma Disorder refers to people who experience severe distress due to persistent childhood abuse and neglect. In essence these are folks who have high “ACE” scores. DTD really differs from the classic trauma diagnosis of PTSD (Post Traumatic Stress Disorder.).
While PTSD is a good definition for acute trauma in adults, it doesn’t apply well to children, who are often traumatized in the context of relationships,” says Boston University Medical Center psychiatrist Bessel van der Kolk, MD, one of the group’s co-leaders.
“Because children’s brains are still developing, trauma has a much more pervasive and long-range influence on their self-concept, on their sense of the world and on their ability to regulate themselves.”
So while there are similarities between people diagnosed with PTSD and those with DTD there are significant differences as well. Both tend to have symptoms such as hypervigilance, anxiety, potential for dissociation, flashbacks, panic attacks, sleep disturbances and nightmares. But DTD is at its core about relational trauma. That means that those core emotional wounds are about basic bonds of attachment and connection that were deeply damaged due to neglect and abuse.
Those with DTD also can develop profound challenges with maintaining healthy friendships and intimate relationships as well as have a hard time with a good sense of trust and boundaries. There can also be increased feelings of internal fragmentation with greater chance of a disturbed body image, eating disorders, shame, guilt and low self-esteem. Emotional regulation can be particularly hard and small triggers can lead to expansive states of anxiety, panic, rage, catatonia, confusion, dissociation and even psychosis. Addictive patterns and self-injury such as cutting are some common ways to manage the underlying internal feelings of disconnection and fragmentation. Suicidal thinking and behavior can also be common to explore a way of ending the pain.
Humans are profoundly social creatures, and when a sense of essential trust is broken with one’s closest family, it can damage all further relationships and can lead to greater periods of isolation, fragmentation and disconnection. This can spiral into worsening social anxiety and depression.
Healing from this form of trauma really is about learning ways to manage the intense emotional states that were hard wired as a child and to engage in healthy relationships with good personal boundaries and greater trust. The good news is that many people have discovered ways to navigate the depths of their core emotional wounds and heal from familial trauma.
There are a number of therapies designed to help people work through these profound childhood trauma symptoms. Dialectical Behavior Therapy (DBT) has been extremely helpful for many people and increasingly somatic therapies (TRE, Somatic Experiencing) have been developed to help people navigate the challenges of childhood trauma. EMDR is a useful tool for some people though a number of people feel that is best used for working through pinpoint discrete event trauma and less for complex forms of childhood trauma. Finally, numerous non-western models of working through developmental trauma have long been utilized such as acupuncture and yoga. (Please see the next article for more in depth discussion of various healing modalities for developmental trauma.)
Trauma and the Body
What we are learning is that childhood trauma contributes to a wide variety of detrimental biological changes. At the developmental stage of life, trauma can induce structural changes in the amygdala, hippocampus, and prefrontal cortex of the brain. There is some evidence that there is long term decreased activity in the portions of the brain linked to emotional regulation. There is some evidence that repeated trauma leads to a smaller hippocampus, which can then increase the risk for increased post-traumatic stress symptoms.
Trauma is also connected to a heightened chance of musculoskeletal pain, hypertension, obesity, cardiovascular disease, autoimmune diseases and fibromyalgia.
Trauma interrupts healthy patterns of responding to stress in our nervous system. In a normal response to stress, the hypothalamus signals the pituitary gland to send a message to the adrenal glands to release adrenaline and cortisol in a system known as the HPA axis. Adrenaline spikes your heart rate, blood pressure, sends blood flow to the muscles and dilates your pupils. Cortisol converts fat into sugar that is released into the blood stream as energy to be used quickly. This is known as the sympathetic nervous system response and readies us for “fight or flight.”
The problem comes when the stress response is triggered too often, or is overwhelmed with extraordinary trauma. In those cases of excessiveallostatic load , the brain becomes conditioned to be triggered easily and adrenaline and cortisol are released excessively. If this becomes the norm (known as HPA dysregulation) then a host of health problems can develop such as chronic high blood pressure, diabetes, autoimmune diseases, digestive problems, sleep disorders and weight gain.
Trauma also has a strong relationship with gut health and can cause numerous changes that persist into adulthood. Trauma damages this bacteria microbiota and that damage can have long lasting effects such as causing higher systemic inflammatory markers and heightened levels of anxiety, depression and susceptibility to extreme states.
Traditionally psychiatrists have focused on an imbalance of neurotransmitters such as serotonin and dopamine as the leading reasons for mental illness. When we see mental illness through the lens of trauma we are now seeing that depression, anxiety and other forms of persistent distress are much more likely due to systemic inflammation and damage to the gut, the endocrine and nervous system. As Bessel Van Der Kolk writes about trauma, “The body keeps the score.”
Childhood trauma has far reaching implications and can lead to a variety of tangled mental and physical health issues in adulthood. Developmental trauma challenges the core ability to sustain healthy trusting relationships as well as impacting physical health and causing problems such as poor digestion, gut microbiota disturbances, inflammation, HPA dysregulation and associated cardiovascular, immune, nervous system and endocrine health issues. Often the work of healing from developmental trauma means addressing both the physical and emotional disturbances that developed from those childhood wounds. In the next article we will look at some of the best ways to help people heal from childhood trauma.
Some key articles to read and explore about this complex subject:
The long-term costs of traumatic stress: intertwined physical and psychological consequences McFarlane, World Psychiatry 2010
The role of childhood trauma in bipolar disorders, Aas, Henry, Andreassen et al, Journal of Bipolar Disorder
Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems Schmid, Peterman, Fegert et al, BMC Psychiatry
How Trauma Can Effect Your Body and Mind, Christy Matta, World of Psychology
Childhood Trauma, Affect Regulation and Borderline Personality Disorder, a lecture by Bessel Van Der Kolk
A new diagnosis for childhood trauma? Tori DeAngelis, American Psychological Association
Trauma and the development of borderline personality disorder, Van der Kolk, Hosteler, Heron et al, Psychiatric Clinicians North America
A new diagnosis for trauma? Some push for a new DSM category for children who undergo multiple, complex traumas. Tori DeAngelis, American Psychological Association.
Posttraumatic Stress Disorder: Does the Gut Microbiome Hold the Key? Canadian Journal of Psychiatry 2016; Leclerc, Forsythe and Bienenstock
This article written by Jon Keyes, Licensed Professional Counselor.
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