As a practitioner, I saw a number of patients with previous psychotherapies that had failed. The commonest reasons for failure were mis-diagnoses, and of those, a frequent culprit was the failure to recognize the contribution of traumatic experience to a patient’s illness. In retrospect, that wasn’t surprising because the patients generally didn’t know it either. For some, the trauma was not remembered. More frequently, the trauma was something known, but hadn’t been connected with its enduring impact. A blog is not place to talk about the ins and outs of such illnesses, but I mention it to explain my ongoing interest in things traumatic.
Much of what we know about this topic comes from mass trauma like military combat or natural disasters where the cause is known and there are many sufferers, often adults. These findings are informative, but of only limited help in the kind of cases I saw where the events happened in childhood, usually involved other figures, and were not witnessed. Another complication was that, for a time, childhood trauma was a fad diagnosis attracting suggestable patients and therapists alike in an almost circus-like atmosphere – so the diagnosis was often suspect. Fortunately, that era has mostly passed.
I bring it up here because one of the things people focus on is resiliency as an explanation for why some people develop PTSD after traumatic exposure and others don’t – resiliency being a hypothesized quality that protects people from developing PTSD. I’ve balked at the term as it seems like a value judgement – close to strong versus weak. Like the traumatized person was somehow defective, or that the protective resiliency could be taught. I’ve thought of it as a tautology – an objective observation being turned into some hypothetical inner quality. Things like courage, cowardice,or confidence are other examples. I actually thought the patients I saw were some pretty resilient people who had dealt with harsh or unfortunate reality, and survived [I obviously don’t like the notion of resiliency in understanding trauma].
You wouldn’t know it from what I’ve just said, but my topic is preventive medicine and the current focus of psychiatry on preventive strategies. The centerpiece of preventive medicine is early detection and intervention – identifying patients before they get sick, or at least very early in the illness. In psychiatry, we’d love to have biomarkers for things like Schizophrenia so we could try to learn to head off the development of frank psychosis. That was the logic behind the idea of the Attenuated Psychosis Syndrome proposal in the DSM-5 – one of the diagnoses that didn’t pan out.
Back to traumatic illness. I’ve always held that traumatic illness is a psychological matter and that anyone can be traumatized given the right stimulus and circumstances. I’ve been skeptical of the focus on resiliency or on the place of biology in trauma, and so when I read this below, it was with a suspicious eye [for any number of reasons beyond just those mentioned]:
In the Aftermath of Tragedy: Medical and Psychiatric Consequences
by Charles B. Nemeroff and Pascal J. Goldschmidt-Clermont
Academic Psychiatry. 2011 35:4-7.
Epidemiological studies indicate that about 70% of people will experience a traumatic event in their lifetime, but not all of these individuals will develop PTSD. Identifying which trauma victims will develop PTSD is the agreed upon “holy grail” for the PTSD research field. Clearly, a clinically useful metric using a combination of biological, epidemiological, and psychological variables to predict who, at the time of trauma, will develop PTSD will revolutionize the treatment of this common and severe psychiatric disorder. The savings in terms of human suffering, medical and psychiatric comorbidity, reduction in suicide risk, disability, and loss of life as well as economic gains in terms of reduced health care utilization and increased work productivity are virtually incalculable. Considering the almost universal exposure to traumatic events and the vast public health problem that PTSD represents worldwide, the global impact in civilian and military populations will be substantial.
Functional genomics, transcriptomics, and the related fields of proteomics and epigenetics allow high throughput hypothesis generators. These approaches have proven successful in identifying disease biomarkers in several common complex disorders including Alzheimer’s disease, cancer, and diabetes. The concern that the use of blood elements instead of brain tissue does not provide valid data in gene expression appears to be unwarranted. We need to accelerate discoveries for the prevention, diagnosis, and treatment of PTSD. Applying genomics, transcriptomics, epigenetics, and proteomics to elucidate biological predicators of PTSD is an active avenue of investigation. Approximately 30% to 40% of the risk to develop PTSD is heritable and our group has identified some of the most promising candidate genes that mediate vulnerability to PTSD. Much of what we have learned concerning the mammalian response to trauma is derived from basic science discoveries, and these findings, in part, provide the scientific rationale for identifying predictors of PTSD [e.g., inflammatory markers and neuroendocrine alterations]. PTSD is a major global health problem and success will result in a clear and immediate global health impact.The use of such genomic, transcriptomic, epigenetic, proteomic, structural and functional brain imaging, inflammation, and neuroendocrine measures taken together with behavioral and psychological measures will likely achieve the much needed goal of predicting which trauma victims will develop syndromal PTSD and, moreover, will likely help identify predictors of response to the effective treatments of PTSD, both psychotherapeutic and psychopharmacological. In the future, such tools can be brought to bear to help manage the psychiatric sequelae of natural disasters similar to the Haiti earthquake. Immediate intervention for medical-surgical and psychiatric consequences of trauma will surely reduce the resultant morbidity and mortality associated with such events….
Hearing that "Approximately 30% to 40% of the risk to develop PTSD is heritable" repeatedly over the years, I just haven’t believed it. I thought it was an exaggeration, maybe even a fabrication, designed to lead us down some garden path. But this time when I read it, I got some help finding out where that comment comes from, and I read:
A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms.
by True WR, Rice J, Eisen SA, Heath AC, Goldberg J, Lyons MJ, and Nowak J.
Archives of General Psychiatry. 1993 50[4]:257-264.
We studied 4042 Vietnam era veteran monozygotic and dizygotic male twin pairs to determine the effects of heredity, shared environment, and unique environment on the liability for 15 self-reported posttraumatic stress disorder symptoms included in the symptom categories of reexperiencing the trauma, avoidance of stimuli related to the trauma, and increased arousal. Quantitative genetic analysis reveals that inheritance has a substantial influence on liability for all symptoms. Symptoms in the reexperiencing cluster and one symptom in the avoidance and numbing cluster are strongly associated with combat exposure, and monozygotic pairs are more highly concordant for combat exposure than dizygotic pairs. By fitting a bivariate genetic model, we show that there are significant genetic influences on symptom liability, even after adjusting for differences in combat exposure; genetic factors account for 13% to 30% of the variance in liability for symptoms in the reexperiencing cluster, 30% to 34% for symptoms in the avoidance cluster, and 28% to 32% for symptoms in the arousal cluster. There is no evidence that shared environment contributes to the development of posttraumaticstress disorder symptoms.
Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: a twin study.
by Stein MB, Jang KL, Taylor S, Vernon PA, and Livesley WJ.
American Journal of Psychiatry. 2002 159[10]:1675-1681.
OBJECTIVE: Posttraumatic stress disorder [PTSD] develops in only a subset of persons exposed to traumatic stress, suggesting the existence of stressor and individual differences that influence risk. In this study the authors examined the heritability of trauma exposure and PTSD symptoms in male and female twin pairs of nonveteran volunteers.METHOD: Scores on a traumatic events inventory and a DSM-IV PTSD symptom inventory were examined in 222 monozygotic and 184 dizygotic twin pairs. Biometrical model fitting was conducted by using standard statistical methods.RESULTS: Additive genetic, common environmental, and unique environmental effects best explained the variance in exposure to assaultive trauma [e.g., robbery, sexual assault], whereas exposure to nonassaultive trauma [e.g., motor vehicle accident, natural disaster] was best explained by common and unique environmental influences. PTSD symptoms were moderately heritable, and the remaining variance was accounted for by unique environmental experiences. Correlations between genetic effects on assaultive trauma exposure and on PTSD symptoms were high.CONCLUSIONS: Genetic factors can influence the risk of exposure to some forms of trauma, perhaps through individual differences in personality that influence environmental choices. Consistent with symptoms in combat veterans, PTSD symptoms after noncombat trauma are also moderately heritable. Moreover, many of the same genes that influence exposure to assaultive trauma appear to influence susceptibility to PTSD symptoms in their wake.
Heritabilities of symptoms of posttraumatic stress disorder, anxiety, and depression in earthquake exposed Armenian families.
by Goenjian AK, Noble EP, Walling DP, Goenjian HA, Karayan IS, Ritchie T, and Bailey JN.
Psychiatric Genetics. 2008 18[6]:261-266.
OBJECTIVE: To examine the heritabilities of symptoms of posttraumatic stress disorder [PTSD], anxiety, depression, and the shared genetic component of these symptoms among family members exposed to the 1988 Spitak earthquake in Armenia.METHODS: Two hundred members of 12 multigenerational families exposed to the Spitak earthquake were studied using a battery that assessed earthquake exposure and symptoms of PTSD, anxiety, and depression. Heritabilities of these phenotypes were determined using variance component analyses and shared genetic vulnerabilities between these phenotypes were determined using bivariate analyses.RESULTS: Heritabilities were as follows: PTSD symptoms 41% [P<0.001], anxiety symptoms 61% [P<0.001], and depressive symptoms 66% [P<0.001]. The genetic correlation [rhog>0] of PTSD symptoms with anxiety symptoms was 0.75 [P<0.001] and with depressive symptoms it was 0.71 [P<0.001]. The genetic correlation of anxiety with depressive symptoms was 0.54 [P<0.001].CONCLUSION: The heritabilities found in this multigenerational family study indicate that the genetic make-up of some individuals renders them substantially more vulnerable than others to develop symptoms of PTSD, anxiety, and depression. A large proportion of the genetic liability for PTSD, anxiety, and depression are shared. The findings offer promise for identifying susceptibility genes for these phenotypes.
Whoops, Well I can mount some arguments against these findings. The diagnoses were by questionnaire rather than clinical diagnosis. There’s more to "runs in families" than genes. This is all about known traumas and consciously connected symptoms. But still, I wouldn’t have predicted these results. And looking through the papers, they seem to be well conducted studies. So Mea Culpa in my discounting ways here. I think it’s an example of the kind of bias that haunts us in mental health where objective validation is hard to come by and implications drive a lot of thinking. I obviously more enjoy finding somebody else’s bias than my own, but bias is an equal opportunity employer.
I’m still not keen on the concept of resiliency in the kind of cases I dealt with and can’t think of any where one could validate such an idea. And this discussion leaves out the concept of transgenerational transmission of trauma where parents, families, or cultures pass on traumatic experience to their children – something that would certainly be pertinent in Armenia where there was extensive genocide by the Ottoman Turks after World War I [the third paper]. But in spite of my protests, these studies are suggestive of a genetic component to susceptibility in some traumatic mental illness until proved otherwise.
I think the key problem with these studies may be the assumptions behind the calculation of the heritability statistic itself. It has traditionally been based on the assumptions of genetic relatedness put forth by R.A. Fisher in 1918 (monogygotic twins share 100% of their genes, dizygotic share 50%, and so on). The heritability statistic is an estimate of the proportion of phenotypic variance that is due to genetic variance in a population. It is a time and place sensitive estimate.
In the last 8 years or so, our post-genomic map era has led to new methods in molecular biology that have challenged Fisher’s quantitative genetics assumptions. I have seen studies here and there that indicate, at least in a preliminary way, monozygotic twins might be anywhere from 3 to 9 percent different. I think molecular biologists are still challenging each other to reproduce these findings, but if they hold up, the older, traditional findings in behavioral genetics can no longer be regarded with the validity that we once accorded them. We’ll see . . . .
The intergenerational vulnerabilities are the sorts of situations that researchers in epigenetics look at. This is a field that has a long way to go, but some argue that something like what we used to refer to as Lamarckian inheritance might actually have some sort of basis in biology.
Classical Watson and Crick-style genetics is proving to be a bit simplistic (too bad . . . .). In addition to epigenetics, there is the proteome, the metabolome, etc., which, if our civilization still has the money and desire, need to be flshed out, step by step, throughout the rest of the century. Gene to brain to behavior is a path that has so many gaps to fill. The current new sciences of biomarkers research is in its infancy. I would love to fall in love with it, especially with regard to schizophrenia, but cannot (yet . . . .). What I like about the approach is that it draws our attention to peripheral processes in the entire body such as the immune system or glucose metabolism. It also, theoretically, allows for the potential to detect these smouldering systemic processes to be detected early and, perhaps, to the first true biological tests in psychiatry based on molecular phenotypes. We hope we can get lucky with this approach, but since it involves “whole body madness” it dethrones Brainhood as Personhood (and the NIMH switch to brain circuitry as guiding metaphor).
As for the genetics of schizophrenia, in particular, a big multisite study a few years back that was published in Nature led to a findinf that perhaps as many as 10,000 relatively rare gene variants were linked to schizophrenia. This led Nicholas Wade, the NY Times science writer, to make the claim in his NYT blog that this finding was the “Pearl Harbor of schizophrenia research.”
Thanks for that. As I’m sure I made clear, I’m not in love with what Nemeroff has in mind to do with this data – some handy genetic screening device to sentence some proportion of trauma victims to some as-of-yet-to-be-defined treatment. This is the problem of “translational research” – trying to take any research finding straight to the “bedside” before its meaning has been fleshed out.
Thanks for the comment…
1BOM,
Could you expand a bit more on why you’re not keen on the concept on resiliency? I’m not trying to argue you should be, I was just curious to hear more about why.
Yes, I was thinking this very thing last night. My mother, her brother, and her sisters were all raised by two sociopaths. Somehow all the children had consciences, so they felt all the shame of what was done to them. They’re all disturbed, but I do believe that they were all resilient to have survived their hellish childhoods.
I can’t convince a mental health professional that I don’t have PTSD from my bad childhood. I understood from a young age that my parenting units were messed up and the rest of life wasn’t going to be like that. I’d get out. And I did, at fourteen, through grace and good luck.
I have PTSD from an experience in nuclear forces, and I believe I’m quite resilient. My beef with the treatment of PTSD is that it is treated as a single disease-like state, that is the same for everyone. Psychologically dealing with being raped, for instance, cannot be the same as psychologically dealing with having killed a family at a checkpoint. Psychologically dealing with having participated in the murder of a person, cannot be the same as psychologically having taken part in the extinction of the human race (from where you were sitting). Trauma is very personal, yet coldly impersonal or dehumanizing at the same time.
Transcending an experience requires soul-searching and repeated reevaluations, and sometimes forgiveness.
But, when childhood sexual abuse was a hot topic in the mental fields, there was always that woman in the group who would natter on about how she couldn’t remember it, while everyone else was trying to forget. And the woman who didn’t remember, was always pretty obviously an alcoholic.
I worked at a day care center when the “ritual sexual abuse” that didn’t happen in that L.A. daycare center was the news of the day. Professionals convinced children and their parents that the children had experienced abuse in a way that only an actual witch could have pulled off in a place as public as a daycare center with a large, uncovered plate glass window facing the street. Some of the parents of the children in my daycare class were terrified of me all of a sudden. The media is also too blame for hysteria, but the psychologists and psychiatrists made it easy for them.
Wiley,
Those were, indeed, crazy days.
You mention an important point. Disaster and Combat PTSD can be somewhat uniform, but the usual case is a unique mental illness, based on the specifics of the experience. That’s actually true for the military cases, once you get past the first several meetings.
Annon,
Big topic. What I mean by tautology is that resiliency is defined by not having PTSD when someone thinks you should. I think it comes from the old Shell Shock days, as if trauma is a ‘shock.’ I think the nidus of future PTSD is not so much a function of what happened or the magnitude of the trauma itself, but rather its impact. People who develop PTSD have a rapidly escalating terror that puts them “in the red” – in an altered state that is a disruption in the self that remains as a the experience of a psychological death. If I read what I just said, I’d think it sounded like psychobabble, but I’d be glad to explain it better if we had a week or so. The point is that I came to think that the persistent lesion is in the ongoing sense of being…
Yes, the Nemeroff piece is yet another example of the hyperbolic Futureworld or Tomorrowland discourse. There’s a place for it — but for some reason the whole history of psychiatry, particularly American psychiatry, relies on it as a dominant discourse to legitimize its own continued existence and relevance in the absence of hard biological findings or effective treatments for those already ill (especially with severe conditions such as one might find in inpatient units). I think it really took off a century ago with the eugenics/mental hygiene movement and is an expression of American pragmatism, optimism and progressivism. Prevention was the rallying cry — nothing could be done for those already swelling the state hospitals. I have a quote on a poster in my office, attributed to Noam Chomsky (who actually said something slightly different): “One waits in vain for psychologists to state the limits of their knowledge.” All too true for American psychiatry as well.
Even twins raised in identical circumstances experience life differently.
The Trouble with Twin Studies http://www.madinamerica.com/2013/03/the-trouble-with-twin-studies/
The best preventive “medicine” for children to survive beyond early childhood may be having grandmothers, maternal grandmothers… Nature, volume 428, March 11 2004, Kristen Hawkes’ article The grandmother effect.
Wiley, your comments are appreciated, lucid points for me to ponder. Thank you!
In Bjugn, a small place in Tröndelag, 7 men, the chief of police among them, were accused of sexual abuse of preschoolers in a kindergarden. The case unravelled, based on rumers, faulty medical “evidence” and hysteria, spread by uncritical media. Only positive outcome was knowledge of greater normal genital variations in children and less gullibility regarding experts’ medical testimony. The damage done lingers in those involved and divisions in the community, 20 years hence.
I watched Insel’s TED-talk, grand visions for a future soon reached, hyperbole, hubris, black holes of omissions like a seller of … politics?
http://www.madinamerica.com today links to a lengthy article in Acta Psychiatria Scandinavica on the topic of resiliency, more than a hundred references, of which the few I checked out were male researchers in epigenetics in “non-human animal research”, i e rodents and monkeys.
I’ve heard a male lecture on measured effects of maternal licking behavior in laboratory rats, influencing myelination, modification of gene expression, (possibly) inherited by pups copying mothers amount of licking more or less…instantly rising the ghost of “schizophrenogenic mothers” in this and other females.
Challenged as to effect of fathers, the male answered, exasperation showing, that rat fathers have no role in research laboratories.
But he had showed that researcher had matched American children with varied backgrounds with their anomymized charts of more or less myelation according to reported quality of childhoods, defined by the rat research on amount of maternal licking. Then he spilled the beans. These children were all fatherless. .
Sorry, prematurely posted comment..
The children with reduced myelination were all fatherless.
resiliency is a popular concept
see wikipedia – psychological resiliency http://en.wikipedia.org/wiki/Psychological_resilience
the iraq/afghan war removed the veil that had obscured the high rates of PTSD among troops in war
there is big money in making everyone feel good about treating the veterans and especially in being comfortable with the next war
the more that people are resilient the less likely they will be stressed out
lets make everyone resilient
1BOM,
Do you have acces to this paper?
http://www.ncbi.nlm.nih.gov/m/pubmed/23403911/
It is getting a lot of coverage.
richard noll made a comment on epigenetics that reminded me of a book i am reading
he said.. “The intergenerational vulnerabilities are the sorts of situations that researchers in epigenetics look at. This is a field that has a long way to go, but some argue that something like what we used to refer to as Lamarckian inheritance might actually have some sort of basis in biology.”
http://en.wikipedia.org/wiki/Lamarckism
Lamarckism (or Lamarckian inheritance) is the idea that an organism can pass on characteristics that it acquired during its lifetime to its offspring (also known as heritability of acquired characteristics or soft inheritance).
the book is: History beyond trauma : whereof one cannot speak, thereof one cannot stay silent
the authors: Authors: Jean-Max Gaudillière, Françoise Davoine
they describe another way to conceptualize trauma, more especially the treatment of psychosis
book reviews
http://www.apadivisions.org/division-39/publications/reviews/history.aspx
“The authors radically locate psychosis within a social and historical field of investigation. In regard to “madness”, they assert; “we never use this word to describe the structure of an individual but instead to characterize a form of social link in an extreme situation” (p. xxii). It is precisely the unsymbolized and unremembered trauma of such “extreme situations” that come to haunt the psychotic subject. Within psychosis there is a collapse of time as well as personal identity. The individual is inhabited in the present not only by ghosts from his own earlier life experience, but also those of preceding generations.”
http://www.janushead.org/7-2/DavoineGaudilliere.pdf
“Davoine and Gaudilliere conceptualize madness as a social phenomenon intimately connected to the traumas of war. Madness is a “. . . form of social link in an extreme situation. . . People said to be crazy, in the ordinary sense of the term, show us what it was necessary to do in order to survive.” (p. xxii) The patient in treatment may not be the direct victim of trauma, but may instead be carrying an unspeakable encounter handed down through generations.”
more about the authors at yale holocaust research project
http://www.yale.edu/traumaresearch/Research%20Teams.htm#DavoineGaudilliere
For a view on where the field is headed, I suggest you check out http://www.ncbi.nlm.nih.gov/pubmed/23407816. Unfortunately, the abstract is not very detailed in terms of data, but the NIMH has a summary of the article with some additional background info.
This paper shows how researchers are looking at individual variability in a measurable psychological trait (threat bias) and how this trait interacts with a certain gene to influence likelihood of developing PTSD.
I’d really be curious to hear your thoughts on this kind of research approach.
“Let’s make everyone resilient” – sounds straight out of the crazies’ book of breeding a new master race, not Aryan this time, Resilient! Thanks, jamzo, and for the link to History beyond trauma. Piecing together what’s left of lives seared by the Resilient.
I find the “resiliency” argument to be kind of insulting. If you have certain traits, you have the moral failing of being less resilient? But psychiatry is all about these kinds of character judgments, isn’t it?
For many years, my sister insisted I became depressed from our horribly dysfunctional family and she did not because she was made of superior stuff. Right, being a narcissist trumps being a depressive. Better resiliency must be the key.
As I have my clinical background in child and adolescent psych, I found this an interesting spin on resilience and susceptibility to PTSD:
Peace and War: Trajectories of Posttraumatic Stress Disorder Symptoms Before, During, and After Military Deployment in Afghanistan; Psychological Science December 2012 vol. 23 no. 12 1557-1565.
Abstract: In the study reported here, we examined posttraumatic stress disorder (PTSD) symptoms in 746 Danish soldiers measured on five occasions before, during, and after deployment to Afghanistan. Using latent class growth analysis, we identified six trajectories of change in PTSD symptoms. Two resilient trajectories had low levels across all five times, and a new-onset trajectory started low and showed a marked increase of PTSD symptoms. Three temporary-benefit trajectories, not previously described in the literature, showed decreases in PTSD symptoms during (or immediately after) deployment, followed by increases after return from deployment. Predeployment emotional problems and predeployment traumas, especially childhood adversities, were predictors for inclusion in the nonresilient trajectories, whereas deployment-related stress was not. These findings challenge standard views of PTSD in two ways. First, they show that factors other than immediately preceding stressors are critical for PTSD development, with childhood adversities being central. Second, they demonstrate that the development of PTSD symptoms shows heterogeneity, which indicates the need for multiple measurements to understand PTSD and identify people in need of treatment.
Norwegian highly trained, select, voluntarily conscripted soldiers in the Nato ISAF contingent in Afghanistan are nearly at 600. 10 died, creating such public consternation that you’d think going to war is no riskier than any other well paid work. The Danish contingent counts 88 killed, small numbers compared to US losses, Brits’ and Canadians’.
Veterans I’ve met are contesting the politically correct view that wars do not scar and that there’s good help afterwards for those in need. The gist: Being in a relationship with a steady woman is crucial. Those who do not, who flit about, risk detoriorating psychic and physical health, drugs, alchohol, prescription pills etc.
I call my PTSD “BPM” (being properly mortified). Much of PTSD is, I think, sensitivity that doesn’t allow a person to normalize pathological, predatory, and insanely violent behavior. Seeing sociopathy writ large can make it easier to spot its more nuanced expressions. I’ve seen a lot of “normal” people ignore and/or make excuses for sick and abusive behavior, and sick and abusive people. It’s hard to be the person who can see the elephant in the living room a mile away.
Wiley,
BPM is a new one, but point taken. I say people with PTSD have a special knowledge. They know what kind of bad things can happen in the world and have been stripped of the capacity not to see them. As a patient once said, “I envy you. You read the same newspapers I do and run across the same unsavory motives I see, but I can see that you live as if everything’s fine and that you’re safe. I can’t do that. I envy that ability… And, by the way, I think you’re nuts!”
Andy S.
Thanks. Those last two sentences are pure gold in my experience…
Alto,
Is living with a narcissist sister tough?
Especially for someone such as yourself,
Without those traits?
Duane
I’ve heard siblings can begin to act like the other, yet you show no signs whatsoever of being a narcissist. Go figure.
Duane