Trauma and Depression.

 Art by Yiska Dubrae.

The knowledge of how trauma affects psychological and biological developmental has expanded exponentially over the past three decades. We now know how trauma occurs and how the damage caused can be successfully managed and in some cases repaired.  Trauma is a global problem that impacts the health well-being of millions of people and it underscores a lot of negative human behaviour.  The study of psychological trauma has been accompanied by an explosion of knowledge about how experience shapes the central nervous system and the formation of the self. Developments in the neurosciences, developmental psychopathology and information processing have contributed to our understanding of how brain function is shaped by experience and that life itself can continually transform the body and mind. The study of trauma has probably been the single most fertile area in helping to develop a deeper understanding of the relationship among the emotional, cognitive, social and biological forces that shape human development. Starting with post-traumatic stress disorder (PTSD) in adults and expanding into early attachment and overwhelming experiences in childhood, this endeavour has elucidated how certain experiences can “set” psychological expectations and biological selectivity. We have learned that most experience is automatically processed on a subcortical level in the brain; i.e., by “unconscious” interpretations that take place outside of awareness. Insight and understanding have only a limited influence on the operation of these subcortical processes. When addressing the problems of traumatized people who,  continue to react to current experience as a replay of the past, there is a need for therapeutic methods that do not depend exclusively on drugs and cognition.   There are other transformative and (w)holistic approaches.

What if depression wasn’t an illness, it was a response to trauma? In May of 2017 I posted this question on social media where it received unexpected attention from the public as well as from some very prominent social identities.

The question is not entirely new the Anti-Psychiatry Movement of the 1960s and in particular R.D. Liang attempted to link all mental illness to various expectations and inequities within society said to cause anxiety and trauma.  All mental illness has strong components of fear and anxiety, which in turn alters the brain chemistry, whereby it can cause long term damage to the brain’s neurological structure, but the brain also has plasticity and in some cases the brain can repair itself or supplement the damage by using other neurological areas.

The neurological elements of mental illness have become the core focus of treatments for mental disorder, generally by matching the condition with anti-depressant or anti-psychotic drugs. However, while trauma studies became increasingly popular in the 1970s there has been a decline in the deeper understanding of trauma in favour of a quick fix for aberrations and it is only recently that the notion of inter-generational trauma has arisen as a probability rather than a possibility.

There has been a significant philosophical and medical divide between the notion of  mental illness and the incidence of trauma.   Mental illness is partly seen as a social problem and it carries a social stigma.   Moreover, the etiology of generational trauma as a cause of mental dysfunction has received little efficacy in the realms of organic diagnostics.  The word ‘trauma’ conveys an extreme condition of immediate pain and urgency, yet, while the many other names attributed to psychiatric conditions, such as depression, stress or forms of neuroses are generally implicated in the condition, they receive a softer alliteration, whereby the softer meaning can serve to undermine the importance and urgency of the circumstance or its severe experiential ramifications for a quality life, as well as for its long term consequences.

For example,  complex post-traumatic stress disorder (C-PTSD; also known as complex trauma),[i]  is a psychological disorder which is hardly spoken of in society at large, albeit its counterpart, post-traumatic disorder has become well known, but only because of its high incidence amidst soldiers currently returning from wars. The diagnosis of PTSD was originally developed for adults who had suffered from a single event trauma, such as rape, or a traumatic experience during a war.[ii]   However, the situation for many traumatized children is quite different. Children can suffer chronic trauma from events such as maltreatment, family violence, and a disruption in attachment to their primary caregiver,[iii]  which exceed the diagnosis of PTSD because it does not account for the child’s development.  Currently there is no proper diagnosis for this condition, but the term developmental trauma disorder has been suggested.[iv]

Post-traumatic stress disorder (PTSD) was included in the Diagnostic Statistical Manual Vol III (DSM-III,1980), when it was shown that American combat veterans of the Vietnam War were experiencing combat stress.   In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the long term effects of child sexual abuse and domestic violence. This prompted the suggestion that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly when perpetrated during multiple developmental stages.  This gave rise to the notion of complex post-traumatic stress disorder (C-PTSD) which was characterized by additional symptoms such as psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to become an ongoing victim.  In addition, this condition was shown to include a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[v]

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[vi] In the DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children’s attachment needs, they may have particular difficulty in responding sensitively especially to their infant and young children’s routine distress despite constant efforts to do so.[vii]  This situation is exacerbated if the parent is a single parent lacking adequate support.   Although the great majority of survivors do not abuse others,  difficulties in parenting may have adverse repercussions for their children’s social and emotional development. [viii]

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers, older siblings or partners, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.[ix]

C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services. [x]

C-PTSD can become a pervasive way of relating to others in adult life and six clusters of symptoms have been suggested for diagnosis of C-PTSD.  These are

(1) alterations in regulation of affect and impulses;

(2) alterations in attention or consciousness;

(3) alterations in self-perception;

(4) alterations in relations with others;

(5) somatization,

(6) alterations in systems of meaning.

Experiences in these areas may include: [xi]

  • Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).
  • Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.
  • Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings
  • Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator’s belief system or rationalizations.
  • Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.
  • Loss of, or changes in, one’s system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.
  • Loss of a sense of reality accompanied by feelings of terror and confusion (psychosis).

Complex trauma is said to results from repetitive, prolonged trauma, often unintended or inflicted discursively via the perpetrators own history of trauma, which can set up uneven power dynamics. C-PTSD is associated with intimate partner violence (unwanted and painful sexual acts) bondage, kidnap, hostages, indentured servants, slaves, sweatshop workers, prisoners of war, concentration camp survivors, and defectors of cults or cult-like organizations[xii].  Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which include prolonged feelings of terror, worthlessness, helplessness, and deformation of one’s identity and sense of self.[xiii]

 

[i] Cook, A., et. al.,(2005) Complex Trauma in Children and Adolescents,Psychiatric Annals, 35:5, pp-398

[ii] Complex Trauma And Developmental Trauma Disorder” (PDF). National Child Traumatic Stress Network. Retrieved 14 November 2013.

[iii] Ford, Grasso, Greene, Levine, Spinazzola & van der Kolk; Grasso; Greene; Levine; Spinazzola; Van Der Kolk (August 2013). “Clinical Significance of a Proposed Developmental Trauma Disorder Diagnosis: Results of an International Survey of Clinicians”. Journal of Clinical Psychiatry. 74 (8): 841–9. doi:10.4088/JCP.12m08030. PMID 24021504, and Wikipedia Retrieved 8th May 2017.

[iv] Ford, Grasso, Greene, Levine, Spinazzola & van der Kolk; Grasso; Greene; Levine; Spinazzola; Van Der Kolk (August 2013). “Clinical Significance of a Proposed Developmental Trauma Disorder Diagnosis: Results of an International Survey of Clinicians”. Journal of Clinical Psychiatry. 74 (8): 841–9. doi:10.4088/JCP.12m08030. PMID 24021504, and Wikipedia Retrieved 8th May 2017.

[v]   Herman, J. L. (1992). “Complex PTSD: A syndrome in survivors of prolonged and repeated trauma” (PDF). Journal of Traumatic Stress. 5 (3): 377–391. doi:10.1007/BF00977235. and 1997 pp. 119–122.

[vi] Van Der Kolk, B. A.; Roth, S.; Pelcovitz, D.; Sunday, S.; Spinazzola, J. (2005). “Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma” (PDF). Journal of Traumatic Stress. 18 (5): 389–399. doi:10.1002/jts.20047. PMID 16281237, and Wikipedia Retrieved 8th May 2017.

[vii] Schechter, D. S.; Coates, S. W.; Kaminer, T.; Coots, T.; Zeanah, C. H.; Davies, M.; Schonfeld, I. S.; Marshall, R. D.; Liebowitz, M. R.; Trabka, K. A.; McCaw, J. E.; Myers, M. M. (2008). “Distorted Maternal Mental Representations and Atypical Behavior in a Clinical Sample of Violence-Exposed Mothers and Their Toddlers”. Journal of Trauma & Dissociation. 9 (2): 123–147. doi:10.1080/15299730802045666. PMC 2577290 . PMID 18985165., pp. 123-149 and Wikipedia Retrieved 8th May 2017.

[viii] Kaufman, J.; Zigler, E. (1987). “Do abused children become abusive parents?”. The American journal of orthopsychiatry. 57 (2): 186–192, and Wikipedia Retrieved 8th May 2017.

[ix] Herman, J. L. (1992). “Complex PTSD: A syndrome in survivors of prolonged and repeated trauma” (PDF). Journal of Traumatic Stress. 5 (3): 377–391. doi:10.1007/BF00977235, and Wikipedia Retrieved 8th May 2017.

[x] Straker, Gillian (1987). “The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview”. Psychology in Society (8): 46–79., and Wikipedia Retrieved 8th May 2017.

[xi] Zlotnick, C.; Zakriski, A. L.; Shea, M. T.; Costello, E.; Begin, A.; Pearlstein, T.; Simpson, E. (1996). “The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder”. Journal of Traumatic Stress. 9 (2): 195–205 and Wikipedia. Retrieved 18th May 2017.

[xii] ibid

[xiii] Lewis Herman, Judith (1992). Trauma and Recovery. Basic Books and Wikipedia Retrieved 8th May 2017.

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