Current trends indicate that as many as 1 in 4 females and 1 in 7 males have experienced sexual abuse in childhood by a member of their family of origin or by a significant other with the role of caregiver. (Herman, Schatzow, p.1) Adults who have experienced this type of trauma in childhood have displayed many of the symptoms of Post Traumatic Stress Disorder (PTSD) experienced by Viet Nam Veterans and persons who have experienced other trauma of a severe nature. While Post Traumatic Stress Disorder can be displayed after only one traumatic event, repeated childhood abuse, particularly that of a sexual nature, has possibly imbedded in the subsequent adult, symptoms so severe as to have possibly altered the chemical brain structure. Is is the body's chronic extreme physiological adaption to tramatic states which likely affects the day-to-day functioning of trauma victims which has been the focus of research over the last decade. Researchers are now speculating that chronic physiological states alter the brain's chemistry affecting the long term functioning of individuals and resulting, among other things, in memory impairment and free floating anxiety of an unperceived nature. It is the purpose of this paper to briefly examine the theoretic views which have developed as a result of investigations into the psychological, physiological and neurological reactions of victims diagnosed with post traumatic stress disorder sharing histories of childhood sexual abuse. The child's psychological symptoms of post traumatic stress, from infancy to adolescence, vary slightly from those of adults. Researcher Kendall Johnson believes it is important to stress not only that there is a cause and effect situation between crisis and behavioral problems in children, but one must also consider the reasons why and how this relationship occurs. Johnson began by mapping symptoms of PTSD as they related to children, from the acute situational where the child experiences perhaps one insidence of sexual abuse, to the delayed reaction responses where repeated acts of abuse occurred. He indicated how trauma affects the developmental process, how it eventually leads to maladaptive behaviors in adolescence and how, if not identified and treated, effects of trauma continue into adulthood. Judith Herman found that with many women, the maladaptive behaviors based in childhood psychological defenses surfaced in therapeutic or inpatient psychiatric interventions. Males who had been physically or sexually abused were more often diagnosed as antisocial personalities. A large number of males are not included in statistical data since, as abuse victims with antisocial traits, they tend to be placed in the correctional population as opposed to the mental health population. Researcher Kendall Johnson cited several studies to point out effects of trauma. In one study, which Johnson identified as by Eth & Pynoos in 1985, the effects of trauma, both long and short term, were the focus of research involving 28 adolescents known to have experienced trauma of a significant nature. Reactions were classified under headings of: cognitive, emotional, physical and behavioral. In that study, the effects, both long and short term, were that these children had "higher than average rates of substance abuse, and other self-destructive behaviors." (Johnson, pp 37) He further stated that researcher Benedek, in 1985, summarized symptoms of childhood trauma as they related to the DSM-III PTSD criteria. Benedek stated that "particular daydreams, fantasies, nightmares (recurrent recollections), and behavioral changes linked to sudden visual and auditory stimuli, may remind children of the traumatic event." (Johnson, pp 43) Benedek also believed as DSM-IIIR criteria were clarified to distinguish the differences between adult and child PTSD, "research and clinical knowledge would sharpen and many children who had been diagnosed as depressive, anxiety disordered, and adjustment disordered would be recognized to be suffering from PTSD." (Johnson, pp 43) Johnson was hopeful that these criteria and resulting changes in type of treatment given, would eventually be reflected in the long-term improvement of mental health for trauma victims. According to Johnson in a study by researcher Terr in 1985, it was discovered that there were certain PTSD symptoms unique to children, these included: "1. children over age 3-4 do not become amnesic about the experience and actually have vivid memory (children under age 3 tend to forget the experience due to normal repressions in the first few years of life and nonverbal encoding of memories-some however, do remember the trauma.) 2. in acute trauma situations children do not tend to have psychic numbing like adults however, chronic stressors like parental abuse do cause psychic numbing. 3. children do not experience flashbacks. 4. in acute situations children's performance does not decline for as long as adult's experience the performance decline. 5. children's repetitive play enactment increases. 6. time distortions are more frequent, including foreshortened view of the future." (Johnson, pp 47) Normal developmental "crisis" stages are often interrupted or maladaptive ways of coping are incorporated into subsequent stages of development causing decreases in the level of functioning into adulthood. Two significant reactions affecting the way normal developmental stages are viewed and handled, as a result of trauma, are developmental anxiety and what Johnson calls premature structuring. Developmental anxiety which is "a reaction to the transition involved in the giving up of old forms of coping that worked at one level of development and the acquisition of new ones appropriate to a new level of development" usually generates positive movement for the individual. (Johnson, pp 56) Already existing levels of anxiety due to trauma can cause hyper arousal or retardation of this developmental process. In premature structuring, which is the "process by which character or personality formation of the child is accelerated due to the demands of the environment, future personality development is constricted." (Johnson, pp 56) It was explained that children of trauma "tend to become overspecialized and over differentiated in a manner that provides immediate survival value but closes off further learning and balanced growth." (Johnson, pp 57) Johnson hoped that by identifying the effects of PTSD symptoms in the developmental stages of children and adolescents, professionals will be better able to plan strategies to help block maladaptive coping behaviors interfering with developmental life stages. Statistics which stood out were found in a study by Fredrick in 1985 concerning psychiatric disturbances found among children. Among children molested, PTSD was ranked first in psychiatric disturbances; of those physically abused it was fourth; yet in cases of disasters, PTSD ranked seventh in ten. (Johnson, pp 49) These figures seemed to agree with part of the study by Terr as mentioned above. The agreement was that children do not react as strongly, long term, to single instances of acute trauma as to chronic trauma that is found with parental abuse. Researcher Judith Lewis Herman lays the foundation of the conditions endured by the child which therefore result in a child's use of such extreme defenses at an early age. Where the child uses both somatic and psychological defenses and Herman terms these "an immature system of psychological defenses used to compensate for failures of adult care and protection"(Herman, pp 96), the conditions are generally an adaption to repeated trauma situations. The author emphasizes that this environment, which to most children should be a family environment of safety and nurturing, is to a trauma child a "pattern of totalitarian control, enforced by means of violence and death threats, capricious enforcement of petty rules, intermittent rewards and destruction of all competing relationships through isolation, secrecy and betrayal."(Herman, pp 98) The result is a chronic state of fear, helplessness and unpredictability. This requires the child to be in a chronic alert and results in psychological defenses which often require altered states of consciousness such as the ability to be attuned to minute changes in the surrounding environment. The children often learn to either avoid or appease the abuser (or both). This leads to a condition of "frozen watchfulness" or a chronic state of "trying to be good", both a result of hyperarousal. It is the fragmentation in memory, knowledge, emotional states and bodily experience that make an integrated sense of identity unduly difficult for these children. Eventually the chronic state of terror, rage, and grief take their toll on the body. Frequently these manifest themselves in what psychiatrists call dysphoria, the chronic state of free floating anxiety. The defenses used to help the child cope with extreme forms of repeated abuse also block the developmental process. More often than not, the outcome is eventually an adult who is quite vulnerable and reactive to issues of abandonment or exploitation in future relationships. Interestingly, it is often these issues which, years later, lead the adult (once abused as a child) into therapy. These adults often overreact to slight or minor occurrences which are only remotely related to the long denied emotions evoked during childhood trauma. On the other hand, it can be repressed or dissociated to one degree or another. This leaves the adult vulnerable to repeated abusive situations which are nearly impossible for them to identify, register and learn from. Many of the conditions of psychological defenses (with the exception of multiple personality which has it's specific origins in childhood abuse and is believed to also be based in inherent personality traits) are fairly common and unquestioned defenses of prisoners of war, victims of rape, holocaust victims and victims of terrorist kidnapping. With child abuse, it appears that in cases of repeated trauma, defensive coping mechanisms are also activated. Van der Kolk contends, and Davis and William agree, that trauma memory is stored differently than normal memory as a result of psychobiologic responses to extreme stress. Persons undergoing extreme stress are unable to effectively use declarative (semantic) memory which is regulated by the thalamus, amygdala and hippocampus. Semantic memory is an active process in which recall depends on existing shema. Although trauma does interfere with semantic memory it does not interfere with non declarative memory systems. When stress causes over stimulation of the amygdala, memories are stored in sensorimotor modalities in the form of somatic sensations and visual impages (van der Kolk, pp 259) Stress disorders such as PTSD are also manifested as memory disorders which display hypermnesia and amnesias. Severe trauma, due to its overwhelming nature, generally renders the individual incapable of associating the event in words or symbols, or to place it in space and time.(van der Kolk, pp 261) Declarative memory requires one to make these associations. It is also believed that trauma memories are retrieved more readily during state dependent situations in which the psychobiologic state is similar to that of the trauma. Lang proposed that emotional memories are stored in 'associative networks' and emotionally laden memries are stimulated when sufficient associations of the trauma are activated.(van der Kolk, pp 255) Studies which indicate impaired cortical control of subcortical areas, by LeDoux and Kolb have led to the supposition that "decreased inhibitory control may occur under a variety of circumstances: under the influence of drug and alcohol, during sleep (as in nightmares), with aging, and after exposure to strong reminders of traumatic past."(van der Kolk, pp 261) Impaired cortical control implies the pass by of the cortical and septohippocampal activity and may be responsible for delayed onset of PTSD responses. An interesting element for me was the association of age with delayed syptoms of PTSD. During William's study of women who did not recall past documented trauma, there was speculation that some of the women who did not recall the abuse, were younger at the time of William's study than those with delayed recall. William's speculated whether an increase in age would result in further evidence of delayed recall.(i.e. recall of indexed abuse possibly had more to do with age at the time of reinterview than age at which the indexed abuse occurred.) (Williams, pp 115) Biologic responses occur as a result of stress, setting off neurohormones which result in the flight or fight response of the sympathetic nervious system. An animal study by Adamex showed that when there was increased stimulation of the amygdaliod and hippocampal activity, there were also permanent alterations in the limbic physiology which caused lasting changes in defensiveness and predatory agression (van der Kolk, pp 261) During periods of extreme stress endogenous opiods were released inhibiting pain during the traumatic event. It also caused a "freeze response which, during the period of trauma, rendered the individual animal unable to consciously experience or remember the situation" (van der Kolk, pp 257) It is speculated that it is the secretion of endogenous opiods which assist in the use of the coping mechanism of dissociation. Other research studies involving animal responses to extreme stressors and subsequent research relative to trauma in humans indicate very specific biologic responses which appear to interfere with memory storage. In the animal kingdom "flight or fright" responses, as a result of fear or danger, are significant factors required for survival of species. Automatic responses to fear involving secretion of hormones to regulate bodily responses have been studied extensively over the last decade. Van der Kolk believes sufficient documentation and study of the biological responses to trauma have been obtained to formulate hypotheses regarding the roles physiology and biology play in both trauma response and the memory storage. Neurobiologist Edelman, in 1987, indicated that the basic neural structure of the central nervous system is in place at birth. Development occurs as the synapses strengthen between the neuronal groups. Comtemporary research indicates that the ability to categorize is one of the most fundamental of mental acitvities. Current researchers tend to agree with Janet that "what memory processes the best is not specific events but the quality of experience and the feelings associated with it (Edelman, 1987)."(van der Kolk, pp 439) Memory tends to be processed by schemas and categories and consequentlly, where there is a prior store of knowledge, the individual integrates new related knowledge more rapidly. This process is generally done on an unconsious level. It is generally only when difficulty arises that the conscious kicks in. "Memories easily become inaccurate when new ideas and pieces of information are constantly combined with old knowledge to form flexible mental schemas."(van der Kolk, pp 441) Myelinization in the brain ocurs at different stages of development up until puberty. Various research (Jacobs and Nadel 1985; Schacter and Moscovitch 1984) "indicates that infantile amnesia is the result of lack of myelinization of the hippocampus."(van der Kolk, pp 442) The hippocampus allows memories to be placed in their proper context of time and place. This system remains vulnerable even after myelinization. "Severe or prolonged stress can suppress hippocampal functioning creating context-free fearful association which are hard to locate in space and time. This results in amnesia for the specifics of traumatic experiences, but not the feelings associated with them (Nadel & Zola Morgan 1984; Sapolsky et al, 1984) Piaget's theory of development begins with the sensorimotor, than perceptual and later symbiolic and linguistic organization. It is believed that the inability to express traumatic memory in words "leaves it to be organized on a somatosensory or iconic level: as somatic sensations, behavioral reenactments, nightmares and flashbacks (Brett & Ostroff 1985)."(van der Kolk, pp 442-443) At the time of trauma the individual experiences intense autonomic reaction. As a result, it is believed that memories are "fixed".(van der Kolk, pp 443) DSM IV field trials, 1991, noted that adults who experience one time trauma tend toward hyperamnesia whereas repeated traumas experienced by a child tend toward chronic amnesias. Noradrenergic pathways in the locus coeruleus of the brain trigger the autonomic system to react to threat. In previous traumatized individuals, this system is triggered prematurely over incidents remotely related to the original trauma (Similar to salivation of Pavlov's dogs to conditioned stimuli. The arousal of the autonomic system begins the secretion of noradrenaline which, if stress is prolonged, activates the production of endogenous opiods. The secretion of endogenous opiods dulls the perception of both physical and psychological pain. The hippocampus, amygdala and frontal lobes are subsequently affected, resulting in the fight/flight response. (van der Kolk et al, 1989) Van der Kolk believes that many symptoms associated with Post Traumatic Stress Disorder (PTSD) can also be misdiagnosed as other psychiatric disorders. Since PTSD symptoms may not present themselves for years into the future, the traumatic event and its dissociated effects, can be misleading in many clinical presentations. Other than multiple personality, panic disorders and chronic pain syndromes, it may also be a factor in borderline personality disorder and hysterical disorders. Van der Kolk believes that the difficulty in treating these disorders may be based in the physiological reactions have not been readily identified as contributing factions to the cyclic nature of the anxiety and stress inherent with post traumatic symptoms. According to van der Kolk there are indications in his research of trauma which include biologic, psychodynamic and social consequences. Past research had also docused on the symptoms associated with personality change due to trauma. Pavlov reported "defensive reaction" to indicate reflexive responses to environmental threat."(Van der Kolk, pp 4) This would appear to be borne out with over reactive responses of Viet Nam Veterans to such stimulus as a helicopters flying over head years after the war experience. There is also Freud's theory of repetitive compulsion and Janet was aware of clients responses to trauma as including diminished responsiveness. The individual's energy is used to ward off effects of trauma leaving them depleted of appropriate responses to current events. While the focus was on psychological responses, few were researching the neurological or physiological correlates of trauma effect. Van der Kolk addresses to the factors which affect trauma responses. He lists "severity of the stressor, genetic predisposition, developmental stage, social support system, prior traumatization and preexisting personality."(Van der Kolk, pp 10-12) I will highlight points of interest several of these factors. One important element not mentioned in the Diagnostic Symptoms Manual IV criteria for the level of stressor indicators, is the meaning the individual places on the event regardless of its intensity. H. Krystal viewed this as a significant factor in how an individual adapted to the trauma.(Van der Kolk, pp 5-6). Van der Kolk suggests that there may be indications of genetic predisposition for stress reactions in attachment and separation responses. Also, stress responses appear to be affected by the individual's level of cognitive development. Van der Kolk addresses the separation cry and its trauma response which has psychobiological consequences. From birth, the child develops in a social context and Van der Kolk quotes Bowlby's hypothesis that "the most powerful influence in overcoming the impact of psychological trauma seems to be the availability of a caregiver who can be blindly trusted when one's own resources are inadequate."(Van der Kolk, pp 32) Van der Kolk states that animal studies clearly link disturbances in early attachment as a cause of lifelong maladaptive psychobiological effects. Apparently human research is also indicating that "there may be particularly vulnerable stages of development related to maturational processes in the central nervous system" which may be affected. (Van der Kolk, pp 33) There is a tendency for children experiencing separation trauma to overreact to subsequent mildly related situations and to handle anxiety poorly. Ample research has been done with animal species. Separation causes physiological distress in many species. It was found that in some species separation distress "caused drop in temperature, cardiac and respiratory depression and behavioral arousal. It was found in squirrel monkeys that there were highly elevated plasma cortisol levels even when behavior of these animals was no longer evident." (Van der Kolk, pp 40) It is believed that the endogenous opioid system controls separation distress. In several studies it was discovered that morphine in small doses, reserpine, meprobamate, diazepam, sodium pentobarbital, amphetamines and alcohol do not have an effect on separation distress in animal primates. Apparently only Clonidine, an alpha 2 noradrenergic receptor agonist, has shown promising results. Researchers are encouraged by this finding as it suggests that separation distress is "specifically controlled by the opioid system".(Van der Kolk, pp 41). Animal studies are also indicating that the opiate receptors can be affected during critical stages of development. "Social isolation in young mice was found to cause decreased brain opiate receptor density." Unfortunately this does not always translate to humans. In monkeys "high stress responsiveness and high social status were correlated with low resting levels of ACTH. This stress responsiveness may be passed on to the next generation. One study found a correlation between the cortisol response to separation in monkey infants and the position of their mothers in the dominance hierarchy."(Van der Kolk, pp 45) It appears that chronic stress increases ACTH and cortisol levels, which in turn, increases serotonin metabolism and consequently lowers serotonin levels. Serotonin negatively affects pain tolerance and the ability to feel pleasure. A product of serotonin levels is 5-hydroxy indole amino acid. Low levels of 5-HIAA have been associated with despair and suicide in humans. Apparently serotonin has been well researched using animal primates and there was ample evidence that "blood serotonin levels were state dependent: levels were greatly affected by spontaneous and induced changes in social status and by temporary isolation."(Van der Kolk, pp 46) On the other hand, studies of infants separated from their mothers, did indicate changes in the hypopthalamic serotonin (5-HT), adrenal gland catecholamine synthesizing enzymes, plasma cortisol, heart rate, body temperature and sleep.(Van der Kolk, pp 43) Researchers found that when these physiological changes occurred, there tended to be long term neurobiological changes. Van der Kolk noted that in recent years research has linked neurological and genetic abnormalities to schizophrenia, affective disorders, phobias and attention deficit disorders. Many of these researchers implicate genetics encoded in DNA as responsible. Van der Kolk questions whether social attachment in infants, and its subsequent disruption, don't also have a basis for neurological implications. I don't see an inconsistency here. The nature/nurture influences do not have to be mutually exclusive. Investigation of the neurological effects of trauma is a relatively new undertaking by researchers. I cannot honestly say that I could at this stage form an opinion on the neurological effects caused by sexual abuse occurring in childhood. Ample research has been done with animals. Differences in species seem to indicate that specific systems do not always regulate the same physiological reactions. It seems higher organisms have adapted so that certain functions have evolved in complex ways which allow multifunctioning redundant patterns instead of the individual, simpler pathways of the lower organisms. While one can argue that what is studied and found in animal research does not necessarily generalize to humans, it appears plausible that trauma can cause neurological damage or malfunction. We are biological creatures and can't be exempt from long lasting effects of stressors in our environment. The question that intrigues me, is whether changed behavior patterns, offsetting the physiological symptoms of the autonomic system in adulthood, can reverse neurological effects of early childhood trauma. Perhaps due to individual differences, it can.
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