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The Long Shadow of Trauma

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Childhood abuse may be our number one public health issue

By Mary Sykes Wylie

Back in the late 1970s, a motley crew of Vietnam War vets, sympathetic psychiatrists, antiwar activists, and church groups undertook a crusade to have a hastily-assembled new diagnosis almost completely innocent of scientific research included in the DSM-III. Driven by a sense of mission and responsibility to the huge population of Vietnam vets and buoyed by the accumulating everyday clinical evidence that their war experience had profoundly disrupted the lives of thousands and thousands of young men, this unlikely coalition prevailed. Once established as a distinct disorder in the official manual of psychiatric diagnoses, the otherwise unaccountable behavior of badass vets—their hair-trigger tempers, violence toward wives and girlfriends, drinking and drugging, difficulty getting and keeping jobs, social alienation—suddenly made sense. There was a reason for it and the reason had a name and that name was post-traumatic stress disorder (PTSD). By giving words—a verbal shape, a definition—to an amorphous constellation of symptoms, what had before been invisible became a part of standard professional discourse.

As a diagnosis, PTSD is quite straightforward. A person is exposed to a traumatic event or events "that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others," causing "intense fear, helplessness, or horror," and followed, down the line, by variations on intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were reoccurring, etc.), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia connected to important parts of the experience), and increased arousal patterns (insomnia, hypervigilance, irritability, and so on). Clear, brief, intuitively sensible, the definition of PTSD implies a kind of satisfyingly simple, dramatic, and implicitly moral story line: individuals are innocently minding their own business when—wham!—they're slammed by a frightful, shattering, life-threatening happenstance, and are never the same again. The trauma may have "ended," but not in the perpetually recycling memories and disrupted nervous systems of the victims.

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?"

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