The Body Keeps the Score

by Bessel van der Kolk MD

  29.R. Yehuda, et al., “Vulnerability to Posttraumatic Stress Disorder in Adult Offspring of Holocaust Survivors,” American Journal of Psychiatry 155, no. 9 (1998): 1163–71. See also R. Yehuda, et al., “Relationship Between Posttraumatic Stress Disorder Characteristics of Holocaust Survivors and Their Adult Offspring,” American Journal of Psychiatry 155, no. 6 (1998): 841–43; R. Yehuda, et al., “Parental Posttraumatic Stress Disorder as a Vulnerability Factor for Low Cortisol Trait in Offspring of Holocaust Survivors,” Archives of General Psychiatry 64, no. 9 (2007): 1040 and R. Yehuda, et al., “Maternal, Not Paternal, PTSD Is Related to Increased Risk for PTSD in Offspring of Holocaust Survivors,” Journal of Psychiatric Research 42, no. 13 (2008): 1104–11.

  30.R. Yehuda, et al., “Transgenerational Effects of PTSD in Babies of Mothers Exposed to the WTC Attacks During Pregnancy,” Journal of Clinical Endocrinology and Metabolism 90 (2005): 4115–18.

  31.G. Saxe, et al., “Relationship Between Acute Morphine and the Course of PTSD in Children with Burns,” Journal of the American Academy of Child & Adolescent Psychiatry 40, no. 8 (2001): 915–21. See also G. N. Saxe, et al., “Pathways to PTSD, Part I: Children with Burns,” American Journal of Psychiatry 162, no. 7 (2005): 1299–304.

  32.C. M. Chemtob, Y. Nomura, and R. A. Abramovitz, “Impact of Conjoined Exposure to the World Trade Center Attacks and to Other Traumatic Events on the Behavioral Problems of Preschool Children,” Archives of Pediatrics and Adolescent Medicine 162, no. 2 (2008): 126. See also P. J. Landrigan, et al., “Impact of September 11 World Trade Center Disaster on Children and Pregnant Women,” Mount Sinai Journal of Medicine 75, no. 2 (2008): 129–34.

  33.D. Finkelhor, R. K. Ormrod, and H. A. Turner, “Polyvictimization and Trauma in a National Longitudinal Cohort,” Development and Psychopathology 19, no. 1 (2007): 149–66; J. D. Ford, et al., “Poly-victimization and Risk of Posttraumatic, Depressive, and Substance Use Disorders and Involvement in Delinquency in a National Sample of Adolescents,” Journal of Adolescent Health 46, no. 6 (2010): 545–52; J. D. Ford, et al., “Clinical Significance of a Proposed Development Trauma Disorder Diagnosis: Results of an International Survey of Clinicians,” Journal of Clinical Psychiatry 74, no. 8 (2013): 841–49.

  34.Family Pathways Project, http://www.challiance.org/academics/familypathwaysproject.aspx.

  35.K. Lyons‐Ruth and D. Block, “The Disturbed Caregiving System: Relations Among Childhood Trauma, Maternal Caregiving, and Infant Affect and Attachment,” Infant Mental Health Journal 17, no. 3 (1996): 257–75.

  36.K. Lyons-Ruth, “The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental States, and Hostile/Helpless Relational Processes,” Journal of Infant, Child, and Adolescent Psychotherapy 2 (2003): 105.

  37.G. Whitmer, “On the Nature of Dissociation,” Psychoanalytic Quarterly 70, no. 4 (2001): 807–37. See also K. Lyons-Ruth, “The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental States, and Hostile/Helpless Relational Processes,” Journal of Infant, Child, and Adolescent Psychotherapy 2, no. 4 (2002): 107–19.

  38.Mary S. Ainsworth and John Bowlby, “An Ethological Approach to Personality Development,” American Psychologist 46, no. 4 (April 1991): 333–41.

  39.K. Lyons-Ruth and D. Jacobvitz, 1999; Main, 1993; K. Lyons-Ruth, “Dissociation and the Parent-Infant Dialogue: A Longitudinal Perspective from Attachment Research,” Journal of the American Psychoanalytic Association 51, no. 3 (2003): 883–911.

  40.L. Dutra, et al., “Quality of Early Care and Childhood Trauma: A Prospective Study of Developmental Pathways to Dissociation,” Journal of Nervous and Mental Disease 197, no. 6 (2009): 383. See also K. Lyons-Ruth, et al., “Borderline Symptoms and Suicidality/Self-Injury in Late Adolescence: Prospectively Observed Relationship Correlates in Infancy and Childhood,” Psychiatry Research 206, nos. 2–3 (April 30, 2013): 273–81.

  41.For meta-analysis of the relative contributions of disorganized attachment and child maltreatment, see C. Schuengel, et al., “Frightening Maternal Behavior Linking Unresolved Loss and Disorganized Infant Attachment,” Journal of Consulting and Clinical Psychology 67, no. 1 (1999): 54.

  42.K. Lyons-Ruth and D. Jacobvitz, “Attachment Disorganization: Genetic Factors, Parenting Contexts, and Developmental Transformation from Infancy to Adulthood,” in Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd ed., ed. J. Cassidy and R. Shaver (New York: Guilford Press, 2008), 666–97. See also E. O’connor, et al., “Risks and Outcomes Associated with Disorganized/Controlling Patterns of Attachment at Age Three Years in the National Institute of Child Health & Human Development Study of Early Child Care and Youth Development,” Infant Mental Health Journal 32, no. 4 (2011): 450–72; and K. Lyons-Ruth, et al., “Borderline Symptoms and Suicidality/Self-Injury.

  43.At this point we have little information about what factors affect the evolution of these early regulatory abnormalities, but intervening life events, the quality of other relationships, and perhaps even genetic factors are likely to modify them over time. It is obviously critical to study to what degree consistent and concentrated parenting of children with early histories of abuse and neglect can rearrange biological systems.

  44.E. Warner, et al., “Can the Body Change the Score? Application of Sensory Modulation Principles in the Treatment of Traumatized Adolescents in Residential Settings,” Journal of Family Violence 28, no. 7 (2003): 729–38.

  CHAPTER 8: TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT

  1.W. H. Auden, The Double Man (New York: Random House, 1941),

  2.S. N. Wilson, et al., “Phenotype of Blood Lymphocytes in PTSD Suggests Chronic Immune Activation,” Psychosomatics 40, no. 3 (1999): 222–25. See also M. Uddin, et al., “Epigenetic and Immune Function Profiles Associated with Posttraumatic Stress Disorder,” Proceedings of the National Academy of Sciences of the United States of America 107, no. 20 (2010): 9470–75; M. Altemus, M. Cloitre, and F. S. Dhabhar, “Enhanced Cellular Immune Response in Women with PTSD Related to Childhood Abuse,” American Journal of Psychiatry 160, no. 9 (2003): 1705–7; and N. Kawamura, Y. Kim, and N. Asukai, “Suppression of Cellular Immunity in Men with a Past History of Posttraumatic Stress Disorder,” American Journal of Psychiatry 158, no. 3 (2001): 484–86.

  3.R. Summit, “The Child Sexual Abuse Accommodation Syndrome,” Child Abuse & Neglect 7 (1983): 177–93.

  4.A study using fMRI at the University of Lausanne in Switzerland showed that when people have these out-of-body experiences, staring at themselves as if looking down from the ceiling, they are activating the superior temporal cortex in the brain. O. Blanke, et al., “Linking Out-of-Body Experience and Self Processing to Mental Own-Body Imagery at the Temporoparietal Junction,” Journal of Neuroscience 25, no. 3 (2005): 550–57. See also O. Blanke and T. Metzinger, “Full-Body Illusions and Minimal Phenomenal Selfhood,” Trends in Cognitive Sciences 13, no. 1 (2009): 7–13.

  5.When an adult uses a child for sexual gratification, the child invariably is caught in a confusing situation and a conflict of loyalties: By disclosing the abuse, she betrays and hurts the perpetrator (who may be an adult on whom the child depends for safety and protection), but by hiding the abuse, she compounds her shame and vulnerability. This dilemma was first articulated by Sándor Ferenczi in 1933 in “The Confusion of Tongues Between the Adult and the Child: The Language of Tenderness and the Language of Passion,” International Journal of Psychoanalysis, 30 no. 4 (1949): 225–30, and has been explored by numerous subsequent authors.

  CHAPTER 9: WHAT’S LOVE GOT TO DO WITH IT?

  1.Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Penguin, 2013).

  2.http://www.thefreedictionary.com/diagnosis.

  3.The TAQ can be accessed at the Trauma Center Web site: www.traumacenter.org/products/instruments.php.<
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  4.J. L. Herman, J. C. Perry, and B. A. van der Kolk, “Childhood Trauma in Borderline Personality Disorder,” American Journal of Psychiatry 146, no. 4 (April 1989): 490–95.

  5.Teicher found significant changes in the orbitofrontal cortex (OFC), a region of the brain that is involved in decision making and the regulation of behavior involved in sensitivity to social demands. M. H. Teicher, et al., “The Neurobiological Consequences of Early Stress and Childhood Maltreatment,” Neuroscience & Biobehavioral Reviews 27, no. 1 (2003): 33–44. See also M. H. Teicher, “Scars That Won’t Heal: The Neurobiology of Child Abuse,” Scientific American 286, no. 3 (2002): 54–61; M. Teicher, et al., “Sticks, Stones, and Hurtful Words: Relative Effects of Various Forms of Childhood Maltreatment,” American Journal of Psychiatry 163, no. 6 (2006): 993–1000; A. Bechara, et al., “Insensitivity to Future Consequences Following Damage to Human Prefrontal Cortex,” Cognition 50 (1994): 7–15. Impairment in this area of the brain results in excessive swearing, poor social interactions, compulsive gambling, excessive alcohol / drug use and poor empathic ability. M. L. Kringelbach and E. T. Rolls, “The Functional Neuroanatomy of the Human Orbitofrontal Cortex: Evidence from Neuroimaging and Neuropsychology,” Progress in Neurobiology 72 (2004): 341–72. The other problematic area Teicher identified was the precuneus, a brain area involved in understanding oneself and being able to take perspective on how your perceptions may be different from someone else’s. A. E. Cavanna and M. R. Trimble “The Precuneus: A Review of Its Functional Anatomy and Behavioural Correlates,” Brain 129 (2006): 564–83.

  6.S. Roth, et al., “Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder,” Journal of Traumatic Stress 10 (1997): 539–55; B. A. van der Kolk et al., “Dissociation, Somatization, and Affect Dysregulation: The Complexity of Adaptation to Trauma,” American Journal of Psychiatry 153 (1996): 83–93; D. Pelcovitz, et al., “Development of a Criteria Set and a Structured Interview for Disorders of Extreme Stress (SIDES),” Journal of Traumatic Stress 10 (1997): 3–16; S. N. Ogata, et al., “Childhood Sexual and Physical Abuse in Adult Patients with Borderline Personality Disorder,” American Journal of Psychiatry 147 (1990): 1008–1013; M. C. Zanarini, et al., “Axis I Comorbidity of Borderline Personality Disorder,” American Journal of Psychiatry 155, no. 12. (December 1998): 1733–39; S. L. Shearer, et al., “Frequency and Correlates of Childhood Sexual and Physical Abuse Histories in Adult Female Borderline Inpatients,” American Journal of Psychiatry 147 (1990): 214–16; D. Westen, et al., “Physical and Sexual Abuse in Adolescent Girls with Borderline Personality Disorder,” American Journal of Orthopsychiatry 60 (1990): 55–66; M. C. Zanarini, et al., “Reported Pathological Childhood Experiences Associated with the Development of Borderline Personality Disorder,” American Journal of Psychiatry 154 (1997): 1101–1106.

  7.J. Bowlby, A Secure Base: Parent-Child Attachment and Healthy Human Development (New York: Basic Books, 2008), 103.

  8.B. A. van der Kolk, J. C. Perry, and J. L. Herman, “Childhood Origins of Self- Destructive Behavior,” American Journal of Psychiatry 148 (1991): 1665–71.

  9.This notion found further support in the work of the neuroscientist Jaak Panksepp, who found that young rats that were not licked by their moms during the first week of their lives did not develop opioid receptors in the anterior cingulate cortex, a part of the brain associated with affiliation and a sense of safety. See E. E. Nelson and J. Panksepp, “Brain Substrates of Infant-Mother Attachment: Contributions of Opioids, Oxytocin, and Norepinephrine,” Neuroscience & Biobehavioral Reviews 22, no. 3 (1998): 437–52. See also J. Panksepp, et al., “Endogenous Opioids and Social Behavior,” Neuroscience & Biobehavioral Reviews 4, no. 4 (1981): 473–87; and J. Panksepp, E. Nelson, and S. Siviy, “Brain Opioids and Mother-Infant Social Motivation,” Acta paediatrica 83, no. 397 (1994): 40–46.

  10.The delegation to Robert Spitzer also included Judy Herman, Jim Chu, and David Pelcovitz.

  11.B. A. van der Kolk, et al., “Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma,” Journal of Traumatic Stress 18, no. 5 (2005): 389–99. See also J. L. Herman, “Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma,” Journal of Traumatic Stress 5, no. 3 (1992): 377–91; C. Zlotnick, et al., “The Long-Term Sequelae of Sexual Abuse: Support for a Complex Posttraumatic Stress Disorder,” Journal of Traumatic Stress 9, no. 2 (1996): 195–205; S. Roth, et al., “Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM‐IV Field Trial for Posttraumatic Stress Disorder,” Journal of Traumatic Stress 10, no. 4 (1997): 539–55; and D. Pelcovitz, et al., “Development and Validation of the Structured Interview for Measurement of Disorders of Extreme Stress,” Journal of Traumatic Stress 10 (1997): 3–16.

  12.B. C. Stolbach, et al., “Complex Trauma Exposure and Symptoms in Urban Traumatized Children: A Preliminary Test of Proposed Criteria for Developmental Trauma Disorder,” Journal of Traumatic Stress 26, no. 4 (August 2013): 483–91.

  13.B. A. van der Kolk, et al., “Dissociation, Somatization and Affect Dysregulation: The Complexity of Adaptation to Trauma,” American Journal of Psychiatry 153, suppl (1996): 83–93. See also D. G. Kilpatrick, et al., “Posttraumatic Stress Disorder Field Trial: Evaluation of the PTSD Construct—Criteria A Through E,” in: DSM-IV Sourcebook, vol. 4 (Washington: American Psychiatric Press, 1998), 803-844; T. Luxenberg, J. Spinazzola, and B. A. van der Kolk, “Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment,” Directions in Psychiatry 21, no. 25 (2001): 373–92; and B. A. van der Kolk, et al., “Disorders of Extreme Stress: The Empirical Foundation of a Compex Adaptation to Trauma,” Journal of Traumatic Stress 18, no. 5 (2005): 389–99.

  14.These questions are available on the ACE Web site: http://acestudy.org/.

  15.http://www.cdc.gov/ace/findings.htm; http://acestudy.org/download; V. Felitti, et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58. See also R. Reading, “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology,” Child: Care, Health and Development 32, no. 2 (2006): 253–56; V. J. Edwards, et al., “Experiencing Multiple Forms of Childhood Maltreatment and Adult Mental Health: Results from the Adverse Childhood Experiences (ACE) Study,” American Journal of Psychiatry 160, no. 8 (2003): 1453–60; S. R. Dube, et al., “Adverse Childhood Experiences and Personal Alcohol Abuse as an Adult,” Addictive Behaviors 27, no. 5 (2002): 713–25; S. R. and S. R. Dube, et al., “Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study,” Pediatrics 111, no. 3 (2003): 564–72.

  16.S. A. Strassels, “Economic Burden of Prescription Opioid Misuse and Abuse,” Journal of Managed Care Pharmacy 15, no. 7 (2009): 556–62.

  17.C. B. Nemeroff, et al., “Differential Responses to Psychotherapy Versus Pharmacotherapy in Patients with Chronic Forms of Major Depression and Childhood Trauma,” Proceedings of the National Academy of Sciences of the United States of America 100, no. 24 (2003): 14293–96. See also C. Heim, P. M. Plotsky, and C. B. Nemeroff, “Importance of Studying the Contributions of Early Adverse Experience to Neurobiological Findings in Depression,” Neuropsychopharmacology 29, no. 4 (2004): 641–48.

  18.B. E. Carlson, “Adolescent Observers of Marital Violence,” Journal of Family Violence 5, no. 4 (1990): 285–99. See also B. E. Carlson, “Children’s Observations of Interparental Violence,” in Battered Women and Their Families, ed. A. R. Roberts (New York: Springer, 1984), 147–67; J. L. Edleson, “Children’s Witnessing of Adult Domestic Violence,” Journal of Interpersonal Violence 14, no. 8 (1999): 839–70; K. Henning, et al., “Long-Term Psychologi
cal and Social Impact of Witnessing Physical Conflict Between Parents,” Journal of Interpersonal Violence 11, no. 1 (1996): 35–51; E. N. Jouriles, C. M. Murphy, and D. O’Leary, “Interpersonal Aggression, Marital Discord, and Child Problems,” Journal of Consulting and Clinical Psychology 57, no. 3 (1989): 453–55; J. R. Kolko, E. H. Blakely, and D. Engelman, “Children Who Witness Domestic Violence: A Review of Empirical Literature,” Journal of Interpersonal Violence 11, no. 2 (1996): 281–93; and J. Wolak and D. Finkelhor, “Children Exposed to Partner Violence,” in Partner Violence: A Comprehensive Review of 20 Years of Research, ed. J. L. Jasinski and L. Williams (Thousand Oaks, CA: Sage, 1998).

  19.Most of these statements are based on conversations with Vincent Felitti, amplified by J. E. Stevens, “The Adverse Childhood Experiences Study—the Largest Public Health Study You Never Heard Of,” Huffington Post, October 8, 2012, http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp _1_b_1943647.html.

  20.Population attributable risk: the proportion of a problem in the overall population whose problems can be attributed to specific risk factors.

  21.National Cancer Institute, “Nearly 800,000 Deaths Prevented Due to Declines in Smoking” (press release), March 14, 2012, available at http://www.cancer.gov/newscenter/newsfromnci/2012/TobaccoControlCISNET.

  CHAPTER 10: DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

  1.These cases were part of the DTD field trial, conducted jointly by Julian Ford, Joseph Spinazzola, and me.

  2.H. J. Williams, M. J. Owen, and M. C. O’Donovan, “Schizophrenia Genetics: New Insights from New Approaches,” British Medical Bulletin 91 (2009): 61–74. See also P. V. Gejman, A. R. Sanders, and K. S. Kendler, “Genetics of Schizophrenia: New Findings and Challenges,” Annual Review of Genomics and Human Genetics 12 (2011): 121–44; and A. Sanders, et al., “No Significant Association of 14 Candidate Genes with Schizophrenia in a Large European Ancestry Sample: Implications for Psychiatric Genetics,” American Journal of Psychiatry 165, no. 4 (April 2008): 497–506.