by Bruce Perry
She was too frightened to tell her mother what Duane was doing; he threatened her with even worse if she told. Feeling that the situation was inescapable, Amber did what she could to get control over it. She began to serve Duane drinks and behave provocatively, with the aim of getting the abuse over with. Knowing when it would happen allowed her to study and sleep through the night rather than worrying about when he’d come into her bedroom. In essence, she could schedule and isolate her terror so that it didn’t interfere with the rest of her life. Her grades improved again and, to those around her, she seemed to be back to herself. Although her behavior probably doubled the frequency of the molestation, the control she gained over the situation allowed her to manage her anxiety such that it minimized the effects that the abuse had on her daily life. Unfortunately, of course, this would later produce a whole new set of problems related to her guilt over her feelings of complicity in his actions but, at the time, it helped her cope with the trauma.
When she was actually being raped or sodomized, Amber dissociated, withdrawing into her Black Death/Raven fantasy world. She would be chased by evil creatures and demons, but she would always triumph over them, as in a role-playing video game. The fantasy was elaborate and detailed. In fact, it was so encompassing that she literally no longer felt what was actually happening to her body. She encapsulated the trauma in a way that allowed her to function and cope, although, of course, she still suffered its effects when she was exposed to cues that reminded her of what had gone on, such as Duane’s scent or the smell of certain drinks that he favored. Such cues would prompt a dissociative response that she could not control, in which she retreated to her “safe” world and did not respond to outside stimuli. The most extreme reaction was the one that had put her in the hospital the day after he called.
The abuse had continued for several years. Then, when Amber was around nine, her mother caught Duane in bed with the little girl, and immediately kicked him out. She didn’t blame Amber, as many mothers unfortunately do in such situations, but, other than calling the police, she didn’t seek help for her, either. Sadly, the district attorney didn’t pursue the case after the perpetrator moved out of state. And Jill had problems of her own to deal with: as a single mother with few skills, she now had to struggle to support herself and her daughter. She and Amber made many moves from state to state, seeking better employment opportunities. Jill eventually managed to go back to school and get a higher paying job, but the instability and the abuse had done its damage to Amber.
Amber continued to cope on her own, getting decent, but not spectacular, grades. Intelligent as she was, she almost certainly could have done better but, probably at least in part because of what had happened to her, she stayed a B-student and an underachiever. Though she was not the most popular girl in her class, she was not the least popular either. She hung out with a group of teens in the middle of the social spectrum who were “Goths,” dressed in black but were not especially extreme in their behavior. They didn’t drink or take drugs, for example, but their interest in mysticism and alternative culture made them tolerant of those who did. A recent study of Goth youth culture, in fact, found that it tends to attract adolescents like Amber who have histories of self-harm. Interestingly, becoming a Goth didn’t increase self-harm: before these teens found a community that accepted their “dark” interests, in fact, they were more prone to cut or otherwise harm themselves.
In school, Amber discovered that pinching or deeply scratching her arms relieved some of her anxiety. And later, in private, she found that cutting her skin could produce a dissociative state, allowing her to escape what she experienced as an intolerable build-up of stress. “It’s like I have magical skin,” she told me, describing how cutting into it with a knife or razor prompted an incredible sense of relief and access to her “safe” place. Many teens, of course, find similar escape with drugs.
Though teen drug use is often seen as simple hedonism or rebellion, in fact, the teenagers who are most at risk for lasting drug problems are those like Amber, whose stress response systems have suffered an early and lasting blow. Research on addicts and alcoholics finds dramatically increased numbers of early traumatic events, as compared to those who have not suffered addictions. The most severe addicts’ histories—especially amongst women—are filled with childhood sexual abuse, loss of parents through divorce or death, witnessing severe violence, physical abuse and neglect and other trauma. Brain scans of those who’ve experienced trauma often reveal abnormalities in areas that also show changes during addiction. It may be that these changes make them more vulnerable to getting hooked.
While self-mutilation, too, is often seen as an act of rebellion or attention-seeking, in most cases it is probably better understood as an attempt at self-medication as well. Cutting releases brain opioids, which makes it especially attractive to those who have been previously traumatized and found relief in dissociation. Although anyone who cuts will experience some degree of opioid effect, the experience is far more likely to be perceived as pleasurable and attractive to those who have a sensitized dissociative response from previous trauma and are in emotional pain. The same is true of people who use drugs like heroin or Oxycontin. Contrary to popular belief, most people who try these drugs do not find them overwhelmingly blissful. In fact, most people don’t like the numbing sensation they produce. But those who suffer the after-effects of severe stress and trauma are likely to find the substances soothing and comforting, not deadening.
Curiously, stimulant drugs like cocaine and amphetamine replicate the other common natural reaction to trauma: the hyper-arousal response. Both drugs increase the release of the neurotransmitters dopamine and noradrenaline (also called norepinephrine). Both of those brain chemicals skyrocket during hyper-arousal. Just as the dissociative experience bears a physiological and psychological resemblance to the opioid “high,” the stimulant high is physiologically and psychologically comparable to the hyper-aroused state. In both stimulant “highs” and hyper-arousal, the person experiences an elevated heart rate, heightened senses and a feeling of power and possibility. That feeling is needed to fuel fight or flight, but it also explains why stimulants increase paranoia and aggression. Brain changes related to hyper-arousal may make some trauma victims more prone to stimulant addiction, while those related to dissociation may prefer opioids like heroin.
AS MY COLLEAGUES and I began to recognize how trauma affects the brain and body, we began to look for pharmacological methods to treat some of its symptoms. We hoped that this might prevent the children we were able to reach at an early age from developing problems like drug addiction and self-mutilation later on. We knew, for example, that opioid-blocking drugs like naloxone and naltrexone might reasonably be tried to blunt sensitized dissociation. We had already studied clonidine as a way to reduce hyper-arousal. Though Mama P. had, with some justification, been afraid that we might “drug up” the children she cared for if we used medications—or that we might decide that medications were all that was needed, and leave out love and affection—we found that the right medication can be helpful if used in the right context.
One of the first patients we tried naltrexone with was a sixteen-year-old boy named Ted. Like Amber, he had come to our attention because of his physical symptoms, not his psychological problems. Ted had what seemed to be unpredictable fainting episodes; sometimes at school, he would pass out. As in Amber’s case, medical tests revealed no discernable heart disorder, nor did he have a diagnosable neurological problem like epilepsy or a brain tumor that might cause such symptoms. Throwing up their hands and deciding that Ted was inducing unconsciousness in some kind of bizarre teenage attention-seeking gesture, the doctors who had ruled out these other problems called in psychiatry.
Ted was tall, rail-thin and good-looking, but he carried himself as though he were depressed: slouching, moving with little confidence, seeming as though he wanted to disappear. He didn’t meet the criteria for depression, however. He didn’t re
port unhappiness, lack of energy, suicidal thoughts, social distress, sleeping problems or any of the other classic symptoms of the disorder. His only apparent problem was that about twice a week, he would suddenly faint.
When I began to talk to him, though, I discovered that there was more. “I feel like a robot sometimes,” he told me, describing how he felt removed from the emotional aspects of his life, almost like he was watching a movie or going through the motions without fully experiencing what was happening around him. He felt detached, disconnected, numb: classic descriptions of dissociation. As I got to know him I began to find out what had prompted his brain to protect him from the world.
Starting before elementary school, Ted had been a continual witness to domestic violence. His stepfather frequently beat his mother, and this was not just the occasional slap or push, but rather full-on assaults that left her bruised, scarred and terrorized into complete submission. More than once, his mother had to be hospitalized. As Ted got older he began to try to protect his mother and found that he could redirect the man’s rage from her to him. As he put it, “I’d rather get a beating then watch my mother get beat up.” Although it didn’t happen immediately, it was seeing her child hurt that finally prompted Ted’s mom to end the relationship.
But by this point, Ted was ten years old. He’d lived most of his life with the daily threat or actual occurrence of serious violence. He’d become socially withdrawn and isolated. His teachers called him a “daydreamer,” noting that he often seemed to be “miles away” rather than paying attention to the class around him. However, he participated enough to get average, though not outstanding, grades. Even more so than Amber, he seemed to have discovered a way of fading into the background, recognizing that earning grades that were either too low or too high would bring him attention. He didn’t care if the attention for high grades was positive, since he found any attention stressful, even threatening. Ted seemed to have made up his mind that the best way to avoid any potential for further abuse was to be invisible, to disappear into the vast undifferentiated gray middle. And, until he began fainting in junior high school, that’s what he did.
I proposed a trial of naltrexone to see if it would stop the fainting episodes. As noted earlier, when people suffer extreme traumatic stress, their brains can become “sensitized” to future stressors, and it takes smaller and smaller amounts of stress to set the system off and prompt a full-blown stress response. As part of this stress response, especially when the stress is severe and appears inescapable, the brain releases opioids. By using a long-acting opioid blocker like naltrexone, I hoped to prevent these opioids from having an effect when they were released by his sensitized system, and thereby stop the fainting.
Ted agreed to try it and to continue seeing me for therapy.
He took the medication for four weeks, during which he had no further fainting episodes. But because the drug blocked the opioid response that allowed Ted to dissociate, he now became very anxious when he faced new or stressful experiences. This is a common problem with many drugs in psychiatry, and in general medicine. A drug may be excellent at eliminating a particular symptom, but does not treat the whole person and deal with the full complexity of his problem, and therefore it may exacerbate other symptoms. In fact, we found that parents and teachers often thought that naltrexone “made the child worse” because rather than “spacing out” in response to perceived stress, many children began to have hyper-arousal symptoms instead. These “fight-or-flight” reactions appeared far more disruptive to adults because the children now appeared more active, more defiant and sometimes even aggressive. We could give clonidine to minimize the hyper-arousal, but without helping the child learn alternative coping skills, the medications had no enduring effects. We ultimately decided that while there were certain cases in which naltrexone could be helpful, it had to be used with great care.
Ted had problems that ran much deeper than occasional fainting. He had a dissociative disorder that had deeply affected his ability to deal with emotional and physical challenges. In order to help this young man, and not just “resolve” the medical issue that had brought him to us, we needed to help him learn how to cope with his stress. Thanks to the naltrexone, his brain was no longer automatically responding to minor stresses by shutting down the whole system, but now we needed to help his mind learn how to handle life stress in a healthier, more comfortable and more productive way.
As with Amber, it was not only Ted’s sensitized stress system that had led to his problems, it was also the associations he’d made related to his abuse that were getting in his way. When Ted and I began to talk, I started to understand that his fainting was most often triggered by interactions with men and with the trappings of masculinity—cues that reminded him of his abuser, who had been an extremely macho military man. The fainting itself had been precipitated by his entry into late adolescence, a situation that exposed him to mature men far more often than before. Now, not only did he have contact with male teachers and coaches, but also he, along with his peers, was beginning to show signs of adult manhood. As a young boy he could avoid many of these triggers, but now they were everywhere.
In order to teach him to respond to these cues without overreacting and engaging a dissociative response once he was no longer taking the naltrexone, I needed to have him experience them in a safe setting. I decided to give him the shorter-acting opioid blocker, naloxone, at the beginning of his therapy session with me, expose him to male-related cues and help him face them so that they would no longer be so powerfully stressful to him. By the end of our session, the naloxone would wear off, so that if he did experience cues later on, he could dissociate if he felt extremely threatened.
To maximize the effect, I had to act a lot more stereotypically masculine and macho than I usually do, which was a lot easier back then when I was a bit younger and in pretty good condition! On days I had therapy with Ted, I would tuck my shirt into my pants to emphasize the male characteristics of my waistline and roll up my sleeves to expose my forearm muscles. It seems silly (and sometimes it felt silly), but it allowed him to develop a healthy relationship with a male and get used to such cues. When he began to experience feelings and memories related to the abuse, I could calm him and reassure him that he was safe, and he could see for himself that he could handle things without having to shut down.
Ted was highly intelligent, and I explained the rationale for our treatment to him. He soon came up with his own ways of furthering the process. He got assigned to record statistics for the school basketball team, which would let him be around young men in situations where he would be safe and comfortable and could develop new associations to replace those that had previously prompted his symptoms. His fainting never returned and, while he continued to try to “fade into the background,” he became better at fully experiencing his own life.
I made progress with Amber, too. We met each week for the first ten months following her ER visit. Since she did not have regular fainting episodes and had some degree of control over her dissociative symptoms, I decided not to use naloxone or naltrexone. I looked forward to our sessions. Her intelligence, creativity and sense of humor allowed her to articulate her story in ways that gave me greater insight into other children who weren’t able to be as clear about what they were going through. But she was also fragile, overly sensitive, dark and tired inside. It takes a great deal of energy to remain vigilant and “on guard” the way Amber was; it is exhausting to view the entire world as a potential threat. She didn’t just fear physical threats, either. She tended to twist positive comments from others into neutral remarks, neutral interactions into negative exchanges and any negative cues into catastrophic personal attacks.
“They hate me,” she would say. She was constantly perceiving slights where none were intended, which made the relationships she did have difficult and eliminated many others before they could start. As a result, much of our time was spent trying to get her to see these interactions as clear
ly as she could see so much else about her life. This part of our work was basically cognitive therapy, which is one of the most effective treatments for depression. Amber’s abuse had produced a number of depressive symptoms, one of which was self-hatred. Often, people like Amber believe that others can “sense” that they are unworthy and “bad,” that they deserve to be hurt and rejected. They project their self-hate onto the world and become sensitized—indeed, hypersensitive—to any sign of rejection.
The key to recovery, then, is to get the patient to understand that her perceptions aren’t necessarily reality, that the world might not be as dark as it seems. With Amber, it was slow work. I wanted to help her understand that not everyone was out to hurt her. There were people—teachers, peers, neighbors—who could be kind, supportive and positive. But she often shut out people to protect herself from the pain and terror Duane had brought to her in the past.
One day as she walked through my office door, she asked, “Did you know that the raven is the smartest bird?” She looked me in the eyes, almost challenging me. She plopped into a chair, putting her feet up on a little coffee table.
“No, I didn’t know that. Why do you say that?” I shut the door to my office and sat down in my desk chair, swiveling it to face her.
“Corvus Corax.” She spoke the Latin species name for the common raven.
“You know Latin?”