The Body Keeps the Score

by Bessel van der Kolk MD

  3.R. Yehuda, et al., “Putative Biological Mechanisms for the Association Between Early Life Adversity and the Subsequent Development of PTSD,” Psychopharmacology 212, no. 3 (October 2010): 405–417; K. C. Koenen, “Genetics of Posttraumatic Stress Disorder: Review and Recommendations for Future Studies,” Journal of Traumatic Stress 20, no. 5 (October 2007): 737–50; M. W. Gilbertson, et al., “Smaller Hippocampal Volume Predicts Pathologic Vulnerability to Psychological Trauma,” Nature Neuroscience 5 (2002): 1242–47.

  4.Koenen, “Genetics of Posttraumatic Stress Disorder.” See also R. F. P. Broekman, M. Olff, and F. Boer, “The Genetic Background to PTSD,” Neuroscience & Biobehavioral Reviews 31, no. 3 (2007): 348–62.

  5.M. J. Meaney and A. C. Ferguson-Smith, “Epigenetic Regulation of the Neural Transcriptome: The Meaning of the Marks,” Nature Neuroscience 13, no. 11 (2010): 1313–18. See also M. J. Meaney, “Epigenetics and the Biological Definition of Gene × Environment Interactions,” Child Development 81, no. 1 (2010): 41–79; and B. M. Lester, et al., “Behavioral Epigenetics,” Annals of the New York Academy of Sciences 1226, no. 1 (2011): 14–33.

  6.M. Szyf, “The Early Life Social Environment and DNA Methylation: DNA Methylation Mediating the Long-Term Impact of Social Environments Early in Life,” Epigenetics 6, no. 8 (2011): 971–78.

  7.Moshe Szyf, Patrick McGowan, and Michael J. Meaney, “The Social Environment and the Epigenome,” Environmental and Molecular Mutagenesis 49, no. 1 (2008): 46–60.

  8.There now is voluminous evidence that life experiences of all sorts changes gene expression. Some examples are: D. Mehta et al., “Childhood Maltreatment Is Associated with Distinct Genomic and Epigenetic Profiles in Posttraumatic Stress Disorder,” Proceedings of the National Academy of Sciences of the United States of America 110, no. 20 (2013): 8302–7; P. O. McGowan, et al., “Epigenetic Regulation of the Glucocorticoid Receptor in Human Brain Associates with Childhood Abuse,” Nature Neuroscience 12, no. 3 (2009): 342–48; M. N. Davies, et al., “Functional Annotation of the Human Brain Methylome Identifies Tissue-Specific Epigenetic Variation Across Brain and Blood,” Genome Biology 13, no. 6 (2012): R43; M. Gunnar and K. Quevedo, “The Neurobiology of Stress and Development,” Annual Review of Psychology 58 (2007): 145–73; A. Sommershof, et al., “Substantial Reduction of Naïve and Regulatory T Cells Following Traumatic Stress,” Brain, Behavior, and Immunity 23, no. 8 (2009): 1117–24; N. Provençal, et al., “The Signature of Maternal Rearing in the Methylome in Rhesus Macaque Prefrontal Cortex and T Cells,” Journal of Neuroscience 32, no. 44 (2012): 15626–42; B. Labonté, et al., “Genome-wide Epigenetic Regulation by Early-Life Trauma,” Archives of General Psychiatry 69, no. 7 (2012): 722–31; A. K. Smith, et al., “Differential Immune System DNA Methylation and Cytokine Regulation in Post-traumatic Stress Disorder,” American Journal of Medical Genetics Part B: Neuropsychiatric Genetics 156B, no. 6 (2011): 700–708; 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.

  9.C. S. Barr, et al., “The Utility of the Non‐human Primate Model for Studying Gene by Environment Interactions in Behavioral Research,” Genes, Brain and Behavior 2, no. 6 (2003): 336–40.

  10.A. J. Bennett, et al., “Early Experience and Serotonin Transporter Gene Variation Interact to Influence Primate CNS Function,” Molecular Psychiatry 7, no. 1 (2002): 118–22. See also C. S. Barr, et al., “Interaction Between Serotonin Transporter Gene Variation and Rearing Condition in Alcohol Preference and Consumption in Female Primates,” Archives of General Psychiatry 61, no. 11 (2004): 1146; and C. S. Barr, et al., “Serotonin Transporter Gene Variation Is Associated with Alcohol Sensitivity in Rhesus Macaques Exposed to Early‐Life Stress,” Alcoholism: Clinical and Experimental Research 27, no. 5 (2003): 812–17.

  11.A. Roy, et al., “Interaction of FKBP5, a Stress-Related Gene, with Childhood Trauma Increases the Risk for Attempting Suicide,” Neuropsychopharmacology 35, no. 8 (2010): 1674–83. See also M. A. Enoch, et al., “The Influence of GABRA2, Childhood Trauma, and Their Interaction on Alcohol, Heroin, and Cocaine Dependence,” Biological Psychiatry 67 no. 1 (2010): 20–27; and A. Roy, et al., “Two HPA Axis Genes, CRHBP and FKBP5, Interact with Childhood Trauma to Increase the Risk for Suicidal Behavior,” Journal of Psychiatric Research 46, no. 1 (2012): 72–79.

  12.A. S. Masten and D. Cicchetti, “Developmental Cascades,” Development and Psychopathology 22, no. 3 (2010): 491–95; S. L. Toth, et al., “Illogical Thinking and Thought Disorder in Maltreated Children,” Journal of the American Academy of Child & Adolescent Psychiatry 50, no. 7 (2011): 659–68; J. Willis, “Building a Bridge from Neuroscience to the Classroom,” Phi Delta Kappan 89, no. 6 (2008): 424; I. M. Eigsti and D. Cicchetti, “The Impact of Child Maltreatment on Expressive Syntax at 60 Months,” Developmental Science 7, no. 1 (2004): 88–102.

  13.J. Spinazzola, et al., “Survey Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and Adolescents,” Psychiatric Annals 35, no. 5 (2005): 433–39.

  14.R. C. Kessler, C. B. Nelson, and K. A. McGonagle, “The Epidemiology of Co-occuring Addictive and Mental Disorders,” American Journal of Orthopsychiatry 66, no. 1 (1996): 17–31. See also Institute of Medicine of the National Academies, Treatment of Posttraumatic Stress Disorder (Washington: National Academies Press, 2008); and C. S. North, et al., “Toward Validation of the Diagnosis of Posttraumatic Stress Disorder,” American Journal of Psychiatry 166, no. 1 (2009): 34–40.

  15.Joseph Spinazzola, et al., “Survey Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and Adolescents,” Psychiatric Annals (2005).

  16.Our work group consisted of Drs. Bob Pynoos, Frank Putnam, Glenn Saxe, Julian Ford, Joseph Spinazzola, Marylene Cloitre, Bradley Stolbach, Alexander McFarlane, Alicia Lieberman, Wendy D’Andrea, Martin Teicher, and Dante Cicchetti.

  17.The proposed criteria for Developmental Trauma Disorder can be found in the Appendix.

  18.http://www.traumacenter.org/products/instruments.php.

  19.Read more about Sroufe at www.cehd.umn.edu/icd/people/faculty/cpsy/sroufe.html and more about the Minnesota Longitudinal Study of Risk and Adaptation and its publications at http://www.cehd.umn.edu/icd/research/parent-child/ and http://www.cehd.umn.edu/icd/research/parent-child/publications/. See also L. A. Sroufe and W. A. Collins, The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2009); and L. A. Sroufe, “Attachment and Development: A Prospective, Longitudinal Study from Birth to Adulthood,” Attachment & Human Development 7, no. 4 (2005): 349–67.

  20.L. A. Sroufe, The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2005). Harvard researcher Karlen Lyons-Ruth had similar findings in a sample of children she followed for about eighteen years: Disorganized attachment, role reversal, and lack of maternal communication at age three were the greatest predictors of children being part of the mental health or social service system at age eighteen.

  21.D. Jacobvitz and L. A. Sroufe, “The Early Caregiver-Child Relationship and Attention-Deficit Disorder with Hyperactivity in Kindergarten: A Prospective Study,” Child Development 58, no. 6 (December 1987): 1496–504.

  22.G. H. Elder Jr., T. Van Nguyen, and A. Caspi, “Linking Family Hardship to Children’s Lives,” Child Development 56, no. 2 (April 1985): 361–75.

  23.For children who were physically abused, the chance of being diagnosed with conduct disorder or oppositional defiant disorder went up by a factor of three. Neglect or sexual abuse doubled the chance of developing an anxiety disorder. Parental psychological unavailability or sexual abuse doubled the chance of later developing PTSD. The chance of receiving multiple diagnoses was 54 percent for children who suffered neglec
t, 60 percent for physical abuse, and 73 percent for both sexual abuse.

  24.This was a quote based on the work of Emmy Werner, who has studied 698 children born on the island of Kauai for forty years, starting in 1955. The study showed that most children who grew up in unstable households grew up to experience problems with delinquency, mental and physical health, and family stability. One-third of all high-risk children displayed resilience and developed into caring, competent, and confident adults. Protective factors were 1. being an appealing child, 2. a strong bond with a nonparent caretaker (such as an aunt, a babysitter, or a teacher) and strong involvement in church or community groups. E. E. Werner and R. S. Smith, Overcoming the Odds: High Risk Children from Birth to Adulthood (Ithaca and London: Cornell University Press, 1992).

  25.P. K. Trickett, J. G. Noll, and F. W. Putnam, “The Impact of Sexual Abuse on Female Development: Lessons from a Multigenerational, Longitudinal Research Study,” Development and Psychopathology 23 (2011): 453–76. See also J. G. Noll, P. K. Trickett, and F. W. Putnam, “A Prospective Investigation of the Impact of Childhood Sexual Abuse on the Development of Sexuality,” Journal of Consulting and Clinical Psychology 71 (2003): 575–86; P. K. Trickett, C. McBride-Chang, and F. W. Putnam, “The Classroom Performance and Behavior of Sexually Abused Females,” Development and Psychopathology 6 (1994): 183–94; P. K. Trickett and F. W. Putnam, Sexual Abuse of Females: Effects in Childhood (Washington: National Institute of Mental Health, 1990–1993); F. W. Putnam and P. K. Trickett, The Psychobiological Effects of Child Sexual Abuse (New York: W. T. Grant Foundation, 1987).

  26.In the sixty-three studies on disruptive mood regulation disorder, nobody asked anything about attachment, PTSD, trauma, child abuse, or neglect. The word “maltreatment” is used in passing in just one of the sixty-three articles. There is nothing about parenting, family dynamics, or about family therapy.

  27.In the appendix at the back of the DSM, you can find the so-called V-codes, diagnostic labels without official standing that are not eligible for insurance reimbursement. There you will see listings for childhood abuse, childhood neglect, childhood physical abuse, and childhood sexual abuse.

  28.Ibid., p 121.

  29.At the time of this writing, the DSM-5 is number seven on Amazon’s best-seller list. The APA earned $100 million on the previous edition of the DSM. The publication of the DSM constitutes, with contributions from the pharmaceutical industry and membership dues, the APA’s major source of income.

  30.Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Penguin, 2013), 239.

  31.In an open letter to the APA David Elkins, the chairman of one of the divisions of the American Psychological Association, complained that DSM-V was based on shaky evidence, carelessness with the public health, and the conceptualizations of mental disorder as primarily medical phenomena.” His letter attracted nearly five thousand signatures. The president of the American Counseling Association sent a letter on behalf of its 115,000 DSM-buying members to the president of the APA, also objecting to the quality of the science behind DSM-5—and “urge(d) the APA to make public the work of the scientific review committee it had appointed to review the proposed changes, as well as to allow an evaluation of “all evidence and data by external, independent groups of experts.”

  32.Thomas Insel had formerly done research on the attachment hormone oxytocin in non-human primates.

  33.National Institute of Mental Health, “NIMH Research Domain Criteria (RDoC),” http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml.

  34.The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2005).

  35.B. A. van der Kolk, “Developmental Trauma Disorder: Toward a Rational Diagnosis for Children with Complex Trauma Histories,” Psychiatric Annals 35, no. 5 (2005): 401–8; W. D’Andrea, et al., “Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis,” American Journal of Orthopsychiatry 82 (2012): 187–200. J. D. Ford, et al., “Clinical Significance of a Proposed Developmental Trauma Disorder Diagnosis: Results of an International Survey of Clinicians,” Journal of Clinical Psychiatry 74, no. 8 (2013): 841–849. Up-to-date results from the Developmental Trauma Disorder field trial study are available on our Web site: www.traumacenter.org.

  36.J. J. Heckman, “Skill Formation and the Economics of Investing in Disadvantaged Children,” Science 312, no. 5782 (2006): 1900–2.

  37.D. Olds, et al., “Long-Term Effects of Nurse Home Visitation on Children’s Criminal and Antisocial Behavior: 15-Year Follow-up of a Randomized Controlled Trial,” JAMA 280, no. 14 (1998): 1238–44. See also J. Eckenrode, et al., “Preventing Child Abuse and Neglect with a Program of Nurse Home Visitation: The Limiting Effects of Domestic Violence,” JAMA 284, no. 11 (2000): 1385–91; D. I. Lowell, et al., “A Randomized Controlled Trial of Child FIRST: A Comprehensive Home-Based Intervention Translating Research into Early Childhood Practice,” Child Development 82, no. 1 (January/February 2011): 193–208; S. T. Harvey and J. E. Taylor, “A Meta-Analysis of the Effects of Psychotherapy with Sexually Abused Children and Adolescents, Clinical Psychology Review 30, no. 5 (July 2010): 517–35; J. E. Taylor and S. T. Harvey, “A Meta-Analysis of the Effects of Psychotherapy with Adults Sexually Abused in Childhood,” Clinical Psychology Review 30, no. 6 (August 2010): 749–67; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; 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.

  CHAPTER 11: UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY

  1.Unlike clinical consultations, in which doctor-patient confidentiality applies, forensic evaluations are public documents to be shared with lawyers, courts, and juries. Before doing a forensic evaluation I inform clients of that and warn them that nothing they tell me can be kept confidential.

  2.K. A. Lee, et al., “A 50-Year Prospective Study of the Psychological Sequelae of World War II Combat,” American Journal of Psychiatry 152, no. 4 (April 1995): 516–22.

  3.J. L. McGaugh and M. L. Hertz, Memory Consolidation (San Fransisco: Albion Press, 1972); L. Cahill and J. L. McGaugh, “Mechanisms of Emotional Arousal and Lasting Declarative Memory,” Trends in Neurosciences 21, no. 7 (1998): 294–99.

  4.A. F. Arnsten, et al., “α-1 Noradrenergic Receptor Stimulation Impairs Prefrontal Cortical Cognitive Function,” Biological Psychiatry 45, no. 1 (1999): 26–31. See also A. F. Arnsten, “Enhanced: The Biology of Being Frazzled,” Science 280, no. 5370 (1998): 1711–12; S. Birnbaum, et al., “A Role for Norepinephrine in Stress-Induced Cognitive Deficits: α-1-adrenoceptor Mediation in the Prefrontal Cortex,” Biological Psychiatry 46, no. 9 (1999): 1266–74.

  5.Y. D. Van Der Werf, et al. “Special Issue: Contributions of Thalamic Nuclei to Declarative Memory Functioning,” Cortex 39 (2003): 1047–62. See also B. M. Elzinga and J. D. Bremner, “Are the Neural Substrates of Memory the Final Common Pathway in Posttraumatic Stress Disorder (PTSD)?” Journal of Affective Disorders 70 (2002): 1–17; L. M. Shin et al., “A Functional Magnetic Resonance Imaging Study of Amygdala and Medial Prefrontal Cortex Responses to Overtly Presented Fearful Faces in Posttraumatic Stress Disorder,” Archives of General Psychiatry 62 (2005): 273–81; L. M. Williams et al., “Trauma Modulates Amygdala and Medial Prefrontal Responses to Consciously Attended Fear,” Neuroimage 29 (2006): 347–57; R. A. Lanius et al., “Brain Activation During Script-Driven Imagery Induced Dissociative Responses in PTSD: A Functional Magnetic Resonance Imaging Investigation,” Biological Psychiatry 52 (2002): 305–311; H. D Critchley, C. J. Mathias, and R. J. Dolan, “Fear Conditioning in Humans: The Influence of Awareness and Autonomic Arousal on Functional Neuroanatomy,” Neuron 33 (2002): 653–63; M. B
eauregard, J. Levesque, and P. Bourgouin, “Neural Correlates of Conscious Self-Regulation of Emotion,” Journal of Neuroscience 21 (2001): RC165; K. N. Ochsner et al., “For Better or for Worse: Neural Systems Supporting the Cognitive Down- and Up-Regulation of Negative Emotion,” NeuroImage 23 (2004): 483–99; M. A. Morgan, L. M. Romanski, and J. E. LeDoux, et al., “Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163 (1993): 109–13; M. R. Milad and G. J. Quirk, “Neurons in Medial Prefrontal Cortex Signal Memory for Fear Extinction,” Nature 420 (2002): 70–74; and J. Amat, et al., “Medial Prefrontal Cortex Determines How Stressor Controllability Affects Behavior and Dorsal Raphe Nucleus,” Nature Neuroscience 8 (2005): 365–71.

  6.B. A. Van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8, no. 4 (1995): 505–25.

  7.Hysteria as defined by Free Dictionary, http://www.thefreedictionary.com/hysteria.

  8.A. Young, The Harmony of Illusions: Inventing Post-traumatic Stress Disorder (Princeton University Press, 1997). See also H. F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (Basic Books, 2008).

  9.T. Ribot, Diseases of Memory (Appleton, 1887), 108–9; Ellenberger, Discovery of the Unconscious.

  10.J. Breuer and S. Freud, “The Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud (London: Hogarth Press, 1893).

  11.A. Young, Harmony of Illusions.

  12.J. L. Herman, Trauma and Recovery (New York: Basic Books, 1997), 15.