(from Undoing Depression: What Therapy Doesn’t Teach You and Medication Can’t Give You. Second edition © 2010, Little, Brown & Co.)
What’s the link between trauma and depression? For one thing, more trauma—including more childhood and chronic trauma—accounts for the current epidemic of depression. It seems like more and more people are made vulnerable, chiefly because their childhood experiences don’t enable them to build a resilient self; then they have to face a much more stressful and difficult adult world than we were designed for. Let me explain.
After almost a century during which Freudian theory, with its focus on the mind alone, dominated psychiatry, the Vietnam War reminded everyone that there was a physical structure called the brain as well. Soldiers came back with symptoms that we eventually recognized as Post-Traumatic Stress Disorder (PTSD): nightmares and flashbacks that are so vivid that the person believes he’s right back in combat, the avoidance of anything related to the experience, danger of violent behavior, hypervigilance, dissociation. We now understand that these symptoms are caused at least partly by the effects of overwhelming emotional trauma on the physical brain. In any trauma, where the person suddenly fears for his life, or that of someone close to him, excess cortisol (a stress hormone, part of the fight-or-flight response) is secreted by the brain. Normally, when the stress stops, the stress hormones stop as well. But when we continue to experience fear and flashbacks, too much cortisol can damage the hippocampus. This is part of the short-term memory system, where memories of events up to about two weeks ago are temporarily stored, waiting until they are woven into part of our story about ourselves. A lot of cortisol in the hippocampus means we have especially vivid memories for highly emotional events, like remembering exactly where we were on 9/11. But too much cortisol short-circuits the hippocampus and interferes with the process of weaving together short-term memories so they can be put in long-term storage. Thus, the PTSD sufferer relives, rather than remembers, traumatic experiences. It’s like the difference between remembering and dreaming. When I remember something, I’m aware that I’m in the present, looking back on the past. But when I’m dreaming, the only “I” there is is back in the dream. So in PTSD, you have nightmares while you’re awake. No wonder you’re hypervigilant. No wonder you want to sleep with your KA-BAR knife, and your wife is scared of you.
But it doesn’t take combat experience to leave you with PTSD: any situation in which you feel terrorized and fearful for your life can do it. The longer the experience lasts, the more likely a PTSD response. Currently the incidence of PTSD in the U.S. is estimated at about five percent for men, ten percent for women—the higher rate for women because the experience of victimization and helplessness that goes with rape and abuse may make the difference between PTSD and a normal stress reaction. But clearly this is a continuum; there are many, many cases of “mild” PTSD that don’t meet all the diagnostic criteria but can make for miserable lives. Rape, abuse, battery, victimization and helplessness all can lead easily to trauma reactions—which takes us to our next subject, chronic stress and complex PTSD.
Judith Herman, in her now-classic book Trauma and Recovery, opened clinicians’ eyes to see that the result of exposure to prolonged, repeated abuse and the experience of being subjected to totalitarian control, which she labeled “complex PTSD,” is in many ways worse than simple PTSD. And she pointed out that the experience of battered wives and abused children is not that different from POWs—the learned helplessness, the hopelessness, the constant fear, the brain damage that goes with physical or sexual abuse. After adding up all the data I know about domestic violence and child abuse, I estimate conservatively that about 30 percent of Americans are suffering from complex PTSD. Most of my patients, even those from “good families,” tell me of experiences amounting to abuse or neglect. Not necessarily beatings or sexual abuse, but emotional abuse: treating the child harshly or sadistically, micromanaging the child expecting perfection, yelling, name-calling, shaming, stripping the child of dignity, making the child toe the line just to show who’s boss, or scaring or humiliating the child in sadistic “fun.” And then perhaps acting as if nothing had happened the next day; or having an elaborate emotional scene where the parent tearfully asks for forgiveness while unloading on the child all his or her own problems. Yet most adult patients are shocked when I tell them that in my opinion childhood experiences like this amount to abuse. They know it wasn’t right, they feel alienated from their parents now because of it—but it seems to be easier to believe that they themselves are somehow culpable, rather than think of their parents as child abusers. Remember Robert, from Chapter 1: if you are treated like dirt long enough, you begin to feel like dirt.
It’s really the enormous body of work by Allan Schore, a highly respected neurological scientist, that has shown us the connections between childhood experience, the child’s brain development, and the adult’s mental health. Schore is able to account for and explain many of the observations that alert psychotherapists had discovered independently: for instance, that the majority of adults labeled borderline personality disorder had been abused as children, or experienced severe disruptions in early attachment; or that many adults with addictive problems seemed to have cold or emotionally unavailable caregivers; or that many adults with autoimmune disorders were sexually abused as children. Since these were only anecdotal data, responsible therapists held back from suggesting that child abuse "caused" borderline personality or autoimmune disease, or that parental rejection was linked to substance abuse. Schore, with his encyclopedic knowledge of the literature from diverse fields—attachment research, longitudinal child development studies, brain research—has been able to provide strong support for these causative links at work. His bottom line: Childhood experience—not only trauma and neglect, but also simply a poor relationship between caregiver and child—results in damage to the structure of the brain itself. This damage to the brain in turn results in things like damage to our ability to experience and control emotions; an unstable self-concept; damage to our ability to protect our immune system from the effects of psychological stress; difficulty in forming relationships; reduced ability to focus, concentrate, and learn; and damage to our capacity for self control.
When I state these conclusions in presentations, more than a few people are incredulous: Do you mean that what happens in childhood can cause brain damage that lasts into adulthood? That affects our health, our ability to think, our relationships? Perhaps I shouldn’t use the term “brain damage” because it’s so inflammatory, but I want to get their attention. Of course childhood experience affects the physical brain. Everything we think, feel, and remember is somewhere in the structure of the brain itself. Our brains embody our experiences. If your childhood is full of bad experience, it leaves its scars on the brain. If the scars weren’t there, it would be easy for us to just stop self-destructive behavior when it’s pointed out to us. But instead, we have to find ways to undo, heal, or grow new circuits to replace those old scars.