Dr. Bessel van der Kolk, MD (left) and leaders in brain science and attachment are calling for a hard look at developmental trauma. Developmental Trauma Disorder (DTD) was identified by van der Kolk in 2005, but the psychiatric Powers That Be deny it exists. [FN1]
“Clearly our field would like to ignore social realities,” Dr. van der Kolk said recently, “and study genes…”
He’s also shown it’s at the root of borderline personality disorder and bipolar disorder. He implies (I’m sure it’s true) that it’s at the root of most cases mis-diagnosed as ADHD/ADD. See van der Kolk video: http://www.acesconnection.com/clip/bessel-van-der-kolk-childhood-trauma-affect-regulation-and-borderline-personality-disorder-69-min
I dubbed it “trauma since the sperm hit the egg” when I realized I had it. Dr. Allan Schore calls it “trauma in the first 1000 days, conception to age two.” It used to be called “complex PTSD” (C-PTSD) or “Early Trauma” (ET).
Developmental trauma starts in utero when we don’t have much more than a brain stem, and goes on during the pre-conscious years. It can continue until 24 or 36 months depending on when the thinking brain (frontal cortex) comes on line. That’s up to 45 months living in general anxiety to non-stop terror — before age 3. A very long time to an infant.
DTD occurs as a continual process, not discrete incidents, while a baby has not developed a thinking brain able to recall incidents. Frequently it occurs before there are any discrete incidents.
“No one can see it” means “it never happened.” As I’ve said, “No one beat me or raped me. What’s wrong with me?” Try getting that treated.
Neuroscientists Dr. Daniel Siegel, MD, Dr. Bruce Perry MD and others detail how attachment failures cause developmental trauma in this video: www.youtube.com/watch?v=jYyEEMlMMb0 [FN2]
Insecure Attachment as the Cause
DTD is a “Relational Trauma, trauma in the context of a relationship” as Dr. Allan Schore (left), father of attachment theory in the U.S., identified it in the 1990s. [FN3] Only relational processes can explain DTD, not incidents.
Yet all the American Psychiatric Association (APA) can fathom is Post-Traumatic Stress Disorder (PTSD) — since it’s caused by a visible incident such as war injury or rape. Developmental trauma has no incident. It’s ingrained in brain and visceral tissue, with no obvious “big bang,” so some call it “little ‘t’ trauma,” as opposed to visible PTSD “Big ‘T’ Trauma.”
Insecure attachment and attachment disorder generally are the cause of developmental trauma, not vice versa, Dr. van der Kolk details in his May 2005 Psychiatric Annals pdf noted above and in FN1. He emphasized this again in a terrific May 10, 2013 speech at Yale on child trauma, borderline personality disorder and bipolar disorder (click for video). He lists DTD’s symptoms as relational and chronic: inability to concentrate or regulate feelings, chronic anger, fear and anxiety; self-loathing; aggression, self-destructive behavior. [FN4A]
Working with the National Center for Child Traumatic Stress Complex Trauma Network (NCTSN), van der Kolk reports that he ran a survey of 40,000 children nationally being treated for multiple traumas. Most of them “do not meet the criteria for PTSD… (as) the majority of issues are not specific traumas, but issues in their attachment relationships,” he says.
Van der Kolk describes studies by his colleague Dr. Marylene Cloitre, on attachment problems as the cause of DTD. “Marylene looked at chronic complex trauma symptoms, then she did child attachment interviews, Dr. Mary Main’s interviews, in which I hope all of you have been trained, because they are very very helpful to see what were peoples’ experiences of their childhoods,” he said [referring to the Adult Attachment Interview (AAI)]. [FN4B]
Dr. Cloitre found “that pure PTSD symptoms are a function of specific traumatic incidents, but the other symptoms she identified – affect dysregulation, mood regulation, anger expression, chronic suicidality, self-injury, disturbance in relations with self and others… do not occur in PTSD. They are rather a function of a disturbed attachment relationship,” van der Kolk repeated.
Yet psychiatry, he says, “is not good at treating attachment difficulties. There is very little treatment” of it. Innovative somatosensory healing programs at van der Kolk’s Trauma Center in Boston using “theater programs, yoga, martial arts for kids, etc. — to get them inter-personally attuned — are not standard treatment even though we do statistical research and publish it,” he notes.
The Body Keeps the Score
Because DTD happens before we have a thinking brain, the body is forced to store all the memories as somatic trauma. “There is somatization. The body keeps the score,” he says, the title of his latest book, “this is a somatic experience, and you become a terrified organism. Your immune system changes, your stress hormone system changes and your perception of your body changes.”
PTSD’s existence was hard to get recognized at first, too. It took Dr. van der Kolk and friends a chunk of the 1970s and ’80s to get the government to stop insisting that war trauma didn’t exist. Doctors finally established the diagnosis PTSD by showing that Vietnam vets were re-living discrete terrifying incidents from the past.
But “in fact there was no basis for any opinion about the prevalence” of any childhood trauma, even of childhood sexual abuse, before the 1995-1998 Adverse Childhood Experiences (ACE) Study, study co-director Dr. Vincent J. Felitti, MD, notes. “That’s because such information is almost completely protected by shame and secrecy, by families, and by individuals. Doctors also have been inhibited by our own ignorance and major gaps in our training, from asking into certain areas of patient history.” [ FN5]
In 1995 Felitti ran an obesity program at Kaiser Permanente in San Diego. But he had a 50% drop-out rate, just when those quitting were losing up to 100 pounds. “As we interviewed almost 300 of the dropouts, every other person spoke of having childhood sexual abuse; most of them seemed to have been waiting to tell someone after hiding it for years,” Felitti said. “They also often mentioned verbal and physical abuse and other traumatic experiences such as watching their mother being beaten.
“We were amazed. I thought, ‘This can’t be true. People would know if that were true. Someone would have told me in medical school.’ [FN6]
“We wanted to know: to what degree does this happen in the whole population? That’s how we created the ACE Study. We took at first 8 and later a total of 10 categories of traumatic childhood experiences which we’d heard about from our obese patients, then found 17,421 average, middle-class adults who agreed to interviews.
“We were astonished to find that the percent of the general public who suffer from traumatic experiences in childhood and adolescence is far higher than imagined… Two-thirds (64-67%) of middle class subjects had one or more types of childhood trauma, and 38-42% had two or more types. One in six had an ACE Score of 4 or more; one in nine had an ACE Score of 5 or more.” In less privileged populations the numbers are far higher.
Similarly, Dr. van der Kolk describes a patient in the 1980s who could not recall if she were sexually abused, yet drew portraits of her family with menacing genitals. “So we went to the textbook — Freedman, Kaplan, & Sadock’s ‘Comprehensive Textbook of Psychiatry’ — with which I sat for my board exam in psychiatry. It said: ‘Incest is very rare; it happens in 1 out of 1.1 million women.’ At the time there were about 200 million Americans, so I thought, ‘Hmm… About 100 million women, 110 women are incest victims; how come 47 of them are in my office?’/” [FN4 Yale video.]
“The text says it is also very benign,” he went on quoting it: ‘There’s no agreement about the role of father-daughter incest as a source of psychopathology. The act offers an opportunity to test a fantasy whose consequences are found to be gratifying and pleasurable…In many cases it allows for a better adjustment to the external world. The large majority of them are none the worse for the experience ’. ” [FN7]
Developmental Trauma: Psychiatrists Still in Denial
But even today, until DTD is in the APA’s official Diagnostic and Statistical Manual of Mental Disorders (DSM), most mental health professionals will not diagnose or treat it, and no insurance company will cover it.
So in 2012 Dr. van der Kolk’s NCTSN network submitted data on 200,000 children around the world to the APA to document DTD. He spoke on DTD before the National Association of State Mental Health Directors, which treats 6.1 million patients a year with a $29 billion budget, and they wrote to the APA urging that DTD be included in the next DSM-5 in 2013.
But the APA refused and in June 2013, issued DSM-5 without mention of developmental trauma. Van der Kolk in his Yale video ridicules the APA for asking only two questions on child trauma in preparing DSM-5: “1. Can we assume life was pretty good growing up? and 2. Was anyone in your family a drug addict or an alcoholic?”
“Clearly our field would like to ignore social realities,” van der Kolk responds, “and study genes or biological functions — because for us to actually find out how the environment shapes the brain, would get us into very difficult situations.”
The APA refusal letter actually made a veiled dig against the Adverse Childhood Experience (ACE) Study and denied that “childhood adverse experiences” are a “substantive” problem – which is outrageous. Dr. van der Kolk read that letter at Yale in May 2013 and let ’em have it:
APA: “The consensus was there was just too little evidence to include DTD in the DSM-5. There have not been any published accounts about children with this disorder.”
Dr. vdK aside: “No, because it’s not in the textbooks!”
APA: “The notion that childhood adverse experiences lead to substantive developmental reduction is more clinical intuition than a research-based fact. “
Dr. vdK aside: “We submitted research data on 200,000 children from around the world to substantiate our diagnosis.”
APA: “The statements made cannot be backed up by prospective studies.”
Dr. vdK aside: “Actually, they can.”
Dr. van der Kolk could make a lot more money as a TV comedy star, after dealing with this idiocy for a lifetime. Despite the tragedy, his psychiatrist audience also had a good laugh — the APA is that absurd.
Developmental trauma is the “invisible” part of “the Silent Epidemic of Attachment Disorder.” [FN8]. DTD can happen as a by-product when a mother or her child are beaten or sexually abused – but it also happens on a wide-spread basis with no visible incident.
Perhaps 20-40% of our population goes through life never knowing they even have DTD. That’s why many of them go on to become leaders of industry and government. That’s why Dr. van der Kolk has said that the US Congress is “dissociated,” or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides. (To me that means more than 50% of Congress has attachment problems, which is why they made a career of trying to control others. ) [FN9]
Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.
FN1 van der Kolk, Bessel, MD, “Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories,” Psychiatric Annals 35:5, 401-408, May 2005 www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf
This article also details how developmental trauma is attachment-based: “Early patterns of attachment inform the quality of information processing throughout life . Secure infants learn to trust both what they feel and how theyunderstand the world…. (more),” he reports.
But “When caregivers are emotionally absent, inconsistent, frustrating, violent, intrusive, or neglectful, children are liable to become intolerably distressed and unlikely to develop a sense that the external environment is able to provide relief. Thus, children with insecure attachment patterns have trouble relying on others to help them, while unable to regulate their emotional states by themselves. As a result, they experience excessive anxiety, anger and longings to be taken care of. These feelings may become so extreme as to precipitate dissociative states or self-defeating aggression…”
Dr. van der Kolk has been Medical Director of The Trauma Center in Boston for 30 years (www.traumacenter.org).
FN2 Daniel Siegel, MD, et.al, “Trauma, Brain & Relationship: Helping Children Heal,” www.youtube.com/watch?v=jYyEEMlMMb0
Introductory video on Attachment Disorder and how development of the mind-body system can cause trauma. Copies at www.postinstitute.com/dvds.
FN3 Schore, Allan N., PhD, “Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, & Infant Mental Health,” 2001, www.trauma-pages.com/a/schore-2001b.php
FN4A van der Kolk, Bessel, MD: Video, Yale University, May 10, 2013, “Childhood Trauma, Affect Regulation, and Borderline Personality Disorder,” http://acesconnection.com/video/bessel-van-der-kolk-childhood-trauma-affect-regulation-borderline
FN4B Cloitre, Marylene, et. al, (NYU Child Study Center, Department of Psychiatry, New York University Medical College, email@example.com), “Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories,” Journal of Traumatic Stress, 2008 Jun;21(3):282-9. doi: 10.1002/jts.20339. Abstract: Despite the consistent documentation of an association between compromised attachment and clinical disorders, there are few empirical studies exploring factors that may mediate this relationship. This study evaluated the potential roles of emotion regulation and social support expectations in linking adult attachment classification and psychiatric impairment in 109 women with a history of childhood abuse and a variety of diagnosed psychiatric disorders. Path analysis confirmed that insecure attachment was associated with psychiatric impairment through the pathways of poor emotion regulation capacities and diminished expectations of support. Results suggest the relevance of attachment theory in understanding the myriad psychiatric outcomes associated with childhood maltreatment and in particular, the focal roles that emotion regulation and interpersonal expectations may play. http://www.ncbi.nlm.nih.gov/pubmed/18553408
FN5 Vincent J. Felitti, MD; Robert F. Anda, MD, MS; “The Lifelong Effects of Adverse Childhood Experiences,” Chapter 10 of Chadwick’s “Child Maltreatment,” Sexual Abuse and Psychological Maltreatment, Encyclopedic Vol 2 of 3, STM Learning, Inc., Saint Louis, p.203-215; March, 2014
FN6 Stevens, Jane, “The Adverse Childhood Experience Study” — the largest, most important public health study you never heard of — began in an obesity clinic,” ACEsTooHigh.com
FN7 Freedman, Alfred M., Kaplan, Harold I., & Sadock, Benjamin J., “Comprehensive Textbook of Psychiatry,” 2nd Edition, Williams and Wilkins Co., Baltimore, 1975; 2609 pages. Now in 9th edition; known since 4th edition as “Kaplan and Sadock’s.”
FN8 Lanius, Ruth A., MD; Vermetten, Eric; Pain, Claire; Editors, “The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic,” Cambridge University Press, 2010. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician,” American Academy of Pediatrics, 2012 (New York Times 1-7-12), and many more.
FN9 van der Kolk, Bessel, MD, “What Neuroscience Teaches Us About the Treatment of Trauma,” June 6, 2012 webcast, National Institute for the Clinical Application of Behavioral Medicine (NICABM) : Most of Congress is “dissociated,” van der Kolk told this 2012 globally-televised webcast, or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides. We already knew from Korea and Vietnam that “for every solider that will die on the battlefield, there will be 30 suicides, as is happening right now,” van der Kolk said. But “society dissociates from the reality of it and then Congress says, ‘Oh, gosh, isn’t that amazing!’ No it’s not amazing, that’s what happens!”
Short promo clip: http://www.nicabm.com/nicabmblog/how-trauma-traps-survivors-in-the-past/
Link to buy video, mp3 audio, transcripts: http://www.nicabm.com/trauma-2012-new/
On Congress, see also http://www.theatlantic.com/politics/archive/2014/06/why-it-matters-that-politicians-have-no-experience-of-poverty/371857/
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