Clinical and Health Affairs

Child Maltreatment and Brain Development

By David McCollum, M.D.

Abstract A growing body of research has linked childhood experiences of maltreatment with a host of physical conditions that manifest in adulthood. In addition, newer neuroimaging techniques have documented structural changes that occur in the brains of individuals who suffer early maltreatment. This article briefly reviews the literature on these topics and outlines the connection between abuse in childhood and health problems in adulthood.

It has long been observed that some children raised in violent, abusive, or neglectful settings grow up to express violence, anger, depression, or to be engaged in drug use, alcoholism, or criminal activity. The thinking has been that children copy what they see and hear. When antisocial behavior is the norm and when it is reinforced by adults in the environment, children repeat it. During the past 15 years, scientific and clinical research has begun to document that more is at work. Anatomical and functional alterations occur in the brains of children who are exposed to adverse events.1 Research has also shed light on the less obvious link between childhood abuse and lifetime physical and mental health outcomes.2,3 This article reviews some of the research showing the neurobiological, neuroanatomical, and physiological effects of early life stressors and how they might relate to ongoing medical problems later in life.

The Connection between Abuse and Disease Repeated exposure to adverse or harmful events in childhood has been linked to many adult health consequences. The adverse experiences that have been studied most are sexual abuse, physical abuse, and neglect. Anda et al. identified additional experiences that influence health behavior and outcomes, including mother treated violently, mental illness, substance abuse, incarcerated household member, and parental separation or divorce.4 Because at least 30% of children in this country experience some form of child abuse prior to age 18, we can expect adverse childhood experiences to have a significant impact on the health care system.5

New technologies such as functional MRI, PET, and MRI/T2 relaxometry (T2-RT) have enabled scientists to identify the chemical and structural differences between the central nervous systems of abused and nonabused individuals.6,7 This research shows that many health problems including panic disorder/post-traumatic stress disorder, chronic fatigue syndrome, fibromyalgia, depression, some auto-immune disorders, suicidal tendencies, abnormal fear responses, preterm labor, chronic pain syndromes, and ovarian dysfunctioncan be understood, in some cases, as manifestations of childhood maltreatment.8-13

Brain Development An infants brain is equipped with an overabundance of neurons, synaptic potential, and dendrites. DNA is responsible for early brain development. But after birth, experience helps to determine which neurons will persist, which synapses will develop and become permanent, and which connections will take prominence or be subdued. Myelination, formation of the protective sheath surrounding nerve fibers, continues throughout childhood and, in some areas of the brain,

into the third decade of life. This process establishes final, permanent linkages within the brain structures.14

The limbic system is the part of the brain most vulnerable to adverse childhood experiences. The system is made up of the amygdala, hippocampus, cingulate gyrus, thalamus, hypothalamus, and putamen. Related structures include the cerebellar vermis, prefrontal cortex, and visual and parietal cortex. The limbic system is responsible for the generation and control or inhibition of emotions. It is also involved in interpreting facial expressions and evaluating danger, is responsible for the fight-or-flight response to stress, and integrates emotional reactions and connects them with the physical response. Various components are also involved in memory, both implicit and explicit, and in learning (Table).

Brain Sequelae Stress initiates a series of hormonal responses in the limbic system. The initial response to stress or danger is activation of the hypothalamic-pituitary- adrenal (HPA) axis. This occurs in the locus coeruleus and the sympathetic nervous system, causing a release of the hormones norepinephrine, serotonin, and dopamine. The amygdala reacts to this hormone release and, in turn, stimulates the hypothalamus to release corticotrophin-releasing factor (CRF). CRF, itself, acts as both a hormone, to stimulate adrenocorticotropin hormone (ACTH) secretion, and as a neurotransmitter, affecting areas of the cortex that are involved in executive functioning (eg, motivation, planning, and logic).15 Increasing ACTH secretion then leads to elevated glucocorticoids (cortisol). High levels of glucocorticoids have been shown to negatively affect the hippocampus, resulting in decreased dendritic branching, changes in synaptic terminal

structure, and neuronal loss.16 A feedback mechanism in the hypothalamus and the hippocampus normally brings these levels back to their resting state.

If this process occurs repeatedly, CRF and glucocorticoids remain elevated, which eventually causes structural changes in the brain and impedes the feedback mechanism, leading to an imbalance in hormones and dysregulation of the HPA axis.17

Signs of Stress in the Brain Several studies have shown a measurable reduction in the size of the amygdala, hippocampus (primarily the left side), corpus callosum, and the cerebellar vermis, and an increase in size of the putamen and lateral ventricles in both children and adults who experienced repeated childhood trauma.18-20 These changes are thought to be an effect of elevated glucocorticoid levels inhibiting myelination in these structures.14 Because most areas of the limbic system are high in glucocorticoid receptors, they are susceptible to the effects of early childhood abuse.

Functional changes have also been noted in the anterior cingulate gyrus and the visual and parietal cortex. Elevated resting levels of CRF have been found in the spinal fluid of abuse victims.21 Elevated T3 levels have also been found in patients with a history of childhood abuse.22

Dopamine, which is released during the stress response, stimulates areas of the prefrontal cortex, probably resulting in heightened attention and improved cognitive capacity. Chronic stress, however, appears to cause an overproduction of dopamine, which can result in reduced attention, increased overall vigilance, as well as a diminished capacity to learn new material and increased paranoid and psychotic behavior.23

Serotonin stimulates both anxiogenic and anxiolytic circuits, which create and reduce anxiety. Decreased serotonin levels in the prefrontal cortex have been found as a result of chronic stress. Suicidal behavior, depression, and aggression have been shown to result from low serotonin levels.

Substance P, a neuropeptide found throughout the body that participates in the pain response and inflammation, has been found at much higher levels in the spinal fluid of those with significant abuse history. Studies in rats showed that injecting high levels of substance P in the spinal fluid caused a significantly exaggerated pain response to a noxious stimulus.24

Related Health Problems The health problems associated with these changes in the brain are significant. According to Anda et al., atrophy of the hippocampus, amygdala, and prefrontal cortex, and the subsequent dysfunction is related to anxiety, panic, depressed affect, hallucinations, and substance abuse. Increased locus coeruleus and norepinephrine activity have been related to tobacco use, alcoholism, illicit drug use, and injectable drug use. Defects in the amygdala and related deficits in oxytocin result in sexual aggression, sexual dissatisfaction, perpetration of intimate partner violence, and impaired pair bonding.4

Anderson et al. used a novel technology called static functional MRI T2 relaxometry (T2-RT) on a population that had experienced childhood sexual trauma and found evidence of significant changes in the cerebellar vermis in abused individuals compared with nonabused individuals.6 The vermis has been shown to play a role in suppressing excitability within the limbic system. The most consistent anatomical finding in children with ADHD is a reduction in the size of the cerebellar vermis. Other studies show similarities in hormonal changes in children with ADHD.

Famularo showed a high correlation between traumatic family environments and ADHD comorbidity.25,26

Allsworth showed that dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis, common in people who have been abused, leads to ovarian dysfunction and early menopause.13 This is likely to increase the risk of cardiovascular disease in these women because estrogen is reduced prematurely and, therefore, its protective function is lost earlier, increasing risk for cardiovascular disorders. Another interesting finding is that early stress may lead to premature involution of the thymus gland. Anti-nuclear antibodies, which attack the bodys own tissues instead of foreign toxins and are frequently present in people with systemic lupus erythematosus, also have been found at higher levels in girls who have been sexually abused compared with those who have never experienced abuse.9 The link between fibromyalgia and sexual abuse has been extensively studied.27 Dysregulation of the HPA axis has been found in most patients with fibromyalgia.28 Substance P is found in high levels in this population. Irritable bowel syndrome has also been shown to be correlated with childhood sexual abuse, and higher levels of substance P have been found in the colonic mucosa of individuals who were maltreated as children. Also, increased glucocorticoid has been shown to act on the intra-abdominal adipocytes leading to increased fat storage.4 Findings that memory pathways are adversely affected by exposure to abuse may explain some amnesia, delayed recall of abuse, and dissociative disorders.29 Some authors consider conversion reactions and pseudoseizures a form of dissociative disorder.30

Conclusion For years, we have ignored the potential influence of childhood traumatic experiences on adult

disease, preferring to look for genetic causes of disease and pure biochemical factors without considering experiential influences. Given new evidence that trauma in childhood alters the physiology of the brain, it is time for all physicians to be educated about the full health impact of violence and abuse and be trained to explore these issues as the true etiology of or an underlying potentiating factor that contributes to their patients maladies. MM

David McCollum is an emergency physician at Ridgeview Medical Center in Waconia, chair of the AMA National Advisory Council on Violence and Abuse, and president-elect of the Academy on Violence and Abuse.

References 1. De Bellis MD, Keshavan MS, Clark DB, et al. A.E. Bennett Research Award. Developmental traumatology. Part II: Brain development. Biol Psychiatry. 1999;45(10): 1271-84. 2. McEwen BS. Allostasis and allostatic load: implications for neuropsychopharmacology. Neuropsychopharmacology. 2000; 22(2):108-24. 3. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med. 2003;37(3):268-77. 4. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2005 Nov 29. 5. Bremner JD. Neuroimaging of childhood trauma. Semin Clin Neuropsychiatry.

2002;7(2):104-12. 6. Anderson CM, Teicher MH, Polcari A, Renshaw PF. Abnormal T2 relaxation time in the cerebellar vermis of adults sexually abused in childhood: potential role of the vermis in stress-enhanced risk for drug abuse. Psychoneuroendocrinology. 2002;27 (1-2):231-44. 7. Teicher MH, Dumont NL, Ito Y, Vaituzis C, Giedd JN, Andersen SL. Childhood neglect is associated with reduced corpus callosum area. Biol Psychiatry. 2004;56(2):80-5. 8. Kendall-Tackett KA. Physiological correlates of childhood abuse: chronic hyperarousal in PTSD, depression, and irritable bowel syndrome. Child Abuse Negl. 2000;24(6):799-810. 9. De Bellis MD. The psychobiology of neglect. Child Maltreat. 2005;10(2):150-72. 10. Modestin J, Oberson B, Erni T. Possible correlates of DSM-III-R personality disorders. Acta Psychiatr Scand. 1997;96(6):424-30. 11. Horan DL, Hill LD, Schulkin J. Childhood sexual abuse and preterm labor in adulthood: an endocrinological hypothesis. Womens Health Issues. 2000;10(1):27-33. 12. Kendall-Tackett KA. Treating the Lifetime Health Effects of Childhood Victimization. Kingston, NJ: Civic Research Institute; 2003. 13. Allsworth JE, Zierler S, Krieger N, Harlow BL. Ovarian function in late reproductive years in relation to lifetime experiences of abuse. Epidemiology. 2001;12(6): 676-81. 14. Teicher MH, Andersen SL, Polcari A, Anderson CM, Navalta CP. Developmental neurobiology of childhood stress and trauma. Psychiatr Clin North Am. 2002; 25(2):397426, vii-viii. 15. Arborelius L, Owens MJ, Plotsky PM, Nemeroff CB. The role of corticotropin-releasing factor in depression and anxiety disorders. J Endocrinol. 1999;160(1):1-12. 16. Bremner JD. Does stress damage the brain? Biol Psychiatry. 1999;45(7):797-805.

17. Heim C, Newport DJ, Heit S, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA. 2000;284 (5):592-7. 18. Driessen M, Herrmann J, Stahl K, et al. Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Arch Gen Psychiatry. 2000;57(12):1115-22. 19. Brambilla P, Soloff PH, Sala M, Nicoletti MA, Keshavan MS, Soares JC. Anatomical MRI study of borderline personality disorder patients. Psychiatry Res. 2004;131(2):125-33. 20. Bremner JD, Randall P, Vermetten E, et al. Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abusea preliminary report. Biol Psychiatry. 1997;41(1):23-32. 21. Lee R, Geracioti Jr. TD, Kasckow JW, Coccaro EF. Childhood trauma and personality disorder: positive correlation with adult CSF corticotropin-releasing factor concentrations. Am J Psychiatry. 2005;162(5):995-7. 22. Friedman MJ, Wang S, Jalowiec JE, McHugo GJ, McDonagh-Coyle A. Thyroid hormone alterations among women with post-traumatic stress disorder due to childhood sexual abuse. Biol Psychiatry. 2005;57(10):1186-92. 23. Bremner JD. Long-term effects of childhood abuse on brain and neurobiology. Child Adolesc Psychiatr Clin N Am. 2003;12(2):271-92. 24. Li X, Clark JD. Hyperalgesia during opioid abstinence: mediation by glutamate and substance P. Anesth Analg. 2002;95(4):979-84, table of contents. 25. Famularo R, Fenton T, Kinscherff R, Augustyn M. Psychiatric comorbidity in childhood post traumatic stress disorder. Child Abuse Negl. 1996;20(10):953-61. 26. Teicher MH, Andersen SL, Polcari A, Anderson CM, Navalta CP, Kim DM. The

neurobiological consequences of early stress and childhood maltreatment. Neurosci Biobehav Rev. 2003;27(1-2):33-44. 27. Alexander RW, Bradley LA, Alarcon GS, et al. Sexual and physical abuse in women with fibromyalgia: association with outpatient health care utilization and pain medication usage. Arthritis Care Res. 1998;11(2):102-15. 28. Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;75:6-21. 29. Bremner JD, Krystal JH, Charney DS, Southwick SM. Neural mechanisms in dissociative amnesia for childhood abuse: relevance to the current controversy surrounding the false memory syndrome. Am J Psychiatry. 1996;153(7 Suppl):71-82. 30. Akyuz G, Kugu N, Akyuz A, Dogan O. Dissociation and childhood abuse history in epileptic and pseudoseizure patients. Epileptic Disord. 2004;6(3):187-92.

PTSD and Childhood Trauma

By Bob Murray, PhD

Over the years my wife, and fellow therapist, Alicia Fortinberry, and I have treated many people who were suffering from what is called post traumatic stress disorder or PTSD including a number of Vietnam veterans. In talking to the vets I noticed that a pattern was developing which caused me to widen my enquiries to veterans who went through the same experiences in Asia, but who did not have the symptoms of PTSD.

I have not had the time to do a formal study, but I have come to some very interesting conclusions regarding the disorder, which have been confirmed by some recent studies. I have

become convinced of the strong link between PTSD and depression and between both of those and childhood trauma.

The Origins of PTSD

I have long been interested in the effect of childhood trauma in the development of a number of mood disorders such as depression and dysthemia (a milder form of on-going depression). I believe that depression childhood can be a form of dissociative disorder a way the child escapes the harsh reality of his or her environment through a slowing down of mental activity. Almost all patients that I have seen who were depressed when they were children were the victims of some sort of abuse: physical, sexual or verbal in the form of criticism or implied threats of violence or abandonment. I am not saying that all depression is the result of childhood trauma or that all children who were abused become clinically depressed, just that in many children there seems to be a causal relationship between early abuse and depression.

In dealing with the vets I found the same sort of relationship -- those who were diagnosed with PTSD tended to have traumatic childhoods and those who were free of PTSD did not.

What is PTSD? Although traumatic events have long been known to cause psychological problems, the disorder itself was first formally characterized in the early 1980s. Even now it is the subject of controversy, with many psychiatrists and clinical psychologists saying a diagnosis of PTSD is meaningless (see articles in recent editions of the British Medical Journal). Personally I do not subscribe to this view, rather I believe the problem is one of inaccurate diagnosis.

Generally speaking PTSD is identified by the following three symptoms: 1) re-experiencing traumatic events (ie, obsessive recollections, flashbacks, nightmares); 2) avoidant symptoms (fear of being with people); and 3) signs of hyperarousal (easily startled, irritable). Traumatized people often suffer from a combination of PTSD, depression and other anxiety disorders.

Often the victims of PTSD are mis-diagnosed. For example, some patients will present more severe symptoms of hyperarousal with severe depression. The re-experiencing of events is often mis-diagnosed as "obsessiveness" within a depressive disorder. Hyperarousal symptoms may be mis-diagnosed as insomnia and anxiety within a major depressive episode. Other PTSD victims are mis-diagnosed with obsessive-compulsive disorder.

Danger of Misdiagnosis

People with symptoms such as social avoidance, hyperarousal or anxiety may have also selfmedicated their condition with alcohol to mute the symptoms and, as with active alcoholics, they may deny their drinking. Still other patients may experience mixed obsessive recollections with flashbacks and, at times, auditory and visual hallucinations. These patients may be misdiagnosed as dissociative or psychotic.

Patients with severe insomnia, symptoms of hyperarousal, severe irritability and racing thoughts may be misdiagnosed as manics or hypermanic borderline patients (patients whose mania centers around a desperate fear of abandonment).

A careful interview is necessary to make an accurate diagnosis and discover new behavioral traits wich separate PTSD from other disorders. (Alicia, once worked with a psychiatrist at a major NY hospital who claimed to be able to accurately diagnose schizophrenia and other

disorders within the space of a 3 minute interview!) Usually the patients are put on drugs, and very often the wrong drugs, as a result of these misdiagnoses.

And yet PTSD is one of the most common psychiatric disorders, affecting nearly 8% of the population [R.C. Kessler, et al. (1995), "Post Traumatic Stress Disorder in the National Comorbidity Survey", Archives General Psychiatry 52(12):1048-1060] and is growing fast. I believe there are two stages in the development of PTSD. Firstly there is childhood trauma which may or may not lead to the onset of a diagnosable depressive or anxiety. Then a second traumatic incident or set of circumstances arise which trigger the full-blown PTSD. In my view there must be these two stages and the onset of PTSD is dependent on a traumatic event or environment in childhood.

However I think that we ought to look again at the meaning of 'trauma.' Certain kinds of trauma are obvious early physical, sexual or verbal abuse, war, abandonment, poverty, class or racial or ethnic purging ('ethnic cleansing' or the holocaust), natural disasters and parental separation and most studies have restricted themselves to these areas.

Secondary Victims

Over the last few years mental health experts have begun to widen the definition of trauma. Andrei Novac, MD, associate clinical professor at the University of California, Irvine, writing in Psychiatric Times [(2001) 17:4] notes the enormous increase in the speed of the availability of information concerning traumatic events. "For instance, news of natural disasters, catastrophes and genocides are made widely available, instantaneously, via 24-hour cable news networks, creating an enormous pool of spectators to negative events. This is significant, as the study of

traumatic stress has determined that not only victims but also those being confronted with and witnessing traumatic events may be vulnerable to post traumatic stress disorder."

In other words the primary trauma may be one that happened to a child, or one that a child witnessed and similarly the secondary trauma, the one which actually triggers PTSD may also be one which the sufferer witnessed rather than actually experienced.

The original traumatic event may also be passed down generationally. A 1998 study by R. Yehuda , et al Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors [American Journal of Psychiatry, 155(9):1163-1171] confirmed that offspring of Holocaust survivor parents with PTSD have a higher lifetime risk for PTSD and report more distress after traumatic events. Thus, along with the exposure to their parents' traumatic stories and their trauma-related acquired behavioral patterns, these offspring may have a biological vulnerability to traumatic stress and PTSD transmitted to them from their parents.

In our own practices Alicia and I have noticed that women whose mothers were the victims of sexual abuse, for example, were likely to manifest all the signs of a sexual abuse survivor themselves. Children of alcoholics can often exhibit the behavioral characteristics of 'dry drunks.' Whether these are passed down biologically, as some have argued, through an inherited imbalance of cortisol or other neuro transmitters, or through childhood idealization of certain types of behavior (which explanation I tend to favor) is a matter of keen debate.

The net result of all this is that we must look at traumatic events as having a ripple effect causing PTSD disposition generationally and through the viewing of others' trauma (the creation of what might be called 'secondary victims).

Trauma, Personality and the Brain

Childhood abuse or trauma has a pronounced effect in brain development. It can lead to subtle structural abnormalities in the frontal lobe, which is closely related to the limbic system the seat of our emotions. These abnormalities may result in deep-seated personality deficits (for example, an inability to be empathetic, or pathological narcissism) that are not readily diagnosable as psychiatric disorders. This may explain why early exposure to traumatic stress or disruptive changes in environment may result in more fundamental behavioral changes that are more often diagnosed as personality disorders.

Some of these individuals may be prone to aggression and dehumanization of others in the service of a cause that they find noble. Many of the 20th century's most notorious leaders including Hitler (who was a child abuse victim and whose secondary trauma would have been WWI), Stalin, Mao and Pol Pot fit into this category.

The highly stressed society in which we live may itself be a cause of what Novac calls the "overextended boundaries of compensatory biological systems, creating an environment that is suboptimal for time appropriate maturation of certain brain areas."

The ripple effect of trauma means that traumatized people create families in which there may be a biological or other predisposition to trauma.

Treating PTSD

PTSD has proven spectacularly resistant to most forms of conventional therapy, though drugs, talk therapy, rap groups and a combination of all have been tried with varying degrees of

success. In my view one of the problems is that PTSD is seen as fundamentally different from depression rather than as an extreme form of that disorder. Depression can also cause not-too dissimilar changes in brain structure and chemistry even though the personality changes and behavioral effects of the two disorders can be, on the surface, quite different.

In my treatment of PTSD sufferers I have achieved most success when I examined and treated the earlier childhood traumas and resulting depression first rather than the more obvious secondary trigger. The original trauma can induce a rather rigid, fearful personality, one less able to cope flexibly with stressful events in later life.

This is as true of rape victims as it is of war veterans. In treating rape survivors, it is important to find out if there is a history of sexual abuse in their family. Obviously it takes some tact to extract this information and a great deal of trust on the part of the victim.

Sarah was referred to me by the rape crisis center in New York. She was 27 and had been a victim of date rape and was also clearly suffering the symptoms of PTSD. She was not alone in this, studies have shown that 50% of all rape victims experience PTSD symptoms [D.A. Tomb (1994), "The Phenomenology of Post-traumatic Stress Disorder", Psychiatric Clinic North America, 17(2):237-250]. She was having recurring nightmares concerning the event and a tremendous sense of guilt. The most common form of therapy for PTSD is what is called reexposure therapy, which is not unlike the therapy commonly given to phobics. However in rape, and other sexual abuse cases, I do not believe that this is a good idea since it only increases the sense of guilt. Instead I began by letting her talk about whatever came into her mind.

It was clear that she had been depressed for a long time. Childhood depression is, in my view, always a flashing light, rather like a history of eating disorders, indicating the possibility of abuse.

She began to talk about her family and I gently encouraged her. She spoke freely about her sister, her mother and her father, though I noticed a stiffening in her body and a note of anger when she mentioned her mother. The one she didn't mention was her brother, other than to say he was seven years older than she. I was curious about this omission. It transpired that her brother had molested her constantly over a period of five years from the age of four. She had repeatedly told her mother who refused to believe her and made her feel that if there was any truth in her allegations that she must have been the guilty one. I was the first person she had told this to.

Once the original secret was out, so to speak, she relaxed somewhat. Over the course of several sessions she was able to focus her anger away from herself and to begin to accept her own innocence. This freedom from guilt led her to be able to come to terms with the more recent incident and, over a period of a few months, the symptoms of PTSD subsided.

One last point to be born in mind in treating all victims of traumatic stress, whether the result is depression, anxiety attacks, or PTSD, is that the trauma is perpetuated in the body as well as in the brain. It is as if the body of the victim is perpetually on alert for the next blow, critical remark or sexual attack and is therefor held very rigidly. This is true even of depressed or anxious ballet dancers or athletes which Alicia and I have treated. These people are more prone to injury because of this 'emotional holding pattern' as I call it. They are also less likely to let go of the emotional impact of the trauma while this somatic pattern persists.

It is therefore important, in our view, for the patient to undergo gentle Feldenkrais-type body work of the kind that Alicia (a prominent Feldenkrais practitioner as well as psychotherapist) and I have incorporated into our practice and into our professional training program, in conjunction with talk therapy. This is especially true of PTSD sufferers whose somatic rigidity can be quite extreme.

PTSD, like depression, can also be somatized. In an individual who was not allowed to express negative emotions as a child these emotions can be expressed as physical illness such as chronic fatigue syndrome or fibromyalgia [cf S. Dubovsky MD "Mind/Body Deceptions", pub. Norton 1997, pp 43-56]. It is important for physicians to look beyond the "physical" symptoms of such illnesses and bear in mind the possibility of an underlying traumatic or emotional cause.

To sum up, PTSD is common, often misdiagnosed and mistreated. It is, however treatable if the therapist takes the time and patience to look at the traumas that happened before the triggering incident. By allowing the patient to come to terms with these earlier events, and by dealing with the probable underlying depression and anxiety resulting from them, then a better long-term result is likely to be achieved. Feldenkrais-type body work is also an essential element in the treatment of most PTSD sufferers.

In some areas of psychology (especially in psychodynamic theory), psychologists talk about defense mechanisms, or manners in which we behave or think in certain ways to better protect or defend ourselves. Defense mechanisms are one way of looking at how people distance themselves from a full awareness of unpleasant thoughts, feelings and behaviors. Psychologists have categorized defense mechanisms based upon how primitive they are. The more primitive a defense mechanism, the less effective it works for a person over the long-term. However, more primitive defense mechanisms are usually very effective short-term, and hence are favored by many people and children especially (when such primitive defense mechanisms are first learned). Adults who dont learn better ways of coping with stress or traumatic events in their lives will often resort to such primitive defense mechanisms as well. Most defense mechanisms are fairly unconscious that means most of us dont realize were using them in the moment. Some types of psychotherapy can help a person become aware of what defense mechanisms they are using, how effective they are, and how to use less primitive and more effective mechanisms in the future.

Primitive Defense Mechanisms

1. Denial Denial is the refusal to accept reality or fact, acting as if a painful event, thought or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. Many people use denial in their everyday lives to avoid dealing with painful feelings or areas of their life they dont wish to admit. For instance, a person who is a functioning alcoholic will often simply deny they have a drinking problem, pointing to how well they function in their job and relationships. 2. Regression Regression is the reversion to an earlier stage of development in the face of unacceptable thoughts or impulses. For an example an adolescent who is overwhelmed with fear, anger and growing sexual impulses might become clingy and start exhibiting earlier childhood behaviors he has long since overcome, such as bedwetting. An adult may regress when under a great deal of stress, refusing to leave their bed and engage in normal, everyday activities. 3. Acting Out Acting Out is performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, Im angry with you, a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a childs temper tantrum is a form of acting out when he or she doesnt get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

4. Dissociation Dissociation is when a person loses track of time and/or person, and instead finds another representation of their self in order to continue in the moment. A person who dissociates often loses track of time or themselves and their usual thought processes and memories. People who have a history of any kind of childhood abuse often suffer from some form of dissociation. In extreme cases, dissociation can lead to a person believing they have multiple selves (multiple personality disorder). People who use dissociation often have a disconnected view of themselves in their world. Time and their own self-image may not flow continuously, as it does for most people. In this manner, a person who dissociates can disconnect from the real world for a time, and live in a different world that is not cluttered with thoughts, feelings or memories that are unbearable. 5. Compartmentalization Compartmentalization is a lesser form of dissociation, wherein parts of oneself are separated from awareness of other parts and behaving as if one had separate sets of values. An example might be an honest person who cheats on their income tax return and keeps their two value systems distinct and un-integrated while remaining unconscious of the cognitive dissonance. 6. Projection Projection is the misattribution of a persons undesired thoughts, feelings or impulses onto another person who does not have those thoughts, feelings or impulses. Projection is used especially when the thoughts are considered unacceptable for the person to express, or they feel completely ill at ease with having them. For example, a spouse may be angry at their significant other for not listening, when in fact it is the angry spouse who does not listen. Projection is often the result of a lack of insight and acknowledgement of ones own motivations and feelings. 7. Reaction Formation Reaction Formation is the converting of unwanted or dangerous thoughts, feelings or impulses into their opposites. For instance, a woman who is very angry with her boss and would like to quit her job may instead be overly kind and generous toward her boss and express a desire to keep working there forever. She is incapable of expressing the negative emotions of anger and unhappiness with her job, and instead becomes overly kind to publicly demonstrate her lack of anger and unhappiness.

Less Primitive, More Mature Defense Mechanisms

Less primitive defense mechanisms are a step up from the primitive defense mechanisms in the previous section. Many people employ these defenses as adults, and while they work okay for many, they are not ideal ways of dealing with our feelings, stress and anxiety. If you recognize yourself using a few of these, dont feel bad everybody does. 8. Repression

Repression is the unconscious blocking of unacceptable thoughts, feelings and impulses. The key to repression is that people do it unconsciously, so they often have very little control over it. Repressed memories are memories that have been unconsciously blocked from access or view. But because memory is very malleable and ever-changing, it is not like playing back a DVD of your life. The DVD has been filtered and even altered by your life experiences, even by what youve read or viewed. 9. Displacement Displacement is the redirecting of thoughts feelings and impulses directed at one person or object, but taken out upon another person or object. People often use displacement when they cannot express their feelings in a safe manner to the person they are directed at. The classic example is the man who gets angry at his boss, but cant express his anger to his boss for fear of being fired. He instead comes home and kicks the dog or starts an argument with his wife. The man is redirecting his anger from his boss to his dog or wife. Naturally, this is a pretty ineffective defense mechanism, because while the anger finds a route for expression, its misapplication to other harmless people or objects will cause additional problems for most people. 10. Intellectualization Intellectualization is the overemphasis on thinking when confronted with an unacceptable impulse, situation or behavior without employing any emotions whatsoever to help mediate and place the thoughts into an emotional, human context. Rather than deal with the painful associated emotions, a person might employ intellectualization to distance themselves from the impulse, event or behavior. For instance, a person who has just been given a terminal medical diagnosis, instead of expressing their sadness and grief, focuses instead on the details of all possible fruitless medical procedures. 11. Rationalization Rationalization is putting something into a different light or offering a different explanation for ones perceptions or behaviors in the face of a changing reality. For instance, a woman who starts dating a man she really, really likes and thinks the world of is suddenly dumped by the man for no reason. She reframes the situation in her mind with, I suspected he was a loser all along. 12. Undoing Undoing is the attempt to take back an unconscious behavior or thought that is unacceptable or hurtful. For instance, after realizing you just insulted your significant other unintentionally, you might spend then next hour praising their beauty, charm and intellect. By undoing the previous action, the person is attempting to counteract the damage done by the original comment, hoping the two will balance one another out.

Mature Defense Mechanisms

Mature defense mechanisms are often the most constructive and helpful to most adults, but may require practice and effort to put into daily use. While primitive defense mechanisms do little to try and resolve underlying issues or problems, mature defenses are more focused on helping a person be a more constructive component of their environment. People with more mature defenses tend to be more at peace with themselves and those around them. 13. Sublimation Sublimation is simply the channeling of unacceptable impulses, thoughts and emotions into more acceptable ones. For instance, when a person has sexual impulses they would like not to act upon, they may instead focus on rigorous exercise. Refocusing such unacceptable or harmful impulses into productive use helps a person channel energy that otherwise would be lost or used in a manner that might cause the person more anxiety. Sublimation can also be done with humor or fantasy. Humor, when used as a defense mechanism, is the channeling of unacceptable impulses or thoughts into a light-hearted story or joke. Humor reduces the intensity of a situation, and places a cushion of laughter between the person and the impulses. Fantasy, when used as a defense mechanism, is the channeling of unacceptable or unattainable desires into imagination. For example, imagining ones ultimate career goals can be helpful when one experiences temporary setbacks in academic achievement. Both can help a person look at a situation in a different way, or focus on aspects of the situation not previously explored. 14. Compensation Compensation is a process of psychologically counterbalancing perceived weaknesses by emphasizing strength in other arenas. By emphasizing and focusing on ones strengths, a person is recognizing they cannot be strong at all things and in all areas in their lives. For instance, when a person says, I may not know how to cook, but I can sure do the dishes!, theyre trying to compensate for their lack of cooking skills by emphasizing their cleaning skills instead. When done appropriately and not in an attempt to over-compensate, compensation is defense mechanism that helps reinforce a persons self-esteem and self-image. 15. Assertiveness Assertiveness is the emphasis of a persons needs or thoughts in a manner that is respectful, direct and firm. Communication styles exist on a continuum, ranging from passive to aggressive, with assertiveness falling neatly inbetween. People who are passive and communicate in a passive manner tend to be good listeners, but rarely speak up for themselves or their own needs in a relationship. People who are aggressive and communicate in an aggressive manner tend to be good leaders, but often at the expense of being able to listen empathetically to others and their ideas and needs. People who are assertive strike a balance where they speak up for themselves, express their opinions or needs in a respectful yet firm manner, and listen when they are being spoken to. Becoming more assertive is one of the most desired communication skills and helpful defense mechanisms most people want to learn, and would benefit in doing so.

*** Remember, defense mechanisms are most often learned behaviors, most of which we learned during childhood. Thats a good thing, because it means that, as an adult, you can choose to learn some new behaviors and new defense mechanisms that may be more beneficial to you in your life. Many psychotherapists will help you work on these things, if youd like. But even becoming more aware of when youre using one of the less primitive types of defense mechanisms above can be helpful in identifying behaviors youd like to reduce.