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The Long Shadow of Trauma

July 6, 2010

Mary Sykes Wylie wrote a compelling article about PTSD and the battle to get it included in DSM III. (The Long Shadow of Trauma, Psychotherapy Networker, March/April Fueled by the behaviors exhibited by soldiers returning from Viet Nam, PTSD came to describe recycling memories causing crippling behaviors.

What is important in the storyline to me is Wylie’s explanation of the emergence of patients who claimed to have PTSD, but who had never been in battle. They were not recycling memories of war, but were still exhibiting the crippling behaviors evident in returning soldiers. This patient base was almost entirely women. The opening point of Wylie’s article was that soldiers exhibiting PTSD could not get help for it until it was recognized by DSM III as a covered diagnosis. The major thesis of the article was that for women exhibiting the symptoms resembling PTSD, they also needed a diagnosis recognized by DSM IV before they could be covered (for reimbursement by medical insurance).  But the battle for DSM IV recognition proved to be more difficult because of the source of the symptoms. It was not battle during war, it was the unspeakable traumas endured by these women at the hands of their male relatives—incest and sexual abuse.

The symptoms discovered among those with “a history of interpersonal childhood sexual and physical abuse were ’vastly different’ from the disaster victims with simple PTSD.” Among the symptoms described by Wylie are “inability to regulate their emotions, self-destructiveness, dissociation, amnesia, suicidality, shame, hopelessness, despair, wide-ranging somatic complaints and so on.” They also had PTSD symptoms. The name given to this new range of symptoms related to childhood sexual and physical abuse was DESNOS, or “diagnosis of extreme stress, not otherwise specified.” As Wylie points out, unless a body of symptoms has a diagnosis, it is not likely to qualify for funding to study the relationship between the symptoms and the traumas inflicted earlier in life.

What is interesting about the string of symptoms attributable to treatment in childhood is the manifestation of differing responses by victim of childhood inflicted trauma. Alicia Lieberman is credited in Wylie’s article with “thinking about the co morbidity with trauma.” What she meant is that the patient who started her thinking met clinical diagnoses for 4 different disorders, but as a whole person would not benefit by treatment for any one of them in isolation from the others. Dr. Robert Anda, a co-principal investigator for the Adverse Childhood Experience Study (ACES) described the state of research in the 1990’s as consisting of a bunch of BBs. They symptoms were well studied, and generally attributed to a causal factor. However, he described the historical findings of the ACES as the bucket that assembled the symptoms (BBs) into one causal bucket.

So DESNOS began to assemble a variety of symptoms recognized in DSM III and relate them to childhood maltreatment. This created a clinical resolution to a severe problem in that it allowed study of and funding for treatment for childhood abuse symptoms.

Let me say now that my experience in Native Alaska is that the symptoms of childhood abuse are substantial and incontrovertible. This is not to say that all Native families are abusive. Non Native communities exhibit similar symptoms. However, the recent series of lawsuits against the Catholic Church and Jesuits in Alaska uncovered decades of sexual abuse of Alaska Native children. Substance abuse is regularly reported as rampant in rural Alaska. The fact that 39% of Alaska’s prison population consists of Alaska Native men points to substantial levels of crime in Native Alaska. We clearly have a problem that has erupted with all of the signs of severe childhood abuse trauma symptoms in our adults.

The ACES pioneering results relates childhood abuse to the risky behaviors we adopt in response to childhood trauma, and actually helps to define what those traumas are with its 10 defined behaviors. The risky behaviors we adopt, and the symptomatic results of childhood trauma, contribute to our negative health outcomes. Smoking, overeating and obesity, substance abuse, depression, anger with violence and suicide contribute to a substantial number of Alaska Native deaths annually.

Chugachmiut has made the decision to treat our whole patient. Native and Rural Alaska has a dearth of behavioral health counselors. We have 5 who are currently analyzing what it would take to help our tribal members address their childhood abuse issues and help to eliminate their risky behaviors. Trauma informed therapy appears to be one method to help address our client’s issues. We know we need to substantially support methods of behavioral change. This can be difficult as anyone who has tried to quit smoking, drinking or lose weight knows.

Another problem we need to anticipate, and which needs more research, is the question of co morbidity of symptoms. What might happen, for example, if we treat substance abuse successfully. Will this lead to emergence of another symptom, such as depression, or suicidal thoughts, or promiscuity? If we successfully overcome eating disorders, will anger or violence emerge? I don’t know. Treating the whole person may help, but what does treating the whole person really mean.

Wylie’s article certainly helps us develop some of our thinking about how to address the issues raised through our Restoration to Health program. As I read my own writing today I am not sure I am making my point. This often happens as I search for answers to questions raised about our programs. As with any continuous improvement effort, we need to go through this period of reflection, contemplation and development of our message. So, although this blog may be difficult to comprehend for some, I want to release it so that others might help me to develop my thinking.

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