The Psychobiology of Trauma and Child Maltreatment

from Falcon - Tuesday, April 17, 2007
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The exploding field of Neurobiology has provided a new dimension to our understanding of child neglect and abuse. The effects of early stress on the developing brain and nervous system is now well-documented in the literature. This article explores the potential of these effects on children growing up in cults.

Many of the symptoms experienced by former cult members and observed by clinicians can now be conceptualized as a sub-optimal stress response resulting in affect dysregulation in its various forms. Due to the inadequate and often abusive parenting practices to which members were often exposed it is not surprising that symptoms such as anxiety, depression, rage, dissociation, emotional constriction, and substance abuse/dependence might occur. This article seeks to explain how these symptoms develop and what might be done to repair the harm.

Child maltreatment includes all intentional and unintentional harm to, or avoidable endangerment of, anyone under age 18. This definition includes emotional neglect and physical, sexual, and emotional/verbal abuse. Neglect as a form of child maltreatment occurs when caregivers fail to meet a child’s basic needs, including stimulation and education. Abuse includes all actions that are harmful to a child’s well-being, whether deliberately inflicted or not. The victim does not have to be directly affected; witnessing abuse is just as life changing, if not more so.

Affect Regulation
Some of the most robust findings in the psychopathology literature are the negative effects of maltreatment on the child’s (and later the adult’s) ability to regulate his/her emotions. Without affect regulation, dealing with life’s ups and downs becomes a daily roller coaster ride that has an impact upon all aspects of a person’s life. Affect regulation refers to the ability to soothe and comfort oneself when one is agitated or anxious, as well as the ability to enliven oneself when one is depressed, bored, or dissociated (i.e., to regulate up or down, respectively). From a neurobiological standpoint, affect regulation can be seen as at the core of healthy development and affect dysregulation as at the core of psychopathology. Symptoms such as anxiety, panic attacks, or depression can be conceptualized as failures of regulation. Coping and defense mechanisms can be viewed as strategies to regulate affect and return the organism to a state of homeostasis. Thus, we have an affect-regulation spectrum. On the adaptive end are coping mechanisms, such as exercising, listening to music, or doodling during a long lecture. At the dysfunctional end of the spectrum are addictions (alcoholism, drug abuse) and other maladaptive behaviors such as fighting.
There are times, however, when even the healthiest person cannot manage to shift her/himself out of a dysregulated state, and in that case s/he needs to be able to reach out to others for this kind of assistance. People who are unable to do so would live a very schizoid existence. Likewise, people who always use others to help shift them out of dysregulated states—i.e., who are incapable of self-regulation—wear out their friends and family, and might be viewed as having a dependent or borderline personality disorder. In summary then, the ability to both self- and other-regulate are hallmarks of good mental health.
Childhood abuse and neglect damage the ability for affect regulation. To better understand this, we need to understand the physiology of the normal stress response. Our fight/flight/freeze reactions are rooted in a primitive part of our brain, primarily the amygdala.

Neurochemicals

A simple explanation for the normal stress response is as follows: Faced with immediate danger, the body pumps out the adrenaline hormones known as cortisol and epinephrine. Epinephrine is fast acting, efficient, and short lasting; in contrast, cortisol is slower to rise but stays in the blood stream longer. These hormones go to our heart, which begins beating faster, and to our muscles, to prepare our bodies either to fight or to run away when we don’t think we have a chance of winning the fight. In addition, epinephrine and its derivative, norepinephrine, are responsible for narrowing attention so that we don’t get distracted but are able to bring all our mental faculties to bear on the present danger. Obviously, this response has survival value and, thus, has survived evolutionary modifications over time.

The Hypothalmic-Pituitary-Adrenal Axis

There is a wonderful feedback loop in the brain, known as the HPA (Hypothalmic-Pituitary-Adrenal) axis, which lets the body know when the danger is over and to return to baseline. This response occurs when cortisol reaches a certain critical level. When that happens, the body gets the message that the emergency chemicals are no longer needed, so the body can relax. For example, when we slam on the car brakes because we almost went through a red light, cortisol levels are elevated in our bloodstream. Soon afterward, when we catch our breath and realize we are safe and there are no cops around, the brain sends signals that tell the pituitary and adrenal glands responsible for cortisol levels that everything is okay, and the body returns to its former homeostatic state. In this way, we have warp speed when we need it to cope with the crisis, but we don’t live there. This feedback loop is important because although cortisol is necessary in the short-run, it is toxic in the long run. And while epinephrine gets in and out of the body quickly, as previously mentioned, cortisol is slower to return to baseline and, therefore, can be harmful to the organism. If left in the bloodstream too long, cortisol actually burns out synaptic connections in the brain and wears out bodily organs, which can lead to various illnesses—ulcers, heart disease, and so on. In other words, under chronic stress, these hormone levels, especially that of cortisol, are turned ON but unable to turn OFF.
For children who have been maltreated, the problem is that they do, in fact, live in this chronic state of emergency, and their bodies continue to be “at the ready” to fight or flee. Initially, adrenaline levels rise more quickly, but cortisol levels fail to reach the critical level for shutdown. One theory for this phenomenon is that the brains of traumatized people have fewer cortisol receptors, paradoxically making them less sensitive to knowing when the emergency is over, and thus leaving them in a highly anxious state. This chronic state of readiness puts a tremendous strain on their bodies. Research has shown, for example, that traumatized children are from 10 percent to 15 percent more likely to suffer from cancer, heart disease, and diabetes as adults.

The Amygdala

To explain further, the amygdala, a primitive brain structure situated at the top of the brain stem, “acts as a sensory gateway to the limbic system”, or emotional brain. The amygdala can become sensitized to fear and danger. Repeated stress causes the amygdala to become irritable and reactive, which results in a situation known as kindling. This is an appropriate term because, just as a small spark can set a whole neighborhood up in flames, the neurons neighboring an irritable amygdala can be set off easily.

The Hippocampus

Heightened levels of sustained cortisol also inhibit the normal functioning of another brain structure, the hippocampus. The hippocampus functions much like a filer, putting information into its proper time and space folders. The hippocampus is also implicated in long-term memory consolidation. Thus, if your hippocampus is functioning normally, it will tell you that you are reading this article in this journal in this particular year (where and when). The hippocampus, however, is especially sensitive to stress. During trauma it gets flooded with cortisol, the stress hormone, and when that happens, it goes offline. Therefore, the traumatic memory does not get placed into its rightful chronological and spatial folders. Subsequently, when a stimulus reminiscent of the original trauma triggers the memory, the person responds as if the event were happening here and now instead of there and then. The ubiquitous phenomena of flashbacks and intrusive thoughts characteristic of PTSD are the result. To further elucidate this process I turn now to a discussion of how memories are encoded in the brain.

Implicit and Explicit Memory

Discussion of the psychobiology of trauma would be incomplete without a discussion of different types of memories and how traumatic memories get reactivated. Implicit memory, also known as nondeclarative and procedural memory, characterizes the right brain (where the limbic system primarily resides). Since the right brain is dominant for the first three years of life, memories of our earliest experiences are laid down in the right brain, in implicit or procedural memory. These early bedrock imprints exert a powerful influence over us in subsequent years.
Around four years of age, our left brain becomes dominant and, along with it, explicit memory, which begins to develop approximately two years earlier. Explicit memory, also called declarative memory, becomes possible because language is more developed by this time and memories are laid down in the symbols of the culture—i.e., language. Explicit memory is also conscious memory.
As noted, the hippocampus is a major structure that functions to consolidate long-term explicit memories. Therefore, when the hippocampus is inhibited from functioning, as in traumatic situations, explicit memory cannot occur. Although the amygdala registers the trauma, the hippocampal “secretary” has not filed it properly. The trauma is “remembered” in implicit memory in perceptual, behavioral, and emotional ways only. Later on, other perceptual, behavioral, and emotional stimuli reminiscent of the traumatic event will “trigger” these unprocessed implicit memories, and the amygdalic urge to fight or flee will often be the result.
For example, a woman molested as a child reacts with disgust and withdraws when her husband initiates sex. Her response is automatic, driven by her amygdala. Both she and her husband are confused by this reaction because she truly loves him and wants to be close. However, the roots of her reaction have been dissociated from consciousness and her conditioned reaction to the molestation is encoded in her implicit memory’s neural circuits. The hippocampus has not registered important information (time and context) of the earlier event, so the woman’s amygdala is in charge of the present interaction.
Research on PTSD confirms that hippocampal volume is lower in people who develop PTSD following a trauma compared to those similarly exposed who do not develop the disorder. Therefore, the files of those who develop PTSD are less likely to be in chronological order because of the lower number of hippocampal neurons. However, the causal direction has not been definitively established to date; in other words, does chronic stress burn out hippocampal neurons, in turn resulting in PTSD, or do people who develop PTSD have smaller hippocampal volume to begin with? Tempting though it may be to presume the former, recent research seems to point in the other direction—i.e., that people with smaller hippocampi prior to the trauma are more likely than others to develop PTSD when traumatically exposed. However, this finding, that people with reduced hippocampal volume are more at risk for PTSD, does not resolve the nature/nurture controversy because it does not necessarily mean they are born with a smaller hippocampus. Prior trauma, such as a childhood history of abuse, might explain the hippocampal reduction. Research on humans is appropriately hampered in resolving these issues since we can’t induce trauma intentionally and then see what happens.

The False Memory Controversy

Impairment of the hippocampus during trauma also lends support to the controversial phenomenon of delayed recall (a.k.a. “recovered” or “false” memory). In psychotherapy, as patients begin to talk about their earlier trauma, hippocampal activation occurs and memory fragments are consolidated into an integrative whole. Implicit memory circuits link up with explicit memory circuits to form a coherent neural network. In this way, a previously “forgotten” memory, or one that had lain in shadow, may come to consciousness or be further clarified.
Conversely, we also know that children can be suggestible and many variables influence accurate recall (age, interval between occurrence and recall, stress arousal levels, etc. For example, Goldberg (1997) has shown how “false memories” can be implanted by therapists with an agenda, and how unconscious processes can influence autobiographical (explicit) memory. Nevertheless, because dissociated memories are sometimes implicit memories, a traumatized person in therapy may resurrect these implicit memories and place them in a context of explicit memories directly or indirectly associated with the implicit memory of the trauma in order to construct a cathartic explanation for the implicit traumatic memories. This constructed explanation may then function as an explicit memory of the trauma, which gives the person a capacity to process the trauma in ways that free him/her from its negative effects. This constructed memory/explanation may reflect the objective situation with varying degrees of accuracy, which, because therapists can rarely test the objective truth of the constructed memory, accounts in part for the controversy surrounding “recovered memories.” However, even if some details of the “memory” are inaccurate, the essence of the experience, i.e., the implicit emotional memories, may nonetheless be captured in the therapeutic construct, which, regardless of its accuracy of detail, can help liberate clients from the intrusive automaticity of improperly processed, nonverbal, implicit memories of trauma.

Other Brain Impairments

Maltreatment also results in diminished left hemispheric development. Each brain hemisphere has its own memory/learning system as noted above and is specialized for certain functions. The right hemisphere is more specialized for affect since the limbic system, the emotional brain, if you will, is more plugged into that half. The left hemisphere, the linguistic brain, is specialized for language, giving voice to right hemispheric experiences. The two hemispheres communicate with one another through the modem of the corpus collosum, nerve fibers that connect the right and left hemispheres. In people with abuse histories as well as in people with PTSD, the corpus collosum has been found to be thinner so that the left hemisphere is handicapped in putting words onto emotional experiences. Additionally, during trauma the area in the brain responsible for speech, known as Broca’s area, shuts down, resulting in the well-known phenomenon of “speechless terror”.
The ability to put feelings into words is an important component for affect regulation in adults. Clinicians have intuitively known this, so that psychotherapy involves helping the client “talk about” his/her experiences—i.e., put left-brain symbols on right-brain emotions/experiences. The inability to do so keeps the traumatic experiences “stored” in the right brain/limbic areas and unavailable for exploration. This then puts people at risk for all forms of psychopathology.

Norepinephrine and Dissociation

The other stress hormone mentioned earlier, norepinephrine (NE), may have other consequences. As previously noted, NE focuses attention, and, like cortisol, is helpful as a short-term response but detrimental long term. When attention is narrowed to certain stimuli, other stimuli are shut out. NE is one of the chemicals behind the flashbulb memories mentioned earlier. From an evolutionary perspective, this focusing response is desirable. If a hunter is being attacked by a wild boar, he is more likely to survive if he can focus all his attention on the boar’s distance and speed, and not get distracted by the beautiful waterfall behind the boar or thoughts about his beloved waiting at home. Thus, while NE allows some data to be remembered in bold relief and placed into long-term, hippocampal memory, other data may be tuned out. In the case of child sexual abuse, for example, NE may cause the child to focus on only a part of the event, entering it into long-term memory, but losing other information that might be important. Consequently, the smell of semen might be easily recalled along with an associated feeling of disgust, but the abuser himself may have been excluded from conscious awareness. As an adult, then, the victim/survivor might feel nauseous during a sexual encounter with an appropriate partner (as in our previous example) and lose all enjoyment that sexual activity might otherwise bring. In other words, knowledge of the abuser may be dissociated from the rest of the event, a common characteristic of PTSD. A former client of mine told me how she had focused on a doll in her room while her father was sexually violating her. She is now phobically avoidant of dolls but has little (explicit) memory of the abuse. The problem with dissociated material is that it doesn’t remain unconscious; it leaks out in many of the symptoms characteristic of PTSD: nightmares, flashbacks, autonomic hyperarousal, intrusive memories, and somatic complaints.
Additionally, people who have been sexually abused are prone to the oft-noted clinical phenomenon of revictimization; that is, people who have been abused as children too often become subsequent victims of rape or domestic violence. Prone to using dissociation as a way of coping with stress, they may tune out cues that alert other people to potential danger. Another theory proposed to explain this phenomenon is that, because the stress response is less sensitive in many cases, the person does not pick up the danger signals that would alert others to leave. Potentially dangerous situations might feel familiar and not raise concern for the formerly abused person.

Attachment

Another aspect of brain development that is important to understand in looking at the psychobiology of trauma has to do with the connections between the lower, more primitive brain regions (limbic and reptilian areas) and the higher cortical regions (neo-cortex, frontal lobes) that enable us to think, reason, organize, judge, and so on. A well-functioning brain has strong connections up and down so that people can integrate thinking and feeling. Otherwise, they either “live in their heads,” as we say, where they are cut off from their feelings, or, on the flip side, they are flooded with affect and cannot reason. Neither situation is desirable.
A key factor in how these synaptic connections form and how strong they are appears to be the relationship between the primary caregiver, usually the mother, and the infant. When the mother is attuned to the infant’s cues and able to respond sensitively, contingently, and in a timely fashion to her child, a proliferation of dendritic growth in the child’s right brain connects these lower and higher cortical regions. Additionally, the “good-enough mother” acts as a psychobiological regulator, calming and soothing the child when s/he is distressed and enlivening her/him when s/he is bored or dissociated. The child then develops a secure attachment to the mother. Eventually, the baby will be able to internalize these functions and become able to regulate his/her own affect. But if these functions are lacking in the primary caregiver, they will have serious consequences for the child.
EEGs have shown that the human infants of depressed mothers exhibited excessive right frontal lobe activity, which is biased for negative emotions, emotional reactivity, and psychopathology. Researchers at Baylor Medical Center also found that babies of depressed mothers, who were unable to play with their children, had smaller and less complex brains than babies of nondepressed mothers. And brain scans of two-year-old Romanian orphans who had not been held and played with showed little or no activity in the parts of their brains dedicated to emotions. Thus, they were unable to attach because they could not feel.
An insecure attachment has been shown to put people at risk for psychopathology. Specifically, the attachment category known as disorganized/disoriented appears to create a vulnerability to developing PTSD after experiencing a traumatic event as an adult. This may be due to the fact that children with this “D” attachment style learned to use dissociation to cope with early childhood stress. Unable to fight or flee as children, they froze or dissociated (they “got away” psychologically) as a way of coping, and this behavior became their preferred mode of dealing with stress. From the trauma literature we know that people who dissociate during a traumatic event are more likely than others exposed to the same event to develop PTSD. A logical interpretation of this finding would suggest that people who grow up in chaotic, neglectful, and/or abusive homes that foster disorganized attachment are more at risk for PTSD. This is borne out in research on foster children, where the most prevalent attachment category observed was “D". It would not be such a great leap then to assume that people who grow up in cults, where parents are distracted, frustrated, confused, shamed, deprived, and angry would develop disordered attachment and thus be at risk for PTSD.

Neurobiology, Trauma, and Cults

This article has focused on the effects of the biological component of trauma on the normal stress response, affect regulation, and information processing. Understanding this component helps create a more comprehensive clinical picture that informs treatment of survivors. Traumatic experiences and child maltreatment have been extensively documented in the cult literature but to date the biological component has not been addressed in relation to those experiences. A neurobiological perspective may illuminate some of the trauma-related symptoms observed in cult survivors.

Re-experiencing and Avoidance

Biological explanations can shed much light on the symptoms of re-experiencing and avoidance. Trauma survivors are prone to re-experiencing because the information they initially received was not processed completely due to the overwhelming emotional affect accompanying it. Parts of the experience were dissociated and not entered into explicit memory. Thus, these portions remain unintegrated in implicit memory circuits, in perceptual, emotional, and behavioral networks. The dissociated material (sights, sounds, smells, etc.) acts as “triggers” later on, flooding the survivor with emotions similar to those accompanying the original event. Conversely, triggers can induce dissociated states, sometimes called “floating,” which may appear in the form of “flashbacks,” intrusive thoughts, and nightmares.
To clarify further, “flashbacks” are implicit memories made up of sensations, perceptions, emotions, and behavioral tendencies. They can be conceptualized as experiences that were not processed explicitly because Broca’s area (the speech center) shuts down during high emotional states and the hippocampus goes offline. Without intervention, the dissociated experiences remain trapped in the limbic system, forever vulnerable to “triggering” attacks. Within the safety of the empathic therapeutic relationship the survivor can begin to “speak of the unspeakable” and gain some control over his/her internalized cult world.
A compelling case in point, for which the therapist obtained some corroboration, concerns a woman who spent her earliest childhood in a group that practiced sadistic ritual abuse. W’s account describes methods used to instill dissociation. She was, for example, shocked with a cattle prod in her childhood to stop her crying and threatened with additional shocks if she should ever show emotion again. She states, “So began our conditioning to hold our feelings inside no matter what horrific atrocities we would witness” (such as being forced to observe a woman literally being torn apart by wild dogs). The cattle prod was only one means of intimidation in a long history of threats and terrorizing experiences. Her inability to leave the cult resulted in severe Dissociative Identity Disorder when her mind could no longer keep the walled off material out of consciousness. Although the actual memories were not repressed, the affect associated with them had been compartmentalized and relegated to her unconscious. By her early 30’s W was experiencing fugue states where she lost time and found herself in strange places without knowing how she got there or why people were calling her by other names.

Heightened arousal

The third prong of PTSD, heightened arousal, is also further clarified through greater neurobiological understanding. Affect dysregulation is at the core of heightened arousal—an inability to regulate emotional states. These include such post-trauma characteristics as the startle response and emotional volatility. The startle response is an amygdala reaction, the early warning system we inherited from our reptilian ancestors. Once the amygdala registers a particular stimulus as dangerous, that stimulus gets generalized to others and the survivor loses the ability to discriminate among threats. Constantly hypervigilant, sleep becomes problematic and results in insomnia and other sleep difficulties often noted in trauma survivors, who not only fear losing control but are afraid of their dreams.
Likewise, emotional volatility and irritability are characteristic of heightened arousal. As noted in an earlier section the pre-frontal cortex is inhibited during high amygdala activation. Heightened arousal results because there are no breaks put on the fight or flight reaction. The person goes from 0 to 100 in a split second; aggression and rage may result. Overwhelmed and ashamed by their own behavior, traumatized people attempt to control these eruptions through suppression and avoidance. However, these attempts at containment inevitably fail because they cannot hold back the flood of affect pushing for release. A vacillation between emotional constriction and emotional volatility results.
Because survivors are prone to states of indiscriminate heightened arousal they often avoid activities that stimulate the sympathetic branch of the autonomic nervous system (ANS). Additionally, any body arousal can act as a trigger. Thus, survivors learn to distrust their bodies and become unable to use emotional signals to inform their decisions.
From the perspective of neurobiology, behaviors such as aggression, substance abuse, and domestic violence can be seen as attempts to regulate affect. Depression and anxiety can be viewed as failures to do so. Obviously, this applies to all kinds of trauma survivors, not just those exiting cults. Cult survivors, however, may be unique among trauma victims in that the cult actually predicts that these behaviors will occur. As a means of control members are given “dread” messages about what will happen if they leave the group. This prophesy often comes true because the cult member lacks healthy emotion regulation and the life skills necessary to function in the world. She often has to leave family and friends behind and, thereby, give up a support network that, however imperfect, was all that she had. Without the ability to regulate affect, interpersonal relationships become a challenge, leaving the former member isolated and believing that “the world really is a cold, uncaring place,” just as the cult leader said it was. The ex-member then turns to whatever sources of relief may be available—drugs, alcohol, promiscuous sexuality, and other addictions— to regulate his or her heightened affect.

Attachment

As mentioned previously, early attachment experiences are the key ingredient to optimal brain development, particularly the right (emotional) brain, which is dominant for the first three years of life. Since the limbic system is primarily in the right brain, emotional experiences will be “stored” there. A mother who is frustrated, angry, and consumed with anxiety herself, as is often the case with mothers in cults, is unable to regulate her own affect let alone that of her child. Thus, the child may be left in prolonged negative affect states that stress his or her immature nervous system.
Likewise, in an environment such as certain polygamist Mormon groups (e.g., the Fundamentalist Latter-Day Saints, or FLDS), where mothers are required to have a child per year, resulting in litters of children, mothers may not be able to provide the one-on-one dyadic relationship necessary for optimal brain development. When parents’ roles are hijacked by the leader who regulates his/her own affect by manipulating, controlling, and often abusing his/her followers, parents are likely to displace their frustration/anger onto the more vulnerable members of the community, the children. This may have been the case with Lisa Woznick’s mother who is described as irrationally abusive:
“She’d lash out at me, screaming, and attack me with our shag carpet rake—often with no provocation. She’d beat me with it, or whatever else she could get her hands on, for my purported transgressions, or any other reason she used to justify her abusive behaviors. She slammed me into the walls at times for getting in her way, even though I was just playing silently in our den or living room.” (Woznick, 2006, p. 2)
Additionally, in an environment lacking in stimulation, where education is prohibited and extracurricular activities denied, the brain cannot develop robust synaptic connections. The primitive amygdala impulses do not get mediated by the more evolved prefrontal cortex. The result is that raw emotions are not metabolized or clarified by thinking, and thoughts are not given emotional significance. Thus do the various forms of child maltreatment pass on intergenerationally. The memory traces of interactions with dysregulated others are laid down in implicit memory banks and get reactivated in subsequent attachment situations, that is, with their own children. And so it is that the consequences of child maltreatment also get passed from generation to generation.
The good news is that the brain remains plastic throughout life, and new neural networks can be formed in the context of a nurturing, empathically attuned environment. Psychotherapy and/or a secure relationship can override the earlier traumatic experiences, healing and reshaping the brain.

(Doni Whitsett, Ph.D., L.C.S.W.