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Manual of Articles Sections 15 - 28
• Traumatized people calculate life’s chances differently. They look out at the world through a different lens. And in that sense they can be said to have experienced not only a changed sense of self and a changed way of relating to others but a changed worldview.
• The hardest earned and most fragile accomplishment of childhood, basic trust, can be damaged beyond repair by trauma. Human beings are surrounded by layers of trust, radiating out in concentric circles like the ripples in a pond. The experience of trauma, at its worst, can mean not only a loss of confidence in the self, but a loss of confidence in the surrounding tissue of family and community, in the structures of human government, in the larger logics by which humankind lives, in the ways of nature itself, and often (if this is really the final step in such a succession) in God.
The mental health system is filled with survivors of prolonged, repeated childhood trauma. This is true even though most people who have been abused in childhood never come to psychiatric attention. To the extent that these people recover, they do so on their own. While only a small minority of survivors, usually those with the most severe abuse histories, eventually become psychiatric patients, many or even most psychiatric patients are survivors of childhood abuse. The data on this point are beyond contention. On careful questioning, 50—60 percent of psychiatric inpatients and 40—60 percent of outpatients report childhood histories of physical or sexual abuse or both. In one study of psychiatric emergency room patients, 70 percent had abuse histories. Thus abuse in childhood appears to be one of the main factors that lead a person to seek psychiatric treatment as an adult.
Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized. They are likely to receive a diagnosis that carries strong negative connotations. Three particularly troublesome diagnoses have often been applied to survivors of childhood abuse: somatization disorder, borderline personality disorder, and multiple personality disorder. All three of these diagnoses were once subsumed under the now obsolete name hysteria. Patients, usually women, who receive these diagnoses evoke unusually intense reactions in caregivers. Their credibility is often suspect. They are frequently accused of manipulation or malingering. They are often the subject of furious and partisan controversy. Sometimes they are frankly hated.
These three diagnoses have many features in common, and often they duster and overlap with one another. Patients who receive any one of these three diagnoses usually qualify for several other diagnoses as well. For example, the majority of patients with somatization disorder also have major depression, agoraphobia, and panic, in addition to their numerous physical complaints. Over half are given additional diagnoses of “histrionic,” “antisocial,” or “borderline” personality disorder. Similarly, people with borderline personality disorder often suffer as well from major depression, substance abuse, agoraphobia or panic, and somatization disorder. The majority of patients with multiple personality disorder experience severe depression. Most also meet diagnostic criteria for borderline personality disorder. And they generally have numerous psychosomatic complaints, including headache, unexplained pains, gastrointestinal disturbances, and hysterical conversion symptoms. These patients receive an average of three other psychiatric or neurological diagnoses before the underlying problem of multiple personality disorder is finally recognized.
All three disorders are associated with high levels of hypnotizability or dissociation, but in this respect, multiple personality disorder is in a class by itself. People with multiple personality disorder possess staggering dissociative capabilities. Some of their more bizarre symptoms may be mistaken for symptoms of schizophrenia. For example, they may have “passive influence” experiences of being controlled by another personality, or hallucinations of the voices of quarreling alter personalities. Patients with borderline personality disorder, though they are rarely capable of the same virtuosic feats of dissociation, also have abnormally high levels of dissociative symptoms. And patients with somatization disorder are reported to have high levels of hypnotizability and psychogenic amnesia.
Patients with all three disorders also share characteristic difficulties in close relationships. Interpersonal difficulties have been described most extensively in patients with borderline personality disorder. Indeed, a pattern of intense, unstable relationships is one of the major criteria for making this diagnosis. Borderline patients find it very hard to tolerate being alone but are also exceedingly wary of others. Terrified of abandonment on the one hand and of domination, on the other, they oscillate between extremes of clinging and withdrawal, between abject submissiveness and furious rebellion. They tend to form “special” relations with idealized caretakers in which ordinary boundaries are not observed. Psychoanalytic authors attribute this instability to a failure of psychological development in the formative years of early childhood. One authority describes the primary defect in borderline personality disorder as a “failure to achieve object constancy,” that is, a failure to form reliable and well-integrated inner representations of trusted people. Another speaks of the “relative developmental failure in formation of introjects that provide to the self a function of holding-soothing security”; that is, people with borderline personality disorder cannot calm or comfort themselves by calling up a mental image of a secure relationship with a caretaker.
Similar patterns of stormy, unstable relationships are found in patients with multiple personality disorder. In this disorder, with its extreme compartmentalization of functions, the highly contradictory patterns of relating may be carried out by dissociated “alter” personalities. Patients with multiple personality disorder also have a tendency to develop intense, highly “special” relationships, ridden with boundary violations, conflict, and the potential for exploitation. Patients with somatization disorder also have difficulties in intimate relationships, including sexual, marital, and parenting problems. Disturbances in identity formation are also characteristic of patients with borderline and multiple personality disorders (they have not been systematically studied in somatization disorder). Fragmentation of the self into dissociated alters is the central feature of multiple personality disorder. The array of personality fragments usually includes at least one “hateful” or “evil” alter, as well as one socially conforming, submissive, or “good” alter. Patients with borderline personality disorder lack the dissociative capacity to form fragmented alters, but they have similar difficulty developing an integrated identity. Inner images of the self are split into extremes of good and bad. An unstable sense of self is one of the major diagnostic criteria for borderline personality disorder, and the “splitting” of inner representations of self and others is considered by some theorists to be the central underlying pathology of the disorder.
The common denominator of these three disorders is their origin in a history of childhood trauma. The evidence for this link ranges from definitive to suggestive. In the case of multiple personality disorder the etiological role of severe childhood trauma is at this point firmly established. In a study by the psychiatrist Frank Putnam of 100 patients with the disorder, 97 had histories of major childhood trauma, most commonly sexual abuse, physical abuse, or both. Extreme sadism and murderous violence were the rule rather than the exception in these dreadful histories. Almost half the patients had actually witnessed the violent death of someone close to them.
In borderline personality disorder, my investigations have also documented histories of severe childhood trauma in the great majority (81 percent) of cases. The abuse generally began early in life and was severe and prolonged, though it rarely reached the lethal extremes described by patients with multiple personality disorder. The earlier the onset of abuse and the greater its severity, the greater the likelihood that the survivor would develop symptoms of borderline personality disorder. The specific relationship between symptoms of borderline personality disorder and a history of childhood trauma has now been confirmed in numerous other studies.
These three disorders might perhaps be best understood as variants of complex post-traumatic stress disorder, each deriving its characteristic features from one form of adaptation to the traumatic environment. The psysioneurosis of post-traumatic stress disorder is the most prominent feature in somatization disorder, the deformation of consciousness is most prominent in multiple personality disorder, and the disturbance in identity and relationship is most prominent in borderline personality disorder. The overarching concept of a complex post-traumatic syndrome accounts for both the particularity of the three disorders and their interconnection. The formulation also reunites the descriptive fragments of the condition that was once called hysteria and reaffirms their common source in a history of psychological trauma.
Many of the most troubling features of these three disorders become more comprehensible in the light of a history of childhood trauma. More important, survivors become comprehensible to themselves. When survivors recognize the origins of their psychological difficulties in an abusive childhood environment, they no longer need attribute them to an inherent defect in the self. Thus the way is opened to the creation of new meaning in experience and a new, unstigmatized identity.
Understanding the role of childhood trauma in the development of these severe disorders also informs every aspect of treatment. This understanding provides the basis for a cooperative therapeutic alliance that normalizes and validates the survivor’s emotional reactions to past events, while recognizing that these reactions may be maladaptive in the present. Moreover, a shared understanding of the survivor’s characteristic disturbances of relationship and the consequent risk of repeated victimization offers the best insurance against unwitting reenactments of the original trauma in the therapeutic relationship.
Reflection Exercise #1
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