The Compulsion to Repeat the
Trauma Re-enactment, Revictimization, and Masochism
Bessel
A.
van der
Kolk, MD*
During the formative years of contemporary psychiatry much attention was paid to
the continuing role of past traumatic experiences on the
current lives of people. Charcot, Janet, and Freud all noted that
fragmented memories of traumatic events
dominated the mental life of many of their patient
and built their theories about the nature and treatment of psychopathology on
this recognition. Janet thought
that traumatic memories of traumatic events persist as
unassimilated fixed ideas that act as foci for the development of alternate
states of consciousness, including dissociative phenomena, such as fugue states,
amnesias, and chronic states of helplessness and depression. Unbidden memories
of the trauma may return as physical sensations, horrific images or nightmares,
behavioral reenactments, or a combination of these. Janet showed how
traumatized individuals become fixated on the trauma: difficulties in
assimilating subsequent experiences as well. It is "as if their
personality development has stopped at a certain point and cannot expand
anymore by the addition orassimilation of new elements." Freud independently
came to similar conclusions. Initially, he thought all hysterical symptoms were
caused by childhood sexual"seduction" of which unconscious memories
were activated, when during adolescence, a person was exposed to situations
reminiscent of the original trauma. The trauma permanently disturbed the
capacity to deal with other challenges, and the victim who did not integrate
the trauma was doomed to "repeat the repressed material as a
contemporary experience in instead or . . . remembering it as something belonging
to the past."
In this article, I will show how the trauma is repeated on
behavioral, emotional, physiologic, and neuroendocrinologic levels, whose
confluence explains the diversity of repetition phenomena. Many traumatized
people expose themselves, seemingly compulsively, to situations reminiscent of
the original trauma. These behavioral reenactments are rarely consciously
understood to be related to earlier life experiences. This "repetition
compulsion" has received surprisingly little systematic exploration during
the 70 years since its discovery, though it is regularly described in the
clinical literature. Freud thought that the aim of repetition was to gain
mastery, but clinical experience has shown that this rarely happens; instead,
repetition causes further suffering for the victims or for people in their
surroundings. Children seem more vulnerable than adults to compulsive
behavioral repetition and loss of conscious memory of the trauma.70,136.
However, responses to projective tests show that adults, too, are liable to
experience a large range of stimuli vaguely reminiscent of the trauma as a
return of the trauma itself, and to react accordingly.39,42
BEHAVIORAL RE-ENACTMENT
In behavioral re-enactment of the trauma, the self may play
the role of either victim or victimizer.
Harm to Others
Re-enactment of victimization is a major cause of violence.
Criminals have often been physically or sexually abused as children. In a
recent prospective study of 34 sexually abused boys, Burgess et al. found a
link with drug abuse, juvenile delinquency, and criminal behavior only a few
year later. Lewis has extensively studied the association between childhood
abuse and subsequent victimization of others. Recently, she showed that of 14
juveniles condemned to death for murder in the United States in 1987, 12 had
been brutally physically abused, and five had been sodomized by relatives. In a
study of self-mutilating male criminals, Brach-y-Rita concluded that "the
constellation of withdrawal, depressive reaction, hyperreactivity,
stimulus-seeking behavior, impaired pain perception, and violent aggressive
behavior directed at self or others may be the consequence of having been
reared under conditions of maternal social deprivation. This constellation of
symptoms is a common phenomenon among a member of environmentally deprived
animals."
Self-destructiveness
Self-destructive acts are common in abused children. Green
found that 41 per cent
of his sample of abused children engaged in head banging,
biting, burning, and cutting. In a controlled, double-blind study on traumatic
antecedents of borderline personality
disorder, we found a highly significant relationship between
childhood sexual abuse and various kinds of self-harm later in life,
particularly cutting and self-starving. Clinical reports also consistently show
that self-mutilators have childhood histories of physical or sexual abuse, or
repeated Surgery. Simpson and Porter found a significant association between
self-mutilation and other forms of self-deprecation or self-destruction such as
alcohol and drug abuse and eating disorders. They sum up the
conclusions of many students of this problem in stating that
"self-destructive activities were not primarily related to conflict,
guilt and superego pressure, but to
more primitive behavior patterns originating in painful
encounters with hostile caretakers during the first years of life."
Revictimization
Revictimization is a consistent finding. Victims of
rape are more likely to be raped and women who were physically or sexually
abused, as children are more
likely to be abused as adults. Victims of child sexual abuse
are at high risk of becoming prostitutes. Russell, in a very careful study of the effects of
incest on the life of women, found that few women made a conscious connection
between their
childhood victimization and their drug abuse, prostitution,
and suicide attempts. Whereas 38 per cent of a random sample of women reported
incidents of rape or attempted
rape after age 14, 68 per cent of those with a childhood
history of incest did. Twice as many women with a history of physical violence
in their marriages (27 per cent), and
more than twice as many (53 per cent) reported unwanted
sexual advances by an unrelated authority figure such as a teacher, clergyman,
or therapist. Victims of
father-daughter incest were four times more likely than
nonincest victims to be asked to pose for pornography.
SOCIAL ATTACHMENT AND THE TRAUMA RESPONSE
Human beings are strongly dependent on social support for
a sense of safety, meaning, power, and control. Even our biologic
maturation is strongly influenced by the nature of early attachment
bonds. Traumatization occurs when both internal and external resources
are inadequate to cope with external threat. Physical and emotional
maturation, as well as innate variations in physiologic reactivity to perceived
danger, play important roles in the capacity to deal with external threat.
The presence of familiar caregivers also plays an important role in helping
children modulate their physiologic arousal. In the absence of a
caregiver, children experience extremes of under-and over arousal that are
physiologically aversive and disorganizing. The availability of a
caregiver who can be blindly trusted when their own resources are inadequate
is very important in coping with threats. If the caregiver is rejecting and
abusive, children are likely to become hyper aroused. When the persons who
are supposed to be the sources of safety and nurturance become simultaneously
the sources of danger against which protection is needed, children maneuver to
re-establish some sense of safety. Instead of turning on their caregivers and
thereby losing hope for protection, they blame themselves. They become
fearfully and hungrily attached and anxiously obedient. Bowlby calls this
"a pattern of behavior in which avoidance of them competes with his desire
for proximity and care and in which angry behavior is apt to become
prominent."
Studies by Bowlby and Ainsworth in humans, and by
Harlow in other primates, demonstrate
the crucial role that a "safe base" plays for normal social
and biologic development. As children mature, they continually acquire new
cognitive schemata in which to frame current life experiences. These
ever-expanding cognitive schemes decrease their reliance on the environment for
soothing and increase their own capacity to modulate physiologic arousal in the
face of threat. Thus, the cognitive preparedness (development) of an individual
interacts with the degree of physiologic disorganization to determine the
capacity for mental processing of potentially
traumatizing experiences.137,141
SEX DIFFERENCES
The frequency with which abused children repeat aggressive
interactions has suggested to Green a link between the compulsion to repeat
and identification with the aggressor,
which replaces fear and helplessness with a sense of
omnipotence. There are significant sex differences in the way trauma
victims incorporate the abuse experience. Studies by Carmen et al. and others
indicate that abused men and boys tend to identify with the aggressor and later
victimize others whereas abused women are prone to
become attached to abusive men who allow themselves and
their offspring to be victimized further.
Reiker and colleagues have pointed out that confrontations
with violence challenges one's most basic assumptions about the self as
invulnerable and intrinsically worthy and about the world as orderly and just.
After abuse, the victim's view of self and world can never be the same again: it must be reconstructed. to incorporate the
abuse experience." Assuming responsibility for the abuse allows
feelings of helplessness to be replaced
with an illusion of control. Ironically,
victims of rape who blame themselves have a better prognosis than those who do
not assume this false responsibility: it allows the locus of control to
remain internal and prevent helplessness. Children
are even more likely to blame themselves: "The child needs to hold on to
an image of the parent as good in order to deal with the intensity of fear and
rage which is the effect of the tormenting experiences." Anger directed against the self or others is always a
central problem in the life of people who have been violated. Reikers concludes
that "this 'acting out' is seldom understood by either victims or
clinicians as being a repetitive re-enactment of real events from the
past."
THE SEPARATION REPONSE
Primates have evolved highly complex ways to maintain
attachment bonds; they are intensely dependent on their caregivers at the
start. In lower primates, his dependency
is principally expressed in physical contact, in humans this
is supplemented by verbal communication. McLean suggests that language is an
evolutionary development from the mammalian separation cry that induces
caregivers to provide safety, nurturance, and social stimulation. Primates
react to separation from attachment figures as if they were directly
threatened. Thus, small children, unable to anticipate the future,
experience separation anxiety as soon as they lose sight of their mothers.
Bowlby has described the protest and despair phases of this response in great
detail. As people mature, they develop an ever-enlarging repertoire of
coping responses, but adults are still intensely dependent upon social support
to prevent and overcome traumatization, and under threat they still may cry out
for their mothers. Sudden, uncontrollable loss of attachment bonds is an
essential element in the development of post-traumatic stress syndromes.
On exposure to extreme terror, even mature people have protest and despair
responses (anger and grief, intrusion and numbing) that make them turn
toward the nearest available source of comfort to return to a state of both
psychological and physiologic calm. Thus, severe external threat may result in
renewed clinging. Because the attachment system is so important,
mobilization of social supports is an important element in the treatment of
post-traumatic stress disorder (PTSD).
INCREASED ATTACHMENT IN THE FACE OF DANGER
People in general, and children in particular, seek
increased attachment in the face of external danger. Pain, fear, fatigue, and
loss of loved ones and protectors all
evoke efforts to attract increased care and most cultures
have rituals designed to provide it. When there is no access to ordinary
sources of comfort, people may turn toward their tormentors. Adults as well as
children may develop strong emotional ties with people who intermittently
harass, beat, and threaten them. Hostages have put up bail for their captors,
expressed a wish to marry them, or had sexual relations with them; 31 abused
children often cling to their parents and resist being removed from the
home;31,80 inmates of Nazi prison camps sometimes imitated their captors by
sewing together clothing to copy SS uniforms.11 When Harlow observed this in
nonhuman primates, he stated that "the immediate consequences of maternal
rejection is the accentuation of proximity seeking on the part of the
infant."114
Walker145 and Dutton and Painter31 have noted that the bond
between batter and victim in abusive marriages resembles the bond between
captor and hostage or cult leader and
follower. Social workers, police, and legal personnel are
constantly frustrated by the strength of this bond. The woman's longing for the
batterer soon prevails over memories of the terror, and she starts to make
excuses for his behavior. This pattern is so common that women engaged in these
sorts of relationships become the recipients of
intense anger for social service personnel. They are then called
masochistic, and like other psychiatric terms, this can be employed
pejoratively rather than conveying an
understanding of the underlying causes and treatment of the
problem. Walker145 first applied ethnology to the study of traumatic bonding in
such couples. A
central component is captivity, the lack of permeability,
and the absence of outside support or influence.31,62,119,145 The victim
organizes her life completely around pleasing her captor and his demands. As
Dutton and Painter point out, "her compliance legitimates his demands,
builds up a store of repressed anger and frustration on her part (which may
surface in her goading him or fighting back during an actual argument, leading
to escalating violence), and systematically eliminates opportunities for her to
build up a supportive network which could eventually assist her in leaving the
relationship."
Walker145 has clarified the operation of intermittent
reinforcement paradigms in such
relationships, applying the animal model of
punishment-indulgence patterns. In child abuse or spouse battering, this
mechanism is accentuated by the extreme contrast of terror followed by
submission and reconciliation. When such negative reinforcement occurs
intermittently, the reinforced response consolidates the attachment between
victim and victimizer. During the abuse, victims tend to dissociate emotionally
with a sense of
disbelief that the incident is really happening. This is
followed by the typical post-traumatic response of numbing and constriction,
resulting in inactivity, depression,
self-blame, and feelings of helplessness. Walker145
describes the process as follows: "tension gradually builds" (during
phase one), an explosive battering incident
occurs (during phase two), and a "calm, loving respite
follows phase three). The violence allows intense emotional engagement and
dramatic scenes of forgiveness,
reconciliation, and physical contact that restores the
fantasy of fusion and symbiosis.87,140 Hence, there are two powerful sources of
reinforcement: the "arousal-jag" or excitement before the violence
and the peace of surrender afterwards, Both of these responses, placed at
appropriate intervals, reinforce the traumatic bond between victim and
abuser.31,145 To varying degrees, the memory of the battering incidents is
state-dependent or dissociated, and thus only comes back in full force during
renewed situations of terror. This interferes with good judgment about the
relationship and allows longing for love an reconciliation to overcome
realistic fears.
VULNERABILITY TO DEVELOP TRAUMATIC BONDING
At least four studies of family violence40, 48,63,132 have
found a direct relationship between the severity of childhood physical abuse
and later marital violence. Interestingly,
nonhuman primates subjected to early abuse and deprivation
also are more likely to engage in violent relationships with their peers as
adults.134 as in humans, males tend
To be hyper aggressive, and females fail to protect
themselves and their offspring against danger. Neither sex develops the
capacity for sustained peaceful social interactions.134
People who are exposed early to violence or neglect come to
expect it as a
way of life. They see the chronic helplessness of their
mothers and fathers' alternating outbursts of affection and violence; they
learn that they themselves have no control.
As adults they hope to undo the past by love, competency,
and exemplary behavior.46,87,145 When they fail they are likely to make sense
out of this situation by blaming themselves. When they have little experience
with nonviolent resolution of differences, partners in relationships alternate
between expectations of perfect
Behavior leading to perfect harmony and a state of
helplessness, in which all verbal communication seems futile. A return to
earlier coping mechanisms, such as
self-blame, numbing (by means of emotional withdrawal or
drugs or alcohol), and physical violence sets the stage for a repetition of the
childhood trauma and "return of the
repressed."1,42,46,137
BIOLOGIC RESPONSES TO TRAUMATIZATION
Chronic physiologic hyper arousal to stimuli reminiscent of
the trauma is a
cardinal feature of the trauma response, well documented in
a large variety of traumatized individuals, including victims of child abuse,
burns, rape, natural disasters, and
War.2, 78,84,107,133,142 Because of their decreased capacity
to modulate physiologic arousal, which leads to reduced ability to utilize
symbols and fantasy to cope with stress, they tend to experience later stresses
as somatic states, rather than as specific events
that require specific means of coping.142 Thus, victims of
trauma respond to contemporary stimuli as if the trauma had returned, without
conscious awareness that past injury rather than current stress is the basis of
their physiologic emergency responses. The hyper arousal interferes with their
ability to make calm and rational
assessments and prevents resolution and integration of the
trauma.142 They respond to threats as emergencies requiring action rather than
thought.
Chronic hyper arousal in response to new challenges is also
found in animals exposed to inescapable shock.5 In fact, this phenomenon drew
our attention to the possibility of
using this animal model for the study of human
traumatization.142 Human beings and other mammals are very similar biologically
in respect to such relatively uncomplicated behaviors as fight, flight, and
freeze responses. Exposure to inescapable aversive events
has widespread behavioral and physiologic effects on animals
including (1) deficits in learning to escape novel adverse situations, (2)
decreased motivation for learning
new options, (3) chronic subjective distress,94 and (4)
increased tumor genesis and immunosuppression.143 All this is the result not of
the shock itself but of a helplessness
syndrome that is a result of the lack of control that the
animal has in terminating shock.
Several neurotransmitters have been shown to be affected by
inescapably fearful experiences in animals; they have low resting
cerebro-spinal fluid (CSF) norepinephrine, but under stress they respond with
much higher elevations than other animals. Something has disturbed the
organism’s capacity to modulate the extent of arousal.37, 95,115,116,142
Dysregulation of the serotonin system has been implicated in this.123, 139
Serotonin is thought to be the neurotransmitter most involved in modulating the
actions of other neurotransmitters; 19 it has also been implicated in the fine
tuning of emotional reactions, particularly arousal and aggression.18
Traumatization also causes
dysregulation of the endogenous opioid system in both
animals and humans. We will discuss this phenomenon and how this could explain
the clinical phenomenon of compulsive re-exposure to trauma.
STATE-DEPENDENT LEARNING
Both Janet74 and Freud observed that early memory traces
could be activated by later events that cause partial reliving of earlier
traumas in the form of affects states, anxiety, or re-enactments. Their
patients generally had a poor memory for traumatic childhood events, until they
were brought back, by means of hypnosis, to a state of mind similar to the one
they were in at the time of the trauma. In the past few decades, these notions
have
gained scientific confirmation with the discovery of
state-dependent learning; for example what is learned under the influence of a
particular drug tends to become
dissociated and seemingly lost until return of the state
similar to the one in which the memory was stored. State dependency can be
roughly related to arousal levels. For
example, state-dependent learning in humans is produced by
both psycho stimulants and depressants: alcohol, marijuana, barbiturates, and
amphetamines as well as other psychoactive agents.32 Reactivation of past
learning is relatively automatic: contextual stimuli directly evoke memories without
conscious awareness of the transition. The more similar are the contextual
stimuli are to conditions prevailing at the time of the original
storage of memories, the more likely the probability of
retrieval. Both internal states, such as particular affects, or external events
reminiscent of earlier trauma
thus can trigger a return to feeling as if victims are back
in their original traumatizing situation. Thus, battered women who otherwise
behave competently may experience
themselves within the battering relationship like the
terrified child they once were in a violent or alcoholic home.119 Similarly,
war veterans may be asymptomatic until they become intimate with a partner and
start reliving feelings of loss, grief, vulnerability, and revenge related to
the death of a comrade on the battlefield but that are now incorrectly
attributed to some element of the current relationship.
Disinhibition resulting from drugs or alcohol strongly facilitates the
occurrence of such reliving experiences, which then may take the form of acting
out violent or sexual traumatic episodes.107
During states of massive autonomic arousal, memories are
laid down that powerfully influence later actions and interpretations of
events. Long-term activation of memory
tracts is observed in animals exposed to a highly stressful
stimulus.51,81 This pheromenon has been attributed to massive noradrenergic
activity at the time of
the stress.129 In traumatized people, visual and motoric
reliving experiences, nightmares,
flashbacks, and re-enactments are generally preceded by
physiologic arousal.30 Activation of long-term augmented memory tracts may
explain why current stress is
experienced as a return of the trauma.
"RETURN OF THE REPRESSED" OCCURS IN SITUATIONS OF
THREAT
Under ordinary conditions, most previously traumatized
individuals can adjust psychologically and socially. Studies have shown this to
be true of victims of rape, 82 battered women, 63 and victims of child abuse.53
Nonhuman primates subjected
to extended periods of isolation may later become reasonably
well integrated socially. However, they do not respond to stress in the same
ways as their nontraumatized
peers. Studies in the Wisconsin primate laboratory have
shown that, even after an initial good social adjustment, heightened emotional
or physical arousal causes social
withdrawal or aggression.86 Even monkeys that recover in
other respects tend to respond inappropriately to sexual arousal and
misperceive social cues when threatened by a
dominant animal.4,95,101 Animals with a history of trauma
also have much more intense catecholamine responses to stress85 and a blunted
cortisol response.25
Stress causes a return to earlier behavior patterns
throughout the animal kingdom. In experiments in mice, Mitchell and
colleagues98, 99 found that arousal state
determines how an animal will react to stimuli. In a state
of low arousal, animals tend to be curious and seek novelty. During high
arousal, they are frightened, avoid
novelty, and perseverate in familiar behavior regardless of
the outcome. Under ordinary circumstances, an animal will choose the more
pleasant of two alternatives. When
hyper aroused, it will seek the familiar, regardless of the
intrinsic rewards.99 Thus shocked animals returned to the box in which they
were originally shocked,
in preference to less familiar locations not associated with
punishment. Punished animals actually increased their exposure to shock as the
trials continued.98 Mitchell
concluded that this perseveration is no associative, that
is, if uncoupled from the usual rewards systems, animals seek optimal levels of
arousal,10,122 and this mediates
patterns of alternation and perseveration. Because novel
stimuli cause arousal, an animal in a state of high arousal will avoid even
mildly novel stimuli even if it would
reduce exposure to pain.
"THE COSTS OF PLEASURE AND THE BENEFITS OF PAIN'
Solomon127 proposes
an "opponent process theory of acquired motivation" to explain
addictive behavior that originates in frightening or painful events. He points
out that frequent exposure to stimuli, pleasant or unpleasant, may lead to
habituation; the resulting withdrawal or abstinence state can take on a
powerful life of its own and may become an effective source of motivation. In
drug addiction, for example, the motivation changes from getting high
(pleasure) to controlling a highly aversive withdrawal state. In contrast with
drug taking, which initially is pleasant, many initially aversive stimuli, such
as sauna bathing, marathon running, and parachute jumping, may also be
eventually perceived as highly rewarding by people who have
repeatedly exposed themselves to these frightening or painful situations.
Parachute jumpers, sauna bathers, and marathon runners all feel exhilaration
and a sense of well being from the initially aversive activities. These new
sources of pleasure become independent of the fear that was b necessary to
produce them in the first place. Solomon concludes that certain behaviors can
become highly pleasurable: "…if they are derived from aversive
processes they can provide a relatively enduring source of
positive hedonic tone following the removal of the aversive reenforcer. Fear
thus has its positive conquences."127
Solomon and colleagues have applied these observations to
imprinting and social attachment. Their research showed that young animals
responded with increasing distress to repeated separations.66 Habituation did
not occur, and attachment in fact increased, provided that the imprinting
object was presented at fairly regular intervals. Starr130 demonstrated that
there is critical decay duration, the time that it takes for
the withdrawal response to the original stimulus to wear
off. If the reinforcing stimulus of the imprinting or attachment object is
presented at intervals greater than
the critical decay duration, increased attachment does not
occur. However, animals earlier exposed to repeated separations are more
vulnerable to increased distress upon
later separations: "repeated exposures to the
imprinting object took less time and fewer exposures than did the original
exposures." The strength of the imprinting eventually decays by disuse,
but some residues of past experiences remain and facilitate the reactivation of
the temporarily dormant system. Readdiction to nicotine and
opiates occurs much faster than the initial addiction. If
Starr is correct, similar processes account for social attachment to aversive
objects and thus "the law of social
attachment may be identical to the law of drug
addiction."130
Solomon and coworkers established experimentally that animal
and people become habituated to the original stimulus, whether it is morphine,
parachute jumping or
marathon running, but the withdrawal syndromes that follow a
large number of arousing events retain their integrity over time, and recur
when the original stimuli are reintroduced.127 Thus, the positive reenforcer
loses some of its power, but the negative
reinforcer gains power and lasts longer: parachute jumpers
continued to feel exhilarated after jumping, even when they feel less year
beforehand. Solomon hypothesized that
endorphins are secreted in response to certain environmental
stresses and play a role in the opponent process. We have recently found
evidence that supports this view.
ADDICTION TO TRAUMA
Some traumatized people remain preoccupied with the trauma
at the expense of other life experiences137, 141 and continue to re-create it
in some form for themselves or for
others. War veterans may enlist as mercenaries,128 victims
of incest may become prostitutes,47,120,125 and victims of childhood physical
abuse seemingly provoke subsequent abuse in foster families53 or become
self-mutilators143a Still others identify
with the aggressor and do to others what was done to
them.21,39 Clinically, these people
are observed to have a vague sense of apprehension,
emptiness, boredom, and anxiety when not involved in activities reminiscent of
the trauma. There is no evidence to support Freud's idea that repetition
eventually leads to mastery and resolution. In fact, reliving the trauma
repeatedly in psychotherapy may serve to re-enforce the preoccupation and
fixation. Many observers of traumatic bonding have speculated that victims
become addicted to their victimizers. Erschak33 asks why the batterer does not
stop when injury and pain are apparent and why does the victim not leave? He
answers, "they are addicted to each other and to abuse. The system, the
interaction, the relation takes hold; the individuals are
as powerless as junkies."
ENDOGENOUS OPIATES AND ATTACHMENT
Thus Starr, 130 Solomon, 127 Erschak and others may be right
in postulating that people can become physiologically addicted to each other.
There is now considerable evidence that human attachment is, in part, mediated
by the endogenous opiate system. Research in
non-human primates shows that social attachment is related
to the development of core neurobiologic functions in the primate brain. Early
disruption of the attachment bond
causes long-lasting psychobiologic changes that not only
reduce the capacity to cope with subsequent social disruption but also disturb
parenting processes and create similar vulnerability into the next generation.
In recent years knowledge about the brain circuits involved in the maintenance
of afflictive behavior are precisely those most richly endowed with opioid
receptors.83 Behavioral studies show that the endogenous opioid system plays an
important role in the maintenance of social attachment. According to
Panksepp and colleagues, the separation response in rats can
be inhibited with doses of neuroactive agents to have yielded reliable
behavioral effects. Minute injections of
morphine abolish both the separation cry in rate infants and
the maternal response to it.100,103-105 Morphine-treated mothers (1 mg per kg)
disregard male intruders, often
attempting no defense of their offspring at all. One mother
permitted a male intruder to eat her pups.
Blocking of opioid receptors with naloxone causes increased
huddling in nonhuman primates, where as activation of brain opioid systems can
decrease gregariousness.34,104 Lack of care giving during the first few weeks
of life decreases the number of opioid receptors in the cingulate gyrus in
mice.13 Panksepp and colleagues have shown that the loss of social support
decreases brain opioid activity and produces withdrawal symptoms; emotive
circuits mediating loneliness-panic states are apparently activated or
disinhibited. Re-establishment of social contact may, among
other neural changes, activate endogenous opioid systems, alleviating
separation distress and strengthening social bonds.103 If brain opioid activity
fulfills social needs, opioid blockade might be expected to influence such
other forms of gratification as sex. Indeed, opioid systems interact with the
brain systems that regulate sex-steroid secretion, 56 and naloxone facilitates
sexual behavior in some mammals.49, 96
High levels of stress, 3 including social stress, 97 also
activate opioid systems. Animals exposed to inescapable shock develop
stress-induced analgesia (SIA) when
re-exposed to stress shortly afterward. This analgesic
response is mediated by endogenous opioid and is readily reversible by the
opioid receptor blocker naloxone.79 In humans elevations of enkephalins and
plasma beta endorphins have been reported following a large variety of
stressors.26, 28,73 In testing the generalizability of the phenomenon of SIA to
people, we found that seven of eight Vietnam veterans with
PTSD showed a 30 percent reduction in perception of pain
when viewing a movie depicting combat in Vietnam. This analgesia can be
reversed with naloxone.107, 143b
This amount of analgesia produced by watching 15 minutes of
a combat movie was equivalent to that which follows the injection of 8 mg. of
morphine. We concluded that
Beecher9 was right when, after observing that wounded
soldiers require less morphine, he speculated, "strong emotions can block
pain" because of the release of endogenous
opioid. Our experiments show that even in people traumatized
as adults, re-exposure to situations reminiscent of the trauma evokes as
endogenous opioid response analogous to that of animals exposed to mild shock
subsequent to inescapable shock. Thus, re-exposure to stress may have the same
effect as the temporary application of exogenous opioids, providing a similar
relief from anxiety.50
Field113 has suggested that normal play and exploratory
activity in infants are dependent on the presence of a familiar attachment
figure that modulates physiologic arousal by providing a balance between
soothing and stimulation. She, Reite, 115,116 and others has shown that in the
absence of the mother, infant experiences by psychological disorganizing
extremes of under- and over arousal. This soothing and arousal may be mediated
by alternate stimulation of different neurotransmitter systems, in which the
endogenous opioid system is likely to play a role, especially in subjective
experience of safety and soothing. Endogenous opioids decrease central
noradrenergic activity, 6 and their activation may thus inhibit hyper arousal.
Childhood abuse and neglect may cause
a long-term vulnerability to be hyper aroused, expressed on
a social level as decreased ability to modulate strong affect states. "On
a continuum from low to high physiologic
arousal there is an optimal level for every organism. The shape
of an individual's optimal stimulation curve may depend on the level of
stimulation received during early
experience."37 As a result, people who were neglected
or abused as children may require much higher external stimulation of the
endogenous opioid system for soothing than those whose endogenous opioids can
be more easily activated by conditioned responses based on good early care
giving experiences. These victimized people neutralize their hyper arousal by a
variety of addictive behaviors including compulsive re-exposure to situations
reminiscent of the trauma.
CHILDHOOD TRAUMA, ENDOGENOUS OPIOIDS, AND SELF-HARM
If recent animal research is any guide, people, particularly
children, who have been exposed to severe, prolonged environmental stress will
experience extraordinary
increases in both catecholamine and endogenous opioid
responses to subsequent stress. The endogenous opioid response may produce both
dependence and withdrawal phenomena resembling those of exogenous opioids. This
could explain, in part, why childhood trauma is associated with subsequent
self-destructive behavior. Depending on which stimuli have come to condition an
opioid response, self-destructive behavior may include chronic involvement with
abusive partners, sexual masochism, self-starvation,
and violence against self or others. In a recent study, we
found that patients' reports of early childhood physical and sexual abuse were
highly correlated with self-mutilation and self-starvation in adulthood.143a
This controlled study supports numerous other clinical reports about the
relationship between childhood abuse and self-destructive behavior.52, 106,118
In these people, self-mutilation is a common response to abandonment; it is
accompanied by both analgesia and an altered state of consciousness, and it
provides relief and return to normality. The pain, cutting, and burning are
apparent attempts at "repairing the cohesiveness of the self in the face
of overwhelming anxiety."35 This pattern is reminiscent of spouse abuse
described by Walker: 145 "tension gradually builds, an explosive battering
(self-mutilating) incident occurs, and a 'calm, loving respite' follows."
Bach-y-Rita7 studied men who were in prison because they
habitually took out their frustrations on others violently. He found that they
started to self-mutilate in prison when no external object of violence was
available. Thus acts of violence that the perpetrator
regards as horrible may, in fact, produce somatic calm.
The evidence for involvement of the endogenous opioid system
in self-mutilation is fairly good. A recent study found increased levels of
metenkephalins in habitual
self-mutilators during the active stage of self-harm, but
not 3 months later.27 Opioid receptor blockade has been found to decrease
self-mutilation.60,117 The specific biologic factors that account for the
relief felt by these traumatized people who habitually harm themselves or
others are still unknown.
TREATMENT IMPLICATIONS
Compulsive repetition of the trauma usually is an
unconscious process that, although it may provide a temporary sense of mastery
or even pleasure, ultimately perpetuates chronic feelings of helplessness and a
subjective sense of being bad and out of control. Gaining control over one's
current life, rather than repeating trauma in action, mood, or somatic states,
is the goal of treatment.
Although verbalizing the contextual elements of the trauma
is the essence of treatment of acute post-traumatic stress, the essential
elements of chronic post-traumatic reactions generally are retrieved with
difficulty and often cannot be dealt with until reasonable control over current
behavior can assure the safety of both the patient and those in the patient's
immediate surroundings. Failure to approach trauma-related material very gradually
leads to intensification of the affects and physiologic states related to the
trauma, leading to increased repetitive phenomena. It is important to keep in
mind that the only reason to uncover the trauma is to gain conscious control
over the unbidden re-experience or re-enactments. Prior to unearthing the
traumatic roots of current behavior, people need to gain reasonable control
over the longstanding secondary defenses that were originally elaborated to
defend against being overwhelmed by traumatic material such as alcohol and drug
abuse and violence against self or others. The trauma can only be worked
through after a secure bond is established with another person. The presence of
an attachment figure provides people with the security necessary to explore
their life experiences and to interrupt the inner or social isolation that
keeps people stuck in repetitive patterns. Both the etiology and the cure of
trauma-related psychological disturbance depend fundamentally on security of
interpersonal attachments.
Once the traumatic experiences have been located in time and
place, a person can start making distinctions between current life stresses and
past trauma and decrease the
impact of the trauma on present experience.137
Self-help organizations for people with addictions or with
backgrounds that include childhood traumas or parental addictions have
elaborated a model of treatment that
appears to address many of the core issues of repetitive
traumatization. These groups provide people with both human attachments and a
meaningful cognitive frame for dealing with the sense of helplessness that is
central to these problems. They focus on the development of
"serenity," which can be understood both as a state of automatic
stability and of being at peace with one's surroundings.
These groups teach that the way to gain this serenity is by learning to trust,
by surrendering, and by making contact
and developing interpersonal commitments. They provide a
support network that attempts to avoid the barriers that people create to
bolster their individual differences, and
they thus endeavor to circumvent the shame of being helpless
and vulnerable that perpetuates social isolation. Shame and social isolation
are thought to promote
regression to earlier states of anxious attachment and to
addictive involvements. In these circles it is said that: "No pain is so
devastating as the pain a person refuses to
face and no suffering is so lasting as suffering left
unacknowledged."23 There is emphasis on living in the here and now, generally
with the acknowledgement
that in contrast to victimized children, adults can learn to
protect themselves and make a conscious choice about not engaging in
relationships or behaviors that are known to be
harmful. The underlying assumption is that conclusions drawn
from a child's perspective retain their power into adulthood until verbalized
and examined. In a group
context, victims can learn that as children they were not
responsible for the chaos, violence and despair surrounding them, but that as
adults there are choices and
Consequences.23, 137
These groups also teach that in order to avoid repetition,
one has to give up the behavior, drug, or person involved in the addiction.
Acknowledging the addictive quality of the involvement is known as overcoming
denial. Avoiding acknowledging the feelings promotes acting out. Traumatized
people need to understand that
acknowledging feelings related to the trauma does not bring
back the trauma itself, and its accompanying violence and helplessness. There
must be emphasis on finding replacement activities and experiences that are
more rewarding, successful and powerful in the immediate present. These may
include being of help to victims of similar traumas as one's own.
Psychotropic medicines may be of help to decrease autonomic
hype arousal and decrease all or none responses. Lithium, beta-blockers, and
serotonin reuptake blockers such as
flouxetine, may be particularly helpful. By decreasing hyper
arousal, one decreases the likelihood that current stress will be experienced
as a recurrence of past trauma.
This facilitates finding solutions appropriate to the
current stress rather than the past.139 The use of medications that affect the
opioid system should be regarded as experimental and at this time needs to be
avoided except in life-threatening cases.
In our last study on patients with borderline personality
disorder Judith Herman and I (unpublished data, 1988) asked our self-mutilating
subjects what had helped them most in
Overcoming the impact of their childhood traumas, including
their self-mutilation. All subjects attributed their improvement to having
found a safe therapeutic relationship
In which they had been able to explore the realities of
their childhood experiences and their reactions to them. All subjects reported
that they had been able to markedly decrease a variety of repetitive behaviors,
including habitual self-harm, after they had established a relationship in
which they felt safe to acknowledge the realities of both their past and their
current lives.
SUMMARY
Trauma can be repeated on behavioral, emotional,
physiologic, and neuroendocrinologic levels. Repetition on these different
levels causes a large variety of individual
and social suffering. Anger directed against the self or
others is always a central problem in the lives of people who have been
violated and this is itself a repetitive re-enactment of real events from the
past.
People need a "safe base" for normal social and
biologic development. Traumatization occurs when both internal and external
resources are inadequate to cope with external
threat. Uncontrolable disruptions or distortions of
attachment bonds precede the development of post-traumatic stress syndromes.
People seek increased attachment in the
face of danger. Adults, as well as children, may develop
strong emotional ties with people when intermittently harass, beat, and,
threaten them. The persistence of these
attachment bonds leads to confusion of pain and love.
Assaults lead to hyper arousal states for which the memory can be
state-dependent or dissociated, and this memory only
returns fully during renewed terror. This interferes with
good judgment about these relationships and allows longing for attachment to
overcome realistic fears.
All primates subjected to early abuse and deprivation is
vulnerable to engage in violent relationships with peers as adults. Males tend
to be hyperagressive, and females fail
to protect themselves and their offspring against danger.
Chronic physiologic hyper arousal persists, particularly to stimuli reminiscent
of the trauma. Later stresses tend to be experienced as somatic states, rather
than as specific events that require specific means of coping. Thus victims of
trauma may respond to contemporary stimuli as a return of the trauma, without
conscious awareness that past injury
rather than current stress is the basis of their physiologic
emergency responses. Hyper arousal interferes with the ability to make rational
assessments and prevents
resolution and integration of the trauma. Disturbances in
the catecholamine, serotonin, and endogenous opioid systems have been
implicated in this persistenence of
all-or-nothing responses.
People who have been exposed to highly stressful stimuli
develop long-term potentiation of memory tracts that are reactivated at times
of subsequent arousal. This activation
explains how current stress is experienced as a return of
the trauma; it causes a return to earlier behavior patterns. Ordinarily, people
will choose the most pleasant
of two alternatives. High arousal causes people to engage in
familiar behavior, regardless of the rewards. As novel stimuli are anxiety
provoking, under stress, previously
traumatized people tend return to familiar patterns, even if
they cause pain.
The "opponent process theory of acquired
motivation" explains how fear may become a pleasurable sensation and that
"the laws of social attachment may be identical to those of drug
addiction." Victims can become addicted to their victimizers; social
contact may activate endogenous opioid systems, alleviating separation distress
and strengthening
social bonds. High levels of social stress activate opioid
systems as well. Vietnam veterans with PTSD show opioid-mediated reduction in
pain perception after re-exposure to a traumatic stimulus. Thus re-exposure to
stress can have the same effect as taking exogenous opioids, providing a
similar relief from stress.
Childhood abuse and neglect enhance long-term hyperarousal
and decreased modulation of strong affect states. Abused children may require
much higher external stimulation to
affect the endogenous opioid system for soothing than when
the biologic concomitants of comfort are easily activated by conditioned
responses based on good early care giving
experiences. Victimized people may neutralize their
hyperarousal by a variety of addictive behaviors, including compulsive
re-exposure to victimization of self and others.
Gaining control over one's current life, rather than
repeating trauma in action, mood, or somatic states, is the goal of treatment.
The only reason to uncover traumatic material is to gain conscious control over
unbidden re-experiences or re-enactments. The presence of strong attachments
provides people with the security necessary to explore their life experiences
and to interrupt the inner or social isolation that keeps them stuck in
repetitive patterns. In contrast with victimized children, adults can learn to
protect themselves and make conscious choices about not engaging in
relationships or behaviors that are harmful.
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