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ABSTRACT Throughout the history of mental health care field, trauma was
prescribed different and frequently opposing roles. In psychoanalysis, the attitude
toward trauma was ambiguous: it was considered a crucial factor, but at the same
time its role could happen to be minimized. In biological psychiatry, it is seen as a
dominant cause of some disorders and completely irrelevant for the others.
In this paper, two issues are discussed: frequency of traumatic events in general
population and among persons with mental disorders; and hypothesized intrapsychic
mechanisms that lead to detrimental consequences of trauma on mental health.
It is advocated that prevention of early, especially attachment, trauma should be
the focus of our work in dealing with mental disorders.
KEYWORDS: trauma, mental disorder, attachment, mentalization
SAETAK Tokom razvoja zatite mentalnog zdravlja, trauma je esto dobijala
razliite, pa ak i suprotstavljene uloge. U psihoanalizi je smatrana kljunim
faktorom nastanka mentalnih poremeaja, ali je u isto vreme mogla biti i
zanemarena, dok je u biolokoj psihijatriji prihvaena za glavni uzrok nekih
poremeaja ali i kao potpuno nevana za druge.
U ovom tekstu u diskutovati dva pitanja: uestalost traumatskih dogaaja u
optoj populaciji i meu osobama s mentalnim poremeajima, te pretpostavljene
intrapsihike mehanizme koji vode do nepoeljnih posledica traume po mentalno
zdravlje.
Na osnovu svih podataka moe se zakljuiti da bi prevencija ranih trauma, a
posebno trauma u odnosima vezanosti, trebalo da bude fokus u naem radu s
osobama koje pate od mentalnih poremeaja.
KLJUNE REI trauma, mentalni poremeaj, vezanost, mentalizacija
adimitri@f.bg.ac.rs, a.dimitrijevic@ipu-berlin.de
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Namely, since the third revision, published in 1980, the Diagnostic and
Statistical Manual does not include discussions about possible causes of mental
disorders and this principle is included even in the generic definition offered
at the Manuals beginning. Without going into details of the possible critique
of this, it should be emphasized that there is one clear exemption to this rule.
The same DSM-III included (in the new category Anxiety Disorders) PostTraumatic Stress Disorders (PTSD), explicitly defined by their cause, and that
cause was trauma. One can reason that behind this is the now omnipresent
biological model of mental disorders (in all cases but PTSD, the causes is in the
dis-balance of neurotransmitters), which suits the pharmacological industry, and
that the role of trauma, and thus of more psychological models, is limited to just
one disorder (Lewis, 2006).
The best, and possibly the only, way to tell who is right and who is wrong
would be to see what research tells us about the incidence of trauma in general
population and in samples of persons with mental disorders. Luckily, we have
more and more solid data about this.
Incidence of trauma
So, is trauma very rare, as we used to believe, or could it be that it is
everywhere around us? And: is it more frequent in the lives and growing up of
the persons with mental disorders?
We can decide on these issues now based on several large-scale
epidemiological studies, mostly done in the United States. In general, it seems
that high incidence of early individual trauma seems not to be disputed in
contemporary scientific literature. In contrast to the 1955 study quoted above,
for instance, more recent estimates claim that there are approximately one
million cases of child abuse and neglect substantiated in the US each year (US
Department of Health, 2005, www.acf.hhs.gov). And we have even more precise
data, showing the incidence of various types of trauma in percentage:
Table 1. Incidence of different types of trauma
in general population (adapted after: Putnam et al., 2015)
Sample size
Type of abuse
Physical abuse
Sexual abuse
Emotional abuse
Women
N=9367
Men
N=7970
Total
N=17337
27
24.7
13.1
29.9
16
7.6
28.3
20.7
10.6
The table shows that the incidence rate changes for different types of trauma,
but is constantly alarmingly high. This impressively large sample shows that in
some cases one quarter or even a third of the subjects were exposed to trauma,
with strong gender differences (e.g., there are more physically abused men, but
more sexually abused women). From this, we cannot make conclusions about
the difference between general and clinical populations, but we will return to
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that shortly. It seems, however, that we have learned that trauma occurs very
frequently in contemporary Western society.
How about cumulative trauma? Is it frequent that the same child gets
molested or exposed to witnessing trauma2 more than once? Here is data from
the same sample:
Table 2. Cumulative incidence of trauma
in general population (after: Putnam et al., 2015)
Sample size
0
1
2
3
4 or more
Women
N=9367
34.5
24.5
15.5
10.3
15.2
Men
N=7970
38
27.9
16.4
8.6
9.2
Total
N=17337
36.1
26
15.9
9.5
12.5
We can be relieved about the almost two fifths of the population who have
grown up without serious trauma. The problem may be, however, important for
the majority, at 63.9%, have been traumatized. Worse still, among them as many
as 37.9% were traumatized more than once, and every eighth subject had adverse
experiences repeatedly (four or more times). This study would, thus, suggest that
there are almost twice more traumatized than non-traumatized individuals and
that almost two fifths of the general population (or, in real numbers, millions
and millions of adults) suffered repeatedly.
To make the matters more worrisome, empirical evidence shows that most
maltreatment happens in the earliest childhood, when it has greater negative
effects on developing mind and brain. The troubling 5.7% children of ages 03
experience trauma or neglect, which is, happily, followed by a steady decline, to
reach 1.9% at the age 1617 (US Department of Health and Human Services,
2014).
Another important question may well be where all this takes place. How
frequent is family trauma?
Table 3. Incidence of family dysfunctions
in general population (after: Putnam et al., 2015)
Sample size
Type of household dysfunction
Substance abuse
Parental separation or divorce
Mental illness
Mother treated violently
Incarcerated member
Women
N=9367
Men
N=7970
Total
N=17337
29.5
24.5
23.3
13.7
5.2
23.8
21.8
14.8
11.5
4.7
26.9
23.3
19.4
12.7
5.1
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We see, again, that the incidence is disturbingly high, and especially for
women. Every fifth subject has experienced at least one type of household
dysfunction, sometimes the rate is higher, and for some it must have been more
than one. It is also significant that four out of five types of the listed family
disfunctions actually make parents emotionally unavailable: substance abuse,
divorce, mental illness and incarceration (this one does not have to involve the
parent, though).3
Based on all this evidence, which comes from recent studies on large samples,
we can conclude that trauma is a widespread phenomenon and that it frequently
happens to infants and preschool children, inside their homes. But, what are the
consequences of trauma? Does this evidence bear clinical importance?
If we consider tables 1&3 together, we may come to the conclusion that many adults report
being traumatized as well as many report coming from dysfunctional families. We do not
know whether these are the same individuals, but it is quite probable that they are. In case
this really is true, it would mean that children cannot get support from their parents when
they need it most.
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General population
3% of men
5% of women
Psychiatry patients
30% of men
3442% of women
3% of men
12% of women
7% of men
1317% of women
18% of men
51% of women
62% of men
62% of women
38% of patients with SCH
17% of patients with BAD
I believe that the table clearly illustrates that certain forms of early individual
trauma are 410 times more frequent among our patients than in general
populations (although values for the latter are much lower than in the studies
performed in the US). This is further underlined by comparison studies that
established differences between psychotic patients with the history of childhood
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trauma and those without it (Read et al., 2004, p. 223), which resulted in the
finding that the consequences of childhood trauma are associated with:
Attachment trauma
One type of trauma has in recent studies been emphasized as specially
important and that is attachment trauma.4 Consequences seem to be most
disturbing when trauma is inflicted in closest relationships, those from which
children expect safety and encouragement for exploration. Children exposed to
attachment trauma frequently develop the so-called disorganized attachment
pattern, characterized by complete lack of strategy in close relationships, freezing
out of movement and expression, and/or incomprehensible behavior. About 15%
of children in non-clinical samples are classified as disorganised (Van Ijzendoorn
& Bakermans-Kranenburg, 1997, p. 136), but this number raises to astonishing
82% of maltreated children (Lyons-Ruth & Jacobvitz, 1999, p. 526).
There is obvious connection between the disorganized attachment in
children and their parents mental health status. Most mothers suffering from
depression and schizophrenia, and about 80% of mothers with anxious disorders,
have insecurely attached children (Greenberg, 1999, p. 478). More than a half of
D-children have parents who had suffered significant loss(es) two years before
the childrens birth that are still unresolved (Lyons-Ruth & Jacobvitz, 1999, pp.
5289, 540; Van Ijzendoorn & Bakermans-Kranenburg, 1997, p. 136).
Disorganized attachment pattern at the age of 12 months, based very
frequently on attachment trauma, is predictive of the following set of variables
(based on Greenberg, 1999, p. 479; Solomon & George, 1999, p. 294):
Another form that is attracting more attention is social or genocidal trauma, but it cannot
be discussed properly here for the lack of space. For detailed review see Delic et al., 2014;
Hamburger, in press.
Recent empirical data about the relationship between attachment and cognition can be found
in Banjac et al., 2013; Dimitrijevic et al., 2013.
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mental health problems in about 80% of these adults, and especially dissociative
phenomena and disorders.
Attachment trauma can also interfere with ethical development and development of empathy.
For a detailed review see Milojevi & Dimitrijevi, 2012, and for empirical data see Milojevi
& Dimitrijevi, 2014.
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The always pragmatic Americans have counted that child abuse prevention programs return
$3, and Parent Child Interaction Therapy $3.64 to every $1 invested (Lieb et al., 2004).
On detrimental effects of parental emotional non-involvement see Fonagy & Bateman, 2008,
p, 145.
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This lead many authors to come up with a very specific etiological hypothesis.
It is now believed that the cause of many mental disorders is a combination of:
a) severe and/or repeated childhood trauma, and b) lack of a person who could
provide the intersubjective foundation for mentalizing. Trauma, thus, does not
have to lead to a mental disorder and will not do so in cases when there are
adults ready to face and recognize childs traumatic experience and offer help in
thinking about and overcoming it (Fonagy, 2000; Levine, 2014).
For many children, unfortunately, benevolent, emotionally available and
mentalizing adults are not present in their social world, and preventive programs
have not reached many others. It is highly likely, as we have seen above, that they
will develop one or several forms of somatic illnesses, deviant behaviors and/
or mental disorders. And it is for them that we need to come up with treatment
procedures. While noumerous psychotherapy variations are considered applicable
for work with victims of trauma, at least one is developed especially for them.
The so called Mentalization Based Treatment is being formulated over the last
decade or so, with all the above mentioned principles in mind (e.g., Bateman &
Fonagy, 2006; for a review see Dimitrijevi, 2011b). Initially aimed at persons
with Borderline Personality Disorder, it is a manualized, short-term treatment,
that should help clients acquire capacity and skill of mentalization. They are first
faced with many questions that should help them realize how much of the inner
and social world they are or have been taking for granted. Subsequently, they
should hopefully start understanding their own and other persons behaviors in
terms of intentional mental states. A randomized control trial has shown that
MBT is highly effective in the follow up after 42 months (Fonagy & Bateman,
2008): patients needed less medication and fewer and shorter hospitalizations,
referred less self-harming and suicidal behavior, and improved educationally and
professionally.
Conclusion
In the last half century, the biological model of mental disorders, and
especially the psychotic ones, has gained such prevalence that discussing anything
but genes, dopamine, and cerebral ventricles is considered obsolete and nonscientific. There were various forms of resistance to admitting the importance of
trauma, including tendency that the best-selling textbooks report about trauma
in a misconceived and one-sided way (Brand & McEwan, 2015). It was only in
recent times that enough evidence was gathered to make it even more obvious
that trauma plays an important role in both development and clinically relevant
conditions of a huge number of children and adults.
The most troubling aspect of this situation, however, is not denial of the
importance of trauma, but the ensuing impossibility for persons with mental
disorders to get what they need at the institutions that are meant to provide help.
Traumatized persons are more often hospitalized than non-traumatized persons
with mental disorders (Read et al., 2004), yet many of them get nothing but
disappointment and conviction that help cannot be found, looking for the fault
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Acknowledgements:
The preparation of this paper was supported by Ministry of Education and
Science of the Republic of Serbia, Grant No. 179018, and by Trauma, Trust, and
Memory Project funded by German Academic Exchange Service [DAAD],
Grant No. 57173352.
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