Is Trauma The Driver?

Yesterday’s speaker at Grand Rounds very much sees mental health interventions through the focus of trauma. Which is fine in its own way. Trauma isn’t good for you and more is worse. We have neglected to ask about possible traumatic experiences which might be important in treating mental health clients. Neglected to do it perfectly, that is. It has been on my hospital’s protocol for all patients for thirty years.

The primary focus was that more symptoms are caused by childhood experiences than we realise, and sometimes they are not verbalized, but encoded in behavior. Well and good, very old-school psychology in some ways, actually. It’s just not the whole picture.

I raised my hand at one point to express the opinion that genetic influences weren’t being referenced, and everything was being put into the trauma basket. I was going to throw in pre-natal as well, but decided it was best to keep it simple. She agreed to some general statement about different temperaments and vulnerabilities, then went straight to epigenetics. She admitted she didn’t understand it that well, gave a passable definition of it, didn’t otherwise answer my objection, and moved on. There was a time when I would have pushed the issue. I was tempted to bring it up again fifteen minutes later when the question of genetics was even more obvious. But I didn’t.

I was interested in her reference to the Kaiser Permanante Adverse Childhood Experiences study. I had heard of it and meant to look it up but never had. The idea is that specific childhood traumas can lead to bad health outcomes for adults, which they as insurers would certainly be interested in. They have data on over 100,000 people who responded to the brief (60+ questions) questionnaire at this point. Big numbers are usually better. Good stuff, as far as it goes. Trauma isn’t good for you, as I said. It makes intuitive sense that bad things in childhood could lead to bad health outcomes as an adult. One newer bit is that if you lived in poverty as a child you were more likely to have a diet dominated by inexpensive starches – potatoes, rice, bread – and thus more likely to be obese as an adult.*Obesity is a health problem.  So poverty can be seen as an indirect cause.

Note that even though the right-hand arrow says conception, that area is gray and fuzzy, and it's not really part of the questionnaire.

There’s just this problem that when you pick up the story of a person’s life at birth, you haven’t actually begun at the beginning.  There are those nine months in utero – that should be a deeper level on the pyramid, a foundation on which the other things are built.  And there is the genetic union at conception, which is itself the product of years of influence, centuries and more.  That is an even deeper foundation of the pyramid. It is invisible not only in the infographic, but in the data.

Thus we know that whatever true things the Kaiser Permanente ACE study shows, we must apply some discount for the prenatal effects, and some discount for the genetic effects. And we have no idea how much – though I’ve been thinking icebergs rather than pyramids for my analogies lately.

The following is perhaps unnecessary, as we have discussed genetics confounding supposedly environmental studies before (and some of you know this better than I do). But two examples: You had a parent who was impulsive and pleasure-seeking.  If you looked at a hundred such parents, you would find a higher-than average number of smokers, of drinkers, of people who marry inappropriate others or cheat on their spouses, of folks who lose their tempers, lose their jobs, overeat, overspend, etc. Their children will thus experience more trauma.  More divorce, more poverty, more abandonment, more beatings.  This is just an average, of course.  Many of those parents may have had strong compensating or coping strategies.  They may have joined a religious group that provided rigor and structure. They may have chosen a profession which allows them to indulge this safely.  They may have slowly learned disciplining strategies because they loved a sport, or ballet, or the military, or being first in their class. Yet the average for the children of that group is going to be more traumatic. The ACE study will pick up all those traumas and explain your adult health risks in those terms.

But you also have half you genetic material from that person, and it may not be his/her impulsivity that drives your behavior, but your own.  Furthermore, who mates with these impulsive, risky people?  You got the other half of your genetic material from them. The parents' temperaments may be controlling or they may be irrelevant.  The Kaiser Permanente study won't tell us.

Similarly, you may be making very bad safety and sexual choices now, and you may attribute that to being sexually assaulted as a child.  There may be something to that. But if your abuser was a blood relative some of your behavior may be hard-wired. Sometimes the sexual predators have long since moved on or gone to jail before they even got to you.  And if not a blood relative, then did the blood relative choose to put you in their company?  Stepparents are much more likely to be abusers, but who invited them over the thresshold?  I don't mean to be accusing of innocent people here.  Some predators are so well disguised that decent people wouldn't pick up on the signals. Some predators only reveal under the influence of alcohol or drugs, not present in the courtship. I'm not trying to kick any of you, here.  My mother married a predator, and I'm not seeing how she would have seen that coming.

My point isn't to deny that trauma is bad, but to highlight that earlier factors, prenatal and genetic, are increasingly shown to be huge.

*In comparing Charles Murray’s Belmont and Fishtown there is reference to the rich eating differently than the poor, and valuing thinness and reserved eating more. It could be a signifier of upper-middle-class or above upbringing when you look at it that way. Fat people are more likely to have grown up poor, and thus not be “quite our kind.” (There are poor cultures that are lower starch users, certainly. I am being very general.)  And of course, there may be some inherited tendency toward obesity as well. We just can’t tell what’s what at present. And some of us, such as trauma-based intervention researchers, don’t seem very curious about knowing the full answer.