Friday, June 17, 2016

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.


james said...

Either way, it sounds like the bottom line is that usually the apple doesn't fall far from the tree.
And yet--as you point out, training and support in virtue can help a lot.

Earl Wajenberg said...

I am reminded about the attitudes held for millennia about class and bastardy. Why be nasty to someone whose mother gave birth to them out of wedlock? I think the assumption was they'd be like their mother, and the mother (and probably the father, too, though the double standard comes into play here) was very impulsive or immoral or inconsiderate of the feelings and standards of her family and community, and in short, not respectable. That is a bad reason for being nasty to someone, and sure to inhibit any efforts at improvement, but it probably had some evidence behind it.

Similarly, "aristocratic blood" might be something of a real thing, by either nature, nurture, or both. True, it might amount to nothing but low empathy, acquisitiveness, and a talent for bullying, but there you are.

Earl Wajenberg said...

I said "sure to inhibit any efforts at improvement." Okay, it might have scared some people straight. Fiction is full of "widows" who moved into a new neighborhood with a small child and carefully cultivated strict respectability. And there's always the value of the bad example - "Don't you go that way. Look what happens." But how often did it simply lead to sliding further down the ladder and staying there?

Laura said...

I think part of the resistance to that line of reasoning was because she was a woman, and so questions about how Mom's behavior at conception and gestation wrecked somebody's potential for a normal life forever are FAR more loaded emotionally for her than for you.

I don't think men (or even childless women) quite "get" how much pregnant women and mothers are patronized and shamelessly manipulated by people around them-- very definitely including medical staff. You're bullied about absolutely everything you do or don't do, always with the tag line that you'll forever ruin your baby's life. And I mean EVERYTHING: every mouthful of food, every sip of liquid, every minute at work, every hobby, every chemical in your environment, everything. Not just, don't take street drugs when pregnant; they hassle you about drinking a cup of coffee, eating one donut, taking cold medicine, owning a pet (any pet), driving a car, you name it.

They'll even blame you for following the advice you had then, but that has since been proven false. An example: my mother was told that you HAD to use formula and give solid food early (~3 mo's), because otherwise the baby wouldn't get the nutrients needed for brain development. But guess what? Those studies were financed by formula makers, and they had an agenda. I was told that, on the contrary, breast milk was the only responsible choice, and my kids would get brain damage (and asthma, and colic, and...) from formula, and nursing for 12 months AT LEAST was necessary. But guess what? Those studies were done by people with an agenda, too, just a different agenda.

So yeah, she's not going to want to listen to you on uterine environment; she's going to hear it as, "it's the womens' fault these people here are f***ed up" and she's sick of it. There have been enough notorious bad examples of that in psychology specifically (e.g. autism is caused by "refrigerator mothers" who don't interact successfully with their babies) that she's got plenty of reason to ignore it this time, too.

Can I whisper something? I'd bet that one of the big draws for "trauma caused it" as an explanation is that, 80-90% of the time, that trauma can be blamed directly on a man. For once, it's not the mother's fault. Except when you then try to turn the focus on why the mother chose to let the step-father across the threshhold (and again, it is the mother and the step-father, not father and step-mother, in 80-90% of the abuse cases).

Assistant Village Idiot said...

Laura, I think you are spot on about the pre-natal influence being off-limits for emotional reasons. I have read of studies suggesting that enormous stress during pregnancy (like being under rocket fire in Israel) showed increase in schizophrenia and male homosexuality. Note: I don't know if those studies were any good. I am putting it out as plausible possibilities. That would make mom not feel quite so vulnerable to blame. But other stresses? We could blithely trace it all back to mom's supposedly bad decisions, sure. My wife certainly got plenty of guilting and tut-tutting during her pregnancies and our boy's early childhoods. She was well-defended because she was a librarian, and had out-read nearly everyone she came in contact with.

The genetic portion may be resisted because it tends to make us feel helpless.

jaed said...

there may be some inherited tendency toward obesity

Between 0.7 and 0.8 of variance in weight, last time I checked a twin metastudy. (That's in the same neighborhood as the genetic determination of height.)

jaed said...

Why be nasty to someone whose mother gave birth to them out of wedlock?

Earl, while your idea seems plausible, I have a suspicion that it's also a no-place-in-society problem. If a society sets someone's status and station based on who their father is, a child with no father of record is a wild card. How you should interact with that child, what the child's appropriate station in life is... all that is mysterious if that child has no father and is growing up in a society where fatherhood is determinative, or even mostly determinative. It's a confusing situation, and it seems to me that confusion might result in a sort of outlaw status - there's no place in the social structure to put someone with no known father.

(Children born in recognized concubinage generally didn't have as high a status as children born in wedlock, but they weren't outcasts.)

Assistant Village Idiot said...

That's way higher than I expectd on obesity. I'll have to poke around at that.

Laura said...

AVI, unfortunately, you're wildly underestimating these peoples' abilities to blame the Mom for not doing the impossible. In the case of the women under rocket attacks in Israel, the "obvious" answer is that she shouldn't have been in such a dangerous place (going where instead?) or should have applied some basic vision-of-the-future and known not to get pregnant when a war was coming. Note that this is EXACTLY what the medical authorities are telling Central and South American women right now about Zika, with 100% seriousness. Over the last few weeks, we've seen Moms simply roasted in the press for failing to have the power to repel dangerous wild animals-- Zika mosquitoes, alligators, gorillas... (Did you notice the Dads were never mentioned in these stories?)

Continuing with my comments on my personal experience with breast feeding: I was actually told, to my face, by a nurse, during my baby's required checkup, that giving her formula was "almost" child abuse, and would likely give her asthma, ADD and probably make her obese too. Instead, I should "do what it takes" to breastfeed, spending 2 out of every 3 hours with the baby at the breast, until the baby and I both "figure it out". Now, breastfeeding for 16 hours a day, indefinitely, isn't realistic for anyone (sleep? hygiene? sanity?); but to make it worse, I was in the Army at the time-- in uniform as a major, in a military medical clinic overseas, after my third combat tour... and currently being treated for a breast infection. But no, the real problem was the baby and I were, literally, too dumb to eat, and wouldn't try harder. And this was just one of many, many, many examples I can give of this sort of thing. That sort of patronizing contempt is just the toxic background radiation that Moms have to deal with in this society. Everything gets read through that lens.

So, returning to your original post: no, women aren't going to hear talk about how the uterine environment can destroy a kid's future as simply an important scientific hypothesis. And the talk about genetic predisposition to bad outcomes will be heard as, "those women shouldn't breed", and maybe, "somebody should ensure they don't breed" or "we should punish them for breeding". This is, alas, not a hypothetical-- it's exactly the mental health and prison sectors who have done exactly this in the past. And not the distant past, either: California prisons got caught sterilizing women inmates "for their own good" as late as 2010.

jaed said...

way higher than I expectd

WRT obesity specifically, I think largely driven by genetic propensity for insulin resistance. It is harder to do generational studies on this directly, because until very recently, we didn't usually test for serum glucose unless you had diabetes symptoms other than weight gain. And of course the thresholds for diabetes used to be higher, so if we look at diagnosis of diabetes across generations we'll get a skewed picture, even leaving aside the people who are insulin resistant but it never gets bad enough to hit the diabetes threshold. I also think most of the population increase in obesity is explainable in terms of the effect of a generation of medical encouragement to 1) eat a diet high in carbohydrate and low in fat and 2) try to address the resulting weight gain with periods of calorie restriction, on a population a fair percentage of which is genetically prone to insulin resistance. "Oops."

(I don't want to interrupt Laura, who is posting some great stuff. I would like to add to it except she's already saying what I would say, only better.)

Earl Wajenberg said...

jaed: "'Why be nasty to someone whose mother gave birth to them out of wedlock?'
"Earl, while your idea seems plausible, I have a suspicion that it's also a no-place-in-society problem."

A good point I had not considered. I also suspect "place in society" and "expected inheritance of character" interact somewhere along the line, though I am not sure where and how.

Sam L. said...

Most every one I meet, I know not their "place in society. Without some clues, I'm willing to go with "they are likely OK".