Clients frequently ask me if their mental and emotional struggles are a result of their genes or their environment. My answer is always the same - "yes". Of course, my simplistic response refers to the interaction between genes and environment that characterizes nearly all mental health conditions, but it clearly belies the centuries of debate on this fundamental and contentious topic. In recent decades, the Cartesian dualism that has traditionally dominated the nature-nurture debate has given way to scientific theories that describe complex, bi-directional relations between genes and environment. These theories of human development have also furthered our understanding of "neural plasticity" the exciting notion that our brains are more malleable and open to change than we once thought.
First, a brief historical regression may be helpful. In the early part of the twentieth century, psychoanalysis was the dominant perspective in psychology and its guardians were particularly keen on environmental influences. In fact, parents of the baby-boomer generation were likely told that schizophrenia was entirely caused by cold, unresponsive mothering (i.e., so-called "schizophrenigenic mothers"). Behaviorism, which rose to prominence in the early-to-middle part of the century, saw human development as a process of learning based on stimulus-response interactions between an organism and its environment. By the nineteen-sixties, the "cognitive-revolution", with its emphasis on internal mental states and the promise of neuroscience advances, largely eclipsed these theories, but still had relatively little to say about the role of genetics.
In the second half of the twentieth century, geneticists began conducting large twin and adoption studies and found that a number of psychiatric conditions showed evidence of genetic heritability. For example, studies showed that schizophrenia occurs in 1% of the general population, but this increases to 6% if a parent is affected and 48% if an identical twin is affected. Findings such as these clearly showed that genetics play a role in many forms of mental illness. However, by the end of the twentieth century, the pendulum had swung too far in the direction of genetic influence, with some researchers claiming that single genes could be wholly responsible for complex phenomena like depression, violence and even suicide (e.g., one research group claimed to have found "the suicide gene").
At the turn of the twenty-first century, genetic theories relying on simple one-to-one relations between a single gene and a psychiatric condition were supplanted by "diathesis-stress" models, which posited that genetic diatheses or "vulnerabilities" could interact with environmental stressors to produce deleterious outcomes. The most prominent study of this genre was published by Caspi et al. in 2002 and showed that the relation between childhood maltreatment and later-occurring antisocial behavior was much stronger for individuals who had the less efficient form of the MAOA gene (a gene that improves the function of nerve transmission in the brain). In other words, genetics alone didn't predict poor outcomes; it was the combination of a genetic predisposition and the stress of childhood maltreatment that led to an increase in antisocial behavior.
Although this particular gene-environment interaction has been replicated a number of times, some researchers have questioned whether the diathesis-stress model tells the whole story. In the last decade, researchers began noticing that when individuals with a genetic "vulnerability" experienced lower levels of environmental stress, they often fared better than those with individuals with the "favorable" form of the gene. For example, in the graph from the Caspi (2002) study (see above), under conditions of no childhood maltreatment, individuals with the "inefficient" form of the gene (red line) actually had lower levels of antisocial behavior than individuals with the "efficient" form of the gene (blue line). In the Caspi study, this difference wasn't statistically significant, but it raised questions about whether it could be a significant finding if studies were designed to see the phenomenon more clearly.
Jay Belsky, a professor of mine at the University of California at Davis, was one of the first to propose that particular genes (like MAOA) may confer risk or benefit, depending on the environment. Instead of thinking of certain genes as merely a liability, he argued that these genes might increase susceptibility to environmental conditions, "for better or for worse". Belsky and colleagues" theory of "Differential Susceptibility" is rooted in an evolutionary argument that, under circumstances where the future is uncertain, it makes sense to have some offspring that are less sensitive, and other offspring that are more sensitive, to environmental conditions. Like a well-diversified financial portfolio with some money in conservative, robust holdings and some money in high-risk stocks that can respond dramatically to market swings (too close to home for some of us), differential susceptibility posits that some people have a more "fixed" genetic makeup that is less vulnerable to environmental conditions, while others have a more plastic or malleable genetic makeup that is more susceptible to the environment, whether it be positive or negative.
Of course, this theory comes with the exciting possibility that reducing environmental stress (e.g., child maltreatment and relational trauma) may be particularly meaningful for individuals with genetic susceptibilities. In a study published in 2008, Bakermans-Kranenburg and her colleagues tested this hypothesis by investigating 157 families with toddlers who showed elevated levels of externalizing problems (e.g., hyperactivity, oppositional behavior, aggression, etc.) They found that their Positive Parenting and Sensitive Discipline intervention program was most effective in reducing externalizing behaviors in those children who had a version of the dopamine gene (DRD4) that has been linked to externalizing behavior and attention-deficit hyperactivity disorder. That is, children who would have traditionally been thought of as carrying a dopamine-related genetic "vulnerability" were in fact most responsive to the positive environmental changes associated with the parenting intervention program.
The results of this study, and many others like it, suggest that improving environmental conditions during childhood can drastically enhance developmental outcomes, especially for those children who are genetically susceptible to environmental influences. However, these findings might also apply to adults - especially considering recent research showing that the brain remains plastic or malleable well into adulthood. For adults with adverse life experiences who are recovering from conditions like depression, addiction, and post-traumatic stress, the genetic susceptibilities that previously contributed to their sensitivity to adverse environmental conditions may also facilitate their responsiveness to the positive changes associated with recovery treatment. In other words, by improving environmental conditions, what was once considered a vulnerability may actually become the very means for plasticity and growth.
As the Serenity Prayer suggests, it takes courage to improve our environmental conditions and there is much of our day-to-day circumstances that remains beyond our control. However, even when we cannot change our external environment, we can always alter our perspective of it. Approaching ourselves, our fellow beings, and the world with a greater measure of acceptance and compassion can literally change the subjective experience of our environment, and in many cases it can also lead to objective changes in the environment. This shift in perspective is bound to feed back into the biology of our being, perhaps most noticeably for those individuals who at one time may have been considered genetically vulnerable, but who might actually be predisposed to resiliency, especially if the right environmental conditions are established.
How many significant figures of history actually suffered with PTSD? We may never know. The diagnosis, now part of our collective 21st century lexicon, did not exist before 1980. Many historians point to the Civil War with the description of Soldier's Heart as the earliest attempt to describe emotional consequences of war. Jonathan Shay wrote about warriors from Greece who incurred the invisible injuries we now diagnose as PTSD. The earliest medical descriptions of PTSD started in the 1830s during the early era of railroads. Numerous collisions and explosions resulted in a condition called "Railway Spine", something akin to mild traumatic brain injury at first, but later described as a psychiatric condition consistent with PTSD.
Did Clara Barton suffer with PTSD? On the basis of Melinda Henninberg's article, (http://www.washingtonpost.com/lifestyle/magazine/clara-bartons-enemy-depression/2012/04/04/gIQAdryXzS_story.html), I would say it was quite likely. More importantly, what can we learn from Clara Barton's rather extraordinary life? I think there are many lessons applicable to modern observers:
Does growing up in a dysfunctional family better prepare you to survive during war, chaos and/or insanity? There is no absolute answer to this question, but a dysfunctional family may actually help you endure the unmanageable. No exotic constructs needed here; if you grew up having to dissociate to survive, you may simply have "more practice"- the equivalent of early military training. Conversely, some individuals are less prepared for chaos if they grew up in a "crazy" family. A lot depends upon context, types of stressors, etc.
My personal observation is that a dysfunctional family background may make you stronger during a crisis, but in the long term it might make recovery, or at least a balanced recovery, much more difficult. Early studies conducted at the University of Minnesota described a population of "invulnerable children". These were kids who grew up with schizophrenic and alcoholic parents but did not have overt problems as adults. In fact, many were highly adaptive and showed no signs of outward difficulty. When this population was studied more closely, researchers learned that outward coping masked many harsh consequences. They later gave up their quest and decided "invulnerable" was a flawed concept. On the flip side, growing up in a safe and nurturing family is no guarantee you will not develop harsh symptoms. We need to consider multiple variables- including frequency of exposure to trauma, intensity of the trauma, duration of the trauma and age of exposure. Invulnerability is a seductive illusion, but even those who look intact may endure severe suffering.
Clara Barton, the founder of the Red Cross, and her struggle with the "black snakes" of depression, illustrates the complex consequences of exposure to and immersion in trauma. While she lacked comprehension to describe the extent of her suffering, her self-described "depression" was insufficient in capturing the multiple and complex symptoms of what we would now call PTSD and co-occurring disorders. Ironically, Clara Barton"s symptoms propelled her into an excessive, perhaps addictive attraction to violence and war, providing her partial relief and affording comfort and relief to millions as well.
Jerry Boriskin, Ph.D, a Senior Fellow at The Meadows, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness. For more information about Dr. Boriskin, please visit his website at http://www.jerryboriskin.com/.
For more about The Meadows'; innovative treatment program for PTSD and other disorders, see http://www.themeadows.com or call The Meadows at 800-244-4949.
The Meadows is pleased to announce a contract with TriWest Healthcare Alliance, a sub-contractor of TRICARE health program. Under this agreement, The Meadows has become an approved TriWest provider for behavioral health and substance abuse inpatient services to eligible beneficiaries.
The TriWest Healthcare Alliance is contracted with the Department of Defense to administer the TRICARE West Region program in the 21-state region. As an approved TriWest provider, The Meadows' inpatient substance abuse and psychiatric services are now available to nearly 2.9 million military members, retirees and their families. The convenient location of The Meadows, just 1.5 hours north of the Phoenix airport, offers easy accessibility to soldiers and their families. This could prove to be extremely beneficial to beneficiaries associated with the seven military bases located in the state of Arizona.
"We are confident that the impeccable reputation of The Meadows combined with our breathtaking campus and state-of-the-art treatment was a critical factor in choosing The Meadows as a network provider," stated Jim Dredge, CEO of The Meadows. "The Meadows has a commitment to servicing our heroes. We have enormous gratitude to those who protect and defend our freedom. It is a great honor to be a network provider for active duty, families and retired enrollees of the TriWest program."
According to Dr. Jerry Boriskin, a Senior Fellow at The Meadows and a consulting expert to the Veterans Administration, this contract is significant because there is a benefit to having as many options available in the various sectors due to the need for occasionally higher levels of care.
Dr. Boriskin, who has worked with the veteran population for 30 years, commented that "The core challenge is to get the veteran or the civilian, for that matter, to work on acceptance, forgiveness, and most importantly self-forgiveness because things were out of control and they were horrible."
Dr. Stephen Brockway, Chief of Psychiatry at The Meadows, explains that treatment for the veteran allows a move to take place from "It's me against the world" to "There are others like me" to "I'm part of the community again."
To learn more about The Meadows' work with trauma and addiction contact an intake coordinator at (866) 856-1279 or visit www.themeadows.com.
For over 35 years, The Meadows has been a leading trauma and addiction treatment center. In that time, they have helped more than 20,000 patients in one of their three inpatient centers or in national workshops. The Meadows world-class team of Senior Fellows, Psychiatrists, Therapists and Counselors treat the symptoms of addiction and the underlying issues that cause lifelong patterns of self-destructive behavior. The Meadows, with 24 hour nursing and on-site physicians and psychiatrists, is a Level 1 psychiatric hospital that is accredited by the Joint Commission.
The political and emotional complexities of PTSD (post-traumatic stress disorder) and TBI (traumatic brain injury) can lead to stigmatization and inaccurate attributions. It has long been assumed that soldiers, especially those who have served in combat, are at higher risk for violence. Following WW II several congressmen introduced proposals to send returning combat troops to islands for "retraining" before returning to civilian life. Following Vietnam we had Rambo movies and veterans "going postal". The facts are both simple and confusing: sudden outbursts of violence are rare and very hard to predict.
The article referenced above summarizes some of what is clear: PTSD and TBI can produce shifts in emotional management and changes in "executive brain function" resulting in possible impulsiveness. Complex phenomena like PTSD and TBI are difficult to study and data is scattered, sometimes inconsistent or contaminated by selective sampling or agency agendas. What is clear is that spectacular episodes of sudden violence are extremely rare, despite media attention. There are often multiple factors involved and these include co-occurring disorders, use of drugs or alcohol, lack of sleep, number of tours, severity of symptom or injury, just to name a few. We would love to have instruments that predict these rare outbursts, but they do not exist. We are reduced to the old maxim I learned decades ago: "the best predictor of future behavior is past behavior".
I do not wish to oversimplify; however, I want to reassure readers, especially military readers, that they are not likely to explode in some horrific headline-grabbing fashion. The title of the Washington Post article is generally accurate. Put aside the complexities of multiple tours, diminished capacity, head injury, partial recall, fugue episodes, sleep deprivation, isolation, and alcohol, and let's focus on the reassuring take-away message. There is no data supporting the worst fear carried by many. Most veterans are well trained, restrained, disciplined, highly ethical, and filled with a sense of justice, loyalty and honor. Most veterans I have treated live with the dread that they could lose control of their impulses and inadvertently hurt someone. Newspaper headlines about sudden violence and suicide add to their burden of fear. As a 66 year old combat Marine with severe health and mobility problems recently stated, "I am still afraid of what I could do to others.- That's why I need to stay away from others." The fear of losing control results in isolation, self-medication, avoidance, and a whole host of symptoms we see with PTSD.
I would argue that the most common symptom is not violence but extreme dedication to work or mission. I do not have the statistics, but from my years of experience I see pro-social zealousness- not antisocial outbursts- as the most common coping mechanism. Over dedication to work/mission becomes almost addictive. It is easy to get lost in working excessive hours, and it is rewarded by recognition and increased revenue. Channeling one's anger is difficult, but workaholism is an extreme response rewarded in our culture. However, family members can be angry and confused, and the internal burden remains hidden. Sleepless nights, avoidance, occasional road rage and other symptoms flourish, often visible only to a few. Spectacular outbursts are rare. PTSD tends to be a condition that most often fits the following: "Great souls suffer in silence." (Friedrich Schiller). The articulation of suffering is often the first step toward recovery.
Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness. For more information about Dr. Boriskin, please visit his website at www.jerryboriskin.com.
For more about The Meadows' innovative treatment program for PTSD and other disorders, see www.themeadows.com or call The Meadows at 800-244-4949.
Is it possible that trauma is good for you? Is there such a thing as Post-traumatic Growth? Are we supporting soldiers coming forth for assistance or are we engaging in denial when we strip away the "D" (disorder) from PTSD? As a clinician and advocate for those who develop PTSD and its more severe variant, Complex PTSD, I am tortured by the contradictions and questions.
Like many in my profession I have read the research and the controversy associated with resilience training. I am critical of many aspects of these endeavors; they promise more than is reasonable and have been implemented prior to empirical validation. Also, the assessments done during training have resulted in lawsuits due to soldiers objecting to being ordered for additional training on spiritual development (viewed as a resilience booster). Nonetheless, there is such a phenomenon as Post-traumatic Growth. I see it all the time, and in fact have been a strong advocate of this construct for decades. I have always encouraged clients with PTSD to "find meaning from the misery", something much easier said than done. It is no great surprise to observe that like heroes of mythology and bible, adversity is often the precursor of strength. Many soldiers and civilians suffering from PTSD go through a long "dark" period before finding hope, meaning and strength. Some never find the positives and withdraw from life or die from their condition(s). On the other hand, it is possible that some individuals skip the downside and move spontaneously toward "growth".
Whether this is common, rare, or the result of training or genetics is still not known.
The military does an outstanding job in training soldiers to survive in combat. However, is it possible to prevent PTSD? The armed forces would love to be able to select those who are most resilient and train them in all ways to become "immune" to trauma, perhaps even strengthened by trauma. I am reminded by the headline in a recent military newspaper: "Bullet-proof Your Brain". Perhaps this concept can be taken a bit too far. We are already struggling with questions about how many tours someone should have before they "break". I seriously doubt we will be able to precisely predict an individual's breaking point, find a medication that will prevent PTSD, or have cognitive techniques that permit individuals to tolerate the impossible. As cited in the article, "These programs were designed to make people happier and healthier," says George Bonanno, a professor at Columbia University who studies trauma and resilience. "That is not the same thing as inoculating people for serious urinate-in-your-clothing type stress - once-in-a-lifetime stress."
So, how do we make sense of the contradictions: is trauma neutral, negative or a positive? Can we expect resilience, growth or a lifetime of symptoms? Will a mistimed introduction of "the positive" possibility help or hurt someone with active PTSD? I am concerned that the expectation of "Growth" can add burden, perhaps shame to those who have PTSD or Complex PTSD. I recall a very powerful example. My client, a high school teacher who had severe PTSD, was being evaluated by a renowned psychiatrist as part of her lawsuit against the physician who misdiagnosed her near-fatal colon cancer. She lived in dread of a recurrence of her cancer; she had severe anxiety symptoms and was not adjusting well to her colostomy bag. The psychiatrist was representing the defense team and his objective was to gather information to deny the existence of her PTSD. She was expecting critical questions and did very well during the hour, no signs of anxiety or anger at his attempts to undermine the reality of her PTSD. At the very end of the interview the psychiatrist switched tone and tried to display empathy. He was an elderly man, partially blind, and said to her, "I had some health problems myself and medical errors were made. I decided that I had to put my memories and emotions in the attic of my brain and then I was over it. You need to do what I did." Ironically, he was trying to be kind but the result was powerful; my client burst into tears, felt invalidated and humiliated. It took us a full hour to help her recover from the trauma expert's mistimed attempt to validate and encourage. She felt shamed and criticized. In this case, a positive message delivered at the wrong time had unintended consequences.
So, while focusing on the positive results of surviving trauma is empowering, it can be invalidating as well. It is all a matter of context and timing.
Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness.