terr childhood trauma

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Spec ia l A rtic le

10 Am J P sych ia try 1 48: 1 , January 1991

Ch ildhood T raum as: A n O u tlin e and O verv iew

L en ore C . T err , M .D .

Ch ildhood psych ic traum a appea rs to be a cru c ia l etio log ica l fac tor in th e d eve lopm en t o fa num ber o fserio u s d iso rders bo th in ch ild hood and in adu lth ood . L ik e ch ildhood rh eum aticf ever, psych ic traum a sets a num ber of d iffe ren t p rob lem s in to m o tion , an y o f w h ich m aylead to a d efin ab le m en ta l cond ition . T he au thor sugg ests fou r cha rac te ristic s re la ted toch ildhood traum a tha t ap pear to las t fo r lo ng period s o f life , n o m a tter w hat d iagno sis th epa tien t even tua lly rece ives. Th ese are visu a lized or o th erw ise rep ea ted ly perceived m em orie so f th e traum a tic even t, repe titive behav iors, traum a-spec ific fea rs, and changed a ttitu d esabou t p eo p le , l ife , and th e fu tu re . She d iv id es ch ildh ood traum a in to tw o ba sic typ es andde fin es th e fin d ing s th a t can be u sed to charac te rize ea ch o f th ese typ es. T ype I traum ain c lu des fu ll, d eta iled m em orie s, om en s, and m ispercep tion s. T ype II traum a in c lu desden ia l and num bing , se lf-h ypnosis and d isso cia tion , and rag e. C ro ssover cond ition s oftenoccu r a fte r sudden , sho ck ing d ea th s o r a cc id en ts tha t leave ch ild ren han d icapped . In th esein stan ces, cha rac te ristic s o f b o th typ e I and type II ch ildhood traum as ex ist s ide by sid e.T h ere m ay be con sid erab le sadn ess . E ach fin d ing o f ch ild hood traum a d iscussed by th eau tho r is il lu s tra ted w ith on e or tw o ca se ex am ples .

(Am J P sy ch ia try 1 991 ; 148 :1 0-20)

M en ta l cond it ion s b rough t on by ho rr ib le ex ter-n a l ev en ts in ch ildhood present a w id e range of

find in g s. I f o n e look s on ly a t th e c lin ica l m an ifes ta tion so f traum a in a g iv en day in th e life o f th e traum atizedch ild , on e cou ld d iagno se conduct d isord er , b o rd er lin ep ersona lity , m ajo r affect ive d isord er, a tten tio n d e fic ith yp erac tiv ity , phob ic d isord er, d issoc ia t ive d isord er,ob sessive -com pu lsive d iso rd er , pan ic d isorder , ad ju st-m en t d isord er, a nd ev en su ch cond it ion s, a s ye t uno f-ficia l in the n om en cla tu re , as p recu rsors of m ultip lep erson a lity or a cu te d issoc ia t ive d iso rd er , and not b ew rong . If on e p rojec ts th is m u lt ip lic ity o f techn ica lly

Presen ted as the S am uel G . H ibbs L ectu re a t th e 140th annualm eetin g of th e A m erican P sych ia tr ic A ssoc ia tion , C h icago , M ay9-1 4 , 1 987 , and a t the annua l m eeting o f th e A m erican P sychoso -m a tic So cie ty , S an F ran cisco , M arch 1989 . R ece iv ed Ju ly 15 , 19 86;rev ision s rece ived M ay 27 , 1987 , and M ay 4 , 1990; accep ted M ay31 , 1990 . From th e D epartm en t of P sych ia try , U n iv ers ity of C a ll-forn ia , S an F ran c isco . A dd ress rep r in t requ ests to D r . T err , 45 0Su tte r S t., S an Fran c isco , C A 94108 .

C opyr ight 1991 Am erican P sych ia tr ic A ssoc ia tion .

correct d iagnoses on to a traum atized ch ild s adult-h ood , on e find s even m ore d iagnostic leew ay .

W e m ust organ ize ou r th ink in g abou t ch ildhoodtraum a, how ever , or w e run th e r isk of n ever seein g th econdit ion a t a ll. L ik e th e young photographer in C or-t# {2 25 }za r s s ho rt st or y and An ton ion is f ilm , B low U p ,w e m ay en la rg e th e d ia gnos tic fin e po in ts o f traum ain to such p rom in en ce th at w e a lto gether lo se the cen -tra l p o in t-th at extern a l forces created the in terna lch anges in th e firs t p lace . W e m ust no t le t ourselvesforget ch ildhood traum a ju st becau se th e p rob lem is sovast .

S tud ies o f adu lts in m en ta l h osp ita ls (1 ) , adu lts su f-fer ing from m ultip le persona litie s (2 ), adu lts w ho areb ord erlin e (3 ), and adolescen ts w ho go on to com m itm urder (4 ) sh ow that th ese adu lts and adolescen ts v eryoften w ere abu sed or sho ck ed in th e ir ow n ch ildhood s.S tud ie s o f adu lt rap e v ic t im s d em on stra te th at th eyoften w ere rap ed o r in cestu ou sly abu sed as ch ild renand tha t th ey are qu ite p ron e to b e in g rap ed aga in -and aga in -in th eir adu lt live s (5 ) . Those w ho harmch ild ren have often b een harm ed them se lves as ch il-


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Am JP sych ia try 148:1 ,J anuary 1 991 11

d ren (6 ). A nd som e of th ose w ho indu lg e in self-m u ti-la t ion or who m ake rep eated su ic id e a ttem p ts g ivev iv id p ast h istor ies o f long -stand ing ch ild hood horrors(7 ) .

O ne cou ld say tha t ch ildhood traum a is so ub iqu i-tou s to th e p sych ia tr ic d isord ers o f ado le scen ce andadu lth ood tha t w e shou ld forge t it , th at it cance ls it se lfou t. W e know , how ev er , th at not every ch ild is d irec tlysho ck ed o r persona lly subjected to terror from th e ou t-s id e . M ost ch ild ren com e from rela tiv e ly k ind , n on -abu siv e fam ilie s . M o st y oungsters are nev er en ro lled ina p edoph ilic d a y-ca re cen ter or happen upon a satan iccu lt. T h e chan ces o f exp er ien cin g a fr igh ten in g flood ,hurr icane , o r ear thquake are not th at grea t . T h ech ances of w itn ess ing a m urder or of be in g k idnapp edare not ov erw helm ing ly h igh . N um bers o f ch ild renshould b e ab le to g et th rough th e ir ch ildhood s w ith ou tany d irect exp osu re to a traum atic even t o r ser ies o fterr ib le even ts. A nd th ey apparen tly do so (8 , 9 ).

E v en if w e w ere to b ro ad en th e d ia gnos is o f ch ild -h ood traum a, as I w ill p ropo se in th is p ap er, to a llowin any ch ild m en ta lly harm ed enough by a sin g le ex -terna l even t o r a long-stand ing ser ie s o f such even ts toqua lify fo r a traum a -re la ted d ia gnosis , w e cou ld notpossib ly cov er everyth in g that w e see in adu lts as aresu lt o f th ese ear ly traum as-th e bo rd er lin e p atien ts,th e patien ts w ith m u ltip le p ersona lity d isord er , a nd th ech ron ic v ic tim s or v ict im izers, fo r in stan ce. W e w ills till need ou r adu lt d ia gno stic sch em es and ou r adu lttrea tm en t p lan s. B u t p erhap s, if w e lo ok ed in a m oreorgan ized fash ion at ch ildhood p sy ch ic traum a and atwha t it d oes, w e w ould recogn ize it as th e im portante tio log ic d eterm inant th a t it ac tu a lly is . W e cou ld b e-g in to see how ch ildhood traum a w ork s. A nd w e cou ldstudy it b e tter.

L ik e ch ildhood rh eum atic fever , w h ich cau ses anum ber o f cond it ion s in adu lth ood rang in g from m i-tra l sten os is to subacu te b acter ia l endocard itis to m as-s iv e heart fa ilu re, ch ildhood p sy ch ic traum a lead s to anum ber of m en ta l chang es th at ev en tua lly a ccoun t forsom e adu lt charac ter p rob lem s, certa in k ind s o f p sy -chotic th ink in g , con sid erab le v io len ce, m uch d issoc ia -tio n , ex trem es o f pa ssiv ity , se lf-m u tila t ive ep isod es,and a va rie ty o f anx ie ty d istu rban ces . E v en thoughhear t fa ilu re and subacu te bac ter ia l endo ca rd it is inadu lth ood look v ery d ifferen t from one ano th er anddem and sp ecif ic trea tm en ts , th eir o rig in a l cau se-th ech ildh ood rheum atic fev er-g iv es an organ iz ing pat-tern to th e physic ian s en tire app roach . E v ery goodin tern is t know s how to ob ta in and asses s a h istory o frh eum atic fever , ev en th ough it w as th e p ed ia tr ic ianw ho or ig in a lly d ia gnosed and trea ted th e sick ch ild .

In th is p ap er , I w ill d e fine ch ildhood traum a andpo in t to fou r fea tu res th a t charac ter ize a lm ost a ll o fth e cond it ion s resu lt in g from ex trem e fr igh t in ch ild -h ood . T hese fou r fea tu res a re seen in ch ild ren su ffer in gth e resu lts o f even ts th at w ere sin g le , sudd en , and un -exp ec ted , th e cla ssica l F reud ian traum as (10 , 1 1 ), andin ch ild ren respond ing to long-s tand ing and an tic i-

p a ted b low s, th ose resu ltin g in th e var iou s ch ild abu sesynd rom es (12 , 13) or surv ivo r synd rom es (14 -16).These fou r fea tu res appear to last for yea rs in th ecou rse of the condition . Th ey a re often seen in adultsw ho w ere traum atized as ch ildren , even though theadu lts n ow ca rry oth er d iagno ses . O n ly on e or tw o ofth ese fou r fea tu res m ay be ev id en t in an ind iv idua ltraum atized as a ch ild ; bu t from th e h istory it is o f tenev id en t th at th e oth er fea tu res p lay ed an im portan tpar t in th e p erson s life .

I w ill d iv id e a ll o f th e traum a-stre ss cond itio n s o fch ildhood in to tw o rough ca tego rie s and ca ll th emtyp e I and typ e II ch ild h ood traum as . 1 w ill p roposeth a t ch ild ren su ffer in g from typ e I traum as, th e resu ltso f on e sudden b low , d iffer in cer ta in w ays from ch il-d ren su ffer in g from type II traum as, th e resu lts o f lon g-stand ing or rep eated ordea ls . I w ill conc lude w ith anote on th e crossov er cond ition s, ch ild hood traum asth a t app ear to se ttle b etw een th e tw o m ajo r typ es th atI p ro po se .

Th is p ap er is large ly theoretica l, a lth ough each po in tw ill b e illu stra ted w ith a clin ica l exam p le . it is b ased ,in par t, upon th ree s tud ie s: th e Chow ch illa k idnapp ingstud y (8 , 17 , 18 ), a retrosp ec tiv e s tudy of 2 0 p re -sch oo lers su ffer ing from a w id e range of traum as thatw ere docum en ted by th ird parties (19), a nd a study ofnorm al la ten cy-ag ed ch ild ren s and ado lescen ts re-sp on ses to the C halleng er space shuttle exp los ion (9 ).The paper is p r im ar ily ba sed , h ow ever , upon m y d in -ica l no tes taken from m ore th an 150 ind iv idua l ch il-dren w ho cam e fo r eva lu atio n o r trea tm en t a fter avar ie ty of ex tern a lly gen era ted horrors. Th e pap er is anattem p t to organ ize and to p rov id e a sch em e of th ink-in g abou t ch ildhood p sy ch ic traum a. I t is n ot m ean t inany w ay as a las t-m inute add ition to th e DSM-IV pro -cess or as a proposa l fo r a n ew and rev is ion aryDSM-V . In stead , it is an ou tlin e and overv iew of agroup of ph enom ena th a t m ay go th e ir var iou s w aysin to th e adu lt d iagnostic g roup s bu t th at shou ld stillh o ld to ge th er in ou r th ink in g b ecau se o f th eir a sso ci-ation w ith the ear liest traum as .

I w ill d efin e ch ildhood traum a a s th e m en ta l re su lt o fon e sudden , ex tern a l b low or a series o f b low s, ren -der ing th e young p erson tem porar ily h e lp less andbreak ing pa st ord in ary cop ing and defen sive op era -tions . A s th e read er w ill n o te , I h ave b road en ed th econ cep t o f traum a to in c lud e not on ly th ose cond it ion sm ark ed by in ten se su rp r ise bu t a lso th ose m ark ed bypro lon ged and sick en ing ant ic ip ation . A ll c hild hoo dtraum a s, a ccord in g to m y defin it ion , or ig in ate fromth e ou tsid e. N one is g en erated so lely w ith in th e ch ild sow n m ind . C h ildhood traum a m ay be accom pan ied bya s yet unknow n bio log ica l changes th at are stim ulatedby th e externa l even ts. T h e traum a beg in s w ith even tsou tsid e th e ch ild . O nce th e ev en ts tak e p lace , a num berof in terna l chang es occu r in th e ch ild . T h ese changesla s t. A s in th e case of rh eum a tic fev er, th e ch ang es s taya ctiv e for years-o ften to th e detr im en t of the y oungv ic t im.


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CH ILD HOOD TR A UMA S

12 Am J Psych ia try 1 48: 1 , Janua ry 1 9 91

FO UR CHARACTER IST ICS COMM ON TO MOSTCA SES O F CH ILDHOOD TRAUM A

There are severa l w e ll-know n chara cterist ic s th atd is tin gu ish th e traum as of ch ildhood . T hough t sup -p ressio n , sleep p rob lem s, ex agg erated star tle re-sp onses, d ev e lopm en ta l reg ression s, fea rs of th e m un -dane , d e lib era te av o id an ces, pan ic , irr ita b ility , a ndhyperv ig ilan ce are p rom in en t am ong th ese .

I cons id er fou r ch aracteris tic s, h ow ever , p articu lar lyimportant in traum atized ch ild ren no m atter w hen inth e cou rse o f th e illn es s one ob serves th e ch ild and nom atter w ha t age th e ch ild is a t th e tim e. T hey a re : 1 )s trong ly v isu a lized o r oth erw ise rep ea ted ly p erceivedm em or ies , 2 ) rep e titive b ehav iors, 3 ) traum a -spec ificfea rs , and 4) changed a tt itud es abou t p eop le , a sp ectso f life , and the fu tu re .

O ne note on traum atic d ream s , th e c lassic F reud iansig n of traum a that I have not in c lud ed in m y list o ffo u r: th e rep e titiv e d ream is a ha llm ark o f traum a , bu tit is n ot a lw ays seen in ch ildhood traum a , esp ecia lly inch ild ren under ag e S. D ream ing appea rs to b e som e-th in g that d eve lop s in to wha t w e recognize as d ream -in g by abou t age 3 o r 4 (20 ). B e fo re th a t, in fan ts phys-ica lly d em on stra te th a t th ey are d ream ing by m ak ingm ou th in g m ovem ents o r litt le sound s in th e ir sleep .T odd lers m ay scream from sleep w ith ou t aw aken ing ,bu t th is k ind of d ream ing is o ften too p rim itive andin exp ressive to estab lish th at traum atic d ream s are a c -tu a lly tak in g p lace (2 1 ). In a study o f 20 ch ild ren w ithdocum en ted traum as that occu rred b efore th e ag e of 5,on ly fou r of th em verba lized th e con ten ts o f th e ird ream s (19 ). T h e rep eated d ream apparen tly is veryd ifficu lt to fin d in m ost traum a s before th e age of 5.Furth erm ore , th ese d ream s often tak e d eep ly d isgu isedfo rm s as tim e progres ses a fter th e traum atic even t. Inth o se ch ild ren o ld enough to d ream and to rem em berth e ir d ream s, traum a tic d ream ing m ay occu r a t in ter -va ls s ev era l years apar t o r in su ch deep ly d isgu isedfo rm s that th e p roces s b ecom es extrem e ly d iff icu lt todis tingu ish from o ther form s o f dream ing .

V isua lized o r O th erw ise R epea ted ly P erce ivedMemo r i e s

The ab ility to re-see o r, occasio na lly bu t le ss fre-qu ently , to re- feel a terr ib le ev ent or a ser ies o f eventsis a n im portan t comm on cha ra cteris tic o f a lm ost a llex terna lly g en erated d isord ers o f ch ildhood (2 2) . R e-seein g is so im po rtan t th a t it som etim es occu rs ev enwhen th e or ig in a l exp er ien ce w as no t a t a ll v isu a l (22 ) .Tactile , p osition a l, or sm ell m em ories m ay also fo llowfrom long -stand ing terrors or sin g le shock s. B u t th etendency to rev isu a lize app ears to b e th e strongest o fa ll o f th ese re -p ercep tion s in ch ildhood traum a. V isu-a liza tion s are m ost strong ly stim u la ted by rem inders o fth e traum atic ev en t, bu t th ey occasio na lly com e upentire ly unbidden .

The v iv id and unw elcom e natu re of retu rn in g trau -m atic v isua liza tion s m arks th em as sp ec ia l to th ese ex-

terna lly gen erated cond itio n s. C h ild ren tend to seeth e ir traum a s and old ord ea ls a t le isu re-du rin g tim esw hen th ey a re bored w ith c las se s, a t n igh t b e fore fa ll-in g asleep , and w hen th ey are a t rest listen in g to th erad io or w atch in g te lev ision . A s opposed to th ose trau -matized a s adu lts , traum a tized ch ild ren rare ly findthem se lves ab rup tly in terrup ted by sudden , d y sphor icv isua l iza tions.

E ven those w ho w ere in fan ts o r todd lers a t th e tim eof th e ir ord ea ls and thu s w ere unab le to la y dow n ,sto re , or retr iev e fu ll verba l m em or ie s o f th eir traum astend to p lay ou t, to d raw , o r to re -see h igh ly v isu a lizedelem en ts from th e ir o ld exper ien ces (1 9 ) . In cases inw h ich the facts o f a sexua l abuse are no t know n , forin stan ce , ch ild ren m ay ind ica te th e ir in terna lized v i-s ions of th e abu se by sk e tch in g w hat th ey see in th e irm ind or a c tin g it ou t a lm ost lik e a m ovie p ic tu re . Su chch ildren m ay use the ir v isua l and position a l senses,sen ses th a t m ay ou tla st th e v erba l m em ory itse lf, todraw p ictures of th em se lv es at the m ost scary m o -m ents o f [th e ir] life. O f cou rse , o ther p ost traum aticfea tu res shou ld b e presen t, too , if the ch ild actu a llywas a traum a vic tim .

T hree and a ha lf y ea rs a fter exp er ien c ing a ser ies o f trau -m atic events, a 5 -y ea r-o ld ch ild w as d iscovered (through por-n ograph ic photo graph s con fisca ted by U .S . C ustom s agen ts)to have b een sexua lly m isu sed in a day-ca re hom e betw eenthe ages of 15 and 18 m on ths . Th e g ir ls pa ren ts d id not d arespeak to h er abou t w hat th ey had learned from the in vesti-g a tors . T hey , in retrospect, rea lized th at she had been sk etch-in g hundred s of nud e adu lts beg inn in g from the tim e w henshe had first begun to d raw .

W hile p la y ing in m y office , th is ch ild to ld m e tha t a babyshe had ju st draw n w as a ll naked and a bad gir l. U n -know in g ly , she h ad just d ep ic ted herse lf. D esp ite the fact thatth e little g ir ls on ly v erb a l m em ory of th e ev en ts w as I th inkth ere w as grav e dang er at a lad y-M aryB eths -h ouse , h ervo lum es of draw ing s rep resented stron g ly v isu a lized e le -m en ts th at she h ad reta ined and had needed to recreate fromth ese very ea rly , n onv erb a l exp er ien ces.

A 40-year-o ld m en ta l hea lth professio na l began w ork in ga t a fa cility fo r m a le ju v en ile d elinqu en ts . O n h is long rid eshom e he began see in g h im se lf a s a todd ler -a ttacked in ashack by a group of o lder ch ild ren . Th e m an d rove to thetow n w here h e had lived un til h e w a s 4 years o ld , and hefound the sh ack th at he had pic tu red . Th e sh ack stoodcatercorn ered to h is o ld hou se .

R epe titive B eha v iors

P lay and behav iora l reen actm en ts are frequen t m an -ifesta t io ns of bo th th e sin g le b low and th e long-stand -in g terrors o f ch ildhood . P sychophy sio log ic rep e tit ion sare le ss frequ en tly ob serv ed in ord in ary p ra ctice, bu tth ey ga in particu la r im po rtance in certa in cu ltu res(23) . P osttraum a tic p la y , d e fin ed by th e p lay ers as fun , is a gr im , long -las tin g , and par ticu la rly con ta -g iou s form of ch ildhood repe titiv e b ehav io r (2 4 ). A l-th ough reena c tm en ts lack th e e lem en t o f fun , th eya lso rep eat asp ec ts o f th e terr ib le even ts. R eena ctm en ts


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LEN OR E C . TER R

Am JPsych ia try 1 48:1 ,Janua ry 1991 13

can occu r a s sin g le b ehav iors, rep ea ted b ehav iors, orbod ily respon ses. R ep e titiv e b ehav iors m ay ev en beseen in ch ild ren w ho w ere expo sed to traum atic even tsb e fo re th e ag e of 12 m on th s (19 ) . In oth er w ord s, ch il-d ren w ho have no verba l m em ory w hatsoever o f th e irtraum as m ay be seen to fee l phy sica l sen sa tio n s or p la yo r ac t in a m anner tha t evok es w hat th ey or ig in a llyexp er ien ced at th e tim e of th e even t. T h e S -y ea r -o ldg irl d escr ib ed in th e p rev iou s case v ign ette , fo r in -s tan ce , exp er ien ced funny fee lin gs in h er tumm yevery tim e sh e saw a fin g er po in ted a t h er . T he porno-g raph ic p ic tu res con fis ca ted by th e cu stom s au tho rit ie ssh ow ed an erec t p en is ja bb ing th e very spot on th e15-18 -m on th -o ld ch ild s b e lly tha t sh e had ind ica tedw hen , a t a ge 5, sh e spok e o f th e funny fee lin gs.

T he ch ildhood su rv iv ors o f sin g le sho ck s and o flo ng-stand ing terrors a re u sua lly en tire ly unaw are tha tth e ir b ehav iors and physica l re spon ses rep eat som e-th in g of th e or ig in a l se t o f th ough ts or em ergen cy re -sp on ses. T hu s, th e p resen ce o r ab sen ce o f b ehav io ra lreena ctm en ts m ay a t tim es b e b e tter d e term in ed fromin terv iew s w ith th ird par tie s .

B ehav iora l reena ctm en ts m ay recu r so frequ ently asto b ecom e d ist in ct p ersona lity tra its . T h ese m ay even -tu a lly g ather in to th e p ersona lity d iso rd ers o f adu lt-h o od , or th ey m ay recu r so phy sio lo g ica lly as to rep -resent w ha t seem s to b e phy sica l d isease . L ong a fterm os t rep ea ted n igh tm ares have d isapp ea red in tod eep ly d isgu ised form , reenac tm en ts con tinu e to cha r-a cterize th e b ehav iors o f traum a tica lly stre ssed ch il-d ren . R ecen t p sy ch ia tr ic in vest iga tion in to th e liv esand w ork s o f im portan t a rtists-E dgar A llen P oe ,E d ith W harton , R en# {233} agr itte , A lfred H itch cock , andIngm ar B ergm an (2 5) , S teph en K ing (26 ), and V irg in iaW oo lf (27 )-sh ow that th ese a rtists reena cted ch ild -h ood traum as b ehav iora lly throughou t th e ir life t im esand a lso p lay ed ou t th e ir traum as in ar tist ic w ork sspann ing th e ir en tire ca reers. If on e cou ld liv e a thou -sand years, on e m igh t com p lete ly w o rk th rough ach ildhood traum a by p la y in g ou t th e terrify in g sce-n ar io un til it n o longer terr ified . T he life t im e a llo ttedto th e ord in ary p erson , h ow ev er , d o es no t app ear to b eenough .

A 6-y ear -o ld g ir l w a lk ed in to a c ircu s ten t and w a s sud -d en ly attacked by a runaw ay lion . Th e an im al to re open h ersca lp and b it in to h er face . Th e g ir l h ad to und ergo severa lsu rg ical pro cedu res to repa ir w hat happened w ith in a fewsecond s tim e . Sh e w a s lef t w ith an un even ha ir lin e and alarg e ba ld spo t. A fter th e extra ord in ary exp er ien ce , th e litt leg ir l p referred B eauty Par lor to a ll o ther g am es of pretend .She com bed her younger sisters h a ir rep eated ly , o ften b r in g-ing th e y ounger ch ild to tears over th e roughness o f thecom b ing . T he little g ir ls d o lls d ev elop ed ba ld spots and un -even ha ir lin es w ith ou t anyon e ever ob serv in g ex ac tly howth ese anom alies cam e in to b e ing . The ch ild , p rev ious ly out-go in g and friend ly , stu ck c lose to hom e and ra re ly venturedou t in to h er n e ighborhood . A t age 6 , h er m ain hopes fo r th efu tu re w ere to g row up and becom e a runw ay m odel or abeau ty par lor lady .

T raum a -Sp ec if ic F ea rs

Som e of th e sp ec ific fea rs re la ted to th e shock s andlong-s tand ing extrem e externa l stres ses o f ch ildhoodcan be avo id ed by m oving ou t o f tow n or by chang inghou ses or ne ighbo rhood s . Fea rs can b e c on dit io ne daw ay by rep eated ly fac in g th e feared ob jec t . M ost ex -trem e ly stre ssed o r p sych ica lly traum atized ch ild rencon tinu e to h arbor one or tw o traum a -rela ted fears,h ow ever , w ell in to adu lth o od . F ears o f spec ific th in gsth at a re re la ted to exp erien ces p rec ip ita ted by trau -m atic even ts are fa ir ly easy to spot , on ce one know sw hat th e traum a m igh t hav e b een . T h is typ e o f litera l,spec ific fea r is p ath ognom onic of the ch ildhood trau -m as. W hereas n eu ro tica lly or d eve lopm en ta lly phob icch ild ren m ay fear al l dogs , th e dog -b itten youngsterw ill fear th e G erm an sh epherd s, the D oberm an s, orw hatever spec ies actua lly created th e traum a tic s ta te .W hereas neu ro tica lly an x ious ch ild ren fear grow in g upo r ge tt in g m arr ied , traum a tized youngs ters fear (andre-crea te ) ora l sex , ana l in tercou rse , o r w hatever p ar-ticu la r sexua l abu se th ey or ig in a lly exp er ien ced .

T raum atized ch ild ren tend a lso to fea r m undaneitem s-th e d ark , stran gers, loom in g objects , be inga lon e , be ing ou tsid e , fo od , an im als, a nd v eh ic le s , forin stan ce. In fac t, fea rs o f th e dark and of b e in g a loneare stron g ly conn ected w ith sudd en sh ock s in th e ear lyyears (9 ) . Bu t th ese m undane fears m ay a lso b e con -n ected w ith a num ber of o th er em otiona l d isord ers andd eve lopm enta l sta ges of ch ildhood . T he pan ic and ex-trem e avo id an ces ob served fo llow ing terrify in g ev en ts,in connec tio n w ith th is m undane g roup of fears, domake th em im portan t to ch ildh ood traum a. B ut thespec ific, litera l k ind s of fear noted in th e p reced ingparag raph a lm o st lab e l th e traum atic cond it ion .W hen one sees th is litera l k ind o f fea r la stin g th rough -ou t the years d esp ite th e natu ra l tend en cie s tow ardspontan eou s d esen sitiza tion , ch ildhood traum a is th em ost lik e ly cau se .

A girl w as sexua lly m isu sed by h er fa ther from age S to age15 , at w hich t im e sh e ran aw ay from hom e, n ev er to return .A s a m arried adu lt o f 38 , sh e fea red sex w ith h er husb andunless sh e in itia ted the act h erse lf. S he respond ed to the fe -m a le -on-top or sid e-to -s ide p os it io ns , p osition s th at h ad no tor ig in a lly been taken by h er fa th er . A ny sexua l p os it io n in gth at w as evocative of th e incestuou s set o f sexu a l postu ress tim ulated fea r , p a in , and revu ls ion .

Chang ed A ttitu des A bou t P eop le , L ife , a nd th e F u tu re

The sen se o f a sev ere ly lim ited fu tu re , a lo ng w ithchanged a tt itud es abou t p eop le and life, app ears to b eim portan t in th e traum a and extrem e stress d isord ersor ig in ating in ch ild h ood . The lim ita tio n o f fu ture per-spective is particu la rly s tr ik in g in traum atized ch ildrenbecau se ord in ary young sters exh ib it a lm ost lim it lessidea s abou t th e fu tu re . T ru ism s, su ch as I liv e one dayat a tim e or I can t gu ess w hat w ill h appen in m ylifet im e , com e from the reth ink ing s th a t occu r in th e


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years after traum atic ev ents . Id eas such as Y ou can ttrust th e po lice or Y ou can t count on anyth in g o ranyon e to p rotec t you a lso fo llow from sing le andlong -stand ing , rep ea ted traum a s. S exua lly traum atizedg ir ls m ay sh r ink aw ay from m en or a ccos t th em w ithov er friend ly advan ces. P ar t o f th is b ehav ior is reenac t-m en t, bu t pa rt re flec ts a tt itud in a l changes. L im ita tion sin scop e and fu tu re p ersp ective in ch ildhood traum avic tim s seem to re flec t th e ongo in g b e lie f th at m oretraum a s a re bound to fo llow . T raum atized ch ild renrecogn ize p ro found vu ln erab ility in a ll hum an be in gs ,esp ec ia lly th em se lv es. T h is sh a tter in g of w hat L iftonand O lson ca ll th e sh ie ld of in v in cib ility (28 ) andwha t E r ik son term s ba sic tru st and au tonom y(29 ) appears to cha ra cterize a lm ost a ll even t-engen -d ered d isord ers o f ch ildhood . T he feelin g o f fu tu re le ss-n es s o f th e traum atized ch ild is qu ite d ifferen t fromtha t o f th e d ep ressed young ster . Fo r th e traum atized ,th e fu tu re is a la nd scap e filled w ith crag s, p its , andm on sters. F or th e d ep res sed , th e fu tu re is a b leak , fea -tu re les s land scap e stre tched ou t to in fin ity .

A 17 -year -o ld boy , search ing for a freew ay shou ld er onw hich to stop h is d isab led car , w as h it from th e rear b y asp eeder . Th e boys au tom ob ile exp lod ed . H e flew out com -p le te ly unscath ed but w atched h e lp less ly a s h is b est fr iendburn ed to d eath in the p assen ger seat.

F or m on th s a fter th e even t th e boy cou ld not w ork andsp en t m ost o f h is d ays m op ing . H e w as p lagu ed w ith badd ream s and fears of fu rth er d isa ster . H e began psychoth er-ap y; and w hen I sa id to h im at th e end of an ea rly sess ion ,S ee y ou next w eek , h e ask ed , H ow do you know it w ill b enext w eek? W ho know s? I m ay d ie on m y w ay ou t o f you roff ice . I m ay be killed ou t there on th e sid ew alk . I d on t coun ton see in g you next w eek . I live day to day-day to day .

A 15-year -o ld g ir l cam e for p sych ia tric trea tm en t b ecau se ,s in ce she w as attack ed at age 8 , she h ad fa iled to vo lun teer orsp eak up in c lass . S ince h er a ccep tan ce in an acad em ic h ighschoo l, sh e cou ld ach ieve n o m ore th an B s b ecause sh e w astoo qu ie t.

T h e g ir l h ad exper ienced sig n ifican t changes in h er atti-tu des abou t life and p eop le w hile she w as ly ing in a hosp ita lroom for 3 m on th s, fo llow ing repa ir s to h er v ag in a , anu s,and periton eum . A m an had grabbed her from a C h inatow ns id ew alk on her w ay hom e from schoo l. H e had taken herin to an abandoned garage and attacked h er vag in a w ith apa ir of ch opsticks . Th e g ir l had dec ided after h er o rd ea l tha tsh e w as chosen by th e deranged m an b ecause sh e hadshow ed too m uch . N ever aga in , she had vow ed to h erse lf,w ou ld sh e ever sh ow . P eop le cou ld not b e tru sted , sheb e lieved . L ife m u st b e endu red , n ot savo red .

FEATURE S CH ARACTER IST IC OF THE SING LE -B LOWTRA UM AS , TY PE I D ISORD ER S

The typ e I traum atic cond it ion s o f ch ildhood fo llowfrom unan ticip a ted sin g le ev en ts. T h ese are c las sica lch ildhood traum as by A nna F reud s d e fin ition (30) .T h ese are a lso th e m ost typ ica l po sttraum atic stressd isord ers th at on e finds in ch ildhood , u sua lly m eetin g

th e cr iter ia o f rep etit ion , av o id an ce , a nd hypera lert-n ess th at rep resen t th e m ajor d iv is ion s in ou r d iagno s-t ic m an ua l, DSM-I I I -R . Those ch ild ren w ho su ffer th eresu lts o f s ing le b low s appea r to exh ib it cer ta in sym p-tom s and sign s th a t d ifferen tia te th e ir cond ition s fromthose resu ltin g from th e m ore com p lica ted ev en ts. T h efind in g s sp ec ia l to s in g le , sh ock in g , in ten se terrors a re1 ) fu ll, d e ta iled , e tch ed -in m em orie s, 2 ) om en s (re t-rosp ec tiv e rew ork ings, co gn it ive reappra isa ls , rea son s,a nd tu rn in g po in ts), and 3) m isp ercep tion s and m is-tim in gs . T yp e I traum a s do not app ea r to b reed themass ive den ia ls , p sych ic num b ings, self-a n esth esias , orp ersona lity p rob lem s th a t charac ter ize th e typ e I I d is -o rd ers o f ch ildhood .

Fu ll, D eta iled M em o rie s

W ith th e excep tion of young sters b e low th e approx-im ate a ge of 28 to 36 m on th s, a lm ost ev ery p rev iou s lyun traum atized ch ild who is fu lly con scio u s a t th e tim ethat h e or sh e exp er ien ces o r w itn es se s on e terrib leeven t d em on stra te s th e ab ility to re tr ieve d eta iled andfu ll m em ories a fterw ard (19). V erba l reco llect io ns ofsin g le sho ck s in an o th erw ise traum a -free ch ildhooda re d eliv ered in an am azing ly c lear and deta iled fa sh -ion . C h ild ren som etim es sound lik e robots as th eys tr ive to tell every deta il as e ffic ien tly a s p ossib le . A s am atter o f fac t, ch ild ren are som etim es ab le to rem em -ber m ore from a sin g le even t th an are th e adu lts w hoobserved th e sam e even t (24 ) . A few deta ils from atraum atic even t o f ch ildhood m ay be fac tu a lly w rongbecau se th e ch ild in itia lly m isp erce ived or m ist im ed th esequ ence of w ha t happ ened . Bu t ch ild ren w ith type Id iso rd ers seem to rem em ber th e even t and to g iv e im -p ress ive ly clear , deta iled accounts o f th e ir exper iences.

Th is rem arkab le re triev a l o f fu ll, p rec ise , v erba lm em or ie s o f a lm o st a ll s in g le-b low traum a s m akes on econ c lud e that th ese m em ories stay a live in a very spe-c ia l w ay , no m atter how m uch con sciou s supp ressionth e traum atized ch ild is a ttem p tin g . M em or ie s o f pro -lo nged or var iab ly rep eated ch ildhood abu ses, on th eoth er hand , app ear to b e re ta in ed in spots, ra th er th ana s c lear , com p le te w hole s (19 ) . Am nesia s, a s a m a ttero f fa c t, a re o ften repo rted in ch ild ren who seem to beh ead ing for th e m u ltip le p ersona lity d isord ers o f adu lt-h ood (3 1) . C h ild ren who have b een rep eated ly phys i-ca lly or sexua lly abu sed m ay w av er in th e ir accu sa -tio n s o f abu sers and w av er in th e com p le ten ess and th ed eta il o f th eir m em orie s. B u t ch ild ren w ho have b eentraum atized a sin g le tim e do not often forg et . A s M a llesay s a t th e con clu sio n of h is au tob io graph ica l film , AuR evo ir L es E n fan ts (198 7) , a ta le o f a sin g le, terr ib leeven t from h is boyhood in o ccup ied F ran ce, O verfor ty y ears hav e passed , bu t I w ill rem em ber everysecond of th at Janua ry m orn ing un til th e day I d ie .

The firs t tim e th at he v isited the p sych ia tr is t, a S -year-o ldboy m inu te ly describ ed h is s tep fa th ers m urder of h is b abybrother . T he in c id ent h ad occu rred 2 w eeks ea r lier . T he boyknew ju st w here under th e te lev isio n tab le in a m o te l room


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LEN ORE C . T ER R

Am J Psych ia try 1 48:1 , January 1 991 15

h e had been h id in g . H e repo rted ex ac tly w here h e had beens it tin g and ly ing before tak in g co ver. H e describ ed th e typ esof b low s tha t fe ll upon h is y ounger s ib lin g and m eticu lou slyrep eated th e attack er s phra ses and th reats . H e sa id tha t h ehad been try in g to fo rg et a ll o f th is bu t cou ld not. T h e boystea ch er had been rep r im and ing h im fo r rep eated ly h id ingunder the d esk s and tab les a t schoo l, bu t n e ith er teach er no rs tud ent recogn ized the s ig n ifican ce of th is b ad b ehav io r.

Ome n sD uring and after sin g le-b low shock s, ch ild ren tend

frequ en tly to a sk th em se lves W hy? and W hy m e?In th is w ay th ey attem p t to ga in retrosp ec tive m a steryov er th e random ness , th e lack of con tro l, a nd th e le ss-th an -hum aneness of the traum a tha t th ey endured .Wh en ch ild ren traum a tized by a sin g le even t b e la ted lyd eve lop a reason w hy every th in g happen ed , a pu rposeto th e en tire a ffa ir , or a w ay tha t th e d isa ster cou ldhav e b een av er ted , con sid erab le m en ta l en ergy goesin to th ese rew o rk ing s o f th e past . 1 have term ed th eseb e la ted resh ift ing s, rea son s, a nd w arn ings om en s(17) , w h ile P ynoos e t a l. ca ll th em cogn itiv e reap -p ra isa ls (1 1 ) . I b e lieve th at w e are d escr ib in g th e sam ephenom enon . T h is k ind of reth ink in g and rew orkingoccu rs m uch m ore o ften after on e sudden ex terna lsh ock than it d oes a fter a p ro longed ser ies o f terr ib leexp erien ces . C h ild ren who have found om en s or rea -son s to exp la in w hy th ey su ffer o ften fee l in ten se lygu il ty . A lthough v ic tim s of typ e II ch ildhood traum aalso exp er ien ce p rofound gu ilt , th e sen se o f gu ilt d oesnot o ften con sc iou sly a lig n itse lf to th e W hy m e?ques tio n . T he rep e tition s and long-stand ing na tu re ofth e typ e II stre sso rs m ake th e inqu iry H ow cou ld Ihave a vo id ed it? far le ss p ressin g than th e questio nH ow w ill I av o id it th e n ex t t im e?

The om en or cogn it ive reappra isa l is a b e la ted w ayin wh ich th e sin g ly traum atized ch ild tr ies to d ea l re t-ro ac tiv ely w ith w hat had been en tire ly un exp ec ted -asudden , su rp r isin g p sycho lo g ica l b low . B ecau se re-p ea ted horro rs en cou rage a sen se o f antic ip a tion andexp ec ta tion , d ifferen t m eans of cop in g com e to b e em -p loyed . T hese m ean s of cop in g even tua lly crea te th ed efin in g cha ra c ter istic s o f th e typ e II d isord ers, ch ar -a cterist ic s th a t are unm a tch ed in th e typ e I d isord ers.

A n 8 -year -o ld boys m oth er bought h im a fan cy skate -b o ard , adm on ish in g h im to rid e on ly on th e sid ew alk . T hefir st S atu rday m orn ing th e boy rod e h is sk ateboard on th esid ew alk , h e w a s run over by a ca r back ing ou t o f a n e igh -bo rs d r ivew ay . T he boy comm en ted a y ea r la ter , I can th elp th ink in g m any , m any tim es abou t w hat M om sa idabou t r id in g skateboard s on s id ew alk s.

A 16-year -o ld g ir l rece ived a slice o f p izza from her b estfr iend as a b ir thday p resent. B it in g in to the p izza , she w aspo isoned by a corros iv e tox in . The g ir l su ffered from intern a lin ju rie s fo r m ore than 6 w eek s. E ven though th e rea l sou rceo f th e po ison w a s found by hea lth offic ia ls a t th e p izza par -b r , th e in ju red g ir l th ough t aga in and aga in abou t th e na tu reo f h er re la t ion sh ip w ith th e friend w ho had purchased th e

p izza . In m inu test deta il she tr ied to figure out a t w ha t po in t

her fr iend had decid ed to k ill h er .

Misperceptions

M is id en tifica tion s, v isu a l h a llu c in ation s, and pecu -liar t im e d istor tio n s o ften occu r to ch ild ren w ho hav eexp erien ced sin g le , in ten se , un exp ec ted shock s (22 ,32 ). In con tra st to th is , th e long-stand ing , ex trem e ex -terna l s tre sse s th a t a ffec t ch ild ren are o ften eng in eeredby perp e tra tors known to th em -care tak ers, teach ers,or fam ily m em bers, for in stan ce. B ecau se of a ch ild sfam iliar ity w ith su ch perp etrators, th e chan ces o f ear lym isp ercep tion s becom e slim . T wo im portan t excep -tio n s to th is gen era l ru le are w hen a type II v ic timth ink s th at h e or sh e sees a on ce -fam iliar abu seryears after los in g track of th e person and w hen aknow n , lo ng-stand ing p erp e tra tor w as n ever p erce ivedcorrec tly by th e ch ild b ecau se o f a d isgu ise th a t h e orsh e w a s w ear in g (as in sa tan ism and cu lts).

M any of th e typ e I ch ildhood traum as in c lud e v isu a lmispercept ions and ha llu c in atio n s. T h ese p ercep tua ld isto rtion s m ay seem to ind ica te o rg an ic m en ta l con -d itio ns or p sy cho ses, bu t a few b iza rre s igh tin g s do notm ake a b ra in d iso rd er or a sch izoph ren ic ep isod e.V isua l h a llu c in ation s and illu sio n s are ob serv ed in ch il-d ren shor tly a fter traum a tic even ts and , a t tim es, longafter sudden , unan tic ip a ted sho cks . M assive releases o fn eu rotran sm itter s in th e b ra in a t th e tim e of th e terrormay account for th ese prob lem s w ith p ercep tion . Bu tthe typ es of substan ces and m echan ism s are , a s ye t ,unknown .

A 7 -y ea r-o ld g ir l rode in a sta tion w agon a longs ide h ersis ter and tw o cous in s on a fam ily ou ting to th e m ounta in s.A loose bould er from an ad ja cen t h ills id e sm ash ed in to th ero of o f th e g ir ls car , k illin g one cou sin and th e g ir ls o ldersis ter , w hile sp ar ing th e g ir l and h er other young cous in . F orth e en su in g year , th e su rv iv in g g ir l saw her sister a t h erbed sid e a lm ost every n ight . T he d ead sis ter v is ited the liv in gch ild dressed in p ink , green , and orange ou tfits. Sh e appearedfu lly fleshed , as she w as in life . T h e v is io n sa id noth in g . Th eyoung su rv iv or felt up set b y a sen se o f m enace em anatin gfrom her sis ters ghost, yet, a t th e sam e tim e, she fe lt odd lycom fo rted by th e s igh t.

F EATURE S CHARACTER IST IC O F VAR IA BLE ,M ULT IPLE , O R LO NG -STAND ING TRAUM AS ,TY PE II D ISORDERS

Type II d iso rd ers fo llow from long-stand ing or re-p eated expo su re to ex trem e externa l even ts. T h e firs tsu ch event, o f cou rse , creates su rpr ise . Bu t the sub se-quen t un fo ld in g of horro rs crea te s a sen se o f an ticip a -t io n . M ass iv e a ttem p ts to p rotec t th e p sych e and topreserve th e se lf a re pu t in to gear . T he d e fen ses andcop ing op era tio n s u sed in th e typ e II d isord ers o f ch ild -h ood -m a ssive d en ia l, rep ressio n , d is soc ia t ion , se lf-an esth esia , se lf-h ypnos is , id en tif ica tio n w ith th e a g-gresso r, a nd agg ressio n tu rn ed aga in st th e se lf-o ften


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16 Am J P sych ia try 1 48: 1 , January 1 991

lea d to p ro found charac ter changes in th e y oungster.E ven though a rep eated ly abu sed youngster m ay notsett le in to a recogn izab le form o f adu lt charac ter d is-ord er un til th e la te teen s or ear ly tw en tie s , ex trem epersona lity p rob lem s m ay em erge even before th e ag eof 5 .

The em otion s st irred up by typ e 11 traum a s are 1) anab sen ce of fee lin g , 2 ) a sen se o f ra ge , o r 3 ) un rem ittin gsadnes s. T h ese em otion s ex is t sid e by s id e w ith th e fearth a t is ub iqu itou s to th e ch ildhood traum as. T ype IId isord ers, und er th e scru tin y of ab le m en ta l h ea lth p ro-fe ss iona ls , m ay com e to b e d iagnosed in ch ildhood a sconduct d iso rd ers, a tten tion d efic it d iso rd ers, dep res-sio n , o r d issoc ia t ive d isord ers . R eco gn itio n o f th e ex -panded group of traum a s tha t I am suggestin g h erem ay he lp to d efin e a comm on etio lo gy and range o ffind in g s for m any o f th ese ch ildhood cond it ion s. O fcou rse , if a ch ild o rig in a lly w as traum atized , on ew ou ld exp ec t to find vest ige s o f th e rep eated v isu a liza -tio n s, rep ea ted b ehav io rs and phy sio lo g ic sen sa tion s,sp ec ific fea rs, and rev is ed id eas abou t p eop le, life , andth e fu tu re th a t app ear to charac ter ize th e ch ildhoodtrauma s .

D en ia l and P sych ic N um bingD en ia l and p sych ic num b ing hav e long b een con sid -

ered c lass ic find in gs o f th e po sttraum atic stre ss d isor -d ers . D ia gnostic p rob lem s often ar ise , h ow ever , b e -cau se m assiv e d en ia l and em otiona l shu tdown are sooften ev an escen t o r ab sen t in ch ild ren w ho hav e gon eth rough sin g le sho ck s (1 7). A lthough con sc iou s sup -pres sion o f th ough ts w ill tak e p la ce in any k ind o ftraum a , and a lth ough br ief , lim ited d en ia l and num b -in g m ay last from m om en ts to hou rs a fter a shock in geven t, m assiv e d en ia l a nd p sych ic num b ing a re p r im ar-ily asso cia ted w ith th e long -stand ing horrors o f ch ild -h ood , w hat I w ou ld ca ll th e typ e II traum as. C h ild renw ho exp erien ce th is ty pe o f stre ss m ay em p loy su chextrem e num b ing and den ia l th a t th ey look extrem e lyw ithd raw n or inhum an . W hen very young , th ey m ayassum e th e gu ise o f Sp itz s hosp ita lism bab ies (3 3 )or o f ha il fe llow w ell m et sup er fic ia lity (34 ), b o th ofw h ich are sig ns o f fa ilu re o f a ttachm en t and of per -son ality o rg an iz ation .

C h ildren w ho exp erien ce typ e II traum as do notcom p la in of go in g num b . T he sen se o f go in g d ead ison e that d ep end s upon y ea rs o f sub jec tive ly know ingwha t it w a s to fee l a live . O n th e oth er hand , ch ild renwho hav e b een repea ted ly b ru ta lized or terror ized doexh ib it m assiv e d en ia l to th e ey es o f th e tra in ed ob -server . Su ch ch ild ren avo id ta lk in g abou t th em se lves.T h ey often go for years w ith ou t say ing a th in g abou tth e ir ord ea ls . T h ey va lian tly try to look norm a l a tschoo l, in th e n e ighborhood , and on th e p layg round .T hey m ay te ll th eir stor ie s on ce or tw ice and en tirelyd eny th em later. (T h is is qu ite d ifferen t from som e ch il-d ren who hav e exp erien ced typ e I traum as, w ho m ayte ll th e ir stor ie s even a t k ind ergar ten Show and T ell.)

C h ild ren w ho exp er ien ce typ e I I traum a s often for -

g et . Th ey m ay forget w hole segm en ts o f ch ild h ood -from birth to ag e 9 , for in stance . W here on e sees thed ifference betw een these fo rgetfu l ch ild ren and or-d inary young sters is in th e m u ltip ly traum atized ch ild srela tiv e ind ifferen ce to pa in , 1a ck of em pathy , fa ilu re tod ef in e o r to acknow led ge fee ling s, and abso lu te a vo id -an ce of p sy cho log ica l in tim a cy . R ep eated ly b ru ta lized ,b enum bed ch ild ren em p loy m a ssive d en ia l-and whenth e ir den ia l-rela ted b ehav io rs c lu ster togeth er , th e re-su ltan t ch ild h ood p ersona lity d isord er (one th at cutsacross adu lt n arcis sistic , a n tiso c ia l, b ord erlin e , andavo id an t ca teg or ie s) is m a ssive .

P rofound p sych ic num b ing in ch ild ren occu rs as anaccomm odation to th e m ost ex trem e , long -stand ing ,or rep eated traum atic situ a tio n s. C h ildhood physica land sexua l abu se rep resen t tw o o f th ese ex trem es.W ha t st ill m akes th e under ly in g id ea of traum a th ecorrect e tio logy and pathogenes is h ere is th e fact thatth e sp ecif ic fears, th e rep ea ted p lay , th e behav iora l andphysio log ic reena ctm en ts, th e tend en c ie s tow ard v isu -a liza tio n s, and th e rev ised id eas abou t life , p eop le , a ndth e fu tu re seem to p ersist in so m any o f th ese ch ild renfor years a fter th e la st abu se s top s .

Su zanna w as 6 years o ld w hen her teen aged broth er b egansexua lly m olestin g her . (I t turn ed ou t th at he , in tu rn , hadbeen sexua lly m olested by a jun ior h igh sch oo l teach er b eforehe began abu sin g Suzanna .) Su zanna once tr ied to te ll hermoth er , N obody s suppo sed to touch you in your- (sh epo in ted a t her gen ita ls). B u t a fter th at sh e sa id noth ing fur-ther to h er p arents , teachers, o r fr iends un til th e sch oo l nu rsed isco vered w hat w as happen ing 2# {1 89}ears after it began .

On psych ia tric exam ination w hen sh e w as a ge 9 , Su zannasp ent m uch of the first h ou r pu sh in g her index finger b ackand fo rth through a sm a ll h o le she h ad m ade w ith th e rest o fher fing ers . Sh e rep eated ly rubb ed the loo se cou ch p illow sover on e ano th er . Sh e sa id o f h er exp erien ces w ith herb ro th er , H e pu t h is p en is w here 1 poop ed . It hu r t. I t o ld h imit hurt, bu t h e sa id nu ttin b ack . I d idn t like tha t a t a ll. I td idnt rea lly fr ighten m e. N ot rea lly . I ju st m ade up m y m indto th ink abou t o ther th in gs.

W hen Su zanna w as ask ed how sh e w as ab le to d o th ism ind tr ick , to th ink abou t o ther th in gs, sh e rep lied , I sayI d on t know over and over to m yse lf. W hen I say m yp rayers I k eep say in g the last w o rd of th e prayer. S om etim esI do it a hundred t im es. I s a y I d ont know a lo t o f tim es inm y m ind each day . . . . Som etim es n ow I find m yself not fee l-ing th ings. I do nt fee l sad or mad w hen I sh ou ld b e . Im no tafra id w hen I sh ou ld b e. I a ct silly and crazy a lo t . T he peop leat m y sch oo l th ink Im funny becau se of it.

Se lf-H ypno sis and D issoc ia tio nSpon tan eou s self-hypnosis , d epersona liza tio n , and

d issoc ia tion are im portant ou tcom es o f rep eated , long-stand ing terrors (th e typ e II traum as ). C h ild ren whohav e b een th e v ict im s of ex tend ed per iod s o f terrorcom e to learn th a t th e s tre ssfu l even ts w ill b e rep eated .Som e of th ese ch ild ren , th e on es, p erhap s, w ho have aninn ate ease of h ypnot izab ility , sp on taneous ly fa ll up onth e techn iqu e o f se lf-h ypnosis . T his m echan ism en -ab le s a ch ild m en ta lly to escap e. Su zanna , th e ch ild


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LEN ORE C . TER R

Am JP sych ia try 148 :1 ,J anuary 1 991 17

descr ib ed in th e p rev iou s parag raph , u sed th e rep eti-tion of a sin g le w ord , th e la st w ord of h er p ray ers, toa ccom p lish th is escap e from pa in and w orry . Sh e a lsolu lled h erself in to m in itran ces by sa y in g I don tknow in h er m ind . T he ch ild ren a t schoo l recogn izedh er a ffec t to be unu sua l. B u t nobody bu t th e ch ildherse lf cou ld recogn ize th e se lf-h ypno sis .

T raum atized ch ild ren who use a g rea t d ea l o f se lf-hypnosis m ay , in fac t, g o on to d eve lop adu lt m u lt ip lepersona lity d isord ers (3 5 ) . T h is is p robab ly a rare con -d it ion . Spon tan eou s d issoc ia t ion , h ow ever , accoun tsfor a num ber of m ore comm on ly ob served find in g s inabu sed ch ild ren -bod ily an es th esias, feelin g s o f in v is-ibility, and am nesia s for cer ta in p eriod s o f ch ildhoodlife.

M u ltip le p ersona lity d isord er , a synd rom e in searchof its ow n p la ce in ou r d iagno stic m anua ls , b elo ngshere , a t least in term s o f e t io log y-th e rep eated , ex -trem e , lo ng-stand ing traum as o f ch ildhood . In ch il-dren , p eriod s o f tim e that canno t b e accoun ted for ,prob lem behav iors, v isu a l and aud itory ha llu cin a tion s ,and heada ch es appear to ind ica te th at th e ch ild is su f-fer ing from m u ltip le p ersona lity p recu rso rs (36 ). M ostself-h ypnotizin g ch ild ren w ho a re typ e II traum a vic -tim s fa ll sh or t o f th e m u ltip le p ersona lity o r p recu rsorsd ia gnoses , h ow ever . T hey d eve lop , in s tead , an es th esiasto bod ily pa in , sexua l an esth es ias, and extrem e em o -tiona l d is tan c in gs . C h ild ren w ho com e to exp ec t th erep etition of terrors rem ove them se lves in any w ay th atth ey can . T hese em o tiona l rem ova ls are not po ssib lefor th e o rd in ary typ e I traum a vic tim .

Fred er ick w as 7 y ears o ld w hen h e w as sen t to live w ith h isaun t b ecau se h is m oth er found ou t, th rough a tap e reco rd in gset up to catch h er husband at in f id e lity , that F red er ick sstep fa th er had been throw in g h im again st w alls w h ile sh eworked th e even in g sh ift. F red erick d id not te ll a nyon e h isyear-long story , d esp ite tw o v is its to th e em ergen cy roomand on e ne ighbo r-in stiga ted protec tive serv ice in vestig a tion .

W hile in h is aun ts cu s tody , F red er ick g lan ced dow n at th eplayg round pavem en t on e day and saw b lood . A fter severa lseconds o f search in g fo r a w ound ed com pan ion , F red er ickrea lized that it w as he w ho wa s b leed in g . T he boy rea lized h ecou ld fee l n o pa in .

In a p sychoth erapy session I ask ed F reder ick how he cou ldm ake th is sort o f th ing happen . It ju s h app en s n ow , h esa id . I u sed to pretend I w as a t a p icn ic w ith m y head onM omm ys lap . Th e firs t tim e m y stepdaddy h it m e, it hurt alo t. B ut th en I found ou t th at I cou ld m ake m yse lf g o onM omm ys lap [in im agin ation i, a nd W in ston cou ldn t hu rtm e that w ay . I k ep t go in on M omm ys la p-I d idn t h av e tocry or scream or anyth ing . I cou ld be som ep lace e lse and notget hu rt . I d ont know how m any tim es W in ston pun ched m eou t. I w a sn t a lw ays pay in a tten tion . L ik e I to ld you , fir st I dbe at a p icn ic on M om s lap . L ater I d idn t h av e to th ink ofno p icn ic -ju s h er lap . N ow if som eth in m akes m e b leed , Idon t th ink of no lap at a ll. I ju s d on t fee l n o pa in .

J am ie w as repeated ly abused by h is a lcoh o lic fa ther . H ehad a lso rep eated ly ob served h is fa ther b eat h is m o th er . A tage 8 , h e w itn essed h is m oth er shoot h is fa th er to d eath .When he w as 9 , th e ch ild w a s p sycho lo g ica lly eva lua ted . A t

that tim e h e to ld m e, I s tarted som e plan ets. I m ad e m yp lan ets up as a gam e. Bu t its rea l n ow . Its no gam e any-m ore. Jam ie describ ed a safe p lan et h e h ad in ven ted longago , h is ow n p lan et . H e a lso had inven ted a num ber of veryun safe p lan ets w h ere p eop le go t k illed . H e sa id tha t he hadcom e to ach iev e in v isib ility b y rep eated ly v isitin g h is ow nsafe p lanet and avo id ing the unsafe on es . S tarting w hen Iw as 6 , h e sa id , I began to fee l in v isib le . W hen m y M ompoin ted a gun at m y D ad . . . I w as th ink in g lik e I d idn t seeit, like T his d idn t h app en . I b lin ked to see if I w a s dream -ing . . . . I rem em ber at f irs t p retend ing I w asn t th ere -th at Id idn t see it -tha t I w a s on m y ow n p lanet. I had gone th erea lo t b efore . W hen M om and D ad w ould f ig ht, I w ould trynot to h ear , n ot to see . Id try to go to s leep . N orm ally Icou ldn t. Id try to get ou t of th e room w here they w ere . I dtry to v isit m y plan et. Bu t n ow m y m ind , yes , it jus t goesb lank . M o stly it h appen s at hom e. A few m inu tes a t a tim e .

Jam ie rep eated ly dream ed by n ight ab ou t h is fa th ersd eath . A nd h e v isu a lized th e k illin g by day . Bu t from th em om en t tha t h is d ad w as sho t, J am ie w ondered if h e h im se lfcou ld tu rn in v is ib le . I know I can , h e sa id . I do it h ere onearth . I d o it a ll th e tim e on m y p lanet. Y ou re just go ing toh ave to b elieve m e. M y fr iends b e lieve it. . . . W hen m y fa therw as b e ing sh ot I fe lt inv is ib le . Bu t if I turn ed in v isib le in fron tof everybody , th eyd tak e aw ay m y pow ers.Rage

R age , in c lud in g ang er tu rn ed aga in st th e self , is as tr ik in g f in d in g in tho se po sttraum a tic d isorders th ata re b rough t on by rep eated or long-stand ing abu ses,the type II d isord ers. O ne ob serves rag e and its nega -t iv e, ex trem e pass iv ity , in th ose typ e II d iso rd ers or ig -m atin g in p laces w h ere tru st or ig ina lly resid ed . D or -oth y O tnow Lew is and h er g roup reported th a t am ongadolescen t d e linquen ts w ho go on to comm it m urder ,ch ron ic physica l abu se is a k ey find ing w ith in a c lu sterof severa l o th er k ey find in g s (36 ). T h e ra ge of th e re -p eated ly abused ch ild cannot sa fe ly be underestim ated .

R eenac tm en ts o f anger m ay com e so frequ en tly inth e typ e I I traum a d isord ers th at hab itua l p attern s o faggress iveness are estab lished . The rage m ay becom eso fea rsom e to the ch ild as to crea te ex trem es of pa s-s iv ity . W ild fluctu ation s of b oth a ct iv e anger and ex -trem e pass iv ity m ay so dom ina te th e c lin ica l p ic tu rethat th e young person is even tua lly g iven a d iagnos is o fb ord erlin e p erson a lity . D efenses a ga inst rage su ch asp assive in to active and iden tifica tion w ith th e aggres-sor a lso pu t the ir ow n p ecu liar stam p s on the type IIch ild . T yp e II ch ild ren have b een know n to attack the irow n bod ies. S e lf-m u tila t ion s or phys ica lly dam agingsu ic id e attem pts occur . Th e fester in g ang er of th e re-peated ly abu sed ch ild is p robab ly a s dam aging a pa r to f th e cond it ion as is th e ch ron ic num b ing . B oth ofth ese , in fa ct , th e num b ing and rage , p robab ly figu rela ter in th e an tiso c ia l, b o rder lin e , n arc issist ic , and m u l-t ip le p ersona lity d iagnoses th a t are so often par t o f th ep ic tu re of th e typ e II traum atized ch ild grow n up .

A S -year-o ld boy w hose new stepm oth er h ad b een ty in gh im w ith rop es and leav ing h im locked up in c lo se ts b ehav edw ell a t k indergarten . A t hom e, h ow ev er , h e took sc issors to


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CH ILD HOOD TRA UMAS

18 Am J P sych ia try 1 48 :1 , January 1 991

h is s tepm oth ers b est lin gerie . H e spr ink led Ind ia ink tw icein to th e fam ily w ash . H e con sis ten tly m anaged not to eat th efood h is s tepm oth er p rep ared for h im . Th e boys stepm oth ersa id he w as a sk ing for th e punishm ents sh e gave h im . A nd sothe abu ses esca la ted .

A 45-year -o ld w om an had been a teenager in summ ercam p w hen th e a tom ic bom b destro yed h er hom e in Hi -rosh im a. (H er im m ediate fam ily w as spa red ; a ll w ere ou t oftow n on A ug. 6 , 194 5 .) A s an adult, th e w om an cou ld no tge t a long w e ll w ith h er Am er ican -born hu sband , a lterna te lyaccus in g h im o f la zin ess , in ep titu de at w ork , and in fid e lity .From th e tim e her daugh ter tu rn ed 13 , th e w om an beganbeliev ing the g ir l to b e prom iscu ous , a liar , a drug addic t, anda th ief . T h e w om an cou ld not get a lo ng w ith her co-w ork ersat th e in ternat io na l law o ffice w h ere she w ork ed . Sh e w asab le , she sa id , to re la te on ly to custom ers from Japan . Th eyrem inded her of th e p eop le [sh e l used to know at hom ew hen [she l w as a g ir l. I in v ited the w om an to com e to m yoff ice to ta lk abou t h er exp er ien ces w ith th e bom b . Sh e m adetw o appo in tm en ts for th is pu rpo se bu t fa iled to appea r foreith er . O bv ious ly , too m uch tim e had e lapsed to p rove anycause-and-effec t hypothes is h ere . I t is in teres ting , how ever ,tha t th e w om an s ang er and su sp ic io usness rested on ly w ithAm erican and A m erican -in flu en ced p eop le . N a tiv e Japan esep erson s , th e v ic tim s, no t the p erp etrato rs of the atom icb om b, w ere en tirely sp ared h er w rath .

CROSSO VER TYPE I-TY PE II T RAUM AT ICCO ND IT ION S O F CH ILDHOOD

W hen a sin g le p sycho lo g ica l sh ock tak es a ch ild sp aren ts life , lea ves a ch ild hom eless , h and icapped , ordis fig ured , or causes a ch ild to undergo p ro longed hos-p ita liza tion and pa in , th e ongo in g stre sse s tend to pu shth e changes in th e ch ild tow a rd those cha ra c ter istic o fth e typ e II ch ildhood traum a s. In th ese ca ses on e oftenfind s fea tu res o f both th e typ e I and th e type II cond i-tions . T ho se ch ildren w ith perm anen t h andicap s, lon g-stand in g pa in , or loss o f sign ificant ob jects are oftenforced in to m ak ing sign if ican t chara cter changes or u s-in g num b in g tr icks to m in im ize th eir p a in . Th ey m aystill r e ta in , h ow ev er , th e cha ra cterist ic s typ ica l o f re -sp on ses to s ing le ev ents-clea r m em ory , p ercep tua ld isto rtion s, and om en s.

Perpe tu a l M ou rn ing and D epress ion

P sych ic sho ck in ter feres w ith ch ild hood b ereav e-m ent and vice versa (37) . Th e com bin ed psycho lo g ica leffec ts o f sh ock and gr ie f con tinue to d rag on th rough -ou t ch ildhood . A s tim e goes by , and th e ch ildhoodm ourning does not p roceed th rough its ord in ary s tag es(38) , th e young traum a vic tim is re in jured -from th ein sid e th is t im e-th rough pro longed exposu re to sad -n ess and loss . T h e p sycho lo g ica l cond itio n of m ix edm ourning and traum a in youth m ay tak e th e gu ise o fmajo r affec tive d isorder and m ay hav e to be treated assu ch , a t least a t first . T here is a h igh ra te of d epress ionin refu gee ch ild ren from bru ta l reg im es (15 , 16 ) . A n

explanation fo r th is f ind in g m ay be th e unreso lvedtraum a th at p oten tia tes and ex tend s the unreso lv edg rie f, th e gr ie f tha t fu rth ers th e traum a, o r b oth .

A 4-year-o ld boy w atch ed h is o ld er sister s ev iscerat io n ina freak a cc id ent in a ch ild rens sw im m ing poo l. B efore th ed isa ster sh e had ask ed h im to p lay , bu t he had refu sed . T helittle g ir l then sat d ow n on an exposed d ra in p ip e . Th e boysp en t a couple of years after th e acc iden t u sing w ood enb locks to bu ild h is ow n perfec t po o l. H e b lam ed him se lf forn ot agree ing to p lay w ith h is sister , an act, he fe lt, th at cau sedh is s ister s in ju ry . T he boy reta in ed a c lear m em ory of a ll o fth e even ts. H e sh ow ed sym p tom s typ ica l o f typ e I traum a.

F o llow in g h is s is ter s death in tran sp lantation surgery 2years after th e a ccid ent, th e b oy b egan to retreat from hisfr iend s , avo id pa rtic ip ating in c lass, and stay silen t m uch ofth e tim e . H is teach ers com p la in ed abou t h is extrem e pa ss iv -ity an d sa id he w as losin g g ro und in su b jects in w h ich h e h ada lready proved h im se lf. H e lost som e w eigh t and stoppeds leep ing th rough th e n igh t. H e lost h is p layfu ln ess and b eganlos ing h is fr iends . H is 2 years of m ou rn in g had in troducedtype II ch aracter istic s in to a p rev ious ly pu re type I d iso rd er .

Ch ildhood D isfig u rem en t, D isab ility , and Pa in

C h ild ren w ho are physica lly in ju red in psych ica llytraum atic acc id en ts tend perp e tua lly to m ourn o ldse lves, p ersona s th at w ere p rev iou sly in tac t and per-fec t. E v en w hen p erp etua l gr ie f is n ot the prob lem ,po sttraum atic phys ica l h and icap s frequ en tly d em andcon sid erab le person a lity reorgan ization in ord er tha tth e ch ild can live w ith a n ew , lim ited se lf. In ch ildren ,ch aracter rea rrangem en ts m ay b ecom e m assive . T od ea l w ith th e pa in and p ro cedu res a ccom pany in g trau-m atic acc id en ts, ch ild ren m ay em p lo y se lf-hypnosis .They m ay exp er ien ce se lf-revu lsion , un rem itt in g gu ilta nd sham e, im poten t ra ge a t th eir p eers w ho shun andtea se th em , and sadness. Su ic id e a ttem p ts are not in -frequ ent in th is g roup . R ober t S to ller suggested in arecen t paper that som e extrem es of adu lt sad om aso ch -istic b eh av ior m ay or ig ina te in p a in fu l illnesses , in ju -r ies , a nd procedures du rin g ch ildh ood . R ather th anse lf-hypnotiz in g , th ese ch ild ren m ay divert th em selvesfrom th e pa in by se lf-stim ulatin g-and thus perp etu-a lly assoc ia te the ir p a in w ith sexua lity (39). Ch i ldhoodsyndrom es o f in jury and shock do no t con sisten tlyqua lify , und er DSM-II I -R cr iter ia , as posttraum atics tress d isorders (4 0). Bu t th ese m ixed syndrom es ofd epress ion , num b ing , ra ge , and fr igh t o ften ca rrym any o f th e fou r cha rac ter istic s th at I assoc ia te w ithch ildhood traum as. A d ju s tm en t to a sudden su rp r ise ,coup led w ith a p ro long ed ord ea l, o ften lie s a t th e or -ig in of th e prob lem .

A k ind ergartn er c lim bed on to a large d epartm ent s tored isp lay tab le , caus in g it to fa ll o ver on to h er face as h ergrandm oth er p a id th e c lerk fo r a purchase . The ch ild s fac ia lb on es w ere sm a sh ed , and a lthough they w ere beau tifu lly re -con stru cted , she look ed qu ite d if feren t th an she had beforeth e acc iden t. O ld fr iend s d id no t recogn ize h er , a nd oth er


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Am J P sych ia try 1 48:1 , J anuary 1991 19

k ind erg ar tn ers to ld the ch ild th a t sh e m us t b e p re tend ing tob e B elinda-sh e cou ld not ac tu a lly be Bel inda .

The litt le g irl, p rev iou sly ou tgo in g , m isch ievou s, and v iva -c iou s, took on a quie t, rem ote , and p erfect ly w ell-b ehavedm ode of behav ior . Tw o years a fter the acc iden t sh e sa id , Iw as a d ev il b e fore , bu t I w as pun ish ed for it. N ow Im good .D esp ite the fact th at sh e exp er ien ced bad d ream s, lik ed top lay a lone under cha irs , and tend ed to m u tila te h er do lls fa ces, B e lindas charac ter change dom inated a ll o th er post-traum atic find ing s.

S UMMARY

There appears to b e a g roup of p rob lem s brough t onin ch ildhood by th e exp er ien ce of ex trem e fr igh t gen -era ted by ou tsid e even ts . S om e o f th ese ch ildhoodprob lem s a re crea ted by on e externa l sh o ck , and oth ersa re crea ted by a m u ltip lic ity o f b low s. U n trea ted , a llbu t th e m ild est o f th e ch ildhood traum as la st for y ea rs .T h e ch ild s respon ses, in fa c t, m ay create a num ber ofd ifferen t k ind s o f p rob lem s in adu lt life . T h ere are fou rcharac ter ist ics , h ow ever , th at seem to a ffect a lm ost ev -eryone sub jec ted to ex trem e terrors in ch ildhood .T hese find in gs seem to last and can be retr iev ed inhis tor ies . They in clud e rep ea ted v isu a liza tio n s or oth erre tu rn in g p ercep tion s, rep ea ted b ehav iors and bod ilyresp on ses , traum a -sp ec ific fears, and rev ised id easabou t p eop le , life , and th e fu tu re. T hese fou r find in gsappea r to rem a in c lu stered tog eth er in ch ildhoodtraum a vic t im s ev en w hen o th er d ia gnoses seem m oreappropr ia te . L ike rh eum atic fev er , ch ildhood traum acrea te s changes th at m ay even tua lly lead to a num bero f d ifferen t d ia gnoses. B u t a lso lik e rh eum atic fev er ,ch ildhood traum a m ust a lw ays b e k ep t in m ind a s apossib le under ly in g m echan ism when th ese var iou scond it ion s appea r .

If on e tak es a ll o f th e d isord ers o f ch ildhood brough ton by extrem e ex terna l even ts and pu ts th em in to th eg en era l ca tego ry of traum a , th ey can be rough ly sub -d iv id ed in to tw o group ings : ty p e I, w h ich is b rough ton by one sudden shock , and typ e I I, w h ich is p rec ip -ita ted by a ser ie s o f ex terna l b low s. C ro ssov er cond i-t ion s are qu ite comm on and dev e lop w hen one b lowcrea te s a long -stand ing ser ie s o f ch ildhood adversitie s .

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terr childhood trauma

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