Developments in Art Therapy for Mental Health

What Words Can’t Express 

The process of making art, like literature, has long been shown to have mental and emotional health benefits. The APA describes art therapy as a type of psychotherapy that helps provide a way to express emotions and experiences not easily expressed in words.[1] The artist Georgia O’Keeffe said, “I found I could say things with color and shapes that I couldn’t say any other way – things I had no words for.” 

The American Art Therapy Association explains that art therapy includes active art-making, the creative process, and applied psychological theory - within a psychotherapeutic relationship - to enrich the lives of individuals, families, and communities.[2] Furthermore, art therapy is used to foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills and reduce conflicts and distress. Although art therapy has been used to treat a range of mental health disorders including anxiety and depression, this type of therapy is particularly applicable to survivors of trauma because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often “wordless and visual nature of traumatic memories.”[3]

MechanismS of Art Therapy  

Art therapy engages the mind, body, and spirit in ways that are distinct from verbal communication. In an article published in the Journal of the American Art Therapy Association, Lusebrink 2010 differentiates art therapy from verbal therapies by the use of art media as a means of expression and communication, the multileveled meaning present in visual expressions, and the therapeutic effects of the creative process.[4] In a schematic framework known as the Expressive Therapies Continuum (ETC), three distinct levels (kinesthetic/sensory, perceptual/affective, and cognitive/symbolic) reflect different functions and structures in the brain that process visual and affective information.[5]  

This is particularly useful because the art therapist can first assess the client’s cognitive and emotional functioning through these different ETC levels in order to better address their strengths, challenges, and progress in art therapy. For example, Hendler et al. (2001) found that in individuals with post-traumatic stress disorder (PTSD), affectively-charged visual stimuli activate limbic regions and sensory areas of the cerebral cortex but not the prefrontal area. This is significant, as visual processing within non-PTSD individuals does include the prefrontal cortex which is critically involved in the emergence of conscious visual perception. On the other hand, client areas of strength would constitute a lack of difficulty in processing visual information on particular levels of the ETC. This framework is useful for helping art therapists determine where the “missing links'' are in terms of the sequence of visual information processing. 

These assessments can act as guidelines for starting points, pathways, and goals in art therapy.[6] The range of kinesthetic, sensory, perceptual, and symbolic opportunities also allow clients to practice and create alternative modes of expressive communication, which can help circumvent the limitations of language.[7] 

Art Therapy Sessions 

Though one can always choose to pursue the arts on their own time to calm and relax the mind, formal art therapy sessions are typically carried out by licensed clinicians, master's-level or higher degree holders trained in art and therapy work. Art therapists work with diverse populations in a variety of settings including hospitals, schools, veterans’ clinics, private practice and psychiatric and rehabilitation facilities.[8] One may choose to engage in a private art therapy session or a group setting with other individuals. 

Before beginning, it is important for the therapist to emphasize that the client does not need to be artistically or creatively inclined to benefit from this process. During a typical session, clients will engage in both art-making and meaningful conversation with the therapist.[9] The therapist's main goal is to describe the goal of art therapy, help the client choose an appropriate medium for expression (e.g., collage, painting, sculpture, drawing), and prompt the client with questions which will shape and guide the art making session. At the conclusion of the session, the therapist and client will debrief. To make sense of the process, they may collaboratively discuss any emotions and feelings that arose during the art making process, the work of art itself and its potential meanings, as well as plans for future sessions.[10] 

Applications for Addressing Trauma 

Art therapy has historically been used to address and treat trauma for a variety of reasons. Art is an effective means of expressing past trauma from a safe environment; it provides emotional distance from the actual event and provides an alternative outlet to confront unresolved trauma memories through the use of symbols and visual media. Additionally, PTSD UK notes how new research has found that art therapy fosters a mind-body connectedness and allows the brain to use mental and visual imagery.[11]

In 2016, Campbell et al. (2016) conducted research to examine the impact of art therapy on those with combat-related PTSD. They administered a series of art therapy sessions in which participants engaged in creating a visual trauma narrative, mapping representations of their emotions, making images of the self before and after the trauma and creating final reflective art pieces. Results from a depression scale score showed that although not statistically significantly different, a trend toward greater reduction in depression symptoms for the test group compared to the control was noted.[12] Although these quantitative measures did not show statistical significance, a more recent study by Berberian et al. (2019) examined the qualitative outcomes of art therapy, or more specifically, montage painting, for active-duty military service members with traumatic brain injuries or PTSD. They found that group art therapy elicited improvement in interpersonal relatedness, as well as the expression of hopefulness and gratification. Art therapy allowed the individuals to work toward creating an individual trauma narrative which is a key component for recovery and healing.[13]

Aside from veterans and active-duty military service members, PTSD within children and early relational trauma has also been addressed through art therapy. Individuals who have experienced trauma at a young age show increased levels of suicide, alcohol addiction, and/or drug addiction later in life, thus art therapy is especially valuable as an early intervention for children who have been exposed to trauma in a variety of contexts and in different forms (e.g., witnessed or experienced gang violence, bullying, loss and grief, domestic abuse, suicide, homelessness, and drug abuse).[14] A study conducted by Woollett et al. (2020) invited school-aged children and their mothers in domestic violence shelters to participate in a pilot study aiming to integrate trauma-informed art and play therapy with traditional cognitive behavioral therapy (CBT). From baseline levels, children's depressive symptoms showed significant reduction and improvement in PTSD symptoms.[15] 

Another specific context which art therapy has been applied to is early relational trauma. This type of trauma is distinct from post-traumatic stress disorder in its emphasis on childhood abuse, various forms of neglect, and other neurological effects that occur during a specific time period when the developing brain was exposed to prolonged trauma.[16] Art therapy can be particularly helpful for early relational trauma clients who exhibit anger and frustration as they struggle to confront and articulate their emotions. The art they make is a non-verbal activity that reflects, mirrors and amplifies expression of the client's internal state of affects. A study by Chong (2015) presented a collection of clinical vignettes in which she notes that school-aged children with early relational trauma showed improvement in dimensions such as confidence, attention span, and the formation of positive relationships in school settings.[17]

Within communities of all ages and backgrounds, art therapy is a flexible, effective and low-intensity intervention for individuals dealing with trauma which can cultivate a greater sense of creativity, empowerment, and independence while fostering a healthy psychosocial relationship with themselves and others.[18] 

If you or someone you know would like to learn more about art therapy and how to incorporate it into your own life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 (2020, January 30). Healing Through Art - APA Blogs - Patients and Families. American Psychiatric Association. https://www.psychiatry.org/news-room/apa-blogs/healing-through-art#:~:text=Art%20therapy%2C%20a%20type%20of,the%20process%20of%20making%20art 

2 American Art Therapy Association. (2014). American Art Therapy Association. https://arttherapy.org/ 

3 Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20(1), 114–130. https://doi.org/10.1080/15299732.2018.1502712 

4 Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy, 27(4), 168–177. https://doi.org/10.1080/07421656.2010.10129380

5 Expressive Therapies Continuum: Three-Part Healing Harmony | Psychology Today. (December 30, 2018). Www.psychologytoday.com. https://www.psychologytoday.com/us/blog/arts-and-health/201812/expressive-therapies-continuum-three-part-healing-harmony 

6 Lusebrink (2010) 

7 American Art Therapy Association 

8 Ibid. 

9 Homepage - The British Association Of Art Therapists. (2022, September 26). The British Association of Art Therapists; BAAT. https://baat.org/ 

10 What Is Art Therapy? | Psychology.org. (2022, February 15). Www.psychology.org. https://www.psychology.org/resources/what-is-art-therapy/#:~:text=During%20a%20session%2C%20an%20art 

11 How art therapy has helped those with PTSD – PTSD UK. (n.d.). https://www.ptsduk.org/how-art-therapy-has-helped-those-with-ptsd/ 

12 Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial. Art Therapy, 33(4), 169–177. https://doi.org/10.1080/07421656.2016.1226643 

13 Berberian, M., Walker, M. S., & Kaimal, G. (2018). “Master My Demons”: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Medical Humanities, 45(4), 353–360. https://doi.org/10.1136/medhum-2018-011493 

14 Helping Kids Cope with Trauma. (October 20, 2017). Cedars-Sinai. https://www.cedars-sinai.org/blog/art-therapy-helps-children-cope-with-trauma.html#:~:text=Art%20therapy%20teaches%20kids%20how 

15 Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107(1), 104564. https://doi.org/10.1016/j.chiabu.2020.104564 

16 Terradas, M. M., Poulin-Latulippe, D., Paradis, D., & Didier, O. (2020). Impact of early relational trauma on children’s mentalizing capacity and play: A clinical illustration. European Journal of Trauma & Dissociation, 100160. https://doi.org/10.1016/j.ejtd.2020.100160 

17 Chong, C. Y. J. (2015). Why art psychotherapy? Through the lens of interpersonal neurobiology: The distinctive role of art psychotherapy intervention for clients with early relational trauma. International Journal of Art Therapy, 20(3), 118–126. https://doi.org/10.1080/17454832.2015.1079727 

18 Boyadjis, A. (2019). Healing the Child Through Expressive Arts Therapy. https://minds.wisconsin.edu/bitstream/handle/1793/79197/Boyadjis%2C%20Andrea%20Thesis%202019%20compiled.pdf?sequence=1&isAllowed=y 

Addressing Mental Health Amongst First Responders: Sometimes Superheroes Need Saving, Too

Hidden Anguish

First responders play a vital and commendable role in society as they display exceptional bravery to save the lives of others, often at the risk of their own. Many first responders encounter unimaginable tragedy and horror on a daily basis, and then are expected to go home and attend to their loved ones. However, separating work from personal life may not be so easy for these individuals as the impact that traumatic events can have on one’s mental health is often left unacknowledged. Frequent exposure to death and tragedy undoubtedly affects one’s psychological state of well-being, including post-traumatic stress disorder (PTSD), substance abuse, depression and especially suicidal ideations. However, along with the societal expectation of first responders to be brave and strong, comes the suppression of such mental health problems and lack of proper psychiatric treatment.[1] 

Risk factors & Causes 

In comparison to the general population, first responders such as law enforcement officers (LEO), emergency medical technicians (EMT), and firefighters are at a greater risk of suicide ideation and suicide. Stanley et. al. (2016) conducted a systematic review of 63 quantitative studies examining the suicidal thoughts, behaviors, and fatalities of first responders, and found them to be at a significantly higher risk than general population samples.[2] Bond & Anestis (2021) conducted a study which showed that 23-25% of LEOs and 46.8% of firefighters experience suicidal ideations, and 10.4% of EMTs report severe lifetime suicidal ideation.[3] Frequent and severe traumatic experiences also lead to a higher risk of PTSD. Approximately 32% of LEOs, 22% of EMTs and 32% of firefighters experience PTSD. In comparison to the general civilian population, out of whom only 7-12% experience PTSD, these rates are concerningly high. There are also various risk factors amongst first responders that can contribute to their increased risk of developing PTSD, including:[4]

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

Proper sleep hygiene (due to long and demanding shift schedules) also plays a role in the increased rates of disorders such as PTSD, depression, and anxiety. A longitudinal study conducted by Feldman et al. (2021) included 135 emergency medical service providers and recorded changes in symptoms of various psychological disorders over the course of 3 months. Their findings revealed that the increase in symptoms of PTSD, depression, and anxiety were all correlated with a poor sleep pattern and lower social support.[5] Erratic sleep patterns are especially problematic given that they compromise inflammatory and physiological stress responses.[6]

Acute stress disorder (ASD) is another common psychiatric disorder among first responders who experience frequent and high-impact stressors. A few pertinent symptoms of this disorder include:[7]

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

ASD is developed once an acute stress response leads to more serious impairments after exposure to a traumatic stress with documented biological or psychological sequelae. Within 3 days of the traumatic event, multiple symptoms within five diagnostic categories will appear. ASD is signified by persistent symptoms well beyond the time frame of an acute stress reaction, which is more common and normal for anyone who experiences a traumatic event. While first responders who are acutely impacted by a trauma may develop ASD, developing ASD puts them at a greater risk for subsequently developing PTSD.[8]

The Three-Step Theory 

Not only do first responders experience greater rates of suicidal ideations, but they are also more likely to actually perform suicidal attempts.[9] Ideation-to-action is outlined by the Three-Step Theory (3ST), which states that there are three subcategories of capability that can shift an individual from suicidal thoughts to actual suicidal actions. These subcategories include:[10]

1. Practical - Broader knowledge of lethal weapons/drugs, and potentially even better access to them. The means of suicidal means are more readily obtainable. 

2. Dispositional - Innate tolerance to death and pain. 

3. Acquired - Learned desensitization and tolerance to death and pain. Having encountered numerous tragic events has built a sense of fearlessness in many first responders.

Suffering in Silence

Since a large majority of first responder suicides go unreported by mainstream media, there is an ongoing lack of knowledge/awareness of the general public to the degree that it occurs.  In addition, barriers exist that prevent first responders from accessing the proper psychiatric care they need when experiencing depression or suicidal ideations. Such barriers include shame and stigma surrounding mental health issues within their professions, as the concept of bravery and courage is heavily instilled upon them during training and work. Moreover, first responders and their families often fail to have open discussions about mental health, which unfortunately fuels the lack of awareness on the issue of first responder suicide.[11] 

Even when a first responder recognizes they are in crisis, several factors often prevent them from seeking adequate help: lack of knowledge on where/how to seek help, fear of confidentiality breach, belief that they cannot show weakness, lack of access and availability to therapy, family burden, pride and denial.[12] Destigmatizing mental health issues and spreading awareness is the first crucial step to ensuring that first responders are able to comfortably and willingly ask for help.[13] First responders should also be informed about mental health disorders and how to facilitate help-seeking.[14]

First responders are often expected to prevent their traumatic experiences from interfering with their professional and personal lives. The culture of first responders may prevent them from seeking actual mental health interventions, due to stigma and self-image. However, doing so often leads to unhealthy coping mechanisms such as substance abuse and high-risk behavior as an outlet for their stressors. Some also practice avoidance, leading to absenteeism in work and home, causing tension with their personal relationships. Conflict may even arise between colleagues, as high-stress environments and internal stressors combine together to create overall tension in the workplace. Therefore, psychoeducation to reduce stigma and subcultural barriers could help encourage first responders to seek treatment. This would eventually remediate their own psychological health and mend other impacted professional and personal relationships in their lives.[15] 

Building Resilience 

High resilience has been shown to be associated with lower symptomology of PTSD, depression, and alcohol abuse in active first responders. Therefore, resilience screening can help to protect the long-term mental health of first responders. High resilience indicates the ability to better tolerate problems, illness, failure, pressure, and feelings of pain.

These adaptive qualities of resilience can be developed in first responders via targeted interventions, including cognitive behavioral therapy (CBT) and mindfulness training programs. These two methods have been proven effective in increasing adaptive resilience amongst health professionals, factory workers, civil servants, and even breast-cancer patients. Employing resilience screening as a first responder begins work, one can identify which workers can most benefit from these targeted interventions to increase resilience, thus decreasing their chances of developing debilitating psychological disorders.[16] 

Thompson and Drew (2020) developed a 21-day program to enhance first responder resilience and tested the program with promising results. Every day over the course of 21 days, participants received a keyword which encouraged them to follow certain practices for the day, such as grit, calm, empathy, and gratitude. They also did 5 minutes of controlled breathing exercises, short readings on the keywords, reflections for the day, and an evening gratitude practice. Gratitude was incorporated into the program to increase sleep quality, life satisfaction, and decrease risk of depressive symptoms. In total, the practice work took only 15 minutes a day, accounting for the busy schedules of typical first responders. The participants responded to the 21 day course well, and a majority indicated that they would continue to use the practices they learned during the course of the program.[17]

Programs such as this one, and other resilience programs, would be beneficial for all first responders to incorporate into their lifestyles to increase resilience against developing mental health issues, promote the necessity of managing one’s mental health and reduce stigma in those suffering with PTSD, depression, anxiety and other work-related mental health disorders. 

If one has been suffering from any mental health disorder due to traumatic stress, such as PTSD or ASD, or is experiencing feelings of heightened anxiety or suicidal ideations, it is crucial to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Heyman, M., Dill, J., & Douglas, R. (2018, April). The ruderman white paper on mental health and suicide of first ... https://firefightermentalhealth.org/system/files/First%20Responder%20White%20Paper_Final.pdf 

2 Stanley, I., Hom, M., & Joiner, T. (2015, December 12). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, emts, and Paramedics. Clinical Psychology Review. https://www.sciencedirect.com/science/article/abs/pii/S0272735815300684?via%3Dihub 

3 Bond, A., & Anestis, M. (2021, October 26). Understanding capability and suicidal ideation among first responders. https://www.tandfonline.com/doi/full/10.1080/13811118.2021.1993397 

4 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard review of psychiatry, 26(4), 216–227. https://doi.org/10.1097/HRP.0000000000000176 

5 Feldman, T. R., Carlson, C. L., Rice, L. K., Kruse, M. I., Beevers, C. G., Telch, M. J., & Josephs, R. A. (2021). Factors predicting the development of psychopathology among first responders: A prospective, longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 75–83. https://doi.org/10.1037/tra0000957 

6 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

7 Ibid.

8 Ibid.

9 Bond, A., & Anestis, M. (2021, October 26). 

10 Heyman, M., Dill, J., & Douglas, R. (2018, April).

11 Stanley, I., Hom, M., & Joiner, T. (2015, December 12).

12 Jones S, Agud K, McSweeney J. (2020) Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness.” Journal of the American Psychiatric Nurses Association. 26(1):43-54. doi:10.1177/1078390319871997

13 Heyman, M., Dill, J., & Douglas, R. (2018, April).

14 Jones S, Agud K, McSweeney J. (2020)

15 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

16 Joyce, S., Tan, L., Shand, F., Bryant, R., & Harvey, S. (2019). Can resilience be measured and used to predict mental... : Journal of Occupational and Environmental Medicine. LWW. https://journals.lww.com/joem/abstract/2019/04000/can_resilience_be_measured_and_used_to_predict.4.aspx 

17 Thompson, J., & Drew, J. M. (2020, July 27). Warr;OR21: A 21-day program to enhance first responder resilience and mental health. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02078/full 

The Unseen Wounds of Dating Violence on Mental Health

Silent Scars

Dating violence is a pervasive issue that inflicts profound wounds on victims, both visible and hidden. The National Coalition Against Domestic Violence reports that 1 in 3 women and 1 in 4 men have experienced intimate partner physical violence such as slapping, injury and sexual abuse.[1] These issues can be difficult to notice from the outside of a relationship, allowing abuse to continue while mental scars shape victims' psychological and physical well-being. The connections between dating violence, abuse, and mental health shed light on the silent struggles endured by survivors.

The Spectrum of Abuse

Abuse in dating relationships takes on various forms - from physical violence to emotional manipulation, coercion, and even digital harassment. The dynamic that leads to violence in a relationship is a power imbalance when one person gains power and control over the other.[2] This may take the forms of threats, intimidation, financial abuse, stalking and isolation[3] and this multifaceted spectrum of dating violence can leave victims feeling trapped in a cycle of abuse. Dating violence shatters victims' sense of security, trust, and self-worth, planting the seeds for lasting mental health challenges. 

Examples of the warning signs of abusive behaviors include:[4]

• Using force or coercion to initiate sexual activity

• Attempting to isolate one from their family or friends

• Using threats

• Breaking objects, creating noise or yelling to establish intimidation 

• Having a history of abuse in past relationships 

• Expressing control financially (refusing for a partner to work)

• Expressing control over where a partner goes, what they wear, who they speak to...

• Frequent mood swings and shifts when in public compared to in private

• Constant jealousy 

Erosion of Emotional Well-being

The emotional toll inflicted by dating violence relates to poor mental health outcomes. Adolescent dating violence is particularly prevalent (i.e., 1 in 3 adolescents have experienced an abusive or unhealthy relationship) and is a predictor of partner violence as an adult.[5,6] Pérez-Marco et al. (2020) note that adolescents characterized dating violence as psychological, sexist, and verbal types of violence.[7] For example, blackmailing or damaging a partner’s dignity are examples of psychological violence.[8] Further, Piolanti et al. (2023) note that adolescent dating violence contributes to increased risk-taking behaviors such as marijuana and alcohol use, and negative mental health such as victimization, a common result of physical or emotional abuse.[9] These poor outcomes were more common among females when compared to males. Additionally, among 116 married women experiencing domestic abuse, Malik et al. (2021) found that abuse was associated positively with depression, anxiety and stress.[10] Domestic abuse was also related to a decreased quality of life.[11] The constant undercurrent of fear, anxiety, and uncertainty from degradation and physical attacks can erode victims' emotional well-being and even skew the perception of their relationship as being “normal” amidst high psychological distress.

Emotional abuse is related to:[12]

• Social anxiety

• Depression 

• Eating disorders

• Post Traumatic Stress Disorder (PTSD)

• Chronic pain

• Shame

• Self-doubt

• Low self-esteem

• Codependency 

Complex Trauma & Misconceptions of Dating Violence

Exposure to dating violence often inflicts complex trauma, or unique forms of psychological injury that can lead to enduring emotional and mental turmoil. The patterns of abuse – the relentless cycle of tension, explosion, and reconciliation – carve a pattern of fear in victims' minds. Complex trauma can manifest as post-traumatic stress disorder (PTSD), anxiety disorders and depression.[13] From an external perspective, relationship violence is commonly misunderstood as bystanders may question why a victim stays in their violent relationship if they are being abused. It is so easy to ask, “Why don’t they just leave?”[14] However, there is a deep manipulative aspect to dating violence that maintains a harmful cycle.

De Sousa et al. (2023) found that among participants ages 15-22 in relationships, control tactics were predominantly isolation, domination, and emotional manipulation.[15] These controlling dynamics establish heavy power imbalances that lead to both a bystander's and a victim's blindness to the harm of a relationship. For example, an abusive partner may conceal their violent tendencies when in public or around peers, but when in private with their partner, inflict abuse. The victim may even develop learned helplessness, in which they have repeatedly experienced violence and eventually stop resisting or trying to change the uncontrollable circumstance. Additionally, it is common for victims to find comfort in their abusive relationship, as they are manipulated to believe that they abuse because their partner “loves them,” as Shawn Guy writes for Genesis Women’s Shelter in an article about teen dating violence.[16] This occurrence is sometimes referred to as Stockholm syndrome, or the psychological response of a positive connection to an abuser.[17]

The Path to Recovery: Empowerment and Support

Victims of dating violence find it challenging to escape their abusers. Feelings of shame, guilt, and societal stigma can create barriers to seeking help. Additionally, financial dependence and isolation enforced by abusers can make it difficult for victims to end relationships.

Professional help through therapy can help survivors regain a sense of agency and control over their lives to minimize the long-term effects of abuse and trauma. For example, Karakurt et al. (2022) found that cognitive-behavioral therapy (CBT), mindfulness, motivational interviewing and expressive writing have led to successful results in increasing empowerment among women who had experienced intimate partner violence.[18] These modalities lowered stress and depressive symptoms, as well.[19]

Empowerment becomes a sign of hope as victims rebuild their self-worth as Pérez-Marco et al. found that empowerment skills were an effective resource to combat negative outcomes of abuse.[20] Treatment for perpetrators of domestic violence is less researched, but also integral to preventing relationship violence and subsequent mental health challenges. Taking into consideration social, societal and developmental contexts may be involved in methods to address high levels of violence exhibited by abusers as well as equitable access to treatment.[21,22]

Dating violence and abuse result in devastating impacts on victims' mental health, inflicting trauma that may never fully fade without proper intervention. By amplifying awareness, education, and access to mental health resources, society can stand against the silent scars left by dating violence and empower survivors on their journey toward recovery.

If one is experiencing any form of abuse or mental health challenges due to a relationship, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Coalition Against Domestic Violence. National Statistics. https://ncadv.org/STATISTICS#:~:text=NATIONAL%20STATISTICS&text=On%20average%2C%20nearly%2020%20people,10%20million%20women%20and%20men.

2 Washington University in St. Louis. (2023). What is Relationship and Dating Violence? https://students.wustl.edu/relationship-dating-violence/

3 Ibid.

4 Ibid.

5 Liz Claiborne Inc and The Family Fund. Teen Dating Abuse 2009 Key Topline Findings. http://nomore.org/wp-content/uploads/2014/12/teen_dating_abuse_2009_key_topline_findings-1.pdf 

6 Piolanti, A., Waller, F., Schmid, I. E., & Foran, H. M. (2023). Long-term Adverse Outcomes Associated With Teen Dating Violence: A Systematic Review. Pediatrics, 151(6), e2022059654. https://doi.org/10.1542/peds.2022-059654 

7 Pérez-Marco, A., Soares, P., Davó-Blanes, M. C., & Vives-Cases, C. (2020). Identifying Types of Dating Violence and Protective Factors among Adolescents in Spain: A Qualitative Analysis of Lights4Violence Materials. International journal of environmental research and public health, 17(7), 2443. https://doi.org/10.3390/ijerph17072443

8 Ibid.

9 Polanti et al. (2023)

10 Malik, M., Munir, N., Ghani, M. U., & Ahmad, N. (2021). Domestic violence and its relationship with depression, anxiety and quality of life: A hidden dilemma of Pakistani women. Pakistan journal of medical sciences, 37(1), 191–194. https://doi.org/10.12669/pjms.37.1.2893

11 Ibid.

12 Telloian, C. (2023, March 23). What Are the Effects of Emotional Abuse? https://psychcentral.com/health/effects-of-emotional-abuse#relationship-impacts 

13 PTSDuk. (2023). Causes of PTSD: Domestic Abuse. https://www.ptsduk.org/what-is-ptsd/causes-of-ptsd/domestic-abuse/

14 Ibid.

15 De Sousa, D., Paradis, A., Fernet, M., Couture, S., & Fortin, A. (2023). "I felt imprisoned": A qualitative exploration of controlling behaviors in adolescent and emerging adult dating relationships. Journal of adolescence, 95(5), 907–921. https://doi.org/10.1002/jad.12163

16 Guy, S. (2020, October 19). When Love is Blind: What Teens Don’t See in an Abusive Relationship. https://www.genesisshelter.org/when-love-is-blind-what-teens-dont-see-in-an-abusive-relationship/

17 Cleveland Clinic. (2022, February 14). Stockholm Syndrome. https://my.clevelandclinic.org/health/diseases/22387-stockholm-syndrome

18 Karakurt, G., Koç, E., Katta, P., Jones, N., & Bolen, S. D. (2022). Treatments for Female Victims of Intimate Partner Violence: Systematic Review and Meta-Analysis. Frontiers in psychology, 13, 793021. https://doi.org/10.3389/fpsyg.2022.793021

19 Ibid.

20 Pérez-Marco, et al. (2020)

21 Oğuztüzün, Ç., Koyutürk, M., & Karakurt, G. (2023). Characterizing Disparities in the Treatment of Intimate Partner Violence. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2023, 408–417. 

22 Wexler D. B. (1999). The broken mirror. A self psychological treatment perspective for relationship violence. The Journal of psychotherapy practice and research, 8(2), 129–141. 

Wounds Outside of Combat: Sexual Trauma in the Military

Sexual Violence: A Prevailing Issue

Sexual violence persists within all branches of the armed forces and in recent years, reports of sexual assault and harassment have garnered national attention. Sexual harassment and assault are also more prevalent within the military than in the majority of civilian organizations. While the armed forces progress in addressing this challenging issue, understanding sexual violence in a military context offers a lesser-known perspective on sexual trauma’s challenges.

In 2020, Fort Hood specialist Vanessa Guillen was assaulted and killed by a fellow soldier within her chain-of-command. This event was one of many that year that increased visibility on issues in the armed forces’ efforts against sexual violation. Even before Vanessa Guillen’s murder, the military was under pressure to improve their culture and overcome rampant reports of sexual assault. In 2004, a Department of Defense (DOD) task force aiming to provide resources to sexual assault survivors made recommendations for systematic changes to better support soldiers who experience sexual violence.[1] Those recommendations included developing a central point of accountability and a unified response system.[2] A year later, the military acknowledged that mandating commanders to be notified of crimes of sexual violence was a deterrent to soldiers who feared retaliation from their supervisors, peers, assailant (all of whom have the potential to be the same person) after reporting and removed this requirement.[3] The task force concluded their investigation by creating training on Sexual Assault Prevention and Response (SAPR) that has been led by the SAPR office, headquartered at the Pentagon. In the subsequent decades, the DOD and Department of Veteran Affairs have continued implemented several policies to improve treatment, clarify reporting procedures and provide long-term support to sexual assault victims.[4]

In 2022, public backlash over the discovery of murdered soldiers at Fort Cavazos, Texas spurred the military to add sexual harassment as a crime under the Uniform Code of Military Justice (UCMJ).[5] Still, despite decades of efforts against sexual violence, in the last two fiscal years research conducted by the Department of Veterans’ Affairs reported an increase of soldiers who filed unrestricted reports after being sexual assaulted and/or harassed. According to a fiscal year 2022 report submitted by the Pentagon, the rate of sexual assaults had risen 1% from the previous year.[6] Officials maintain that the increase of sexual assault reports is a positive step toward addressing the cultural problem because it implies that soldiers have less of a fear of retaliation or ostracization.[7] However, for service members, their families and future recruits, this increase potentially signals that the military is still searching for an enduring solution to the corrosive issue of sexual violence.[8] 

Defining Military Sexual Trauma (MST)

Military sexual trauma (MST) is a term used by the armed forces and Veterans Affairs (VA) to refer to sexual harassment and/or sexual assault that occurs in the military. According to the Department of Veterans Affairs, MST is specifically defined as: physical assault of a sexual nature, battery of a sexual nature, or sexual harassment (unsolicited verbal or physical contact of a sexual nature which is threatening in character) which occurred while the former member of the Armed Forces was serving on duty, regardless of duty status or line of duty determination.[9] Unlike other organizations, the VA extends the definition of MST to sexual harassment to encompass both physical and verbal instances of sexual encounters to which service members did not consent.

Specific examples include, but are not limited to:[10]

• Being coerced or pressured into any kind of sexual activity (with the potential fear of negative repercussions if an individual does not consent, or promises any kind of advantage if they engage) 

• Any form of physical contact or action without consent, including when a person is in a state that renders them completely incapable of communicating (e.g., sleeping, sick, intoxicated)

• Being forced to engage in sexual activity through physical harm such as slapping, kicking, punching or assault with any form of a weapon

• Being touched or grabbed in a sexual way during hazing or training

• Any unwanted comments about a person’s body or sexual activities that they perceive to violate a personal boundary

• Sexual advances that are spoken, gestured, sent through the phone or online

Like the DOD, the VA acknowledges sexual harassment with similar gravity to sexual assault, implementing resources such a hotline, victim advocates, and VA police for any individual who seeks resources or wishes to file a report.[11]

Common Symptoms Post-Trauma

After a sexually traumatizing event, veterans experience elevated rates of mental disorders, physical ailments, and difficulty building interpersonal relationships.

Specific impacts on health include:

Mental  

MST survivors have a high lifetime rate of post-traumatic stress disorder (PTSD) for both men at women, at 65% and 45% respectively.[12] Veterans who report MST and have PTSD are also likely to have comorbid major depression, anxiety, eating disorders, and substance use disorders. MST also exacerbates pre-existing mental health conditions, worsening the symptoms of conditions prior to the trauma-inducing event.[13]

Physical

Sexual difficulties, chronic pain and/or gastrointestinal disease are common physical health problems for service members recovering from sexual assault and/or harassment. [14] Survivors’ cognitive function is also impaired - many recovering service members report reduced ability to pay attention, concentrate and remember details.[15]

Interpersonal Relationships  

In some cases, veterans who experienced sexual abuse harbor trust issues and have problems engaging in social activities and intimacy. Struggling to progress out of isolation, many survivors also report difficulties finding or maintaining work after their military service.[16]

Prevalence of MST in Different Groups

Regardless of a person’s socioeconomic gender, ethnicity or identity there is still a chance that they are vulnerable to predatory behavior and sexual violence. Surveys indicate that 1% of active duty men and nearly 5% of active duty women are victimized in any given 12-month period.[17] In another study conducted in 2016, researchers from the University of Mary Washington compiled statistics on veterans reporting military sexual trauma across the following databases: PsycINFO, PubMed, and PILOTS.[18] The results revealed that 15.7% of current military personnel and veterans report MST when the measure includes both harassment and assault.[19] Additionally, 13.9% report MST when the measure assesses only assault and 31.2% report MST when the measure assesses only harassment.[20] Across all military branches MST was significantly higher among veterans who reported using VA healthcare services.[21]

Women

Women are significantly more likely to experience and report MST than their male counterparts.[22] Roughly one-in-three women veterans have told their VA health care provider they experienced sexual harassment or assault while in the military.[23] Women with MST also have higher rates of PTSD than those with other traumas: 60% and 43%, respectfully.[24]

Men

Contrary to common misconceptions, men are also victims of sexual violence. Male service members have a 3.9% likelihood of reporting abuse when the measure includes both harassment and assault, and a 1.9% likelihood when the measure assesses only assault. Fearing judgment and alienation, male victims underreport sexual assault and/or harasment; Rossellini et al. (2017) note the true number of such men might exceed that of women, as men have a much lower rate of reporting to authorities than their female counterparts.[25] 

Ethnic Minorities

Ethnic minorities (particularly women of color) experience MST at greater levels than their Caucasian counterparts, with research conducted in 2023 at Washington University in St. Louis revealing that 21% of ethnic minority female veterans compared with 1% of ethnic minority male veterans have experienced MST.[26] Black women are also the most-likely to delay disclosure of MST.[27]

LGBTQ+

Research at Washington University in St. Louis also discovered that while non-LGBTQ service members report MST at a rate of 14%, those identifying as sexual minorities report MST at nearly twice the rate at 26%.[28] Experiencing the greatest rate of sexual harassment/assault, nearly 1-in-3 transgender service members (30%) report MST. 

Other Demographics

In a 2022 study conducted at Pennsylvania University, researchers found that those who experienced adversity or trauma during childhood were more likely to experience Military Sexual Trauma (MST) during their service (Auman-Bauer 2022).[29]

Other factors that exacerbate a person’s potential to be sexually assaulted or harassed in the military include:

• Age/young adults

• Having a low level of education

• Being unmarried

• Having a lower rank

• Being within their first contract of recently entered service         

Post-Trauma Care & Recovery

Peer support has emerged as a form of treatment that mitigates symptoms of loneliness and isolation, and is a common example of clinical care and support during an MST survivor’s journey through recovery. Organizations like the Women Veterans Network (WoVeN) and Veterans Sisters are examples of peer support with the mission to increase community and connection and provide resources for women veterans.

Penn State University researchers who identified the connection between MST and previous combat experience and childhood trauma propose screening service members prior to leaving the military in order to try to determine how to best treat them.[30] Under this proposal, the military hands the patients’ information off to the VA, to then provide specific trauma-informed care to service members who have experienced trauma as they transition out of active-duty.[31]

The mobile app Beyond MST provides self-help tips, assessments, and skills-based tools to support the health and well-being of MST survivors. Designed by the VA, this app comes at no cost, does not disclose a person’s personal information, and helps service members regain hope and heal.[32]

Post-MST Psychotherapy

The Veterans Affairs Office of Research and Development conducted a study in 2006 to determine which treatment methods were most effective in treating post-MST symptoms.[33] As the researchers determined, treating sexual violence in military settings is unique and departs from clinical approaches to civilian sexual trauma for two reasons: veterans with MST are likely violated by trusted military personnel and victims are often without access to immediate treatment.[34] Although MST treatments continue to evolve, effective therapies include Cognitive Behavorial Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), and narrative therapy. In certain instances, psychiatrists also prescribe anti-anxiety medication and/or anti-depressants.[35]

Brothers in Arms? Regaining Trust in the Military

As the armed forces continue to work to appeal to a younger generation, the slow improvement with addressing sexual assault has the potential to impact the number and diversity of recruits. In 2021 Secretary of Defense General (Gen.) Lloyd Austin established the Independent Review Commission on Sexual Assault in the Military to improve efforts in accountability, prevention, and victim care.[36] After receiving the commission’s results, Gen. Austin accepted every proposed policy change, and later remarked, “These investments are pivotal to restore the trust of our service members, as well as those considering military service.”[37] The accepted changes include increasing workers within the sexual assault response workforce, including victim advocates and sexual assault response coordinators.

Still, the military has added work to do before it fully controls the sexual assault and harassment within its ranks. In 2013, the investigative documentary The Invisible War earned critical and commercial success for shedding light on the pervasive issue of sexual assault in every military branch.[38] Featuring stories from over 25 soldiers, the documentary was groundbreaking in its final message: a female soldier in combat zones is more likely to be raped by a fellow soldier than killed by enemy fire.[39]

Although the film was made over a decade ago, this statistic still stands, and the victims of sexual assault carry symptoms of PTSD, agoraphobia, and depression - much like their counterparts who endured combat. According to the Rape, Abuse and Incest National Network, these destructive long-term physical, psychological, and social effects of sexual violence on the victims cannot be underestimated, and as veterans integrate into the civilian world, mental illnesses put them at higher risks of homelessness, unemployment, and suicide.[40] Leaders in and outside of the military continue to gain awareness into the emotional and mental impacts of sexual violence. However, the military must not only attempt to eliminate sexual violence by developing new policies and regulations - it must also address the intangible part of its culture that has allowed this violence to persist.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Department of Defense. Task Force Report on Care for Victims of Sexual Assault. National Center on Domestic and Sexual Violence Website. http://www.ncdsv.org/images/DOD_TaskForceReportOnCareForVictimsOfSexualAssault_4-2004.pdf

2 National Resource Center on Domestic Violence (NRCDV). (2021). Sexual violence in the military. NRCDV Website. https://vawnet.org/sc/sexual-violence-military-0

3 Ibid.

4 Ibid.

5 Chappell, B. (2022, January 27). Vanessa Guillen’s murder led the U.S. to deem military sexual harassment a crime. National Public Radio Website. https://www.npr.org/2022/01/27/1076143481/vanessa-guillen-murder-military-sexual-harassment-crime

6 Ware, D. (2023, April 28). Reports of sexual assaults increased in the Navy, Air Force, and Marines in 2022; Army saw a decline. American Legion Website. https://www.legion.org/news/258848/reports-sexual-assaults-increased-navy-air-force-and-marines-2022-army-saw-decline#:~:text=There%20were%208%2C942%20reports%20of,slight%20increase%20from%20last%20year

7 Ibid.

8 U.S. Department of Defense. (2022, September 2). DOD takes measures as sexual assault annual report numbers released. U.S. Department of Defense Website.https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

9  U.S. Congress. (2004). United States Code: Uniform Code of Military Justice, 38 USC 1720D: Counseling and treatment for sexual trauma. Retrieved from the Library of Congress, https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1720D&num=0&edition=prelim

10 U.S. Department of Veterans Affairs. (2023, May 18). Military Sexual Trauma. U.S. Department of Veterans Affairs Website. https://www.mentalhealth.va.gov/msthome/index.asp

11 U.S. Department of Veterans Affairs. (2022, December 12). VA’s Anti-Harassment and Anti-Sexual Assault Policy. U.S. Department of Affairs Website. https://www.va.gov/stop-harassment/policy/

12 Disabled American Veterans (DAV). (2023). What is Military Sexual Trauma? DAV Website. https://www.dav.org/get-help-now/veteran-topics-resources/military-sexual-trauma-mst/

13 Ibid.

14 Ibid. 

15 Ibid.

16 Ibid.

17 Bicksler, B., Farris, C., Ghosh-Dastidar, B., Jaycox, L.H., Kilpatrick, D., Kistler, S., Street, A., Tanielian, T., Williams, K.H. (2014).Sexual Assault and Sexual Harassment in the U.S. Military. Rand Corporation Website. https://www.rand.org/pubs/research_reports/RR870z2-1.html

18 Wilson L. C. (2018). The Prevalence of Military Sexual Trauma: A Meta-Analysis. Trauma, violence & abuse, 19(5), 584–597. https://doi.org/10.1177/1524838016683459

19 Ibid.

20 Ibid.

21 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

22 Wilson (2018)

23 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

24 Yaeger, D., Himmelfarb, N., Cammack, A., & Mintz, J. (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of general internal medicine, 21 Suppl 3(Suppl 3), S65–S69. https://doi.org/10.1111/j.1525-1497.2006.00377.x

25 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

26 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

27 Goldbach, J. T., Schrager, S. M., Mamey, M. R., Klemmer, C., Holloway, I. W., & Castro, C. A. (2023). Development and Validation of the Military Minority Stress Scale. International journal of environmental research and public health, 20(12), 6184. https://doi.org/10.3390/ijerph20126184

28 Ibid.

29 Ibid.

30 Bauer, K.A. (2022, August 24). Military sexual trauma more likely among veterans with prior adversity, trauma. Social Science Research Institute at the University of Pennsylvania Website. https://www.psu.edu/news/social-science-research-institute/story/military-sexual-trauma-more-likely-among-veterans-prior/

31 Ibid.

32 Galovski, T. E., Street, A. E., Creech, S., Lehavot, K., Kelly, U. A., & Yano, E. M. (2022). State of the Knowledge of VA Military Sexual Trauma Research. Journal of general internal medicine, 37(Suppl 3), 825–832. https://doi.org/10.1007/s11606-022-07580-8

33 Goldbach et. al (2023)

34 Suris, A.M. (2006). Treatment for veterans with military sexual trauma. VA Office of Research and Development. https://classic.clinicaltrials.gov/ct2/show/NCT00371644#contactlocation

35 Ibid.

36 U.S. Department of Defense. (2022, September 2). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. Department of Defense Website. https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

37 United States Air Force. (2022, September 5). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. United States Air Force Website. https://www.aflcmc.af.mil/NEWS/Article-Display/Article/3149016/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

38 Huval, R.I. (2013, May 10). Sen Kristen Gillibrand credits The Invisible War with shaping new bill. Public Broadcasting Station Website. https://www.pbs.org/independentlens/blog/sen-gillibrand-credits-the-invisible-war-in-shaping-new-bill/

39 Ibid.

40 Thurston, A. (2022, November 9). Why veterans remain at greater risk of homelessness. The Brink, pioneering research from Boston University Website. https://www.bu.edu/articles/2022/why-veterans-remain-at-greater-risk-of-homelessness/

Chronic Stress & Memory Erosion

The Bright Side of Stress?

Stress is a necessary human experience that keeps us alive.[1] It can be defined by the physical and mental responses we use to combat stressors experienced in our lives, such as threatening situations, insecurity, a tumultuous relationship or academic and work responsibilities.[2] We learn from previous stressors (e.g., avoiding sketchy alleyways we know of, or the signs of “red flags” in a relationship.) These adaptations are how short-term stress can beneficially inform our memory and subsequent learning. Stress-induced fears, anxieties and physiological signals cause us to react to danger or threats so that we know how to avoid a stressor again.

When the brain processes an imminent stressor, the sympathetic nervous system and hypothalamic-pituitary-adrenocortical (HPA) axis react to release adrenaline and glucocorticoids.[3] The sympathetic nervous system activates physiological responses for a fight or flight response. For example, pupils dilate and heart rate increases. The HPA axis regulates the stress response through structures such as the hypothalamus and hippocampus, an important structure for memory, via steroid hormones like cortisol.[4] By a negative feedback loop, the hippocampus’ cortical receptors are activated for the memory and biological learning of a stressful event.[5] As a result, memory is improved following an acute stress response so that our learning is improved for future similar stressful situations.[6,7] 

When Stress Becomes Problematic

While research indicates that short-term or acute stress can promote behavioral adaptations and improve spatial memory, in the same study by Lin et al. (2022), prolonged durations of stress led to behavioral and cognitive impairment in animal models.[8] Relatedly, in humans, long periods of stressful life events lead to cognitive and memory declines in older adults.[9] Additionally, prolonged (i.e., chronic) stress can increase risk of disease and mortality.[10,11] 

Chronic stress causes the body to be constantly out of balance (i.e., allostasis) in response to trying to restore balance (i.e., homeostasis) through energy expenditure.[12] The cumulatively created effect of chronic stress is referred to as allostatic load (when allostasis is repeatedly activated with a lack of adaptation or conclusion of the stress response.)[13] These chronic and repeated stress responses increase cortisol, which negatively affect components of memory (like navigation and long-term memory retention), and structurally damages neurons necessary for memory.[14,15] This leads the human body to be in a constant state of neurological disruption that is not restored, resulting in negative impacts on one’s memory.[16-22]  

Despite these negative health impacts, chronic stress remains an extremely common experience. According to the American Institute of Stress (2022), 94% of American workers say they are stressed at work while 55% of Americans report that they are stressed during any given day.[23] While some degree of stress in life is vital, an allostatic load can decrease well-being and cognition, and should be reduced to promote one’s health and overall life.

What Chronic Stress Looks Like

Chronic stress has particularly negative effects on the hippocampus (related to forming and sustaining memory), amygdala (related to emotional regulation) and neurons in the prefrontal cortex (related to problem-solving and planning).[24] Duman (2004) notes that by using physical restraints on rats, chronic stress was found to decrease neuron length and branching in the hippocampus.[25] Furthermore, increased glucocorticoid circulation leads to decreased neural plasticity (i.e., when neurons adapt and connect to process or establish information), and decreased growth of neurons in the hippocampus.[26] Brain-derived neurotrophic factor (BDNF) signaling, a marker of neural plasticity, is also reduced in the prefrontal cortex and hippocampus following chronic stress.[27] 

Chronic stress essentially impairs memory consolidation and retrieval, making reactivating and forming new information more difficult and less frequent.[28] Memory for spatial and navigating information was found to be impaired due to chronic stress, as well.[29] The body’s homeostatic regulation in response to a prolonged stressor additionally causes chronic neuroinflammation.[30] For these reasons, allostatic load leads to an increased risk of developing certain disorders such as post-traumatic stress disorder (PTSD), depression and neurodegeneration; these risks increase with age and cortisol levels.[31] 

Signs of chronic stress include:[32-34]

• Emotional dysregulation

• Decreased memory for events, general knowledge and navigation

• Social withdrawal

• Depressive symptoms

• Increased anxiety and constant worrying

• Fatigue or low energy

• Immune system dysregulation and impaired disease resistance

• High blood pressure

• Digestive problems

 When chronic stress becomes persistently life-impairing, it can be a significant factor in several disorders, such as those involving anxiety, emotional disruption and cognitive problems. Stress-related cognitive impairment is found in several conditions and disorders:

• PTSD symptom severity is associated with cognitive decline.[35] 

• Chronic stress is a risk factor for dementia.[36]

• In middle age, those with depression and high allostatic load have a higher risk of cognitive decline.[37] 

• Childhood psychological stress (i.e., childhood poverty) is associated with a greater risk for anxiety-related symptoms and allostatic load in adolescence and adulthood with intensity relating to the duration of the allostatic load.[38] 

• Impaired memory in depressed individuals is often attributed to chronic stress and its duration.[39]

Those with anxiety and mood disorders tend to experience psychological stress for lengthy periods. This is why high allostatic load is a factor for memory problems as the brain’s hippocampal neurons atrophy or degenerate and plasticity is disrupted by exhausted homeostatic energy expenditure. 

Perceptive Differences 

While individuals with mood or anxiety disorders are more vulnerable to chronic stress and memory impairment, stress responses can still vary by person and are not exclusive to those who experience such disorders. Chronic stress itself is also not a disorder, but a comorbid risk factor for memory impairment that can look different for everyone.

Internal beliefs vary per individual and are subjective, causing certain situations to be stressful to some and not to others, and leading to varied effects on memory. For example, students’ perceived high stress is found to be partially reliant on low self-efficacy (i.e., belief in self-success) and high emotional attention.[40] Additionally, high stress and cortisol levels lead to worsened memory performance such as declarative memory (i.e., memory for general knowledge and events), and cortisol is found to be in higher levels in females than males.[41,42] This is because cortisol levels are impacted by ovarian hormones such as estrogen.[43] Therefore, higher baseline cortisol levels may lead to high cortisol release when responding to stress.[44] For such reasons, cortisol administration is a way of inducing depression in animal models in addition to physical and social stressors due to chronic exposure. Other individual differences (such as age) may impact perceived stress as in older adults; egocentric stressors (e.g., self-health and financial stressors) were found to be detrimental to cognitive functioning as opposed to non-egocentric stressors.[45] 

Societal stressors may also impact the rate and intensity of the stressors that different groups face. For example, individuals of a sexual minority often experience increased impairment in psychosocial adaptation and overall quality of life likely due to negative stereotyping or stigma consciousness.[46] Menhinick & Sanders (2023) note that fear of violence is also an imminent physical stressor that many LGBTQ+ individuals and racial minorities experience, which can induce chronic stress, depression and PTSD.[47] 

Solutions to Mitigate and Overcome Chronic Stress

Several methods can be employed to tackle chronic stress. A social-psychological approach may look at the stressors that arise from social norms. From such a perspective, effortful social change can alleviate minority stress and threats, which removes the fault from the individual experiencing the neurological effects of stressors and targets the creation of the stressors themselves, such as violence and microaggressions arising from biases.[48] 

In terms of regenerating neurological functioning, Hernandez & Brinton (2022) found that allopregnanolone (a neurosteroid) may activate the GABA-chloride complex and can help to promote neurogenesis or the formation of neurons in the brain.[49] Relating to diet, Szala-Rycaj et al. (2023) found that chicory root insulin and topinambur powder, when supplemented long-term, can alleviate anxiety and cognitive disorder-like symptoms that were induced through chronic stress in animal models.[50] Additionally, Duman (2004) notes that antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been shown to reflect a reversal of neuron atrophy in the hippocampus and promote neural plasticity as well.[51] Note: it is important not to start or stop taking any medications or supplements without first discussing them with your physician and/or pharmacist.

Several evidence-based psychotherapies are effective at preventing and overcoming the effects of chronic stress. Acceptance and Commitment Therapy (ACT) is an approach that focuses on the awareness of mental states and thoughts with particular effectiveness for mood and anxiety disorders.[52] Mindfulness-Based Therapy (MBT) additionally reduces stress through attention to physical experiences and meditation.[53] This modality directly targets psychological stress reduction by promoting relaxation and building mindfulness skills. Cognitive Behavioral Therapy (CBT) is effective in treating stress-related disorders such as PTSD, anxiety, and depression by utilizing cognitive-restructuring of negatively-formed or maladaptive thoughts and behaviors that cause stress.[54] 

Due to the variety of potential stressors that one can experience and the individuality of perceived stress responses, it is possible that a combination of stressor-targeting and personal psychological support is necessary for both avoiding chronic stress and memory impairment, in addition to recovering from chronic stress. In everyday life, acute stress is beneficial for memory and the body, but chronic stress that takes both physical and psychological forms should be avoided as much as possible. Lowering chronic stress may further be promoted through prioritizing safety, relaxation, nutrition, time in nature, engaging in therapy to find ways to cope with stressors, and decreasing time on social media.[55] 

Moreover, this responsibility to avoid chronic stress is not always carried solely by the individual but is also held by a network of people that socially impact each other’s lives every day. In order to reduce the negative memory and health effects of chronic stress, both the individual and the environment by which they interact should be addressed. Stress and memory research continues to rapidly evolve, and may eventually be able to determine how to quantify, possibly by time and neural information, dangerous amounts of allostatic load on the brain and the processes of memory.  

If one is experiencing prolonged or chronic stress that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Hadany, L., Beker, T., Eshel, I., & Feldman, M. W. (2006). Why is stress so deadly? An evolutionary perspective. Proceedings. Biological sciences, 273(1588), 881–885. https://doi.org/10.1098/rspb.2005.3384

2 American Psychological Association. (2023). Stress. In APA Dictionary of Psychology. https://dictionary.apa.org/stress?amp=1 

3 Lenart-Bugla, M., Szcześniak, D., Bugla, B., Kowalski, K., Niwa, S., Rymaszewska, J., & Misiak, B. (2022). The association between allostatic load and brain: A systematic review. Psychoneuroendocrinology, 145, 105917. https://doi.org/10.1016/j.psyneuen.2022.105917

4 Peavy, G. M., Salmon, D. P., Jacobson, M. W., Hervey, A., Gamst, A. C., Wolfson, T., Patterson, T. L., Goldman, S., Mills, P. J., Khandrika, S., & Galasko, D. (2009). Effects of chronic stress on memory decline in cognitively normal and mildly impaired older adults. The American journal of psychiatry, 166(12), 1384–1391. https://doi.org/10.1176/appi.ajp.2009.09040461

5 Ibid.

6 Lenart-Bugla et al. (2022)

7 Peavy et al. (2009)

8 Lin, L., Zhang, J., Dai, X., Xiao, N., Ye, Q., & Chen, X. (2022). A moderate duration of stress promotes behavioral adaptation and spatial memory in young C57BL/6J mice. Brain Sciences, 12(8) doi:10.3390/brainsci12081081

9 Peavy et al. (2009)

10 Bobba-Alves, N., Juster, R. -., & Picard, M. (2022). The energetic cost of allostasis and allostatic load. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105951

11 Selye, H. (1950). Stress and the general adaptation syndrome. British medical journal, 1(4667), 1383–1392. https://doi.org/10.1136/bmj.1.4667.1383

12 Bobba-Alves et al. (2022)

13 Lenart-Bugla et al. (2022)

14 Akan, O., Bierbrauer, A., Kunz, L., Gajewski, P. D., Getzmann, S., Hengstler, J. G., Wascher, E., Axmacher, N., & Wolf, O. T. (2023). Chronic stress is associated with specific path integration deficits. Behavioural brain research, 442, 114305. https://doi.org/10.1016/j.bbr.2023.114305

15 Kirschbaum, C., Wolf, O. T., May, M., Wippich, W., & Hellhammer, D. H. (1996). Stress- and treatment-induced elevations of cortisol levels associated with impaired declarative memory in healthy adults. Life sciences, 58(17), 1475–1483. https://doi.org/10.1016/0024-3205(96)00118-x

16 Peavy et al. (2009)

17  Bobba-Alves et al. (2022)

18 Lenart-Bugla et al. (2022)

19 Prieto, S., Nolan, K. E., Moody, J. N., Hayes, S. M., Hayes, J. P., & Department of Defense Alzheimer’s Disease Neuroimaging Initiative (2023). Posttraumatic stress symptom severity predicts cognitive decline beyond the effect of Alzheimer's disease biomarkers in Veterans. Translational psychiatry, 13(1), 102. https://doi.org/10.1038/s41398-023-02354-0

20 Perlman, G., Cogo-Moreira, H., Wu, C. -., Herrmann, N., & Swardfager, W. (2022). Depression interacts with allostatic load to predict cognitive decline in middle age. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105922

21 Duman R. S. (2004). Neural plasticity: consequences of stress and actions of antidepressant treatment. Dialogues in clinical neuroscience, 6(2), 157–169. https://doi.org/10.31887/DCNS.2004.6.2/rduman

22 Kirschbaum et al. (1996)

23 The American Institute of Stress. (2022). What is Stress? https://www.stress.org/daily-life 

24 Lenart-Bugla et al. (2022)

25 Duman (2004)

26 Ibid.

27 Ibid. 

28 Lenart-Bugla et al. (2022)

29 Akan et al. (2023)

30 Craddock, T. J. A., Michalovicz, L. T., Kelly, K. A., Rice, M. A., Jr., Miller, D. B., Klimas, N. G., . . . Broderick, G. (2018). A logic model of neuronal-glial interaction suggests altered homeostatic regulation in the perpetuation of neuroinflammation. Frontiers in Cellular Neuroscience, 12 doi:10.3389/fncel.2018.00336 

31 Palego, L., Giannaccini, G., & Betti, L. (2021). Neuroendocrine response to psychosocial stressors, inflammation mediators and brain-periphery pathways of adaptation. Central Nervous System Agents in Medicinal Chemistry, 21(1), 2-19. doi:10.2174/1871524920999201214231243 

32 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress 

33 Mariotti A. (2015). The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future science OA, 1(3), FSO23. https://doi.org/10.4155/fso.15.21

34 Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://doi.org/10.17179/excli2017-480

35 Prieto et al. (2023)

36 Ibid.

37 Perlman et al. (2022)

38 De France, K., Evans, G. W., Brody, G. H., & Doan, S. N. (2022). Cost of resilience: Childhood poverty, mental health, and chronic physiological stress. Psychoneuroendocrinology, 144 doi:10.1016/j.psyneuen.2022.105872 

39 Dillon, D. G., & Pizzagalli, D. A. (2018). Mechanisms of Memory Disruption in Depression. Trends in neurosciences, 41(3), 137–149. https://doi.org/10.1016/j.tins.2017.12.006

40 Navarro-Mateu, D., Alonso-Larza, L., Gómez-Domínguez, M. T., Prado-Gascó, V., & Valero-Moreno, S. (2020). I’m not good for anything and That’s why I’m stressed: Analysis of the effect of self-efficacy and emotional intelligence on student stress using SEM and QCA. Frontiers in Psychology, 11 doi:10.3389/fpsyg.2020.00295

41 Kirschbaum et al. (1996)

42 Wolf, O. T., Schommer, N. C., Hellhammer, D. H., McEwen, B. S., & Kirschbaum, C. (2001). The relationship between stress induced cortisol levels and memory differs between men and women. Psychoneuroendocrinology, 26(7), 711–720. https://doi.org/10.1016/s0306-4530(01)00025-7

43 Edwards, K. M., & Mills, P. J. (2008). Effects of estrogen versus estrogen and progesterone on cortisol and interleukin-6. Maturitas, 61(4), 330–333. https://doi.org/10.1016/j.maturitas.2008.09.024

44 Wolf et al. (2001)

45 De France et al. (2022)

46 Dispenza, F. (2023). Chronic illness and disability among sexual minority persons: Exploring the roles of proximal minority stress, adaptation, and quality of life. Psychology of Sexual Orientation and Gender Diversity, doi:10.1037/sgd0000642

47 Menhinick, K. A., & Sanders, C. J. (2023). LGBTQ+ stress, trauma, time, and care. Pastoral Psychology, doi:10.1007/s11089-023-01073-z

48 Riggs, D. W., & Treharne, G. J. (2017). Decompensation: A novel approach to accounting for stress arising from the effects of ideology and social norms. Journal of Homosexuality, 64(5), 592-605. doi:10.1080/00918369.2016.1194116

49 Hernandez, G. D., & Brinton, R. D. (2022). Allopregnanolone: Regenerative therapeutic to restore neurological health. Neurobiology of Stress, 21 doi:10.1016/j.ynstr.2022.100502

50 Szala-Rycaj, J., Szewczyk, A., Zagaja, M., Kaczmarczyk-Ziemba, A., Maj, M., & Andres-Mach, M. (2023). The influence of topinambur and inulin preventive supplementation on microbiota, anxious behavior, cognitive functions and neurogenesis in mice exposed to the chronic unpredictable mild stress. Nutrients, 15(9) doi:10.3390/nu15092041

51  Duman (2004)

52 Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology : IJCHP, 18(1), 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002

53 Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of consulting and clinical psychology, 78(2), 169–183. https://doi.org/10.1037/a0018555

54 Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1

55 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress

To Diagnose or Not to Diagnose: The Debate on Personality Disorders in Adolescence

The Intersectionality of PD in Adolescence 

The presentation of a personality disorder in adolescence is complicated by the ongoing debate of whether personality disorders should be diagnosed. Some licensed health professionals are hesitant to provide a diagnosis due to the belief that adolescence is a period of changing personality,[1] thus, it is not appropriate to judge if a personality is disordered. However, other health professionals argue for the benefits of early detection and treatment, leading to better health outcomes.[2] The impacts of the home environment, genetics and consequences of a diagnosis further complicate this debate.

Effects of Home Environment 

Childhood maltreatment (e.g., neglect, physical abuse) substantially increases the risk of developing a personality disorder.[3] The Minnesota Project by Sroufe et al. (2005) followed a group of high-risk children into adulthood and found that insecure attachment during childhood is strongly associated with the later development of personality disorders in adolescence.[4] Later studies on Borderline Personality Disorders (BPD) further supported the association of adverse childhood experiences as a risk factor for personality disorders. Marchetti et al. (2022) found that a history of childhood maltreatment was associated with higher levels of BPD in adolescents (average age 16).[5] Furthermore, studies by Xiao et al. (2023) found that adolescents with BPD had higher rates of all the assessed childhood traumas when compared to adolescents with non-disordered personalities; this was especially true for emotional neglect (the most commonly seen childhood trauma).[6]

Effects of Biological Factors

Adolescence is a time of biological change, including those that regulate one’s personality. Throughout adolescence, the brain continues to develop in term of myelination and the formation of synaptic networks; thus, the neural basis for many psychological regulatory systems are still in development.[7] Furthermore, the frontal, temporal and occipital lobes of the brain (which are responsible for response inhibition, emotion regulation, planning and organization) are still developing during adolescence, which may account for the increased impulsivity sometimes seen during this period.[8] The increased levels of sex hormones adolescents are exposed to during puberty also affect mood regulation.[9] Therefore, the developmental changes of adolescence can bring forth impulsivity and mood changes, similar to the changes brought by a personality disorder. 

However, studies by Xiao et al. (2023) have found that there are also biological differences in adolescents with personality disorders compared to non-disordered peers.[10] They found that adolescents with Borderline Personality Disorder showed increased Amplitude Low-Frequency Fluctuations in the limbic system (a measure of spontaneous neuronal activity related to the mood swings associated with BPD).[11] Thus, biological factors can also account for differences in the mood swings of adolescents with disordered personalities compared to non-disordered adolescents.

Arguments in favor of a diagnosis

The argument in favor of a diagnosis appeals to the benefits of early diagnosis, specifically: better health outcomes. Paris et al. (2013) report that conditions such as antisocial personality disorders begin in childhood, and as a result of the early onset, psychopathology is more likely to continue.[12] An analysis of personality trait dimensions also supports the early establishment of personality. Studies by Shiner et al. (2009) suggest a continuity from child to adult personality based on findings that certain personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) in childhood predicted later behaviors.[13] Klimstra et al. (2009) distinguish that personality traits change considerably at the ages of 10-15 years old and then stabilize at the ages of 16-21 years.[14] However, according to Cicchetti et al. (2009), since personality disorders (PD) do not begin in adulthood, early investigation is necessary to develop a lifespan model for treatment.[15] Schmeck (2022) further supports the need for early intervention in personality disorders, arguing that early diagnosis rids the stigma associated with PD and lessens the possibility of long-lasting impairments and disability by facilitating the transition into adulthood.[16] 

These benefits of early diagnosis may have been considered by the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the most recent version of the guide to diagnosing mental disorders has changed its age requirements for diagnosing PD. While earlier versions of the DSM did not allow someone under 18 to be diagnosed, the DSM-5 (the most recent version) allows the diagnosis of a personality disorder in someone under 18 if symptoms are present for at least one year.[17] 

Arguments against diagnosis

A study by Laurenssen et al. (2013) found that 57.8% of psychologists working with adolescents acknowledged the existence of personality disorders in this age group; however, only 8.7% of them actually made formal PD diagnoses in the adolescents.[18] The majority of psychologists are reluctant to diagnose adolescents based on the idea that personality is fluid and still developing.[19] Dijk et al. (2021) argue that while personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) are structurally similar between adolescents and adults, there are developmental differences; for example, adolescents appear to be less conscientious.[20] Some psychologists also argue that an early diagnosis is stigmatizing since personality pathology can often be viewed as being unmodifiable.[21,22] Furthermore, according to Adshead et al. (2012), a misdiagnosis of a personality disorder in adolescence can focus attention away from interventions to improve the caregiving environment, particularly if neglect or abuse are present.[23] Perhaps taking the drawbacks of diagnosis into account, the American Psychiatric Association webpage, as of now, states that diagnosis of personality disorders is only applicable to individuals 18 and older (It is important to note that the American Psychiatric Association oversees the DSM-5).[24]

Treatment of PD in adolescence

Personality disorders vary in the ways they impact an individual’s thoughts and ways of expressing themselves, however, they align in their need for treatment to go away.[25] In adults certain psychotherapies (e.g., Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Group Therapy, Psychoanalytic) have shown to be effective for treating personality disorder.[26] If an adolescent is diagnosed with a personality disorder, their treatment plans may differ slightly from adults. Adolescent treatment plans are complex due to a current need for more evidence if adult interventions also work for adolescents.[27] Furthermore, these treatment plans are unique as they often incorporate the adolescent’s school and parents.[28]

If you believe you or your child may have a personality disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Adshead, G., Brodrick, P., Preston, J., & Deshpande, M. (2012). Personality disorder in adolescence. Advances in Psychiatric Treatment, 18(2), 109-118. doi:10.1192/apt.bp.110.008623

2 Cicchetti, D., & Crick, N. R. (2009). Precursors and diverse pathways to personality disorder in children and adolescents. Development and Psychopathology, 21(3), 683-685. doi:https://doi.org/10.1017/S0954579409000388

3 Adshead et al. (2012)

4 Sroufe, A, Egeland, B, Carlson, E et al (2005) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. Guilford Press

5 Marchetti, D., Musso, P., Verrocchio, M., Manna, G., Kopala-Sibley, D., De Berardis, D., . . . Falgares, G. (2022). Childhood maltreatment, personality vulnerability profiles, and borderline personality disorder symptoms in adolescents. Development and Psychopathology, 34(3), 1163-1176. doi:10.1017/S0954579420002151

6 Xiao, Q., Yi, X., Fu, Y., Jiang, F., Zhang, Z., Huang, Q., Han, Z., & Chen, B. T. (2023). Altered brain activity and childhood trauma in Chinese adolescents with borderline personality disorder. Journal of affective disorders, 323, 435–443. https://doi.org/10.1016/j.jad.2022.12.003

7 Adshead et al. (2012)

8 Ibid. 

9 Ibid. 

10 Xiao et al. (2023)

11 Ibid. 

12 Paris, Joel. “Personality disorders begin in adolescence.” Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent vol. 22,3 (2013): 195-6. doi:10.1007/s00787-013-0389-7

13 Shiner, R (2009) The development of personality disorders: perspectives from normal development. Development and Psychopathology 4: 715–34

14 Klimstra, TA, Hale, WW, Raaijmoken, QA (2009) Maturation of personality in adolescence. Journal of Personality, Society & Psychology 96: 898–912

15 Cicchetti et al. (2009)

16 Schmeck, K. (2022, March 17). Debate: Should CAMHS professionals be diagnosing ... - wiley online library. ACAMH. https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12553

17 Personality disorders: Diagnosis. CAMH. (n.d.). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/personality-disorders/personality-disorders---diagnosis#:~:text=According%20to%20DSM%2D5%2C%20features,for%20at%20least%20one%20year.

18 Laurenssen, E. M., Hutsebaut, J., Feenstra, D. J., Van Busschbach, J. J., & Luyten, P. (2013). Diagnosis of personality disorders in adolescents: a study among psychologists. Child and adolescent psychiatry and mental health, 7(1), 3. https://doi.org/10.1186/1753-2000-7-3

19 Paris (2013)

20 van Dijk, I., Krueger, R. F., & Laceulle, O. M. (2021). DSM-5 alternative personality disorder model traits as extreme variants of five-factor model traits in adolescents. Personality disorders, 12(1), 59–69. https://doi.org/10.1037/per0000409

21 Cicchetti et al. (2009)

22 Adshead et al. (2012)

23 Ibid. 

24 What are personality disorders?. Psychiatry.org - What are Personality Disorders? (2022, September). https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders#:~:text=Diagnosis%20of%20a%20personality%20disorder,their%20personalities%20are%20still%20developing.

25 Ibid.

26 Ibid.

27 Adshead et al. (2012)

28 Ibid.

Inherited Memories: Current Research & Popular Misunderstandings

Memory Transmission & Monarch Butterflies

Carl Jung (1875-1961)[1] used the term “collective unconscious” to describe inherited wisdom and intuition from the past.[2] Evidence of the intergenerational effects of trauma have been found in populations affected by subjugation, genocide, racism and war.[3] This raises the question of how these memories are transmitted and whether there are biological mechanisms that enable the transmission of this information beyond environmental upbringing.

In nature, an example of inherited memory might be seen in monarch butterflies who take three generations to return from Mexico to Canada; the last generation knowing the route without any living members having previously been there.[4] Whether the inherited memories that have been demonstrated in cells, worms and butterflies can be extended to mammals has become a growing area of interest to researchers in recent decades.[5] In 2013, researchers at Emory University showed that mice are capable of passing the fear of a specific scent (a smell similar to a cherry blossom) down to future generations, via their sperm.[6] This process (which takes place through a mechanism referred to as “transgenerational epigenetic inheritance,”)  has led many scientists to jump to exciting conclusions as to how this research might be applied to the transmission of memories between generations of humans.[7] Yet researchers are still working to understand the intertwined relationship between epigenetics and genetics.[8]

Transgenerational Epigenetic Inheritance

There are a growing number of studies indicating that trauma may be able to be passed down through epigenetics,[9] which is the study of how the environment and people’s behavior can change the way genes work.[10] In genetic research, however, the environment is used as a general term to refer to anything other than genetics (which may include a person’s actions, the actions of others and the general, physical world).[11]

The term epigenetics is commonly used to refer to two concepts:[12]

1) The ways that packaging or modification of DNA results in the transmission of information within a group of cells (a theory widely accepted by science).

2) The ways that packaging or modifications of DNA might result in transmitting information from one generation to the next (a newer theory not as well established).

Epigenetic changes are reversible (unlike genetic changes) and they do not change a DNA sequence, but rather how the body reads the DNA sequence.[13] In epigenetics, the gene is not changed or damaged, instead the mechanisms of expression (when a gene is converted into functioning proteins) is altered.[14] These changes can affect gene expression by turning genes “on” and “off.”[15] Such molecular pathways with the potential to act epigenetically include histone modifications, DNA methylation, small RNAs and protein-protein interactions.[16]

It is believed that modifications to genetic expression may help an organism to respond to a changing environment and also help its descendants increase their likelihood of surviving.[17] When discussing how information is passed through generations, intergenerational change refers to changes that take place in one generation, whereas transgenerational changes are inherited from two or more generations.[18] Epigenetic transgenerational inheritance therefore refers to inheritance from an environmental exposure (e.g., the effects of an endocrine disruptor such as BPA or DDT) that alters the genetic programming of the germline with the changes transmitted between generations in the absence of direct exposure.[19]

Nonhuman Examples

In nonhuman species, research supports the notion that memories may be transmitted through multiple generations. Erickson (2020) found that the eggs of chickens originally domesticated in the red jungle fowl of Southeast Asia over 4,000 years ago (that later biologically adapted to the higher elevations of Tibet 1,200 years ago) were able hatch eggs when incubated in the lowland environment of their ancestral past unlike a control group of eggs that did not show the same adaptability.[20] Research on worms has also shown specific genes called the Modified Transgenerational Epigenetic Kinetics (MOTEK) are involved with turning epigenetic transmissions through RNA on or off.[21] Similarly, plants also appear to be particularly prone to transgenerational epigenetic inheritance through heritable changes in DNA methylation.[22] These findings raise the question as to whether comparable results can be found in mammals.

Lessons from Mice

In mice, studies have shown that a traumatic event could alter sperm that may affect the behavior of future generations.[23] Dias & Ressler (2014) found that by exposing mice to an odor and associating it with fear before conceiving the next generation of mice, the following two generations showed increased behavioral sensitivity to the same odor.[24] Similar initial research conducted by Gapp (2018) indicated that inheritance of specific trauma symptoms can be transmitted through alterations to long RNA in sperm through several generations in mice.[25] Mukherjee et al. (2018) evaluated five immediate-early genes in mice after memories were stored of either a positive or negative experience and found that the expressions were so unique for each that they could predict which experience the mouse had undergone by simply looking at the gene expression; suggesting the activation profile for each gene can contain information about experiences they have undergone.[26] These examples provide a framework of how environmental information could potentially be passed down through generations at the epigenetic, behavioral and neuroanatomical levels.[27]

To evaluate whether epigenetic changes resulting from environmental exposures could be reversed, Aoued et al. (2019) established fear in mice through olfactory cue-based fear conditioning and then sought to reverse the effects.[28] They did this by training the first generation of mice to associate the odors of either acetone or Lyral with mild foot shocks. They then extinguished this fear by providing odor-only exposure without the presentation of electric shocks. The results showed that first generation offspring did not show behavior sensitivity to the two odors. These findings provide hope for potential therapies in the future that may provide methods for reversing the influence of parental stress in both offspring and the parental germline.[29]

Human Applications

Though environmentally-induced changes passed from one generation to the next are observed relatively often in plants, it has remained elusive in mammals and even more difficult to find in humans.[30] The working memory that human beings, jumping spiders, archerfish and honeybees all possess involve similar genes that are believed to be inherited from the last common ancestor over 600 million years ago.[31] However, the study of transgenerational epigenetic inheritance in humans is difficult to isolate due to the confounding of ecological, genetic and cultural inheritance.[32] Since parental trauma is sometimes linked to childhood emotional abuse, it can be difficult for researchers to disentangle whether the experiences of parents are transferred to offspring as a result of genetics or through lived experiences.[33] With a newly sparked interest on whether epigenetics explains generational trauma, research has been conducted on descendants of abused prisoners from the American Civil War, children in the womb during the Dutch Hunger Winter, and Holocaust survivors.[34] However, within any traumatic situation, the effects may depend on the severity of the trauma, the age of an individual during the event, and whether the trauma was an isolated event or a reoccurring one.[35]

When discussing intergenerational memories in humans, it is important to differentiate between the concepts of transgenerational epigenetically inherited memories and collective memories. Collective memories are the shared remembrance or interpretation of facts about social groups which a person belongs (such as the person’s ethnic group or country) and may range from a national to a global level.[36] However, collective memories have been shown to change with time based on societal perception (e.g., older Americans alive during World War II remember the bombing of Hiroshima as a positive event that ended the war whereas younger Americans view it as a negative event because thousands of innocent civilians were killed).[37] Epigenetic transgenerational memories would be affected by different mechanisms and would not necessarily reflect the same changes as collective memories.

Lessons From Survivors and Their Descendants

To determine whether the epigenetic mechanisms of intergenerational transmission of stress effects can be found in humans, Yehuda et al. (2015) analyzed a specific gene encoding (epigenetic changes in FKBP5 methylation) in Holocaust survivors and their offspring with comparable parent/offspring control groups.[38] Their work found epigenetic alterations in both the exposed parent and offspring that were associated with preconception parental trauma. These findings were believed to be the first evidence in humans of an association between preconception stress effects and epigenetic changes in exposed parents and their adult offspring. Researchers believe these findings may contribute to an increased risk for psychopathology in the offspring of highly traumatized individuals.[39]

Alterations to the sperm of adult men has already been found to take place due to diet, alcohol, smoking, age and toxic exposure.[40] Costa et al. (2018) conducted research looking at children born after the Civil War who survived to age 45, comparing those whose fathers were POWs compared to those whose fathers were non POW veterans of the war. They also compared children born before and after the war in the same family by paternal ex-POW status. Though they did not find any impact of POW status on daughters, they found that sons of ex-POWs who experienced the camps during the harshest conditions were 1.11 times more likely to die than the sons of non POWs even after accounting for family structure, socioeconomic status, quality of marriage, maternal effects, and father-specific survival traits concluding that the findings were most consistent with an epigenetic explanation. However, they were not able to disentangle whether these epigenetic results were due to the stress of captivity or the effects of starvation.[41]

Future Research and Challenges

The University of Zurich’s Laboratory for Neuroepigenetics, run by Professor Isabel Mansuy, conducts research focused on determining molecular and cellular processes underlying how life experiences may influence physical and mental health across generations.[42] The laboratory not only conducts original research pioneering an understanding of transgenerational epigenetic inheritance in mice, but also conducts collaborative studies with clinicians in Europe and Asia to research the relevance as it relates to trauma patients in humans.[43] Professor Mansuy explains that trauma not only affects a person’s brain but also their reproductive system, which could cause depression or borderline personality disorder to be a trait inherited from parents.[44]

Challenges to studying environmentally-induced inheritance in humans include the nonexistence of four generations of human epidemiological cohorts and the ethical considerations of human experimentation.[45] A female fetus growing in the mother’s womb already contains the full complement of eggs, which means the DNA of future grandchildren is already present in a pregnant mother, so that it could take up to four generations to study true trans-generational inheritance in females.[46] In males, these changes could be seen in the next generation, since sperm is continually being produced.[47]

In terms of evolution, the transmission of epigenetic information in a fast-producing animal population could assist that species in rapidly adapting to a new environment, but this could become a maladaptive practice if the actual environment does not match that which was anticipated.[48] This may be one reason that the trait is not observed as much in humans who may come across multiple environments in their lifetimes.[49]

Research Riddled With Controversy

While the implications of epigenetic research have been met with enthusiasm by the press and public, there are scientists who heavily contest both the findings and their presentation. The research conducted by Yahuda et al. on Holocaust survivors was heavily criticized by Professor Ewan Birney, Director of the EMBL-European Bioinformatics Institute, for its small sample size (32 people and 8 controls), the tiny subset of genes used and the possibility of other potential causes for the findings.[50]

Similarly, Kevin Mitchell, a neurogeneticist known for speaking up against “neuro-bollocks,” in an interview with Claire McKenna (2020) explained his belief that there will never be accurate biomarkers (e.g., bloodwork, brain scans) for psychiatric or neurological conditions because the conditions are defined at the level of human behavior explaining, “Even if there’s a dynamic neural state that underpins some aspects of psychosis that we both share, the way that state looks in your brain may be very different from the way it looks in my brain…”[51] Mitchell does not find the transmission of trauma through epigenetic mechanisms plausible because it overly simplifies the relationship between psychological traits and genes explaining that a person’s experiences are expressed through changes in neuroanatomy instead of gene expression.[52]

In his blog, Wiring the Brain, Mithell also wrote an entry on May 29, 2018, reviewing what he believed to be the most prominent research on this topic at the time, and provided detailed information on each study as to why he believed them to be invalid (often small sample sizes and lack of predefined hypotheses).[53] In response, Jill Esher (a research philanthropist who funds pilot studies on exposure-induced nongenetic inheritance) posted a rebuttal on Germline Exposure’s website stating, among other things, that Mitchell cherry-picked the human studies he cited and then countered his argument by citing eleven studies illustrating transgenerational effects in humans and over 30 studies of intergenerational nongenetic inheritance in mammals.[54]

Mosche Szys, a professor of pharmacology at McGill University, similarly supported published findings on epigenetic research in mice telling the New York Times (2018) that dismissals of epigenetic theory are premature by explaining that, “The effects we’ve found have been small, but remarkably consistent and significant….This is the way science works. It is imperfect at first and gets stronger the more research you do.”[55]

Yehuda et al. (2018) (authors of the holocaust research criticized above) sought to clarify misconceptions by explaining that sensational media was oversimplifying their findings, obscuring the boundaries between fact and hypothesis and making inferences with implications far beyond the original findings; citing an example from Teen Vogue that cited their study and warned “You can get PTSD from your ancestors.”[56] They also warn that often articles claiming to debunk the notion that trauma is inherited are citing limitations written into the original research paper by the research team and are in fact debunking an over-interpretation of earlier journalists as opposed to the research itself. This led to an additional warning of inaccurately teaching the public that scientists are debunking one another rather than collaborating through the process of critique and correction.[57]

Potential Applications

Professor Mansuy explained during an interview with Jean Mary Zarate (2023), a senior editor at the journal Nature Neuroscience, that modifications to reproductive cells from traumatic experiences may transmit some of the effects of the exposure to children and research in this field could further our understanding of how inheritance can potentially affect psychiatric disorders including depression, anxiety and borderline personality disorder.[58] She explains there is a lot of work to be done in this field before it can be used to help people directly, but understanding that complex diseases like depression may be inherited from parents directly, instead of being related to something a person has done, would be important for psychiatrists and medical practitioners to know.[59]

This field is a budding new area of research and while the potential implications may excite the public, and at times become exaggerated in the media, the science is not yet understood well enough to be applied in the therapeutic setting. Though in the future, as more research emerges, it may be possible to incorporate these findings into techniques such as cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT) as a multi-pronged approach for addressing the root cause.

While progress in this field may be slow to produce answers, the current lack of understanding of epigenetic transgenerational inheritance does not minimize the reality of generational trauma and collective memories that can be passed down through a variety of other pathways. In addition to the potential for traumatic events that occur through transgenerational epigenetic inheritance, descendants of traumatized individuals may also be affected by the prenatal state of an anxious/symptomatic mother, or trauma affecting a parent’s behavior.[60] If you or someone you know is struggling to process generational trauma, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. 

Contributed by: Theresa Nair

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Fordham F, Fordham M. Carl Jung | biography, archetypes, books, collective unconscious, & theory | Britannica. Britannica Web site. https://www.britannica.com/biography/Carl-Jung. Updated 2023. Accessed Jun 8, 2023.

2 Treffert D. Genetic memory: How we know things we never learned. Scientific American Blog Network Web site. https://blogs.scientificamerican.com/guest-blog/genetic-memory-how-we-know-things-we-never-learned/. Updated 2015. Accessed May 11, 2023.

3 Yehuda R, Lehrner A, Bierer LM. The public reception of putative epigenetic mechanisms in the transgenerational effects of trauma. Environ Epigenet. 2018;4(2):dvy018. doi: 10.1093/eep/dvy018.

4 Treffert (2015)

5 Fisher AG, Brockdorff N. Epigenetic memory and parliamentary privilege combine to evoke discussions on inheritance. Development. 2012;139(21):3891-3896. doi: 10.1242/dev.084434.

6 Gallagher J. 'Memories' pass between generations. BBC News. -12-01 2013. Available from: https://www.bbc.com/news/health-25156510. Accessed May 11, 2023.

7 Ibid.

8 Spinney L. Epigenetics, the misunderstood science that could shed new light on ageing. The Guardian Web site. https://www.theguardian.com/science/2021/oct/10/epigenetics-the-misunderstood-science-that-could-shed-new-light-on-ageing. Updated 2021. Accessed June 2, 2023.

9 Henriques M. Can the legacy of trauma be passed down the generations? BBC Future Web site. https://www.bbc.com/future/article/20190326-what-is-epigenetics. Updated 2019. Accessed May 26, 2023.

10 Center for Disease Control and Prevention, (CDC). What is epigenetics? | CDC. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/genomics/disease/epigenetics.htm. Updated 2022. Accessed May 26, 2023.

11 Birney E. Why I'm sceptical about the idea of genetically inherited trauma. The Guardian Web site. https://www.theguardian.com/science/blog/2015/sep/11/why-im-sceptical-about-the-idea-of-genetically-inherited-trauma-epigenetics. Updated 2015. Accessed June 1, 2023.

12 Ibid.

13 CDC (2022)

14 Benedict C. Can we really inherit trauma? The New York Times Web site. https://www.nytimes.com/2018/12/10/health/mind-epigenetics-genes.html. Updated 2018. Accessed May 26, 2023.

15 CDC (2022)

16 Sarkies P. Molecular mechanisms of epigenetic inheritance: Possible evolutionary implications. Semin Cell Dev Biol. 2020;97:106-115. https://www.sciencedirect.com/science/article/pii/S1084952118301484. doi: 10.1016/j.semcdb.2019.06.005.

17 Lacal I, Ventura R. Epigenetic inheritance: Concepts, mechanisms and perspectives. Frontiers in molecular neuroscience; Front Mol Neurosci. 2018;11:292. doi: 10.3389/fnmol.2018.00292.

18 Sarkies (2020)

19 Skinner MK. Epigenetic transgenerational inheritance. Nature Reviews Endocrinology. 2016;12(2):68-70. https://doi.org/10.1038/nrendo.2015.206. doi: 10.1038/nrendo.2015.206.

20 Erickson J. Past is prologue: Genetic ‘memory’ of ancestral environments helps organisms readapt. University Wire. 2020. Available from: https://www.proquest.com/docview/2405486117?pq-origsite=primo#. Accessed May 14, 2023.

21 Javelosa J. Scientists have discovered how memories are inherited. World Economic Forum Web site. https://www.weforum.org/agenda/2018/12/memories-can-be-inherited-and-scientists-may-have-just-figured-out-how/. Updated 2018. Accessed May 11, 2023.

22 Quadrana L, Colot V. Plant transgenerational epigenetics. Annu Rev Genet. 2016;50:467-491. doi: 10.1146/annurev-genet-120215-035254.

23 Gallagher (2013)

24 Dias BG, Ressler KJ. Parental olfactory experience influences behavior and neural structure in subsequent generations. Nat Neurosci. 2014;17(1):89-96. Accessed May 24, 2023. doi: 10.1038/nn.3594.

25 Gapp K, van Steenwyk G, Germain PL, et al. Alterations in sperm long RNA contribute to the epigenetic inheritance of the effects of postnatal trauma. Mol Psychiatry. 2020;25(9):2162-2174. https://www.nature.com/articles/s41380-018-0271-6. Accessed May 30, 2023. doi: 10.1038/s41380-018-0271-6.

26 Sagar V, Kahnt T. Genetic signatures of memories. eLife. 2018;7:e36064. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862524/. Accessed May 12, 2023. doi: 10.7554/eLife.36064.

27 Dias & Ressler (2014)

28 Aoued HS, Sannigrahi S, Doshi N, et al. Reversing behavioral, neuroanatomical, and germline influences of intergenerational stress. Biol Psychiatry. 2019;85(3):248-256. doi: 10.1016/j.biopsych.2018.07.028.

29 Ibid.

30 Birney (2015)

31 Earl B. Humans, fish, spiders and bees inherited working memory and attention from their last common ancestor. Frontiers in psychology; Front Psychol. 2023;13:937712. doi: 10.3389/fpsyg.2022.937712.

32 Horsthemke B. A critical view on transgenerational epigenetic inheritance in humans. Nature Communications. 2018;9(1):2973. https://doi.org/10.1038/s41467-018-05445-5. doi: 10.1038/s41467-018-05445-5.

33 Yehuda R, Daskalakis NP, Bierer LM, et al. Holocaust exposure induced intergenerational effects on FKBP5 methylation. Biol Psychiatry. 2015;80(5):372-380. doi: 10.1016/j.biopsych.2015.08.005.

34 Benedict (2018)

35 Byrne D. How trauma’s effects can pass from generation to generation. Nature. 2023. https://www.nature.com/articles/d41586-023-01433-y. Accessed May 30, 2023.

36 Roediger H, DeSoto K. The power of collective memory. Scientific American Web site. https://www.scientificamerican.com/article/the-power-of-collective-memory/. Updated 2016. Accessed May 24, 2023.

37 Ibid.

38 Yehuda et al. (2015)

39 Ibid.

40 Costa DL, Yetter N, DeSomer H. Intergenerational transmission of paternal trauma among US civil war ex-POWs. Proc Natl Acad Sci U S A. 2018;115(44):11215-11220. doi: 10.1073/pnas.1803630115.

41 Ibid.

42 University of Zurich (UZ). Laboratory of neuroepigenetics | isabelle mansuy. University of Zurich Web site. http://www.hifo.uzh.ch/en/research/mansuy.html. Accessed May 30, 2023.

43 Ibid.

44 Byrne (2023)

45 Escher J. No convincing evidence? A response to kevin mitchell’s reckless attack on epigenetic inheritance. Germline Exposures Web site. http://www.germlineexposures.org/1/post/2018/07/no-convincing-evidence-a-response-to-kevin-mitchells-reckless-attack-on-epigenetic-inheritance.html. Updated 2018. Accessed Jun 2, 2023.

46 Birney (2015)

47 Ibid.

48 Horsthemke (2018)

49 Ibid.

50 Birney (2015)

51 McKenna C. Kevin mitchell. BJPsych Bull. 2020;44(2):81-83. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283122/. doi: 10.1192/bjb.2020.18.

52 Ibid.

53 Mitchell K. Grandma’s trauma – a critical appraisal of the evidence for transgenerational epigenetic inheritance in humans. . 2018. http://www.wiringthebrain.com/2018/05/grandmas-trauma-critical-appraisal-of.html. Accessed Jun 5, 2023.

54 Escher (2018)

55 Benedict (2018)

56 Yehuda et al. (2018)

57 Ibid.

58 Byrne (2023)

59 Ibid.

60 Yehuda et al. (2018)

When Does Dissociation Become Unhealthy?

Physically I’m Here… Mentally I’m Far, Far Away

Dissociative experiences can be a harmless and even euphoric part of life. This can look like getting lost in your favorite song, watching a beautiful sunset in complete awe or being so engaged in a meditation session that nothing else matters to you in that moment. On the other end of the spectrum, however, maladaptive dissociation can have detrimental impacts on a person’s wellbeing and functionality if left untreated and misunderstood.

Dissociation can severely impair peoples’ ability to effectively integrate their thoughts, memories and emotions with their experience of reality and perception of their identity.[1] The result in such extreme cases is often a highly fragmented sense of life and self-identity that can lead to mental health problems such as depression, anxiety and suicidal thoughts. Understanding the difference between so-called “healthy” and “unhealthy” dissociation is a critical first step for determining whether someone should seek help.

What is “Healthy” Dissociation?

Compared to other psychological defenses, dissociation is unique in that milder versions can be invoked voluntarily. For example, the ability of absorption to be consciously learned and applied combined with its psychological defensive capacity makes it an ideal therapeutic strategy.[2] Absorption consists of disconnecting from one’s current circumstances (both external and psychological) and becoming immersed in another focus. Absorption in music, nature and other positive foci can relieve emotional distress when a person is experiencing emotional or even physical pain.[3] While absorption itself involves some degree of dissociation, it is not indicative of pathological dissociation and can have many advantageous effects. 

In her book, Everyday Music Listening: Absorption, Dissociation and Trancing, Ruth Herbert describes absorption in music as a therapeutic practice that may involve “multi-sensory blending” and “heightened awareness”.[4] She argues that everyday listening can be not only pleasurable or relaxing, but transcendent in a way that is comparable to religious rituals and mindfulness meditation — all of which frequently prompt a state of dissociation. The multitude of ways in which individuals can remold, reinterpret or redirect their own consciousness through absorption in positive foci certainly exemplifies the human brain as a powerful tool in constructing our reality. Healthy dissociation — that is, when one can control it and choose when to do it — has incredible promise in both therapeutic approaches and consciousness research more broadly. So… How can dissociation become a chronic or even debilitating problem, characteristic of the dissociative disorders?

A Very Fine Line

Milder forms of dissociation often provide a defensive function which dislocates affect from ideas, diminishing the impact of disturbing emotional states.[5] For example, a dissociative episode may help foster a state of indifference or neutrality towards a stressful situation. Up to 75% of people experience at least one depersonalization/derealization episode in their lives, with only 2% meeting the full criteria for chronic episodes.[6] Yet, most clinically-noted dissociative episodes typically involve severely dysfunctional behavior, perpetuating the notion that dissociation is not applicable to the overall population.[7]

Upon examining typical manifestations of dissociation as defense mechanisms conducive to survival, we see that dissociation is the “freeze” part of the flight, fight and freeze emergency systems. Taken alone, this is a completely natural mental response to discomfort, stress and adversity. However, the tendency to rely on this “freeze” reaction can be the birthplace of dissociative disorders. Once individuals have learned to use dissociation to cope with an aversive event, dissociation can presumably become automatized and invoked on a habitual basis in response to even minor stressors.[8] Thus, even seemingly isolated experiences of dissociation can become chronic manifestations characteristic of dissociative disorders. It is therefore important that researchers and therapists take note of this link as to not overlook acute, nonpathological episodes in a clinical framework.

The Trauma-Dissociation Link

At some point in life, most people will endure some degree of heartbreak and loss. However, to live through true trauma is a completely different experience. The physical and mental shock of trauma elicits the brain’s immediate survival instincts — one of which being dissociation.[9] The vast majority of people who develop dissociative disorders have experienced repetitive, overwhelming trauma in childhood. Those who have experienced physical and sexual abuse in childhood are at increased risk of dissociative identity disorder (DID). Among people with dissociative identity disorder in the United States, Canada and Europe, roughly 90 percent had been the victims of childhood abuse and neglect.[10] 

Severely dissociative symptoms are manifestations of an automatic defense mechanism that serves to mitigate the impact of highly aversive or traumatic events. The idea of dissociation serving a defensive function can be traced back to Pierre Janet’s 1889 pioneering investigations of dissociative phenomena.[11] In the context of trauma, dissociation can be one of the ways your brain protects us in the face of adversity – both in the present moment and for the future. In a traumatic situation where someone might need to react quickly and instinctively to escape danger, dissociation serves as a way to mentally “check out” so that stress and fear does not overwhelm their mind. Also taking preventative measures, our brains do not want us to relive the shock of a traumatic experience, so it leaps into survival mode, taking steps to conceal or numb what happened. But… If dissociation is a natural response meant to protect us from trauma, how does it become something disordered that requires treatment?

Trapped in Limbo Between Past and Present

Binks & Ferguson (2013) note that while at the moment of the traumatic event dissociation is highly adaptive and protects the psyche from pain and feelings of helplessness and humiliation, individuals who cope with trauma by dissociating are vulnerable to using this method to cope with future stressors.[12] This becomes especially problematic in cases of childhood/adolescent trauma, as these time periods are integral junctures in the development of more persistent personality pathology.[13] Exposure to trauma during these critical periods exacerbates the likelihood of establishing dissociation as a habitual coping mechanism for the rest of life.

Dissociation is paradoxical in that it can relieve trauma survivors of the immediate pain they are in, but can also become a danger in, and of, itself. In the long-run, habitual dissociation established as a standardized defense mechanism early in life produces detrimental consequences. An account of dissociation from the perspective of a childhood trauma survivor illustrates why: “Dissociation makes surviving the abuse much easier… But it also makes living as an adult so much harder.”[14] Contorting the timeline of when trauma is experienced, dissociation keeps someone trapped in a sort of limbo between past and present. It challenges their ability to fully heal and transcend childhood levels of emotional maturity. In turn, dissociation threatens the agency a person has over their own life and, ultimately, the beauty of actually living as opposed to merely surviving.

The Double-Edged Sword

There are many promising avenues for future research in the realm of therapeutic dissociation, keeping in mind that dissociation in the context of mindfulness is vastly different from habitual dissociation evoked as the primary response to trauma. This distinction lies in the agency we have over the dissociation – that is, choosing to dissociate to enhance the experience of living vs. dissociating merely to survive. In this way, dissociation is a double-edged sword, possessing a great potential in encouraging wellbeing when we can control it, but perhaps an even greater potential for danger when it controls us.

If you feel you may be dissociating at unhealthy levels and/or in a way that is interfering with fully living your life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss possible therapeutic options and treatment modalities. Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) are both common forms of psychotherapeutic treatment for all dissociative disorders.[15] To learn more about types of dissociative disorders and effective treatments, feel free to refer to our encyclopedia entry on dissociation.

Contributed by: Sara Wilson

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 American Psychiatric Association. (2022, October). What are Dissociative Disorders? Psychiatry.org. Retrieved 27 May, 2023, from https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociative-disorders. 

2  Bowins, B. E. (2012). Therapeutic Dissociation: Compartmentalization and Absorption. Counseling Psychology Quarterly, 25(3), 307-317.

3 Ibid.

4  Becker, J. (2014). [Review of Everyday Music Listening: Absorption, Dissociation and Trancing, by R. Herbert]. Ethnomusicology Forum, 23(2), 266–268. http://www.jstor.org/stable/43297432.

5  Bowins (2012)

6  National Alliance on Mental Illness. (2023). Dissociative Disorders. Retrieved 27 May 2023, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Dissociative-Disorders.

7  Bowins (2012)

8  Giesbrecht, T., Lynn, S. J., Lilienfeld, S. O., & Merckelbach, H. (2008). Cognitive Processes in Dissociation: An Analysis of Core Theoretical Assumptions. Psychological Bulletin, 134(5), 617-647. https://doi.org/10.1037/0033-2909.134.5.617.

9  Gillette, H. (2021, August 3). Trauma-Related Dissociation: Symptoms, Treatment, Coping, and More. Psych Central. https://psychcentral.com/pro/coping-with-trauma-through-dissociation.

10  American Psychiatric Association.

11  Giesbrecht et. al., (2008)

12  Binks, E., & Ferguson, N. (2013). Religion, trauma and non-pathological dissociation in northern ireland. Mental Health, Religion & Culture, 16(2), 200-209. https://doi.org/10.1080/13674676.2012.659241.

13 Shiner, R. (2023, April 4). Emergence of Personality Disorder in Adolescence: New Findings and Their Implications for Treatment. YouTube. https://www.youtube.com/watch?v=K00Xdcjd7_E&t=416s.

14 Beauty After Bruises. (2023, April 21). Dissociation and Survival vs. Living: A Survivor’s Story. Beauty After Bruises. https://www.beautyafterbruises.org/blog/survivorstory.

15  Cleveland Clinic. (2022, October 24). Dissociative Disorders: Causes, Symptoms, Types & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/17749-dissociative-disorders.