What Every Practitioner Needs To Know About the Link between Childhood Trauma and Chronic Disease
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- A Startling Link Between Childhood Trauma and a 20 Year Shorter Life Expectancy
- Why the Coping Mechanisms of Trauma Survivors Often Increase
the Chances of Developing Chronic Disease
- Can Childhood Trauma Trigger Cancer?
- The Relationship Between Trauma and Heart Disease
- The Link Between Childhood Trauma and Inflammation
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Why the Most Significant Factor
Predicting Chronic Disease
May Be Childhood Trauma
When a monumental study connects two previously unrelated factors and puts them together with astounding results, the implications are too compelling to ignore.
Almost by accident, this is exactly what happened in a study that began in the early 1990s.
Taking two fundamental factors of mind-body medicine, childhood trauma and chronic disease, two physicians, Vincent Felitti, MD along with Robert Anda, MD designed a study based on a clinical hunch.
Noticing that so many of their patients presented with symptoms of chronic disease, they also observed that these same patients were very often survivors of multiple and repeated childhood traumas.
Could there be a link between childhood trauma and chronic disease?
And beyond that, if there were a link, what would it mean to the prediction and healing of chronic disease?
With those questions in mind, the Adverse Childhood Experience (ACE) Study was born.
Acting on their observation of a dominant theme that emerged in the intake stories of thousands of patients, they now give us a benchmark study uncovering the impact of childhood trauma on chronic conditions.
So, how exactly was this remarkable study envisioned, what did they find, and why are the results so compelling?
In short, let's look at the Adverse Childhood Experiences (ACE) Study to see why it has become the major research bridging the gap between trauma and the chronic conditions that plague so many of our patients later in life.
Adverse Childhood Experiences: How the Study Was Conducted
This study is perhaps the largest ongoing scientific research collaboration of its kind (between Kaiser Permanente and the Centers for Disease Control and Prevention).
Analyzing the relationship between multiple categories of childhood trauma and health outcomes later in life, researchers defined nine Adverse Childhood Experiences that can occur in the household prior to age 18:
- Recurrent physical abuse
- Recurrent emotional abuse
- Contact sexual abuse
- An alcohol and/or drug abuser in the household
- An incarcerated household member
- Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
- Mother is treated violently
- One or no parents
- Emotional or physical neglect
The ACE Study used a simple scoring method to determine the extent of each participant's exposure to childhood trauma. Exposure to one category (not incident), qualifies as one point. Points are then added up to derive an ACE Score.
An ACE Score of 0 (zero) would mean that the person reported no exposure to any of the listed categories of trauma. An ACE Score of 9 would mean that all these categories of trauma were reported.
With those definitions and parameters in place, let's get to the questions and the findings.
- The Prevalence of Adverse Childhood Experiences
- From Life Experiences in Childhood to Structural Diseases in Adulthood
- Coping Mechanisms and Chronic Stress: Their Relationship to Adverse Childhood Experiences
- Surprising Discoveries
- Applying What Was Learned: Where Do We Go From Here?
Excerpted Interview: Vincent Felitti, MD with Ruth Buczynski, PhD
Dr. Felitti: We used an ACE score of zero as the reference point. In other words, zero meant no exposure to any of the other ten categories. So, for instance, with an ACE score of six or higher, there is a forty-six-fold - a four thousand six hundred percent increase - in the likelihood of that individual becoming an intravenous drug user later in life as compared to an ACE score zero individual.
With an ACE score of six, there is between a thirty-one and a fifty-fold - a three thousand one hundred to five thousand percent - increase in the likelihood of that individual attempting suicide later in life, as compared to an ACE score zero individual.
Dr. Buczynski: And how about other slightly less dramatic kinds of diseases, such as irritable bowel, hypertension, or myocardial infarction?
Dr. Felitti: Indeed, with myocardial infarction and with the presence of coronary artery disease there was an increase. It was in the hundreds of percent. Similarly, with liver disease, with an ACE score of four and higher I believe there was approximately a two-hundred-and-fifty percent increase in the likelihood of liver disease later in life.
Similarly, we saw distinctly proportionate increases in the likelihood of cigarette smoking later in life, as well as in the likelihood of self-acknowledged alcoholism. An individual with an ACE score of four or higher had a five-hundred-and-fifty percent increase in the likelihood of being a self-acknowledged alcoholic later in life, as compared to ACE score zero self-acknowledge alcoholic.
Dr. Buczynski: After that, what was the most highly significant?
Dr. Felitti: Well I can't rate them numerically, but after that there were innumerable categories, in the hundreds of percents' increase, with the reference points of ACE score zero being the comparison. Ultimately, the real question of course is, "How does this come about?"
Dr. Buczynski: First of all, we need to say that correlation does not prove causation. And you are not implying that it did. What would you hypothesize might be the connection?
Dr. Felitti: Well, before we get to that, since you brought up the "correlation does not equal causation," let me point out that in all of these instances there was a step-wise proportionate increase so that when you move from ACE score zero to ACE score one, to ACE score two, to ACE score three, etc., there was a step-wise increase in the likelihood of that particular outcome. That is of enormous importance.
Dr. Buczynski: So you have interval data.
Dr. Felitti: We have a very clear dose response effect. Perhaps most important was simply talking with patients and having them explain the causality. We have many lengthy videotaped interviews with patients where it is perfectly clear to them what the explanation is between all of this. If people would like an easy way of accessing this, they can go to the website, www.ACEStudy.org.
Two key pieces were: a) the fact that there is a dose response effect with all of this - not merely some general correlation, and b) the fact that, in many instances, the patients themselves are willing and capable of explaining the relationships quite clearly. It is just that ordinarily they are never given the opportunity.
Dr. Buczynski: So how does one get from life experience in childhood to structural disease later in life?
Dr. Felitti: The easy pathway for understanding is through various coping mechanisms - overeating being one.
The issue with obesity, based on our experience in successfully and unsuccessfully treating about thirty thousand obese patients, includes two core problems. One is the use of food for psychoactive benefits. This is even built into the English language: "Sit down; have something to eat. You'll feel better." Secondly are the psychoactive "benefits" - the benefits of obesity per se.
But isn't it bad for you? Of course it's bad for you. The point I'm raising is whether it is not good for you.
If you talk to patients about this, it is quite remarkable what you learn. Every week in our obesity program here, for instance, we have about thirty or so people who show up at a meeting to learn more about the program. Rather than describing the program to them, I tell people that we are going to give them a free sample to show them what would be typical of the program. I explain that the program consists of the same dozen or so people meeting every week for two hours for five months with the same counselor, working on addressing questions that we have found to be important.
The first question is this: "Tell me why you think people get fat." We're not asking "how" - "how" is obvious.
Last week the first answer was from a man with depression. I don't remember the second answer but I do remember the third answer - and that was from a woman, and she said, "People leave you alone." We then write all of these answers down.
It has been a couple of months since anyone has proposed, "My metabolism is ruined" or "Must be genetic" or "It runs in the family." To this I will usually respond, "Really? How interesting. Tell me, does everyone in your family speak English? I see - so speaking English runs in the family as well." The titters of laughter from the rest of the group pretty much kill that one right there.
One of the things that we have found, which is also useful for subjects other than obesity, is probably the single most important question in understanding obesity: "How old were you when you first began putting on weight?" Not finished the job; but first began. Whatever the cause, obviously it had to be then or before. Amongst people who have begun gaining in childhood, the number of times that those ages approximates parental loss through divorce is quite striking.
I have seen nothing in the literature about this, probably because so many of us have been divorced and it is not a comfortable subject to think about.
The second question that we pose to people in the weight program is: "We all know that there are many people who lose a lot of weight, only to regain it all, if not more. For example, they will lose 100 and then regain 120. Why does that happen?"
People always answer, "Because if you don't deal with the underlying issues it will be back." This is a rather remarkable insight. About sixty percent of the time somebody will propose, "Because major weight loss is threatening."
The third question is: "Tell me the advantages of being fat." Not the disadvantages - that's obvious. You can get a government pamphlet to tell you that. The advantages, however, always break down into three categories.
First, it is sexually protective. Anyone who has been molested or raped will quickly understand that. Those are common experiences, however it is uncommon for anyone ever to bring it up or inquire. We did routinely and we learned, in this very middle-class population of seventeen-and-a-half thousand adults in Kaiser Permanente, that twenty-eight percent of women acknowledged a history of childhood sexual abuse, as did sixteen percent of the men.
That was a big surprise, but understandable. No one would have a basis for knowing because no patient brings it up spontaneously and the rest of us have all been taught that it would be impolite to inquire.
"What are the advantages of being fat?" The first category is always: "It is sexually protective." The second category is "physically protective," as suggested in the expression, "throwing your weight around."
In the early days of the Program we had two men who were guards at the state prison downtown. They lost between 100 and 150 pounds each. They did not feel comfortable going into the prison without the extra weight. They felt a lot safer looking as big as a refrigerator.
The third category is "People expect less of you." This is a commonplace observation.
All of these were of enormous importance in realizing that things which are referred to as "public health problems" are oftentimes also unconsciously attempted solutions to personal problems that are lost in time and then further protected by shame, secrecy, and the social taboos against routinely inquiring into certain areas of human experience.
Dr. Buczynski: So, what you're implying is that these may well be efforts at coping or compensating.
Dr. Felitti:Without question. No one smokes to get lung cancer or heart disease. People smoke because of the major psychoactive benefits of nicotine. People ask, "Isn't it risky?" Absolutely! In fifteen or twenty years it is seriously detrimental.
In fifteen or twenty seconds of inhalation, it has very clear benefits. Those are the major activities of nicotine, in terms of anti-anxiety activity, in terms of antidepressant activity, in terms of appetite suppressant activity, and in terms of anger suppressant activity. This has been spelled out in medical literature for decades.
Dr. Felitti: This is a separate yet important issue. I would like to stick with the first one, the coping mechanisms. The common ones are eating, smoking, drinking, and drugging. Alcohol is simple: "Sit down, have a drink - relax." You don't need to think a great deal about that. Street drugs are somewhat more complex. The resistance to understanding it is interesting because anybody my age or older should remember this. Almost everyone knows the demonized street drug crystal meth is a big problem
It is interesting that no one seems to remember that the first prescription antidepressant medication introduced for sale in the United States in 1940 was methamphetamine. It was introduced by Burroughs Wellcome, and the brand name was Methedrine. If anyone has any doubt about this, they can go to any major university library and pull out a bound volume of the Journal of the American Medical Association from 1940 or '41. There they will see full-page ads for Methedrine.
The question therefore becomes; does it mean anything that the first prescription antidepressant medication is exactly the same chemical as crystal meth? Is that just an irrelevant happenstance, or are people unwittingly buying antidepressants on the street? If so, isn't it dangerous? It is equally as dangerous as having Digitalis sold on the street in an unknown dose and impure form. If you don't know what you are doing dosage-wise, Aspirin is quite reliably fatal. Just take fifty.
That is one broad category of some of the most common coping devices leading to a huge array of structural disease: coronary artery disease, diabetes and its sequelae etc., lung disease, and chronic obstructive pulmonary disease. That is fairly easy but somewhat unpleasant to understand.
The more subtle second category is the one previously mentioned. I will back up a little bit earlier, to the idea of the effects of chronic major unrelieved stress over prolonged periods of time, and what that does in terms of flooding a person's body with high levels of circulating cortisone and related stress chemicals.
Everyone has heard that if you take cortisone, to treat rheumatoid arthritis for example, that there are major side effects. There are certainly major benefits, but also major side effects.
It doesn't matter whether you get the cortisone from a prescription bottle or from your own adrenal glands - there is a price to be paid for having unusually high, chronic levels of high circulating cortisol levels.
Often in this situation people's immune systems are suppressed. Sometimes it goes into total disarray. Bruce McEwen of the Rockefeller Institute in New York has written extensively on this subject.
There are so-called "pro-inflammatory cytokines," internally-produced chemicals that are released within one's body. These set up inflammatory reactions in the lining of very small blood vessels, causing them to close down and causing the scarification of whatever piece of organ they had been supplying.
The second big pathway deals with dysregulation. The chronic major stress pathway is responsible for a number of diseases we are beginning to get an understanding of now. Many people believe that if you are the recipient of an organ transplant, for example, you have to be on lifetime immunosuppression. Some people also know that if you are on lifetime immunosuppression, one of the side effects is an increased rate of malignancy in those individuals.
We are all producing low levels of malignant cells at all times. They are readily processed out by our immune systems and we never know the difference. Therefore, getting cancer means one of two things: either you are producing malignant cells at an accelerated rate as might occur from being a heavy smoker or from exposure to dangerous amounts of radiation, etc.; or your body's ability to recognize and process out those cells is impaired. One form of impairment comes from the damage to your immune system while taking immunosuppressant drugs after organ transplantation. Another form comes from chronic major stress over prolonged periods of time.
This would appear to be the second major pathway and it has obvious relevance to our finding of increased rates of cancer in high ACE score patients as well as the fact that we found increased rates of autoimmune diseases in high ACE score patients...
Dr. Buczynski: Which ones?
Dr. Felitti: We have a paper out where we studied twenty-one different autoimmune diseases. Without referring to the paper, I can't quote you reliably off-hand. Rheumatoid arthritis was one. Another interesting illness is the disease primary pulmonary fibrosis. Ten years ago that would have been a rock-solid example of a hardcore structural biomedical disease.
Now it is clear that at least some portion of those cases is due to the release of these so-called pro-inflammatory cytokines causing microscopic blood vessels to become inflamed, to scarify and then cause the destruction of whatever piece of lung tissue that they are supplying by converting it into scar tissue. This is known as primary pulmonary fibrosis.
The breadth of this was quite remarkable, as well as unexpected. We kept stumbling into things, some of which were fairly easy to understand and others of which were much more complex.
We had an interesting experience which led to some interesting insights into this. After several years of the ACE Study it became obvious what we were learning. Then it became clear that we needed to expand our information base so that we were routinely gathering information on everyone.
Our medical questionnaire was already quite comprehensive. It's important that this information, for practical purposes, needs to initially be gathered by questionnaire and this kind of questionnaire should always be filled out at home, not in the doctor's waiting room.
It became evident that we needed to ask a lot of trauma-oriented questions. So, we routinely asked questions like, "Have you ever lived in a war zone? Have you ever been a combat soldier? Who in your family has committed suicide? Who in your family has been murdered? Have you ever been held prisoner, tortured, raped, molested as a child?" etc. So those were some examples. And we added a good dose of those to the questionnaire.
Needless to say, the staff was not exactly thrilled because they correctly realized that this raised the performance bar. Impressively, however, they all became quite capable of dealing with this.
After doing this for a couple of years, a friend of mine introduced me to some people that owned a big data mining company here in San Diego. They used a technique called neural net analysis. Neural net analysis is a rather sophisticated, heavy-duty computer approach to data mining.
Ordinarily, when data mining, you have to have some sense of what question you want answered. In neural net analysis, you absolutely do not. This approach sorts, and repeatedly re-sorts through mountains of data, looking for anything that has a relationship to anything else. Most of the relationships that turn up are simply statistical phenomena and of no interest or relevance whatsoever. The beauty of the technique is that occasionally you discover intense relationships that you never would have thought to look for.
They analyzed the results of over one hundred thousand patient visits using the new questionnaire which included the new trauma-oriented questions. This was about two-and-a-half years' work for the department. To my absolute amazement and embarrassment actually, they found that, coincident with the use of the new questionnaire, there was a thirty-five percent reduction in doctor office visits in the year subsequent, compared to the antecedent year, for a population of over one hundred thousand adult patients.
Dr. Buczynski: What did they make of that?
Dr. Felitti:There was also an eleven percent reduction in emergency room visits. People have said to me, "You sent everyone for therapy, right?" "And that was rare, essentially never." So how did this work? That is a very meaningful question because a thirty-five percent reduction in doctor office visits has extraordinary cost and theoretical implications, even if it lasts for only a year.
As near as we can figure out, we believe we illustrated the profound importance of helping people talk about the worst secrets in their lives and enabling them to go home feeling still accepted afterwards. I slowly came to see that what we had done showed that asking and listening and accepting was doing. That was rather a profound realization.
Dr. Buczynski: How long did it last?
Dr. Felitti: Two years later everything reverted back to the prior base line. One might ask, "Well why was that?" Our best understanding is our use of unified medical records here, which we have used for years. Everything is in one folder; in the early days paper and now electronically. In the folders there are our notes printed literally with laser-like clarity. They might just as well have been printed with invisible ink because no one wanted to go near that information with a pole.
Dr. Buczynski: Did you find any correlation between ACE score and visits to primary physicians or to emergency rooms?
Dr. Felitti: Yes. There is a very distinct relationship, but that is simply made clear from my own experience of talking with large numbers of high ACE score people. I don't believe, however, that we studied that in the ACE Study.
Dr. Buczynski: What are you finding about mortality?
Dr. Felitti: With an ACE score of six and higher, there is almost a twenty-year shortening of lifespan. That was published in October or November last year. Anyone that goes to the www.ACEStudy.org website can find their way quickly to detailed iterations of all the publications and abstractions.
Dr. Buczynski: What would you like to see people do with it?
Dr. Felitti: It will be important to take what we learned here and use it to bring about a change in primary care medical practice: to move it from its current symptom reactive mode to the more comprehensive style that it was originally conceived for.
There is a lot of understandable opposition to that. People complain that there is no time, which is true. On the other hand, there are mechanisms for circumventing that.
The information can be obtained, as we did, by a lengthy questionnaire filled out at home. Then it is read quickly, as we did, or you feed it into a digital scanner that sucks up all the "yes" answers and reformats them into a review of systems output. This would give you a highly legible and highly structured two or three page printout that would take two or three minutes to look at and read.
While we were teaching the staff, as examiners, we would give them a real printout and give them two questions. First, how well do you understand this intellectually? Here are two or three pages of highly detailed information; how do you put all this together? Secondly, what is the first thing you are going to say after you say "Hello?" How do you walk into a room, introduce yourself to a stranger and then move from brief social nicety to talking about the things that nice people don't talk about?
That was an interesting experience. Ultimately everybody became proficient at doing that, but it did require some thinking.
This would be one approach to make comprehensive information (biomedical, psychological, social, family, and in particular trauma-oriented) routinely available in a very organized structure, covering all patients at the very outset of ongoing care. That would be one huge goal.
The other approach would improve parenting skills across the nation, because that is really where this all begins. One cannot simply address the issue: "How are we going to fix this after the fact?" The problems are too numerous. They are too complex.
Sending people for therapy is a nice illusion. It is certainly an act of great kindness and it will be available for a very small number of people. You can turn yourself into the next Mother Teresa and make yourself extremely busy doing that, but you will never notice that you are leaving the great bulk of the problems unrecognized and unaddressed.
If ever there were a need for true primary prevention, this is the area. A primary prevention example would be the polio vaccine. It is a good thing that during the March of Dimes days some money was put aside for vaccine development or we would still be collecting money to build the "bigger and better" Sister Kenny Institutes and to buy digitally-controlled iron lungs for patients.
Primary prevention needs to involve improving parenting skills. I am not speaking about the people with monstrous problems that are going to murder or otherwise destroy their children, for that is too complex to take on currently.
Instead I am speaking about the huge number of people who never had any experience with supportive parenting themselves. How many of them, if they simply saw or understood what it looked like, might be capable and willing to do some of that themselves?
The vehicle for carrying out this improvement would be broadcast television. The technique would be theatre, specifically soap opera. We should weave these ideas into the storyline of soap operas with illustrations of what destructive parenting looks like and how it plays out over time, and contrasting that with illustrations of supportive parenting and how that plays out over time.
The audiences are huge. The bill is paid for; one doesn't need to seek funding from a legislator or from a granting foundation. The material is sufficiently lurid that in the hands of capable writers it is not going to bore anyone.
The use of broadcast television has a demonstrable background. For instance, in Africa, where condom use has been pushed for years to try to reduce the transmission of AIDS, conventional public health approaches got absolutely nowhere. The approach that worked was weaving those ideas into the storyline of soap operas. There have been a couple of books written about that, actually.
Dr. Buczynski: That is a fascinatingly interesting idea...thank you for giving your time for sharing the information with us. I think this is really important for people to know and discuss these ideas. Through discussion we can come up with even more thoughts. One of the things we did not discuss is the neurological theory or hypotheses that trauma might lead to some impairment neurologically, which would then lead to different factors that would affect chronic disease.