A First-Rate Madness (16 page)

The army brought in a new leader, Dr. William Menninger—a more orthodox psychiatrist than Sullivan, and a more typical American too (midwestern, WASP, heterosexual, middle-of-the-road politically). By this time, the war had become brutal. U.S. military deaths were reaching Civil War levels; the army couldn't afford mass psychiatric casualties too. Marshall gave Menninger new instructions: screen out only the most clearly insane draftees and, rather than finding reasons to bring soldiers home, try to keep them at the front. The results were amazing: more draftees passed their psychiatric evaluations, but fewer soldiers developed war neurosis.

Why was this the case? It turned out that all those personality traits—narcissism, dependence, avoidance, schizoid personality—that Sullivan thought would predict war neurosis didn't do so at all. The mass of American soldiers displayed many variations on normal personality, and most of them handled combat well.

One explanation may simply be that Freudian psychiatry was wrong; the theories about who needed to be screened out, and why (such as homosexuals, and those who did not meet the standards of Freudian ideology), were scientifically wrongheaded. This may be why they failed in practice. When Menninger was forced to apply more commonsense notions, psychiatrists observed that most soldiers were able to experience trauma without much mental hardship. When the psychiatrists were looking for war hysteria, they found it; when they stopped looking, they found less of it.

This is the case with all hysteria, that is, with all psychological symptoms that seem to be caused by trauma. In a classic example from medical history, the nineteenth-century French neurologist Jean-Martin Charcot developed an interest in hysterical epilepsy. Young women in Paris would present with highly unusual movements during seizures, quite different from most cases of epilepsy. These movements often mimicked sexual intercourse. Charcot was convinced that this was a unique form of epilepsy with a special lesion in the brain. One of his students, Freud, thought these women had experienced sexual trauma and were unconsciously expressing those traumatic symptoms through the physical symptoms of seizure-like movements. While Charcot was active, many women in Paris presented to doctors with hysterical epilepsy; his clinic was full. After Charcot died and his successors showed less interest in the topic, the frequency of hysterical epilepsy dropped sharply in his clinic. A similar pattern happened in the 1980s and 1990s with multiple personality; a sharp rise in professional interest led to a spike in diagnoses. Later, when professional interest declined, patients apparently stopped having multiple personalities.

So by shifting the doctor's focus, the patients' symptoms can change. This especially happens with trauma-related symptoms. And it seemed to occur in the different approaches taken by Sullivan and Menninger. As we will soon see, Menninger's approach probably approximates the actual rates of PTSD; only a small minority of people exposed to trauma actually have PTSD.

After World War II, psychiatrists began to realize that the relevant question wasn't what caused war neurosis, but why more soldiers weren't suffering from it. The doctors began to shift their focus from risk factors to resilience.

 

 

IN THE INTERVENING half century, we've learned that war is hardly the only source of psychological trauma. Childhood sexual abuse, physical abuse, crime, and major car accidents can have similar effects. In fact, about half of the U.S. population experiences a major trauma at least once; but only 10 percent of those people meet the diagnostic definition of PTSD. So most people who experience trauma do
not
develop PTSD.

The fact that trauma doesn't always lead to PTSD has recently led some resilience researchers, like George Bonanno of Columbia University, to examine all the varieties of response to trauma. Bonanno identifies four major types. First, there is the classic PTSD response: some people experience severe psychological symptoms right after the trauma, and consistently thereafter. This kind of chronic PTSD occurs in only about 5 to 10 percent of people who are exposed to trauma. Then there is delayed PTSD—the Freudian model. In Freud's famous cases, young ladies suffered from severe hysteria, manifesting as physical paralysis of unknown causes. Then, in the course of psychoanalysis, they recovered repressed memories of childhood sexual abuse, after which their hysteria ceased and they were no longer paralyzed. As Bonanno notes, it is rare to actually observe anyone who displays the patterns seen in Freud's famous patients—that is, first suffering a psychological trauma, showing no psychiatric symptoms immediately afterward, but then later developing PTSD. (Instead, people usually experience psychiatric symptoms soon after trauma that get worse over time.) A third “recovery” group suffers initial PTSD symptoms that gradually go away. For instance, after the September 11 attacks, 7.5 percent of New Yorkers met full PTSD criteria initially, but only 1.7 percent at four months, and 0.6 percent at six months. Similarly, in Gulf War veterans with initial PTSD, 62.5 percent no longer had any symptoms a year after their initial trauma. A fourth “pure resilient” group suffers no symptoms of PTSD at any time—either right after trauma or months later. Traditionally this group has either been ignored by researchers or, in the Freudian tradition, thought to have latent symptoms that simply haven't shown themselves yet. And yet people in this fourth group seem able to withstand trauma and continue living normal lives. They aren't happy automatons, ignoring the misery around them; they just don't develop PTSD. The third and fourth groups together characterize what we mean by overall resilience: the experience, following trauma, of some psychiatric symptoms, which eventually go away—or no symptoms at all.

 

 

WHAT MAKES PEOPLE in these two groups more resilient to trauma than people in the other groups? Efforts to answer this question range widely, from studies of inner-city children, to healthy adults with past childhood sexual abuse, to combat veterans, to civilian populations exposed to war and terrorism. I will have to pick and choose among studies, some of which are inconsistent with others, to give a concise narrative, but interested readers can find more detail in the endnotes.

Taken together, this research suggests that resilience emerges from a combination of social support (good friends and family), hardship (bad luck), and certain personality traits (especially hyperthymia). Let's consider each of these factors.

Social support:
Many children raised in socially and economically poor backgrounds grow up to be well-adjusted adults. They are resilient. Researchers find that a common feature in these resilient kids is strong social supports—good relationships with at least one parent and a large circle of childhood friends. (Some psychologists call this “ordinary magic” to emphasize the point that psychological resilience grows out of simple human experiences, such as having a loving parent.) Similarly, in studies on World War II veterans, those with greater social supports before war (meaning intact and supportive families) and during war (meaning intact military units with strong emotional bonds between soldiers) experienced less PTSD. This is the standard view. But there is another possibility based on a study of childhood adversity.

Hardship:
In an uncommon project, unique in that it sought to study resilience and health (rather than illness), trauma researchers advertised for adults who had experienced sexual trauma but hadn't had any psychiatric problems in later life. Many people responded, eager to tell their stories, and researchers picked thirty-one adults—middle-aged, upper middle class, and well educated—as the resilient group, compared with a nonresilient control group, people from similar backgrounds whose earlier traumas had produced severe psychiatric consequences. Friends or family were used to confirm what the subjects themselves described about their lives. Surprisingly, the resilient group reported that they'd had little social and parental support in childhood. In contrast, the nonresilient group reported good social and parental support in childhood. A harsh childhood predicted adult resilience; a more benign childhood produced PTSD.

Perhaps the most common childhood hardship is loss of a parent, by death or divorce, a proven risk factor for adult depression. Studying predictors of greatness in 699 historical figures, psychologist Dean Keith Simonton found that 61 percent of great leaders lost a parent before age thirty-one, 52 percent before age twenty-six, and 45 percent before age twenty-one.

Apparent conflict in the above studies may relate to the difference between hardship and trauma. Trauma is more intense and acute, while hardship is less intense but more long lasting. Poverty is often a hardship, a chronic problem, not a brief intense trauma. It may have different effects, especially in relation to resilience, than a one-time severe trauma (such as battle or rape). In both cases, though, as we'll see, trauma and hardship interact with personality to determine whether or not a person becomes resilient and survives, maybe even thrives, or succumbs.

Personality:
Personality traits that reflect biological temperament are usually set by age three or so, and persist throughout adulthood. They are not themselves produced by trauma. Adults who have higher neuroticism scores experience more PTSD than those with low scores, despite the presence in all cases of childhood sexual abuse. As we saw in the introduction, neuroticism is one of three major personality traits; it measures a person's general level of anxiety. If one tends to worry a lot, one has high scores; if one is usually calm and serene, one has low scores. People with hyperthymic personalities generally have low neuroticism.

Besides low neuroticism, hyperthymia enhances resilience. For example, one study examined psychiatric evaluations from seventy-two terrorist attacks in Russia between 1994 and 2005, during which time 7,416 hostages were taken, 1,609 people were killed, and 2,401 people were wounded. PTSD was more common in those hostages with neuroticism traits (“diffident, doubting, closed persons”), and least likely in hostages with hyperthymic personality traits.

Studies of normal populations may also point to the influence of hyperthymic traits. For instance, “positive emotions” (like gratitude, interest in others, sociability, friendliness, love, a sense of humor) are associated with greater psychological resilience to trauma. These traits are also present to a high degree in people with hyperthymic personalities. In one study of forty-six college students before and after the September 11 terrorist attacks in 2001, presence of positive emotions before the trauma predicted less depression afterward. Similarly, in young adults with childhood sexual abuse, positive emotions predicted better long-term outcomes. Building on this work, Bonanno has used the term “hardiness” to explain resilience, which he defines as “being committed to finding a meaningful purpose in life, the belief that one can influence one's surroundings and the outcome of events, and the belief that one can learn and grow from both positive and negative life experiences.” This is a good description of how people with hyperthymic personality think, and such a worldview might do even more to influence resilience by affecting the kind of social support one receives. Having a circle of supportive friends and family—which Bonanno and others have identified as contributing to resilience—can be seen partly as the
result
of an extraverted, sociable, hyperthymic personality that draws people toward you. Genetic studies with identical versus fraternal twins support this paradoxical link—your genes and your personality partly determine the environment you will experience.

Of all these positive personality traits associated with resilience, I would emphasize humor. Roosevelt and Kennedy were famously witty, a hallmark of hyperthymic personality. Indeed, humor is a central ingredient to resilience. Psychoanalysts have long noted that a good sense of humor is a strong sign of psychological maturity. Freud wrote an entire book about wit, and the psychoanalyst George Vaillant, in his classic fifty-year study of mental health, concluded that humor was the best hallmark of mental health. If so, hyperthymic people, who are often seen as funny, may be the healthiest ones around. Their wit is not accidental to their resilience.

 

 

WE NOW COME TO the paradox of trauma—its
steeling
effect. Not only can it make a person psychiatrically ill, but it can make someone psychiatrically healthier. There is post-traumatic
growth:
trauma itself might not harm some people psychologically at all; it might in fact help them. It is not a matter of getting better
despite
the trauma, but rather
because
of it.

One source of evidence for the steeling effect is a classic study that followed children of the Great Depression into adulthood, which found that those who had experienced
more
childhood poverty grew up to be
more
psychologically healthy (based on standard psychological tests). Here is another way of testing the steeling affect: Are people with past PTSD more, or less, prone to experiencing future PTSD when exposed to new traumas? This question, rarely asked, answered itself in a project run by a research group, with which I was associated, at Massachusetts General Hospital. Given that PTSD symptoms had increased in New York City after the September 11 terrorist attacks, we were interested in the impact of the 9/11 trauma on people with mental illness, specifically those with bipolar disorder. From an earlier study, we'd already gotten data on PTSD prevalence in New York–based bipolar patients before 9/11, so we went back and tested them after the attacks. Just as in the general population, PTSD symptoms rose in people with bipolar disorder after 9/11, except for one group—those who'd
already had
PTSD and recovered from it before 9/11. Without intending to do so, we showed that past PTSD could, like a vaccine, protect against future PTSD.