THE PHYSIOLOGY OF ADDICTION – AND IMPLICATIONS TO TREAT CHILDHOOD ABUSE
There is an enormous lack of understanding of the mental and physical health damage caused by childhood sexual and/or physical abuse – including its aftermath’s role in victims becoming dependent on substances. Sue Cox brings us up to date with research and epigenetics.
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I write in my capacity as founder and director of a large substance-misuse training organisation called Smart-UK which has taught over 10,000 healthcare professionals. During my 35 years of working and teaching in this field, I have become increasingly concerned at the enormous lack of understanding of the mental and physical health damage caused by childhood sexual abuse. Concomitant to this, there is an increasing need to provide clarification to the courts, lawyers, judges and other professionals who are engaged in dealing with childhood sexual-abuse cases. Repeatedly, victims’ cases are being downgraded due to the lack of understanding of the long-term consequences, and this further increases their suffering from the abuse.
There are several important facts to correct. The first regards the fact that victims of childhood clerical abuse often have “addiction” problems, and this is the area of my particular expertise As mentioned, my organisation has taught thousands of healthcare professionals who, in turn, have collectively been responsible for the treatment of many more thousands of patients with addiction problems. Far too many of these patients have a history of childhood sexual abuse, the implication being that a causal relationship exists between these events.
It is hoped that this article might help to shed some light on this particular problem, and provide a more considered approach to decision-making in the future.
HOW CAN ADDICTION BE DEFINED?
Addiction can be defined as the uncontrolled, compulsive use of a substance, person, thought or behaviour for the purpose of changing a person’s emotional state, regardless of any potential consequences, which are not admitted to consciousness. The key point here is that people do not make a choice to become addicted and often are not even aware that they are. People become addicted because the way their brain works – their neurobiology – deviates from the normal position of being able to control their behaviour
WHAT ROLE DOES GENETICS PLAY?
DNA – or deoxyribonucleic acid, to give it its full name – is a chemical which creates the blueprints living things use to store the instructions required to develop, grow and survive. Sequences of DNA which contain a particular set of instructions are called genes.
It might be useful to think of our cells’ nucleus as a library: each book is a chromosome and each chapter a gene. Combining letters of the alphabet produces the words making up the text and DNA is the cell’s alphabet. Sometimes spelling mistakes, changes in the DNA sequence, are made. This is enough to either cause disease outright (cystic fibrosis for example) or, as is the case with addiction, increase risk factors. Psychiatric disorders like addiction or schizophrenia, for example, are very complex disorders. This is because they are caused not by errors in single genes but by changes in several genes which cumulatively increase disease risk.
But perhaps the most important factor that determines whether or not an individual will develop the disease is the environment in which they find themselves.
Addiction is rooted in the interaction of the environment, such as trauma or neglect, with genetically predisposed imbalances in brain function; addiction is a symptom of this gene-environment interaction. Addiction might or might not be caused by our environment alone, or by genetic predisposition alone – but it is becoming more apparent that it could result from a combination of the two.
To summarise this: vulnerable people who are predisposed to addictive behaviour often suffer a specific event or events which trigger their path to addiction. Childhood sexual abuse clearly represents one such event.
WHY IS THE ENVIRONMENT SO IMPORTANT?
In some ways this is very obvious: for example, unless a predisposed individual can gain access to alcohol they cannot become addicted to it. But the environment is more important than this. Our experience of the world affects how our genes function and it is these changes which can trigger the path to addiction. This is known as epigenetics, or “upon genetics”.
WHAT IS EPIGENETICS AND WHY IS IT IMPORTANT IN PSYCHIATRY?
Anecdotally, it is understood by most societies that childhood events significantly influence later adult life. It is for this reason that we try to create a nurturing environment for our children. Although this knowledge is assumed, without scientific evidence it remains unsubstantiated.
DNA can be said to provide the basic blueprint of life, but epigenetic changes provide another complex layer of information. Epigenetics can be described as the transmission and perpetuation of genetic information that is not based on alterations in the DNA sequence (turn to page 39 for an explanation). These changes result from both the chemical marking of the DNA itself and the proteins to which DNA is bound. It is these changes that alter gene expression, the phenomenon by which our body controls which genes are active, and to what degree at any given time.
These epigenetic marks are a molecular response that allows the body to respond to changes in an unpredictable environment. It is striking to note that identical twins, in whom the DNA code is identical, show dramatic changes in their epigenome over time. It is for this reason that identical twins are not identical people. Epigenetics is a mechanism by which life experience is encoded, and alters us.
It is also important to note that, in some instances, these epigenetic marks are heritable. This can have long-standing consequences for the development of victims’ offspring in terms of their cognition and stress response.
Recently, a number of genes have been identified which predispose people to psychiatric disorders. These do not automatically result in disease but these gene variants in combination with life events increase the risk of developing the disorder.
For example, a variant of the gene-encoding enzyme monoamine oxidase A results in the higher metabolism of a chemical in the brain which has been linked to violent behaviour in people who suffered childhood abuse. This higher enzyme activity can be perceived as ‘protective’ – but if people have a gene variant which causes lower activity of this enzyme, then childhood abuse is more likely to cause them to develop violent tendencies (Caspi A, McClay J, Moffitt TE et al 2002: Role of genotype in the cycle of violence in maltreated children. Science 297,851,854).
So, what is happening here is that childhood abuse triggers epigenetic marks which reduce the production of this enzyme, and in the case of those who already produce slightly less than normal, causes its levels to dip below an important threshold.
Similarly, variants of another important brain molecule, the serotonin transporter, either protect or predispose those who suffer childhood trauma from depression (Caspi A, Sugden K, Moffitt TE et al 2003: Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science,301, 386-389).
WHAT IS THE IMPORTANCE OF THIS DATA?
This scientific information allows us to start to understand the molecular events, the physical changes, which lie beneath what has previously been described as “psychological damage”. Because of this research, we are beginning to disentangle the physical effects of dreadful early childhood experiences. These events physically alter the brain, which can dramatically disturb its function, increasing the likelihood of psychiatric conditions including addiction. These changes are often permanent. They occur during a child’s key development phases. And they can be passed on to future generations.
It is reprehensible that those in positions of authority or trust attempt to excuse any crimes of abuse that have been committed merely on the basis that a victim suffers from addiction, and thus that inappropriate low-level ‘treatment’ with no psychosocial support is thus a solution.
It is essential for the courts to isolate and separate, as far as reasonably possible, the stressors which are responsible for switching on the gene expression that results in addictive behaviour. Only in that way can these stressors be addressed so that the behaviours, as well as the suffering of all concerned, start to diminish even to the point where recidivism/reoffending also diminishes.
To improve the quality of legal representation available to those who have suffered abuse, and to get the latter appropriate life-changing help, it is vital that expert witnesses are made available.
RECOVERY IS NOT INEVITABLE
Knowing the mechanisms of action and the neuroscience of addiction, I fully believe that true recovery relies on abstinence. But abstinence itself is, initially, a very powerful stressor, both physically and emotionally. The person loses something perceived as dear, their source of pleasure, their painkiller, their emotional crutch.
A person who has been sexually abused as a child is already dealing with a wealth of fallout from that damage. Alcohol and drugs, including prescription drugs, have often been a huge part of their “self medication”.
If someone has truly become addicted, then neuroscience and experience both demonstrate that abstinence is the only hope for their lives to be saved. Bear in mind that neuroscientific findings do not necessarily mean that a pharmaceutical drug should be applied to change brain chemistry – people can alter their own brain chemistry when they get into and sustain abstinent recovery.
It is my opinion, borne of many years experience, that recovery requires several steps:
1. The removal of denial
3. Indepth learning of the truth of the condition
4. Sustained hard work to build the ability to respond to challenge
5. The improvement of self -respect and status
6. The reduction of feelings of isolation, and an enhancement of connection with others
7. The provision of emotional safety and support without collusion (tough-love)
8. The reduction of stressors, and
9. The empowerment of the individual.
So, even if the person does recover, they are faced with a lifetime of vulnerability and the need for vigilance. This should all be taken into consideration when determining the cost to an abuse victim’s life.
Risk of relapse ranges from 60-90%, with the Global Information System on Alcohol and Health reporting that about 2.5million people die every year from harmful use of alcohol alone. Tobacco kills even more people, and prescribed drugs kill as many people as illegal ones. We must offer the highest educational and professional standards to stem this tragedy.
SUE COX is founder-director of Smart-UK and cofounder of Survivors Voice Europe. Smart-UK trainers include Kim Wager BSc(Hons), MSc, LicAc, DipCHM, MSB who specialises in molecular neuroscience and genetics. Smart’s latest training course is Brains, Bombs and Baddies, a two-day workshop exploring the brain in relation to post-traumatic stress disorder (firstname.lastname@example.org or email@example.com; tel 01926-640525).