From Chapter One
Monster in the Closet
Trauma in the Body
IT IS ALMOST IMPOSSIBLE to pick up a magazine, thumb through a newspaper, or turn on a television news program without being bombarded by recent research on obesity, the latest news on dieting, or the newest celebrities lending their faces to our nation’s problem with addiction. The faces change and the advice varies, but the message remains the same: we Americans have a problem with overindulgence in habits that hurt us. “Behavioral health” is a hot topic because these issues permeate every segment of society and impact each of us directly or indirectly. We tend to write off obesity and addiction as either genetically determined or as inescapable aspects of contemporary living. But the closer these concerns come to affecting our own daily lives, the less cavalier we become. It’s hard to be dismissive about our own diminishing health or that of someone we love in the face of a serious diagnosis, especially when we learn that the diagnosis stems directly from weight gain or addiction.
But what if neither addiction nor obesity is inevitable? What if these conditions arise, as often as not, from a mostly preventable blindness about what humans need to develop constructively?
The first indications of this reality have long been in front of us. The addictions—our hunger to “fill the void” with food or alcohol or drugs,gambling or shopping—were the first symptoms of behavioral ill health that led unsuspecting researchers to the significance of early experience. The single most common behavioral health issue, and one that many of us stumble over, is obesity. Oprah Winfrey has been the face of this issue for millions. For years she has battled her weight, in spite of her access to the best diets, personal trainers and exercise regimens. Having hit the “dreaded 200,” Winfrey revealed in late 2009 that her exquisitely conceived costume for President Barack Obama's inauguration would fade into history unworn—because it didn’t fit her ballooning (still voluptuous) figure. Embarrassed and exhausted, Oprah said:“It’s not about the food. It’s about using food. Abusing food. Too much work.Not enough play. Not enough time to come down. Not enough time to really relax.I am hungry for balance.”1 Mirroring the thoughts of millions of women in this nation, Oprah admitted, “So here I stand forty pounds heavier than I was in2006. . . . I’m mad at myself. I’m embarrassed. I can’t believe that after all these years I’m still talking about my weight. I look at my thinner self and I think, how did I let this happen again?”2
Weight loss is a huge market. Many factors are commonly blamed for the increasing number of fat Americans: fast foods; loss of time to prepare fresh foods, whose relatively higher cost may lead to increasing reliance on prepared food; too much TV; too little exercise; the increasing idleness of American schoolchildren. Genetics and organ diseases such as hypothyroidism can also play a role. But they don’t explain all or even a majority of instances of obesity. The sheer number of diets and weight-loss products and the ineffectiveness of most of them indicate that we’re missing something important. Oprah, being Oprah—a woman whose intelligence has enabled her to grow from an impoverished, chaotic and abusive childhood into the incredible force she has become as an adult— intuitively acknowledges: “My greatest failure was in believing that the weight issue was just about weight. It’s not. It’s about sexual abuse. It’s about all the things that cause people to become alcoholics and drug addicts.”3
The health consequences of being overweight are wide-reaching and the topic of much alarm in our nation. Simply being overweight (body mass index [BMI] of 25 to 29.9) or obese (BMI over 30) significantly increases the risk of disease, including hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis and some cancers, such as breast and colon. Approximately forty different diseases are linked to obesity. The ramifications are staggering. Thirty-four percent of American adults are obese. In addition, 68 percent of adults and one-third of all children and teens in this country (25 million kids) are considered obese or overweight.4 Roland Sturm, a senior economist with the Rand Corporation who has overseen several studies on obesity’s impact on the quality of life, says: “An obese 30 year old has as many chronic conditions as a normal weight 50 year old and reports quality of life that is worse than a 50year old.” Asked what he thinks we should do, Sturm suggests, “Maybe we should start by trying to create an environment that prevents obesity in the first place, especially for children.”5
The rise in obesity has been accompanied by an explosion in diabetes, which more than quadrupled between 1980 and 2009, from5.6 million cases to 24 million. The incidence of type 2 diabetes in children is skyrocketing as well.6 The Centers for Disease Control and Prevention (CDC)has predicted that one in three children born five years ago in this country will develop diabetes. Diabetics are two to four times more likely to develop heart disease or have a stroke and three times more likely to die of complications from flu or pneumonia. Also related to obesity is a stunning rise in the major precursors to cardiovascular diseases. In the spring of 2010, the CDC released findings that nearly half of all Americans have high blood pressure, high cholesterol or diabetes.7
Osteoarthritis is also on the rise, owing to fat.Every extra pound puts additional weight on joints never intended to carry the extra load. According to the CDC, 51.2 million Americans suffer from osteoarthritis, and by 2030, as baby boomers age, the number of cases will increase by over 40 percent.8
There is little question that Americans are losing the battle of the bulge. Certainly it isn’t for lack of trying: the commercial weight-loss market is huge. In spite of a plethora of books and theories on how to lose weight quickly and with minimal discomfort, confusion reigns supreme. Millions of Americans are on a diet on any given day; few are succeeding. Obese teenagers are a new and growing market for stomach bands. More than a thousand American teenagers underwent bariatric surgery in 2007. According to leading specialists, including Reginald Washington, a Denver pediatric cardiologist and past co-chairman of the American Medical Association’s childhood obesity task force,“this is not an end to treatment, it’s a way to get started.”9 A desperate measure perhaps, but the reality, according to Washington, is that traditional diet and exercise are effective only 30 percent of the time.
Dr. Emma Patterson, medical director of the Obesity Institute at Oregon’s Legacy Research Project, echoes the concerns of a growing group of surgeons across the country when she says: “Why wait until they have high cholesterol,kidney and heart problems or need a new knee?”10 Clearly, advertising campaigns targeting kids, the ready availability of soft drinks and junk food, lack of time, information, and resources to buy fresh unprocessed foods, and the lack of safety in some impoverished neighborhoods have all played a role. In fact,teenagers living in poverty are 50 percent more likely than their wealthier peers to be overweight. We know that poverty and poor neighborhoods carry additional loads of stress for families, which raises an obvious question: is there a deeper force at work?
Dr. Sonia Lupien, on staff at the Douglas Hospital in Montreal, believes there is, commenting to a Globe and Mail reporter, “I think stress is a major factor in this.”11 Unquestionably, social status has a significant indirect impact on health, leading to higher rates of cardiovascular disease,diabetes and other lifestyle-related diseases that result, in turn, in an overall lower life expectancy. Low-income people not only eat a poorer diet,they also experience more stress and have fewer resources that support healthy interventions, such as health insurance. Lupien’s research, focused on 450 children from low- to high-income families, found “a three-fold increase in stress hormones in low-income children compared to rich children.”12
Is it possible that we are blind to a deeper force at work? Physicians, researchers, addiction experts and individuals like Patty Worrells are increasingly voicing this question. Patty, whose story appeared in an unlikely publication for such coverage: the Wall Street Journal.Patty was a food addict whose 3:00a.m. binges on half-gallon tubs of ice cream and eight cinnamon rolls for breakfast finally caught up with her.13 In her mid forties, Patty, at five-foot-four, weighed 265 pounds, was diabetic and arthritic. She had gastric bypass surgery and lost 134 pounds in a year. Patty was elated with the changes in her body, which enabled her to fit comfortably into car and airplane seats, restaurant booths and crowded shopping aisles.Then her life shifted again. Eighteen months after the surgery, her food cravings were gone. But she found herself downing fifteen to twenty shots of tequila almost every night. Normally soft-spoken, Patty developed a reputation for wild partying, often waking with scratches and bruises she couldn’t account for. Patty’s domestic partner said, “She became a monster!”
Patty says: “I knew I was going to die.” She recognized the pattern. Her father had died from alcohol abuse, and her sister struggled with addiction. In an effort to protect her mother from confronting yet another alcoholic in the family, Patty struggled for months to hide her drinking. Her turnaround began when her partner, exhausted by Patty’s rages,one evening picked up the telephone and dialed Patty’s mother. “Listen to your daughter,” she said and positioned the receiver to pick up Patty’s alcohol-fueled cursing. The next day Patty, horrified that her mother now knew, attended her first twelve-step meeting. Three weeks later Patty’s mother called with devastating news: Patty’s sister had died from an overdose of Xanax. Patty recalls being grateful she was sober as she drove to be at her mother’s side.
As of the time at which the article was written,Patty was committed to recovery, attending four twelve-step meetings a week,but her course was riddled with relapses. Patty is far from alone in her path from food addiction to bariatric surgery to another addiction. Treatment centers like the Betty Ford Center in Rancho Mirage, California, report increasing numbers of bariatric surgery patients seeking help with new addictions. And alcohol abuse is a hot topic for online support sites like the Weight Loss Surgery Center, which has more than ten thousand subscribers on its e-newsletter list.14 Gastric bypass patients are extremely vulnerable to alcohol abuse, with estimates ranging from5 percent to 30 percent of patients switching from food to alcohol addiction after the surgery. Numbers for those who switch from eating to smoking, according to estimates, are not far behind.15
Replacing one addiction with another—known as“addiction transfer”—is not limited to switches from food to alcohol. The Betty Ford Center notes that about one-quarter of relapsed alcoholics replace alcohol with another type of drug,often opiates.16 There is a growing understanding among researchers that the foundation for addiction transfer is biological. But where it once would have been attributed to genetics, researchers are now looking at brain chemistry.“There are similarities in the circuits that are affected in the processes of addiction and obesity,” says Dr. Nora Volkow, director of the National Institute on Drug Abuse.17 Of particular interest is the observation that obese people, alcoholics and drug addicts all have below-normal levels of dopamine—a hormone associated with pleasure—which contributes to cravings. Addictive substances temporarily boost dopamine.
Research into the pathways of addiction and its underlying brain chemistry has exploded. Dozens of clinical trials are underway at the National Institutes of Health (NIH), some focusing on developing new drugs, others on following the effects of medications previously used for other diseases. Toprimate, a drug used to treat epilepsy and marketed under the name Toprimax, is now being studied for alcohol and cocaine addiction, binge-eating and compulsive gambling. And the antidepressant bupropion (Welbutrin) is often being prescribed for withdrawal from alcohol as well as to treat gambling,obesity and nicotine dependence. The search continues for a pill that will curb our cravings, dampen our appetites, and boost our mood.
But a growing group of researchers are also looking more deeply at what lies beneath this faulty brain chemistry. “Why,” they are asking, “are dopamine levels so low in some people? Are there common variables at the root of this reality?” Dr. Gabor Maté of Vancouver, Canada,author of several best-selling books, the most recent of which is about addiction (In the Realm of Hungry Ghosts), says:
If you look at the brain circuits involved in addiction . . . we’re looking for endorphins in our brains. Endorphins are the brain’s feel good, reward,pleasure and pain relief chemicals. They also happen to be the love chemicals that connect us to the universe and to one another. Now, that circuitry in addicts doesn’t function very well. . . . The issue is, why do these circuits not work so well in some people, because the drugs in themselves are not surprisingly addictive. And what I mean by that is, is that most people who try most drugs never become addicted to them. And so, there has to be susceptibility there. And the susceptible people are the ones with these impaired brain circuits, and the impairment is caused by early adversity, rather than by genetics.18
This concept was not yet on the horizon in the1980s when Kaiser Permanente in San Diego created a clinic for chronically obese patients.The initial effort, headed by Dr.Vincent Felitti, grew out of a very advanced department of preventive medicine that he had created for Kaiser patients. Felitti’s vision was—and is—to return family practice and internal medicine to their roots in preventive care, as opposed to operating as a symptom-driven response to illness. This department became the largest single-site medical evaluation facility in the world, serving 58,000 people a year. When we met with Felitti in California in 2009,he recalled:
“In the course of doing that work it became quickly evident that we needed to create our own risk abatement program. The first project we put together was a weight program. . . .We happened to be in possession of a very powerful technology that allowed us to safely take people’s weight down about a hundred pounds a year. But after about five years of doing this, we realized we had a very big problem, namely, an enormously high dropout rate that was almost exclusively limited to people who were successfully losing weight . . . which drove me nuts! It was wildly counter intuitive, and it was ruining the reputation of the program. . . . It was the exploration of that concern that led us into the ACE Study.”19
Puzzled by the high dropout rate among patients who were successfully losing weight, Felitti decided to interview them in depth about their lives and the reasons they chose to quit the program. He interviewed 186 patients, and then, stunned by his findings, he had five colleagues interview an additional 100. Their unexpected results provided strong evidence that obesity, which the doctors viewed as the problem, was actually a solution to deeper problems. These patients overate to assuage their feelings and used fat to buffer an underlying need not to be vulnerable—physically, emotionally or sexually. Obesity was key to their sense of self-protection. One patient, a woman who had gained 105 pounds in the year after she was raped, said simply: “Overweight is overlooked, and that’s the way I need to be.”20 Typically the patients had never discussed these issues with anyone, not even their physicians. Felitti observed, “We found the simultaneous presence of opposing forces to be common; many of our weight program patients were driving with one foot on the brakes and one on the gas, wanting to lose weight but fearful of change.”
As Felitti was working with obesity in San Diego, Dr. Robert Anda, an epidemiologist and CDC researcher in Atlanta,was simultaneously studying the psychosocial origins of physical diseases,obesity and risk-taking behaviors such as drug and alcohol abuse, smoking and risky sex. Following a presentation Felitti gave in Atlanta on his study of weight program dropouts, he met with Anda, who recognized the significance of these findings.The two physicians ultimately came together to develop the Adverse Childhood Experiences (ACE) Study. The average age of the Kaiser patients was fifty-seven. They were middle-class and preponderantly white, just over 50percent were female, and 54 percent had a college degree. The ACE questionnaires were mailed to patients two weeks after they had been evaluated at Kaiser’s Health Appraisal Center.
Felitti explained that there are really only three major sources of information in medicine: the medical history, the physical exam and laboratory studies. Western doctors and patients tend to focus on lab studies. Yet, he says, “for more than a century, knowledgeable physicians have all concluded that about 80 percent of the time diagnosis comes out of history.Not out of MRIs, not out of physical exams, but out of history. So we put together a rather remarkable questionnaire to gather history.”21
The ACE questionnaire included questions that were pertinent to child maltreatment, including recurrent physical, emotional or sexual abuse. Five other categories asked about growing up in a household characterized by dysfunction due to: (1) alcoholism or drug abuse; (2) an incarcerated household member; (3) someone who was chronically depressed, mentally ill or suicidal; (4) the mother being treated violently; or (5) parents being separated, divorced or otherwise lost to the patient in childhood. The questions were not ephemeral; they were designed to elicit information that could be objectively evaluated. To minimize the degree of subjectivity involved, the questions pinpointed the number,frequency and intensity of specific behaviors in the past lives of patients. The ACE score measured categories of adverse experience, not the number of incidents. Thus, an individual molested repeatedly by several persons got one point for the category. A patient who reported none of the experiences in the ACE categories had a score of 0. A patient who responded yes to one or two categories had a score of 1 or 2, and so on. The researchers then cross-referenced the current health status of more than seventeen thousand adults with their responses to the ACE questionnaire. They have now followed the same group for fifteen years to assess the relationships between their ACE scores and pharmacy costs,doctor office visits, emergency department use, hospitalization and death.
The study looked at the correlations between adverse childhood experiences and ten risk factors associated with the leading causes of morbidity and mortality in the United States, including smoking,severe obesity, physical inactivity, depressed mood, suicide attempts,alcoholism, drug abuse, injection drug abuse, a high life time number of sexual partners and a history of having a sexually transmitted disease. The researchers also examined the relationship between early adverse experiences and the diseases that are among the leading causes of death in the United States:ischemic heart disease, cancer, stroke, chronic bronchitis or emphysema,diabetes, skeletal fracture, liver disease and hepatitis or jaundice.
The single most stunning finding in the ACE Study is the sheer prevalence of adverse childhood exposures. Two-thirds of respondents reported experiences in one or more of the categories. More than a quarter of them had grown up in a household in which there was an alcoholic or drug abuser; the same percentage said that they had been beaten as children. Forty-two percent were exposed to two or more categories of abusive experiences,and one in nine were exposed to five or more. Felitti says the data show that a person exposed to one category of abusive experience has an 87 percent chance of exposure to at least one other category, and a 50 percent chance of exposure to three or more. These experiences tend to occur in clusters. For example, a child in an alcoholic home is typically exposed to other kinds of abuse; no one grows up in a household where Mother is beaten or Dad is in prison but everything else is fine. ACE Study researchers also noted what is called a“dose-response” effect: the higher the ACE score, the worse the outcomes.
Among the findings was that the likelihood of smoking increases with each point on the ACE scale. With a mid range ACE score of 4, a person is twice as likely to smoke, four times more likely to suffer from emphysema or chronic bronchitis, and two and a half times more likely to have chronic obstructive pulmonary disease than a person with an ACE score of0. Compared with a person with no history of adverse childhood experiences, a person with an ACE score of 4 or higher is seven times more likely to be an alcoholic, and six times more likely to have had sex before age fifteen. This person is also twice as likely to have heart disease and twice as likely to have cancer. In addition, those with an ACE score of 4 or higher are forty-six times more likely to be depressed, and twelve times more likely to commit suicide than a person with an ACE score of 0.
Being overweight was actually one of the outcomes less highly correlated with early maltreatment—compared to the extraordinary correlations with depression, suicide and drug abuse. But subsequent research,including a 2009 study reported in the journal Obesity, is now pointing to a link between child abuse and obesity.22 Based on court records from1967 to 1971, researchers compared the adult body mass indexes of 410 children who were substantiated victims of physical abuse, sexual abuse and neglect with303 similar children who had not been mistreated. Adults who had been sexually or physically abused and neglected as children had significantly higher BMI scores than those who had not been abused and neglected.23
As of 2009, the ACE data also have begun to link childhood trauma to premature death. Using the National Death Index,researchers identified 1,539 deaths in the ACE group between 1995 and 2006.They found that people with an ACE score of 6 or higher on average died nearly twenty years earlier than those with a score of 0 (60.6 years versus 79.1years).24 Although the researchers cautioned that this initial look at the link between mortality and childhood trauma involved a relatively small sample, they deemed it statistically significant. High-scoring ACE Study participants were dying substantially younger, “even if you take the absolute number out of it,”noted Dr. David Brown, an epidemiologist at CDC.25
So how are adverse experiences in childhood linked to health risk behaviors and adult disease?The ACE Study reveals two paths. One involves the use of coping substances like nicotine, drugs or alcohol as a contributing factor in the development of disease. But high-risk behaviors don’t explain it all. The second route from adverse childhood experiences to disease is in fact more direct. Participants with an ACE score of 7 who had no evidence of risk-taking behaviors in their history nevertheless had a 30 to 70 percent higher risk of ischemic heart disease in adulthood. Those who had a score of 4 or higher had two to four times the rates of anger and depression, and two to four times the rates of hypertension and diabetes as those with a lower score. As the number of ACE experiences increased, so did the chances of the individual experiencing cancer, chronic lung disease, skeletal fractures and liver disease. The correlations between addictions—nicotine, alcohol and illicit drugs—and early adverse experiences were so strong that the researchers concluded that “addiction” is more attributable to characteristics intrinsic to early life experiences than to characteristics within the drugs themselves. Felitti believes that drug use is a form of self-medication, an attempt to deal with problems that are well concealed by “social niceties and convention.” Citing the fact that a boy with an ACE score of 6 has a 4,600 percent increase in the likelihood of abusing intravenous drugs later, Felitti said:
Is drug abuse self-destructive or is it a desperate attempt at self-healing? This is an important question because if the answer is self-healing, primary prevention is far more difficult than anticipated—possibly because incomplete understanding of the benefits of so-called health risk behaviors causes these behaviors to be viewed as irrational acts that have only negative consequences.Does this incomplete view of drug abuse leave us mouthing cautionary platitudes instead of understanding the cause of our intractable health problems?26
Felitti, Anda and colleagues minced no words about the connections substantiated by their research: “Early childhood trauma can lead to an array of negative health outcomes and behaviors, including substance abuse, among both adolescents and adults. . . . The effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use.”27
Compounding Felitti’s concern is the linkage between addiction and suicide. Drs. Felitti, Anda and their team concluded: “A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship.”28 “Unfortunately,these problems are both painful to recognize and difficult to cope with,”Felitti says: “Most physicians would far rather deal with traditional organic disease.Certainly, it is easier to do so, but that approach also leads to troubling treatment failure and to the frustration of expensive diagnostic quandaries where everything is ruled out but nothing is ruled in. We have limited ourselves to the smallest part of the problem—the part where we are comfortable as mere prescribers of medication. Which diagnostic choice shall we make? Who shall make it? And if not now, when?”29
In summary, adverse experiences in childhood generate strong emotions in children. The feelings and the chemistry they generate become the “monsters” in our “closets,” the closets a metaphor for our bodies, our physical selves. As with the childhood notion of a “monster in the closet,” the invisibility of the impact of emotional trauma on the body only makes it more powerful.
Unrecognized, the now-silenced cry of the child takes the form of physical dysregulation in key systems that regulate health.These internal changes in turn line the path to risk-taking behaviors, including drugs, alcohol, nicotine, addictive eating and risky sex—choices that surface in preadolescence, adolescence or adulthood. Clearly an effort to cope, these self-soothing efforts are ultimately counterproductive when they multiply health risks exponentially. Separately or in combination, addiction and the cumulative effects of a stress response system operating out of balance for too long can catalyze genetically shaped health problems that are typically not diagnosed until late adolescence or adulthood.