Sue Cox co- founder Survivors Voice Europe
Founder-Director SMART-UK
January 2013
The Physiology of Addiction –The implications for childhood sexual abuse victims
I write in my capacity as founder and director of a large substance misuse training organisation called SMART-UK .
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 this further increases their suffering.
There are several very 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 My organisation has taught over ten thousand health care professionals who have collectively been responsible for the treatment of many 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.
However, it is abundantly clear that the criteria being used by legal teams addressing this problem is not evidence based..
A recent high profile British court case is a prime example; the victim’s background was heard, focussing on his addiction, which he maintained directly resulted from childhood sexual abuse by a clergy member. However, the court decided that the root of his addiction was in part “genetic” and part his “personality”; his childhood abuse was concluded to have played very little part.
It is concerning that these important decisions are made by those ill-informed about the neurobiological basis of addiction and the development of “personality”.
It is hoped that this document may help to shed some light on this particular problem, and provide a more considered approach to the legal decision making process 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 individuals 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 is a chemical which creates the blueprints living things use to store the instructions required to develop, grow and survive. Sequences of DNA that contain a particular set of instructions are called genes. It might be useful to think of the 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 and this is sufficient 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 means that they are caused not by errors in single genes but by changes in several genes that 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 is not caused by one’s environment alone, nor is it caused by genetic predisposition-it results from a combination of the two.
To simplify, vulnerable individuals who are predisposed to addictive behaviour, often suffer a specific event (or events) that 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. However the environment is actually far more important than this. Our experience of the world affects how our genes function and it is these changes that can trigger the path to addiction. This is known as epigenetics.
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.
Although DNA can be said to provide the basic blueprint of life, 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. These changes result from both the chemical marking of the DNA itself and the proteins to which DNA is bound; this is important because 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. 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 therefore a mechanism by which life experience is encoded.
It is also important to note that in some instances these epigenetic marks are heritable and this can have long-standing consequences for the development of the offspring in terms of their cognition and stress response. Recently a number of genes have been identified that 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 the enzyme monoamine oxidase A, results in the higher metabolism of a chemical in the brain that has been linked to violent behaviour in those who suffered childhood abuse; this higher enzyme activity is therefore protective. If individuals 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 that reduce the production of this enzyme, that 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) that 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 the brain, which can dramatically disturb its function, increasing the likelihood of psychiatric conditions including addiction; these changes are often permanent, they occur during key development phases and can even 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 on the basis that a victim suffers from addiction. To suggest that they would have become addicted anyway is unacceptable and not borne out by the scientific evidence.
It is clearly important for the courts to isolate and seperate, as far as reasonably possible, the stressors that are responsible for switching on the gene expression that results in addictive behaviour.
To improve the quality of legal representation available to those who have suffered abuse it is vital that expert witnesses are made available – an area in which our organisation would be able to help.
A final Word about Addiction
Addiction should not be trivialised. It is a life threatening, chronic, relapsing condition, which has very low recovery rates. Depending on your substance of choice, risk of relapse ranges from 60 – 90%, with the Global Information System on Alcohol and Health reporting that around 2.5 million people die every year from harmful use of alcohol alone.
Recovery is by no means inevitable.
Knowing the mechanisms of action and the neuroscience of addiction as I do, I fully believe that true recovery relies on abstinence. However,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, and their emotional crutch.
A person who has been sexually abused as a child is already dealing with a wealth of fallout from that damage, and alcohol, drugs, including prescription drugs, have often been a huge part of their “self medication”.
If someone has truly become addicted, then abstinence is the only hope for their lives to be saved.
It is my opinion, borne of many years experience, that recovery requires several steps:
1. The removal of denial
2. Abstinence
3. In depth 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
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.
Sue Cox
