Psychiatry & Psychotherapy Podcast - Adverse Childhood Experiences and Their Lasting Impact on Health: A Comprehensive Guide

Episode Date: January 19, 2024

In today's episode, Dr. Annabel Kuhn, Liam Browning, and Dr. David Puder, embark on an in-depth exploration of adverse childhood experiences (ACEs) and their profound impact on adult mental and physical health. The  CDC defines ACEs as, "potentially traumatic events that occur in childhood." ACEs include (but are not limited to) physical, emotional, sexual abuse, neglect, household dysfunction, such as domestic violence or parental substance abuse. We'll investigate how these early negative events are critical predictors of adult psychiatric diagnoses, including substance use disorders (SUDs), depression, anxiety, PTSD, psychosis, and personality disorders. Our analysis extends to the intricate ways ACEs affect an individual's physiology and psychology. This episode will be the first of a mini-series of several episodes surrounding the impact of ACEs and how we can treat patients who experienced trauma. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

All right, welcome back to the podcast. I am joined today with Liam Browning. He is a medical student going into psychiatry who has spearheaded a lot of reviewing of data on adverse childhood experiences with me. And I'm also joined with Annabelle Kuhn, who is part of my team, who is going to be at a child and adolescent psychiatry program at a small, humble program, Boston Children's. children, part of the Harvard group. So she sees patients in Florida here with me and we'll be doing her child fellowship next year. So excited to have Annabel join us. And I was, this is actually the third recording, and this will be part one. We've decided to do this multiple parts. Yep. And we will be talking about a topic where it's like, it's like, it's a. it's a tough topic because I, when I think about this topic, I'm thinking about different patients. I'm thinking about my own struggles, maybe, or like, it's like beyond the data, right?

But you can look at the data in such an intellectual way. It's kind of like a little bit distancing. And so we're going to be trying to talk about this and the data of adverse childhood experiences in a way that, is humanizing both to ourselves as people who have probably gone through some adverse childhood experiences. Actually, if you look at mental health professionals, there's a higher rate of adverse childhood experiences than other types of residents. We'll get into that data. And then, so we're talking about it from our own perspective of having probably gone through some treating patients who are going through it. We're going to be talking about data and

statistics, which I think it's important to talk about because we don't want like a conceptualization of what it means that is not in reality. We want it to be grounded in like this is what the data actually says currently. We'll talk about what we know, what we don't know, how it's even studied, what happens to the brain, what happens to the inflammation pathways, what happens to the cortisol and the stress systems. We'll talk about generational intergenerational trauma. I'm hoping that this will increase our empathy for ourselves, our empathy for those that we treat. I'm hoping that this can give us a sense of hope so that if you have gone through a bunch of adverse childhood experiences yourself or you're treating those with it, that you're not just in a

hopeless place. And I feel like some people who talk about it in pop psychology, it becomes very hopeless the way they communicate it. So, Liam Browning, any sort of introductory thoughts as we sort of jump into this? And then I'll ask Annabel. Yeah, like you mentioned, this is our third time recording the podcast on this topic. And for me, this is the first time recording it after starting my psychiatry rotation. And I started on inpatient a couple weeks ago. And, you know, of the patients I've been following, so many of them have had,

an extensive traumatic childhood history. And just seeing how that's reflected in different ways of how that affects them, whether that's predisposing them to borderline personality disorder, like narcissistic personality disorder, seeing how they have these different reactions to their trauma. And I think it's important to get it right to actually try to understand what the data is telling us and then try to balance that with our clinical judgment and what we see in clinical practice. So this is really a huge topic for psychiatry and medicine as a whole to try to understand well.

Yeah, Annabelle, any initial thoughts? I know you may remember Annabelle from. We did an episode on catfishing. We did an episode on disorganized attachment. We have another one on avoidant attachment coming up. Yeah, so any thoughts coming into this? Yeah, lots of thoughts. And I'm glad to be included on this third try of this podcast.

This three is my lucky number, so hopefully this will go well for all of us. But yeah, I'm really happy to jump in and give some thoughts to you. So the residency program I work at, I primarily work with veterans. And of course, like with that, I work with people who have severe trauma almost on a daily basis. And a lot of the veterans that I work with also have childhood trauma. And a lot of veterans, like, join the military in order to escape something terrible that's happening at home. And so there's a lot of trauma in the work that I do. And I know this topic is incredibly important in adult and in child and adolescent psychiatry.

And yeah, I'm really excited to talk about this very important topic. Awesome. So maybe I'll start with Liam. Tell me about how common adverse childhood experiences are. Yeah, according to the CDC, about 61% of adults have had at least one ACE and about 16% of people have had four more aces. And, you know, these occur throughout the entire world population, as we'll see talking about the ACE study. It affects all demographics. It doesn't matter of race, socioeconomic status, everyone has experienced some aces.

Yeah. I think like also just like thinking about that number, like 61% is a huge percentage of like the world population. And I think that's what makes it hard to talk about in a clinical setting, I think like providers might be able to identify with these childhood stressors too. And talking about those things may be hard like for the clinician to even talk about. And so, yeah, just because it's so incredibly prevalent. Yeah, there's a number of reasons that it's going to be hard to talk about. I think if you are a mental health professional who's doing more medication management, opening up this conversation may take longer than you have time for. Let's just be real.

So it's like how do you do this in a way that's humanizing that's not just a checklist. You know, maybe you're doing it with the idea that you're going to have some time to unpack it to empathize with it. Also, people feel a lot of shame. Yeah, I was just going to say it's like basically like it's hard to ask the question, and it's hard to know if you have a good enough rapport with a patient to ask that sort of question. And I guess, like, in my experience, like, I'll ask, I'll, like, generally ask, like, hey, like, has anything, like, have you ever been through an experience that was, like,

life-threatening or, like, have you ever, like, without really getting into the details of it, like, has, have you ever been, like, physically, sexually, verbally abused, emotionally abused, And you can tell me as much or as little as you want. You can just say yes or no, or you can say we can move on. I always give the power back to the patient because that's one of the main issues that comes up with trauma is people feel powerless. And so I always put the ball in their court. And then if they say yes, I'll never pry for more information. Generally, people haven't just spilled everything to me when I asked that sort of question.

we just sort of leave it as it is. And then I'll like ask more about like, well, how does this impact your day to day life? And is this something that you've like feel like you've worked through? Or is this something that's still like really, really troubling for you? And we'll kind of go from there. Yeah. I take a very similar approach. And what I will look for is what emotion comes up as they tell me. Some people will very hurriedly, you know, kind of, of yes, no, and you can tell they want to move on. They don't want to go there today, right? And so, you know, I don't, yeah, I'm like you, I don't want to pry when the trust isn't built because it's an important conversation to have when there's enough trust, and it will inevitably

come up as the trust builds. So it's, you know, you don't know when that amount of trust is, when they're ready for it. Another thing, too, one of my super. supervisors has, like, encouraged me to, like, be the one to bring it up. And, like, some of my supervisors I worked with have suggested that maybe a patient wouldn't even bring this up on their own unless, like, specifically asked about it, because it is embarrassing. It is shameful. And so, like, that was something I, like, really learned throughout residency is that I need to be the one who, who brings this up and ask the hard questions. And then and only then can the patient, like, feel, like, really hurt and like really like okay to be in this space with me yeah no i think i think i

asking asking the hard question allows um them to know that you're that you want to know that you're ready to know that you yourself have the capacity to maybe to hold that um you said it's shameful and i think there's something about shame that goes with trauma it's like the shadow of trauma it's not that what happened to them is that they did something bad. I think the very nature of childhood trauma is like they were exposed to something that was bad. Something happened to them that was bad. And then they took that on themselves and they said they started telling themselves, I am bad because this thing happened to me.

And so I think it's important to delineate that the shame is not something I would ever want them to own or to like, like I want to move them out of the shame and a lot of trauma work is actually to empathize with the difficulty of that experience of I am bad I did something bad yeah absolutely and like I think objectively like it may be easy for people to say oh yeah well of course of course it was someone else's fault but but deep down these things get incredibly internalized and and yeah like the shame is the piece that makes it hard to talk about in clinic and with anyone. And sometimes, like, past trauma, like, it's something that a patient may not have ever

even shared with anyone else before a clinician. So it's very private and very personal. And, like, one of the reasons I really love being a psychiatrist is because it's so meaningful to be trusted with such, like, personal information to be trusted to help someone. and yeah, just something I really value. Yeah. I think part of the frame of the work is confidentiality, right? It's that we're not going to be telling their stories to someone else.

Actually, I had a patient of mine who said, yeah, the nice thing about you is that I know I can legally sue you if you tell anyone these stories. And it comes with a little bit of jest, right? But it's like, I feel secure telling you because I know, right, what my rights are. And there's something special about that. And like what you said, like the patients will often tell me, I have only told one person this in my whole life, or I've only told two people this in my whole life. And so there is a special sacred space in that

and hearing the story and hearing the trauma and being equipped, and I think the goal of this episode and this series and the podcast is to equip people to be ready to hear those stories. I was not ready to hear those stories before I was trained as a psychiatrist. I was just not. It's like how do you sit with someone in the midst of loss, in the midst of shame, and say things in such a way that would make them feel less shame,

make them feel hurt and understood? You know, what are common mistakes parents will make when the child tells the parent? The parent will go into their own story. Well, that happened to me and I got through it, or they'll blame them. You shouldn't have been there. Or why did you let that person into your life? So it's very like, it makes the shame worse. And that becomes a secondary trauma.

It becomes like the trauma of telling. Yeah. Okay, so I was thinking about this and acknowledging how impactful these events are in people's lives and the challenges that people will have to overcome because of them. it can help us to know this information, not just know it. And Annabel, if you're on YouTube, was just drinking from a psychiatry and psychotherapy podcast mug. I love the pink color.

It matches my headphones. Thank you. That's awesome. Yeah, I think, like, on that note, yeah, seeing trauma is a hugely impactful life event, it's important to know as a clinician because, like, PTSD and trauma, responses can present with symptoms that are similar to like generalize anxiety disorder, major depressive disorder, and like a patient may be misdiagnosed with something like that, when in reality, like a lot of this is a trauma reaction. And if a clinician doesn't even

know about that, like, of course it's going to look like GAD or MDD. And so diagnostically, it's key. And we're going to get to as well that having a higher A score, having more traumas in your childhood increases. the risk of globally most mental health issues and also a lot of physical issues. And so this really does remind me of the core dialect of dialectical behavioral therapy, which is like given your experiences and the challenges you faced, it's completely understandable why you're struggling right now in the way that you're struggling. Okay, whether they're self-harming, whether they're doing, using substances.

So it's like it does increase the risk of those behaviors. And then the second part of the dialectic, right, is to recognize the patients or your own strong desire to overcome these obstacles. And so to value that as well. And so that's the dialectic, that's the other side of it, right? Which is something like, you know, and together we're going to strive to overcome

because that's one of your goals is you want to overcome and you want to live a life that is rich in relationships and friendships and friendships and meaningful work. So I do think that understanding how trauma impacts the nervous system and how it increased the risk for all these mental health issues can give us more compassion, actually, to see people and understand where they're coming from. So hopefully it reduces. For me, that reduces shame. It's like, well, of course.

You know, one thing, oh, man, it's just like, I heard, this is like such a mind-blowing sort of realization that I had, okay? I'm ready. I don't think I've ever shared this on the podcast. Let's hear it. The strength of the defense, the largeness of the defense, is equal to largeness of the trauma. Or it's like a reaction against the environment, the environment. trauma okay so if someone is heavy intellectualization heavy hypoactive or hypomanic defenses right heavy

you know like defenses against sitting with the underlying emotions probably fear shame anger you know they go somewhere else the defense is so strong it's because underneath it there's something so big so if all you see is the defense it may someone may be off-putting, someone may push your buttons in a certain way. But if you can see that the strength of the defense is actually equal to the strength of the underlying issue, it can make sense of it. I like that one. I've never thought of it like that, but I'm just like thinking about so many different scenarios where that's incredibly true. Yeah, I think that resonates with me as well. And I think what will be interesting to see is that a lot of the research on ACEs and trauma, they do not focus on an individual's defensive structure.

Because, I mean, how do you actually study that in an objective setting and in a way that's scalable? So I think that in psychiatry, we tend to shy away from these perspectives of looking at someone's defensive structure and how that interplays with their symptoms. but in reality we can't really objectively study that as well as we should be able to. I think like in some ways, though, like the defenses are built into the, like, at least the DSM-5 diagnostic criteria for PTSD, like people who, and even like for borderline, which is another trauma response or can be another response to trauma. Like both do you include like risk-taking behaviors or avoidance or dissociation? And like through that lens, yeah, but like from a day-to-day perspective, like, yeah, you're so right.

It can be pretty hard to like to study. That's a good point. Yeah. You know, I think one of the common things that I've seen is like this new research has come up. And then it's like, oh, and what's going to be the treatment of this? It's going to have to be something new. Oh, you know what? Maybe it's brain waves.

Maybe we need to sit there and do like brain biofeedback. It's like, no, the therapy works. right, exercise, diets, all those studies, everything that we've talked about in the podcast to date, the power of the therapeutic alliance, the power of the therapeutic relationship, all of this is the same thing that's going to help someone overcome. It's not like there's going to be some new solution. It's like, so, you know, yeah, it does increase defenses, which lead to conglomerations of personality disorders. I mean, each different personality

disorder will have a different set of defenses. Borderline personality sort of might have projective identification. They are evoking in you a projection of themselves and then getting you to align and join it and become it. Like, that's a defense. And now as you get pulled into this enactment,

maybe you can have a little bit of compassion for them and for yourself. Oh, they're enacting. something from their childhood, a tortured part of their childhood, is being brought forth, and it's really tough. Yeah. I also wanted to say, David, it's really empowering to hear you say that it's like the treatment that we have works and the power of the therapeutic alliance is what really matters, I think,

especially as a trainee. And if there's any other trainees listening, it's, you don't have to know like every single thing about DBT and CBT by the books. I mean, that's great. And if that's your plan, go for it. But I think just like in the process of training while you're still working with patients, it's nice to know that just by having a therapeutic alliance, you can be doing such, like, amazing, positive work with your patients. Absolutely. I think it's the foundation, right? Because, okay, there's other episodes. If this is the first one where we go through common factors. through, like what are the things that make one therapist better than another therapist?

And lo and behold, it has very little to do with modality. Okay, so CBT versus acceptance commitment therapy, about the same. Dialectual behavior therapy versus transfer, focused therapy, about the same. Mentalization-based therapy versus transfer, focus therapy, versus dialectical behavior therapy, about the same. Like, these are studies that have been done and repeated and repeated until it's like, wait, they all all work. You know, that with like good training, good boundaries and high empathy and good therapeutic alliance, like they're going to work. Should we spend time devoting ourselves to learn various ones? Absolutely. And I would even say, as a psychiatrist, I am often referring a patient

to a specific modality because I think they haven't tried it. They have, like, you know, sometimes I'll refer someone to EMDR for a single person. trauma for, you know, maybe they've done some other therapy, but they haven't done EMDR. Maybe they're coming to me and they've done EMDR and now I'm referring them to a good cognitive behavioral therapist or I'm referring them to a good psychoanalyst who, you know, so like the various types of therapies, I think, I think, Liam, you were mentioning this. It's like you have to think of each person individually. Yeah.

Right? And it's like there's not going to be a one-size-fits-all. for all patients. Okay. So, okay, this was a very interesting study right here. This Cassinetti and Tarchi et al, 2004, look how recent that is. Oh. And in this study, which I spoke to one of the authors the other day from Italy, there were 645 psychiatry trainees, and they compared them to other types of trainees, like in other departments. And the psychiatry trainees actually had a higher incidence of adverse childhood experiences and greater attachment insecurity compared with their peer medical specialties.

Additionally, psychiatry residents were more inclined to seek social support. Despite the higher rates of emotional abuse, emotional neglect, physical neglect, they experience lower neuroticism and higher openness, according to the big five characteristics. Isn't that interesting? They were both higher rates of trauma, but this is not something you would expect. You would expect higher neuroticism.

But I think it's because they're in the middle of training. They're in the middle of getting help themselves. They're in the middle of that journey, and so they're actually lower neuroticism, which we're talking about the big five personality types, neuroticism is one of the subdomains, openness is a subdomain. I've done episodes on these individually. Neuroticism usually increases with more traumatic events, but in this group,

there was lower neuroticism. Interesting. Any thoughts on that? I also, I have so many thoughts. I think my first thought that comes to mind is like it's amazing to know that data and to like also pair it with, like, for example, like when I was like in med school, and I would tell whomever. Yeah, I'm going to, like, go into psychiatry.

The first question is like, oh, like, are you, you must be crazy to then. And it's like, ha, ha, ha, like, thanks. But it's maybe, who knows. But anyways, like, it's just, like, such a point, right? That, like, if this is true and, like, this research showed that, like, this is true and that, like, psychiatry residents, like, have higher rates of trauma, then it, like, I guess, like, exemplifies how much bias there is in our society, where, like, if, like, we're seeing people, like, who have a lot of trauma as, like,

aligning with other people have trauma and, like, defining that as, like, something negative or crazy or something's wrong with you fundamentally. It just speaks to, like, art the society at large and maybe, like, some elements of projection, too. People are worried about going to the psychiatrist and being assessed and evaluated and being forced to have things brought up, so they push it on to other people. But, yeah, that's a lot of. But, That's where my mind went with that one. It's really interesting. Oh, yeah.

I've had, there was one trauma surgeon I was working with who liked me, who was like, you should do trauma surgery. But I know you might choose something else, but do anything but psychiatry. That's what he said, quote, end quote. And I kind of, like, was like, uh-huh, uh-huh. Or like another person I remember was like, why don't you do a real medical specialty? Yeah.

Stuff like that. And it's like, uh, you're, just that line shows your level of ignorance. Like, yeah, you can't be a good psychiatrist and not understand a lot of medical stuff.

Like you just, yeah, you just can't. And we'll get into that because look, like trauma increases other medical issues, right? And we'll get into the details on that. So. And it's pretty, it's global.

So Liam, talk about how global trauma is from the data that we have here. Yeah, so there's a 2014 worldwide self-reported study where the rates of physical abuse was 22.6%. Sexual abuse was about 13%. Physical neglect was 16% and emotional neglect was 18%. And to your point about trauma causing multiple medical problems, you know, in the U.S. or in North America alone, the annual cost has been estimated to be about $748 billion. So it's not just a psychiatry problem. It's a medical problem as well for the entire field. Yeah, and I think as we get into this initial study that was so groundbreaking, Phileadie at all, 1998. which was a large study done at Kaiser in California.

So this is Kaiser Permanente, which is an insurance company, but it's also a medical hospital. So you have to have insurance, and usually it's like big corporations that are contracting with Kaiser to buy the insurance. So these are usually people who are working, who have jobs. so largely white middle class okay and um leam would you want to break down the study a little bit for us

yeah sure so like you mentioned it was 8000 mostly white mostly middle class middle aged adults in california and you know the original a study used seven different measures of looking into abuse and household dysfunction uh since then they've since included neglect. But in the study, there were high rates of emotional abuse, physical abuse, sexual abuse, substance abuse in the immediate family, mental illness in the immediate family, witnessing domestic violence and having a household member go to prison, so much so that over 50% of the sample reported experiencing an ACE, and about a quarter of the sample reported experiencing two or more. And of those who experienced

an ACE, like I said, at least half of those experience an ACE reported two or more, and 6.2% experienced four or more ACEs. So it seems that ACEs appear to cluster. So, for example, if someone experienced psychological abuse, then there is a 93% likelihood that they would have experienced any other additional ACE on top of that. Yeah, and, you know, I think from seeing a lot of patients, this makes sense. You know, if you have substance abuse in the family, you're probably going to have other types of abuse as well, whether that's sexual, physical, emotional,

witnessing domestic violence. Like, you could see how these kind of run together. So, okay, break down if they had four or more aces, what was the strength of the odds that they would do health behaviors that would be maladaptive? It was pretty strong. So for considering oneself an alcoholic, it was 7.4 times more likely to, and five times more likely to ever use illicit drugs, more than 10 times more likely to inject drugs, three times more likely to have 50 or more intercourse partners, 2.2 times more likely to

be a current smoker, and 2.2 times more likely to have poor self-rated health. Yeah, so you can see from some of those that four times, if you have four or more aces, you are doing things to cope with the demands of emotions and life and the trauma, the memories, right? We want to, a lot of these patients tell me they just want to escape reality. They don't want to think about it. You know, so they drink to escape, right? They're not drinking to remember. They're drinking to escape.

They're injecting drugs to escape to cope, to suffer less, right? They're having many sexual partners. Often patients will tell me they're doing this in order to, you know, numb themselves. It's like this is where it gets the level of addiction maybe where they're doing something in order to get their mind off of something else, you know, to escape reality in some way. Annabel, any thoughts as you hear these things? Yeah, even like I've heard of people, like many people saying that they watch a lot of porn to try to escape from negative thoughts when they're feeling alone and like overcome by like memories of trauma. So that's another thing that it wasn't listed, but yeah.

Yeah, yeah. And some of those patients will tell me it's not just half an hour once a week porn. It's like a couple hours a day, three. to four hours a day level porn. Yeah. Yeah. I think that's a lot more common than people, like, want to admit. And I think this was discussed like in another episode, too, if I'm not mistaken.

Sounds familiar. I'm actually working on an episode on that. So stay tuned. No spoilers. No spoilers. But it does impact the brain. And I'm curious how it impacts the brain. So I'm going to do a deep dive on that, which.

I guess, yeah. Yeah. Just like thinking about like these behaviors, again, like we were talking about. out how, like, the response and how it interacts with, like, the trauma itself. And, like, you could look at a person and say, oh, yeah, like, I don't know, this person, like, uses drugs. This person's an alcoholic. This person has, like, a ton of sex. They're bad. Something's wrong with them. Like, why would they do that? But it's like, okay, like, why would they do that? Like, they've experienced something very traumatizing that is in no way their fault. And this is a way

that they're choosing to cope with that. And they don't want to do it. This is just like something that works for them. And a lot of people I've spoken to who like come for treatment are hoping to find better coping mechanisms and things that are healthy and like work for like a healthy normal functioning lifestyle. And so I think like it's easy to to be like judgmental and to see something at face value. but it's more important to really dig deep and figure out why is someone doing this. And what purpose is this behavior serving them? And then you can move on from there.

Yeah, it's very much in line with like this, like the dialectic right of DBT. Yes. Which is like knowing your life or partially knowing your life and what you've gone through. It makes sense why you're doing some of these things. And I hear your goals and your desires to overcome. You know, and that's why you're here. So let's work together. But yeah, I like how you say that.

It's like, do we want to evoke shame for the behaviors that are used to cope? Or do we want to have those increase our empathy, that there's something underneath? And it's like, I can't imagine running chemical dependency detox without process groups, without trauma-informed care because it's just,

going to be there like you're going to find it okay let's talk about the adverse health outcomes and i think we're going to need to um like some of this stuff is going to be hard to hear if you've been through a lot of trauma so please know that i'm going to try to make sense of this and uh and add some hope to something that seems very hopeless but Liam since you wrote this out right don't you uh break it down for us how and this is four or more still are we doing four or more aces yes yeah this is four or more Aces. Someone with four more aces, six point six times more likely to attempt suicide according to the study. Four point six times more likely to report being depressed for two or more weeks. One point six times more likely to be obese. Two point two times more likely to have

Exchemic Arc disease. Almost two times more likely to have cancer. Two point four times increased likelihood for stroke. Three point nine times more likely for bronchitis or emphysema. 2.4 times likelihood for hepatitis or jaundice, 1.6 times more likely to have diabetes, 2.5 times more likely to ever have an STI, and even for skeletal fractures, 1.6 times increased likelihood. When I look at this, it seems dire. It seems like, oh gosh, increased risk of stroke, increased risk of cancer, increased risk of diabetes, like, and it's almost double the risk from of these things, increased risk of skeletal fractures. It's like, what?

What is going on? And some of it is like, I ask myself, okay, how much is the maladaptive behaviors? Like we know people who smoke have higher risk of emphysema, lung disease, right, cancer. We know that people who use a lot of injection drugs are gonna have more medical issues. Liam, anything that you found delineating how much of a mediator the poor or the maladaptive

health behaviors are to increase in the risk of the physical issues? Yeah, I think that question is still largely up to debate, but I looked into this a little bit more by looking at two different studies. So one of them was actually using the same data from the study. This is Brown-at-all 2009. And they were looking at people with six or more aces. And they actually found that people with six or more aces died on average 20 years earlier than those without aces. And although there is an equivalent mortality rate between those at six aces and those of zero,

the people with six aces probably were younger. So that means that they had more chronic effects that caused them to die at an earlier age. And so in the study, when they looked at the different odds of dying at the age of 75 or younger than 75, the people's six aces are more compared to zero aces. They're 1.7 times more likely to die before the age of 75. And up to six, no other aces were significant. Up to six, no, say that again, up to six, no more aces were significant. What does that mean? Yeah, so according to the study, if someone had five aces or four aces, they didn't have an increased risk of mortality at a younger age compared to zero aces.

Only the six or more aces group did. Okay. So kind of answering the question of if this is related to the causes of trauma or the outcomes of trauma, like the different behaviors associated with that, when they controlled for the different variables associated with that, such as, prevalent diseases, poor mental health, sexual and reproductive health, social problems, prescription medication utilization. This hazard ratio of 1.7 dropped down to 1.2 and was no longer significant. Okay. So you could read this as the things may go together too much to actually use these things as a control. But I think there's actually a little bit of a hopeful message in this as well of like, okay, if you are someone who's a mental health professional who is not smoking,

not drinking, you are getting treatment, you are seeing mental health professionals, you are working through your stuff, then it's going to reduce your risk quite a bit, right? Because it's the, uh, it's, it's like, it seems like it's a yes and. Like it's, of course the trauma impacts people and they're coping, and the coping is a short-term solution. But the coping patterns that they use are also a long-term detrimental thing. Now, that being said, when I'm treating a patient and they have a lot going on, I may not be worried about them smoking today. Like, hey, let's get you out of the manic episode.

Let's get you out of this place where you're feeling suicidal. We're not going to worry about the smoking today, right? that may be like a secondary issue. But eventually, hopefully we get to all the things that would reduce risk. So that's one of the hopeful messages I have. But tell the second study, and then I'll give my second hopeful message. Yeah, the second study was a prospective cohort study of over 6,000 participants, and they followed them from 1995 to 2018.

And they actually used 20 ACEs. So they included variables related to socioeconomic status and then also self-reported health. And they found that with each ACE, with each additional ACE, there is an increased likelihood of 4% increased mortality risk. But when they controlled for hypertension,

cardiac disease, cancer, stroke, and diabetes, some of these chronic medical conditions, this association fell to 3.3%, but it was still significant. So my sort of read on this is that even when you control for these chronic conditions that are probably the leading causes of death, you still have an increased likelihood of premature mortality. So that could mean that the mortality risk comes from the suicidal behaviors or accidental deaths

and not the main causes of death. Yeah. So the hazard ratio goes to about 1.1. Is that correct? For each additional ACE. Okay. So 1.00 is a lower hazard ratio, but it is there, right? So yet, yes.

Even if someone had 20 aces, it only counts to like, what, 1.6 something? 1.6 overall. And that's pretty similar to what we found in the other study for six or more cases, which was 1.7. So what I would not want is for someone with like six aces who's listening to this who just feels like a death sentence, right? That's what I don't want. And it's like when I have patients who go to a doctor

and the doctor says, you're bone on bone, and that's why you're in pain. And so they walk around with this belief. They're bone on bone and they're gonna die, right? So I'm very hesitant to put out this information without the disclaimer that like, you could actually do some things about this. today, right? And so, for example, in another episode I did 142, I talked about this one study looking

at cardiovascular fitness. And the most fit group compared to the lowest fit group, so the lowest fit group is the bottom 25%. The most fit group was like the top 3%. The increased hazard ratio of being a part of that lowest fit group compared to the top fit group was five, okay, 5.04 to be exact, after controlling for various things. So take that in consideration versus this hazard ratio of having a lot, a lot of aces. So even if you had like a bunch of aces, like 1.6, okay, it's such a bigger hazard to be in really poor physical shape. And so that's one thing you may not be able to control today, like if you're really out of shape today, but you can develop a plan over the course of years to get in much better physical shape.

Okay. And I say years because it is a true journey and I am on that journey myself every day, right, is to fight entropy. And about any thoughts on this? Yeah, lots of thoughts. I think one thing that comes to mind is like you can look at these studies and think like, okay, like, is it the chicken or the egg? Like, is it the trauma that causes all of this or is it the reactions to the trauma?

And it's one thing that I was thinking was like of the people who like reported zero ACEs, I wonder if they were being honest about that. And I wonder like how accurate that that was if the self-report because there is so much shame associated with it. It's like if someone isn't ready to address that like what happened to them in their past, then they might not be ready to like admit that it happened to them like on a self-report scale. So I just wonder about that. But also, like, we do know that, like, people who are living with, like, years and years of unresolved significant trauma have, like, higher cortisol levels and, like, live with a lot of extra stress in their lives. And, yeah, like, getting involved with a mental health provider, exercise, eating right, sleeping well, all of those things combined can absolutely, like, decrease the impact of trauma, like, the impact that the trauma has on your day-to-day functioning.

And therefore, like, ideally or like, logically it would make sense that, like, all of these risk factors could go down. Yeah, and I hear that and I know there's either a person out there who does not have a lot of resources. Or there's a provider who's like, yeah, but you don't know the type of patients that I'm dealing with. These are low resource. People, like, they don't, a lot of them can't get into a therapist or they can't get into a good therapist. or, you know, a lot of them, like, the insurance won't cover treatment, you know. And so I'm aware of that reality, and it's like, it's like at the air of being too hopeful, right? It's like, I could air being too hopeful here saying, like, no, like, there are things that we can do collectively, right?

We can struggle. And maybe as mental health professionals, as a group, we can lobby for better insurance for everyone, right? Maybe as a group we lobby for higher reimbursement so people actually become therapists, you know, and want to see insurance patients. Maybe we can lobby to make the insurance companies have to pay when someone sees someone for mental health and not like make me write three letters

to get the reimbursement. I don't know. So I think that there are things that we can do, and maybe it's not like the solution is simple. Please do not think that I'm sitting here thinking that the solution is simple to this. It is massive. It is overwhelming, but so is trauma.

So is like, but I think it's better to think through like, okay, let's define the problem accurately. And let's define the solution. And then let's use that to empower the next generation, right? So it's meaningful. It's like the work that we do is meaningful, whether it's, you know, whoever you are meeting today to sit down, to give empathy to, to help out, that is valuable, that is part of that journey, that's part of pushing against this big weight

that seems completely unmovable. You know, and intergenerate trauma is passed on, right? So if someone has a really awful, high trauma environment, it's going to be harder for them not to use drugs and alcohol, you know, so that it's going to be like, it's like if you are, if you're seeing this as like a ripple effect, I think it's actually helpful. And if we're trying to ripple it in the opposite direction of trauma,

we're trying to be the healers, we're trying to go out there and move the dial a little bit in the right direction. And so that's my hope. So I want to be hopeful. I want to provide meaning to us as providers that we are in this work. We're in the trenches.

We're trying to make an impact. And of course, it's really, really, really hard. And so I don't want anyone to listen to this and say, like, oh, he's like, this isn't, this is a, a minimization of the trauma. No, it's not. It's actually saying we need to focus on it. Or it's a, it's a it's it's it's it's it's it's it's it's it's it's a simple solution. No, it's not a simple solution. It's really, really hard. Right. And I think like adding on to that too is like we're talking a lot about like dealing with the after effects of trauma and like a lot of people might think like

well like why why don't we just stop trauma from the source and like that the solution for that is incredibly complex and not simple and like intergenerational trauma is is real and people like who were traumatized may you know traumatize others but I think like one area of hope that I was seen from our research that we did is like there was so many psychiatry residents who have like a history of trauma and like looking at that is like okay well that's like a big proportion of people who like something terrible happened to them and yet they're like doing something like good and helping other people with that instead of like perpetuating the trauma that that happened to them.

And so that's. Yep. Absolutely. Yeah. Absolutely. It's like it's meaningful, right? It's meaningful to actually take the awful. I mean, it's unusual, right?

It's like really cool. The human potential to take something awful that happened to them to not repeat it and then to also become part of the solution. for other people who have been through the same thing. It's like, that's beautiful. Yeah. That is beautiful. Yeah.

And I think as we as professionals, you know, we need to support each other. We may do things a little bit different, right? I'm okay if you don't practice exactly the way that I practice. Like, hey, we're all trying to, we're trying to push up against this weight. Hopefully it's not just like Sisyphus pushing up the weight to have it roll down again. you know, you impact one person's life. You do therapy on one person, and it's like generations will be impacted.

And so sometimes you have to like keep that meaning while you're in the trenches with that one patient who's like maybe has that, you know, it's just a lot, right? Because when you sit with someone in the midst of trauma, you feel what they feel. Not only that, but your trauma gets evoked. So it's like you cannot do this work

without getting your own therapy because it's like you will experience vicarious trauma from hearing their traumas and you need someone to process that with. You need to process that and grow through that as well. Okay, I think this is a really nice culmination of episode one of A-scores. Let's just give a little bit of where this is going to go.

We're going to talk about the, increase in mental health issues. We're going to talk about the newest measure that's used for ACE scores, the childhood trauma questionnaire. Short form is the most commonly used one in the past decade. We're going to talk about how ACEs increase psychiatric diagnosis in a dose-dependent manner. We're going to talk about complex PTSD,

the ICD-11 version of, you know, know what is complex PTSD. We're going to talk about PTSD. We're going to talk about borderline personality disorder. We're going to talk about the psychological functioning of different ways in which people psychologically get impacted. And we're going to talk about different types of abuse, the increase in dissociation, how emotional regulation is impacted and negatively impacted. I'm going to talk about the value of an enriched environment. This was a super cool study just to kind of like plug it right now. The Romanian study, these Romanian twins were, these Romanian children were adopted out of really awful, dire situations, weight, height,

brain size, two standard deviations below the mean, IQ, half of what it should be. After a couple years, weight and height normal, head circumference, still one standard evasion below the mean, IQ is still a little bit lower, but almost back to normal. Like, how amazing is that? The enriched environment can change the brain, can change weight, height, body. That's a cool study. We'll talk about that. And yeah, and then we're going to get into the biological aspects. We're going to get in cortisol. We're going to get into the brain changes, the different areas. So, super excited for you guys to join us in this journey. I'm glad, I think we'll keep this episode. We will not scrap this episode. Annabelle, thank you. I feel like you went well. Yeah, absolutely. Thanks for

having me. Yeah, I think it's an exciting series to do. And if you are listening to this and there's that one study that you want to make sure we know about, go ahead and send me an email. go on psychiatrypodcast.com. It's super easy to send me a message. And if you're a researcher in this and you have your own research episode or research episode, research paper that you've done,

and you want us to make sure that we know what it is and how cool it is, you can send that to me as well. So we will be doing this over the course of probably a couple months. So, all right, we'll leave it there for today.