A colleague of mine, an active advocate for identification and treatment of postpartum mental illness, recently posed an interesting concern. With Susan Smith- who in 1995 infamously drowned her children- in the news again because she and Boston Marathon Bomber Dzhokhar Tsarnaev have the same lawyer-my colleague wondered if there was insufficient attention to Smith's postpartum psychosis.
As I reviewed the media coverage, both of the original trial and Judy Clarke, Tsarnaev's and Smith's shared lawyer, I discovered that she was right- there was little to no mention of postpartum psychosis. However, Clarke's tactic clearly achieved her goal of portraying her client's humanity and vulnerability.
Smith was spared the death penalty because Clarke uncovered a story of significant early childhood trauma and abuse. Smith's father committed suicide when Smith was 6, and her stepfather sexually abused her in a secret relationship that continued in to her adulthood. A newspaper article from 1996 quotes Clarke:
This is not a case about evil. . . . This is a case about despair and sadness...Her choices were irrational and her decisions were tragic. She made a horrible, horrible decision to be at that lake that night. She made that decision with a confused mind and a heart without hope. . . . [But] confusion is not evil, and hopelessness is not malice.
What does it mean to conceptualize “mental illness” as separate and distinct from trauma? One could say that, with the context offered of childhood maltreatment, a "confused mind and heart without hope" is a more evocative description than "postpartum psychosis."
Her question got me thinking about compelling research by psychiatrist Martin Teicher about the neurobiological underpinnings of adult mental illness in the wake of childhood maltreatment.
Conduction a vast literature review, Teicher and colleagues differentiated two groups with psychiatric disorders, diagnosed according to the DSM system, with depression, anxiety, substance abuse and PTSD. One group had experienced maltreatment and another had not.
Maltreatment is broadly defined as being “characterized by sustained or repeated exposure to events that usually involve a betrayal of trust.”
It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation and shaming, as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.
The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word “trauma” itself may convey a kind of “not me” response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.
Teicher and colleagues found two subtypes, with significant behavioral and neurobiological differences, despite the fact that individuals in both groups carry the same diagnosis. Those with maltreatment history have earlier age of onset, more severe symptoms, greater suicide risk and poorer response to treatment. There are distinct differences in brain structure and function, stress response, as well as epigenetic changes in gene expression.
These findings offer a window in to how childhood maltreatment gets in to the body and brain. They have great significance in terms of prevention, intervention and treatment. Focusing efforts on supporting young children and their families is a natural conclusion. There are implications for treatment of adults as well. Teicher writes:
Recent recommendations for adults with maltreatment- related posttraumatic stress are to adopt a sequential approach that begins with safety, education, stabilization, skill building, and development of the therapeutic alliance before endeavoring to revisit or rework the trauma, as this may be destabilizing.
He expresses concern over the way these two distinct groups have not been differentiated.
Overall, we suspect that unknowingly mixing maltreated and nonmaltreated subtypes in treatment trials may have left us with an incomplete understanding of risks and benefits. Stratifying study subjects by maltreatment history may provide more definitive insights and delineate a clearer course of action for each subtype.
In other words, rather than treating psychiatric diagnosis according to the current DSM system, that looks at symptoms and seeks to eliminate those symptoms, it is critical, in determining appropriate treatment, that we explore the developmental and historical context of the symptoms.
In his conclusion Teicher writes:
We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier “with maltreatment history” or “with early life stress” to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.
If Susan Smith did have postpartum psychosis, then certainly the specifier “with maltreatment history” would have been indicated. Teicher’s work has relevance to this story in two ways. By supporting new families who are struggling in the face of parental mental illness, we offer the best opportunity to prevent mental illness in the next generation. In addition, as evidenced by Clarke’s success in avoiding the death penalty for her client, by telling the story of the individual, rather than simply naming an illness, we evoke the full complexity of experience that a current DSM diagnosis, without this specifier, does not.