La discusión en torno al concepto de regímenes híbridos

The fields of neurology and psychiatry evolved from a single dis-cipline in the latter part of the nineteenth century, with the earlier cli-nicians in these specialties dealing with both physical diseases of the central nervous systems and diseases of the emotions or neuroses. Al-though theories of hysteria had emerged in prior decades, much of the important early work in this area took place in the Salpetriere Hospi-tal in Paris. There the neuropsychiatrists Charcot and Janet first rec-ognized that patients with hysteria appeared to have the basis for their symptoms in histories of childhood trauma.

Charcot first identified the association of hysteria with the phe-nomenon of dissociation, although he approached the concept from a purely neurological point of view, considering it a hereditary degen-erative process.² Janet expanded the concepts of dissociation in trauma and postulated that intense emotional experience interfered with integration of memory into awareness.³He believed that these emotional experiences caused memories associated with them to be split off, or dissociated, from consciousness and to be stored instead as physical sensations of arousal and panic or as visual memories,

such as flashbacks or nightmares. He also felt that subsequent efforts to keep these memories out of consciousness led to a gradual disinte-gration in personal functioning.⁴Thus, he introduced the roles of dis-sociation and memory into traumatization and addressed the poten-tially permanent and progressive nature of the disorder.

The Austrian neuropsychiatrist, Sigmund Freud, adopted many of these concepts from the Salpetriere in his early papers and initially acknowledged the association of conversion hysteria with childhood sexual abuse.⁵When he presented these findings and opinions to his Viennese colleagues, however, he was met with a storm of criticism, reflecting the cultural rigidity of his Victorian times and the unwill-ingness of the psychiatric community to acknowledge the pervasive-ness of child abuse in existing middle-class society.⁶

As Freud developed his theory of psychoanalysis around the prem-ise of repressed infantile sexuality, he progressively abandoned the concept of traumatization as a physiological disturbance of memory associated with dissociation. Instead, he related hysteria to active re-pression of the sexual and aggressive fantasies of the Oedipal com-plex with the mother, and denied the validity of reports of childhood sexual abuse in his hysterical patients.⁷The almost universal accep-tance of psychoanalytic theory by the field of psychiatry resulted in the almost total rejection of the effect of child abuse and trauma on personality development, character traits, and psychiatric illness for almost eighty years.

Although the two world wars brought back to reality the fact that overwhelming life trauma resulted in profound emotional dysfunc-tion, sporadic attempts to relate this association in a clinical setting were overwhelmed by the prevailing concepts of psychoanalytic the-ory. An exception was the work of Kardiner, a psychoanalyst who at-tempted to restructure his theories of war neurosis based on his observations of the pervasive hypervigilance and sensitivity to envi-ronmental stimuli of his patients. He actually introduced the concept of a physioneurosis related to trauma exposure, and commented on the progressive nature of the syndrome in many of his patients.⁸ Kardiner documented many of the peculiar maladaptive traits of trauma victims that would later be incorporated into current definitions of PTSD. World War II afforded the opportunity to study traumatization in soldiers and concentration camp inmates. These studies in general

Trauma and Brain Plasticity 59

documented the catastrophic effects of severe trauma on subsequent general health, and on the capacity to tolerate stress in later life.^9,10 Many of the postwar clinical investigators who studied these effects of trauma had themselves been part of wartime or concentration camp experiences.¹

The Vietnam War resulted in another resurgence of interest in the effects of traumatic stress. This in turn rekindled interest in the work of Kardiner, and in 1980 led to an attempt to compile a list of symp-toms related to trauma from the existing literature into a unitary syn-drome. The new name for this syndrome was Post-traumatic Stress Disorder, and it was included for the first time in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). At the same time, attention was finally given to the previously ignored and relatively vast population of traumatized women and children.^11,12 Revisions of the definition of PTSD in the DSM (DSM-III-R, 1987, and DSM-IV, 1994) have continued to clarify and focus the epidemi-ology and clinical features of PTSD, but still have not completely de-fined the symptom of dissociation as specifically related to traumatic stress (see Chapter 6).

Since 1980, there has been an explosion of interest and research into the effects of trauma on the human brain and psyche, with the es-tablishment of numerous journals and the publication of many books solely devoted to the study of human traumatic stress. Particularly noteworthy has been the increasing emphasis on the neurochemical, neurohumoral, and neurophysiological changes produced by the ex-perience of trauma and the resulting breakdown of the separation of psychological and biological processes in mental illness. Physiological and behavioral studies in animals exposed to extreme stress have con-tributed greatly to the expanding knowledge of the basic science of trauma.¹³The movement of trauma research away from the psycho-analytic model has resulted in an increased awareness of the preva-lence of trauma in all societies, and its pervasive effects on dysfunc-tional social and personal behavior. It has also fostered further research in the growing area of brain plasticity, not only in the face of physical damage from stroke or injury, but also associated with expo-sure to extreme stress.