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THE \ATlRE OF TR~l'~lATIC ~lEMORIES OF CHILDHOOD ABUSE

jamrs A. (hu, 1\1.D. Julia .\. ~Iatlhe\l"s, Ph.D., )1.D. Lisa M. Frey. P!>J.D. Barbara Ganzel

James A. Chu, M.D.,JuliaA. Matthews, Ph.D., M.D., Lisa M. halfofthe cases. child maltreatment was substantiated. Our Frey, Psy.D.• and Barbara Ganzel, are from the Trauma and clinical experience suggests that these figures represent a Dissociative Disorders Program, McLean Hospilal, Belmont, substantial underestimate ofprevalence; intrafamilial abuse MA, and the Department of Psychiatry, Harvard Medical often occurs in great secrecy and often goes unreported to School. child protective agencies. Leaving aside the question about the accuracy ofreporting. the abuse ofchildren is a very seri­ For reprints writeJamesA. Chu, M.D., 115 Mill SL. Belmont, ous problem for oursociety. While notall, and perhapseven MA 02178. not most, ofthese abused children will develop serious psy­ chiatric difficulties, a substantial number is likely to suffer ABSTRACT lasting effects. In recent years, the explosion a/reporls ofchildhood atmst has raised Tn the past decade, we have begun to understand some questions about the nalure ofmemory far traumatlc events. In par­ ofthe effects ofchildhood abuse. Clinical investigations have Jicular, thn-e has been hmted Ikbau amcerning amnesiafur child­ suggested that early abuse may be associated with numerous hood abuse and 1M validity and tueuracy ofrecovertd ~. psychological and psychiatric difficulties including depres­ This discussion mMws the psydwbiology. rognitiw reJHJrch, clini­ sion, anxiety, emotional lability. impaired self-esteem. social cal research, and clinical practice amuming tmumalic memory. withdrawal, self-destructive behavior. impaired charactero­ From experimental investigatiom and clinical observations, there is logic development, alcohol and drug abuse, eatingdisorders, amp'" evidence to support the existence ofa variety ofmemory pro­ somatization, and various physiologic changes (Barksy, cesses for traumatic events, both conscious and nonconscious. Wool, Barneu, & Cleary, 1994; Bryer, Nelson, Miller, & Krol, Experimental studit5 hatJi! also s/wwn that memory amltnt is dynam­ 1987; COUTlois,1979; Finkelhor, 1984; Gelinas, 1983; ic and subfrd to suggestion and dislQrli.on. TJure is amsU.krabh Goldman, D'Angelo, Demaso, & Mezzacappa, 1992; Hall, Mdma tJuu traumatic menwry may be associated with psychobitr Tice, Beresford, Wooley. & Hall, 1986; Hennan, 1981; logic Jeatures and cognitive chanutnistics that art quilL different Herman, Perry. & van der Kolk, 1989; Herman, Russell, & from ordinary memory. The characteristics oftraumatic menwry an Trocki, 1986; Herman & V"dn der Kolk, 1987; Loewenstein, quite varied and are dependent on the natureofthetraumatic events 1990; Ludolph et al., 1990; Morrison, 1989; National Victim and the age when they were experienced. Clinical evidence and some Center, 1992; Ogata el al., 1990; Pribor & Dinwiddie. 1992; studies suggest that brieJ or limited traumatiuUion nsulJs in Pribar. Yutzy. Dean, & Wetzel, 1993; Russell. 1986; Shapiro, increased dmity or remll (hyJJmnnnia), and a high leuel ojaccu­ 1987; Summit. 1983; Swanson & Biaggo. 1985; van der Kolk. racy amceming the antral €ktails ojthe experience. On the other 1987; van der Kolk. Perry, & Hennan, 1991; Welch & hand, severe and chronicearly tmumaliuUUm may be comdated with Fairburn. 1994; Zanarini. Gunderson, & Marino, 1987). denial, dissodation, and . Clinical studies have supported While many ofthese associated difficulties are based on clin­ the existence ojamnesia and recovered mtnume.s especiallyJor severe ical observations and preliminary findings, there is clearly and chronic childhood abuse. flowever, such memories also may be considerable psychiatric morbidity associated with early most vulnerahJe todulQrli.on and mvrsin recalL Mental heahh pro­ traumatization. JessUmaJs who treat suroivon of childhood abuse slwuld be well In re<:entyears, clinicians and investigators have focused informed aboulthe annplexity ojtraumatic memory in order to pr0.­ on post-traumatic and dissociative symptoms lhatappear to vide a sound and balanced approach to tMr clinical work. be etiologically related to childhood traumatization (Bernstein & Putnam, 1986; Braun, 1990; ehu, 1991; Chu INTRODUCrION & Dill, 1990; Coons, Cole, Pellow, & Milstein, 1990; Donaldson & Gardner, 1985; Kirby. Chu. & Dill, 1993; In the United States in 1990,2.7 million cases of sus­ Putnam, 1985; 1993; Putnam. Curoff, Silbennan, Barban, & pected child maltreatment were reponed to child protec­ Post, 1986; Ross. Anderson, Fleisher, & Norton, 1991; Saxe tive agencies (National Research Council.1993). In nearly etal., 1993; Ulman & Brothers, ]988;van der Kolk& Kadish,

2 DbSOCLnJO\. \ 01 IX. \0 UI...rlJ. 19!15 CHU/1\lAITHEWS/FREY/ GA.\lZEL

1987). Dissociative symptoms including depersonalization, repressed ordissociated earlyexperiences. For some patients, dcreali7.ation, psychogenic amnesia, fragmentalion ofiden­ clinical work wilh recovered memories has been a vehicle tity, and post-traumatic reexperiencing phenomena (e.g., for the resolution of psychiatric symptomatology, and has "flashbacks~ oflraumatic events), are frequent clinical find~ led to an enhanced understanding of the traumatic etiolo­ iogs in disorders that derive from childhood abuse. gies of their difficulties. Recently, however, a number of Dissociative amnesia is at the coreofthe controversy con­ prominent investigators have questioned the validity of cerningtrdumatic memol)'ofchildhood abuse. The idea that recovered memoryand have argued thatsuch memoriescan oveIWhelming experiences can be forgotten and then later be false and that many clinicians may be colluding in the recalled has its origins in major schools of thinking con­ creation ofpseudomemories. A heated debate has emerged cerning intrapsychic experience. Early in this century,Janet regarding therapists' role in the retrieval ofdissociated mem­ (1907) described psychogenic amnesia and theorized that ories ofchildhood abuse. In order to provide an integrated traumatic events could be dissociated from conscious aware· perspective concerning memories of childhood abuse, this ness, only to be remembered at some later point in time. discussion reviews recent findings concerning the psy­ J'reud's psychoanalytic theory included lhe beliehhatevents chobiology of traumatic memory, recent progress in cogni­ that were traumatic or that resulted in intense intrapsychic tive memory research, issues concerning memorydistortion, conflict could be repressed and become unconscious, and clinical research, and clinical practice concerning traumat­ could later be repeated and reexperienced (Freud, 1955). ic memory. Despite the difllculties oftrying to integrate the Freud described repression as an active proces.~, itselfuncon­ findings ofseveral major schools ofscientific endeavor, it is scious, that holds unacceptable or overwhelming thoughts crucial to understand the complexity of Lnlumatic memory and impulses outside of conscious awareness. These theo­ in orderto provide a balanced approach to clinical work with retical constructs laid the groundwork for modern investi­ patients who have memories ofchildhood abuse. gators who were interested in the effects oftraumatic events on memory. THE PSYCHOBIOLOGY OF TRAUMATIC MEMORY Psychogenic amnesia has been observed for over­ whelming and traumatic experience. For example, a recent Clinical experience has suggestcd that traumatic expe­ media report (National Public Radio Morning Edition, riences are often remembered differently than ordinaryexpe­ 1996) documented the Story ofRoss Cheit, an associate pro­ ricnce. Indeed, Lllil>observation is lhe oo..,is fOl" the symptom fessor of political science at Brown University. In 1992, complex ofpost-traumatic stress disorder (PTSD). The cen­ Professor Cheit learned that his nephew wasjoining a boys' tral features of PTSD are hyperarousal, hyperactivity, and chorus. He became quite depressed, and could think ofno repeated reexperiencing of the traumatic events through reason for his depression. However, he soon had the abrupt vivid memories, flashbacks. affective flooding, or night­ recovery ofmemoriesofchildhoodsexual molestation by an mares (American Psychiatric Association. 1994). These administratorofa boys' chorus in asummercamp. Professor symptoms typically coexistor alternate with affective numo. Cheit set out to corroborate his memory. He found other ing, avoidance, and . Each ofthese phenomenacan men who had been molested at the same camp as boys, and be usefully examined as reflections of altered or pathologi­ found twO fonner employees ofthe camp had wimessed some cal memory function. episodes ofsexual molestation. He subsequeOlly found lhe The psychobiologyofPTSD has been reviewed extensively perpetrator, who admitted to the acts. He filed civil suit (Charney, Deutch, Krystal, Southwick, & Davis, 1993; Krystal against the organizers ofthe boys' chorus; the case was set­ etal., 1989; van der Kolk, 1994; van der Kolk & Saporta, 1991; tled in 1994. ProfessorCheitwas notin psychotherapyat the van der Kolk & van der I-Ian, 1991). Many investigators pro­ time he recovered these memories. pose that the symptoms ofPTSD result from the multifaceted Perhaps even more striking are the many adult psychi­ neurohormonal changesthatoccurin response to acute and atric patients who report extensive amnesia for childhood chronic stress, and that memory for traumatic events may events. To some patients, much oftheir childhood is foggy. be processed and stored differently from ordinary memory. Otherscan recount the eventsoftheirpast, butfeel as though It should be noted, however, thatalthough many physiologic these happened to someone else. Many patients describe a changes have been observed in PT$D patients, many of the kind of "Swiss cheese" memory with gaps in their recall of stress-responsive neurohormonal changes (especially in the their early experiences, or even complete amnesia for any brain) have been observed only in animal models. Thus, events over mOOlhs or years. In clinical settings, this exten­ applications ofthese models to humans with PTSD remains sive psychogenic amnesia may be highlysignificant, and many speculative. patients with this kind of amnesia eventually report recov­ At least three stress-responsive neurohormonal systems ered memories ofextensive childhood abuse. have emerged as critical in the developmentofl'TSD: 1) cat­ Manyclinicians and investigators accept recovered mem­ echolamines, including adrenaline, noradrenaline, and ories of childhood abuse as essentially valid reports of dopamine, that modulate bodily activation and arousal par-

3 lllSSOCf,\T[ON, \'01. IX, ~o.l. March 19Q6 ticularly in stressful emergency situations; 2) hormones of Acute srress is associated with similar increases in activ­ the hypothalamic-pirnitary-adrenal (HPA) axis, includingcor­ ityofmidbraindopaminergic neurons, and increased release ticotrophin-releasing factor (CRF), adrenal corticotrophic and metabolism ofdopamine, particularly in the prefrontal hormone (AGrH) , and glucocorticoids, that have an essen­ cortex (see Charney, et aI., ]993). The prefrontal dopamin­ tial role in maintaining physiological and psychological ergicsystem may besignificantfor focused attention and vig­ homeostasis; and 3) endogenous opioids, opiate-like sub­ ilance. and the increased dopaminergic function may be a stances produced by the bodyin response to stress. Persistent factor in the hypeIVigilance ofPTSD. The prefrontal cortex increases in catecholamine activity, alterations in hormon­ is also postulated to mediate memory search and retrieval al functions in the HPA axis, and opioid responses have all via its extensive connections to the hippocampal system been documented in patients with PTSD (Charneyetal., 1993; (Moscovitch, 1992). Abnormality in this system may con­ McFall, Murburg, Roszell, & Veith, 1989; Pitman, van cler tribute to experiencesofintrusive rememberingsuch as flash­ Rolk, Orr, & Greenberg, 1990; Southwick et aL, 1993; van backs, failures of remembering such as amnesia, or misat­ der Kolk, 1994; Yehuda, Giller, Southwick, Lowy, & Mason, tribution of the source of the memory. 199]).As discussed below, each ofthese systems also has com­ Hormonal activity in the HPA axis is highly responsive plex effects on memory function that may be fundamental to acute stress, producing an immediate increase in CRF, to the memory disturbances seen in post-traumatic syn­ ACTH, and glucocorticoids (Sapolsky, Krey, & McEwen, dromes. 1986). CRF not only stimulates release ofACfH from the pitu­ Patients with PTSD exhibitmultiple symptoms ofheight­ itary, but also acts as a neurotransmitter itself, enhancing ened arousal, including an exaggerated startle response, activity in locus ceruleus adrenergic neurons (Axelrod & increased response to stress-related stimuli, panicattacks, and Reisine, 1984; Yehuda et al., 1991). Glucocorticoid recep­ hypeJVigilance (American Psychiatric Association, 1994; tors are particularly abundant in the hippocampus. a brain Charney et aI., 1993; van der Kolk, 1994). The early recog­ structure thought to be central in memory function. nition ofthese persistent physiologic changes led Kardiner Clucocorticoids receptor density in the hippocampus is to characterize PTSD (then called a "war neurosis") as a "phy­ decreased by bothacute stress and circulatingglucocorticoid sioneurosis"(Kardiner, 1941). Autonomic reactivity has been hormones (Sapolsky, Krey, & McEwen, 1986). Finally, there quantitatively studied in combat veterans with PTSD (Orr, is considerable evidence for glucocorticoid toxicity to the 1994; Pitman. Orr, Forgue, Altman, deJong, & Hen, 1990; hippocampus, resulting in eventual neuronal ceU death in Pitman et at, 1987). When patients with PTSD are exposed a dose and time dependent manner. Hippocampal cell death to u-auma·related stimuli in a controlled laboratory setting, occurs in aging. and is accelerated by stress. Hippocampal they exhibitmarked psychophysiological arousal, such as ele­ neuronal degeneration has been demonstrated in monkeys vated heart rate, increased gaJvanic skin response. and after either prolonged stress or prolonged administration increased tone in facial musculature. Recently these obser­ ofglucocorticoid.<; (Sapolsky, 1986; Sapolsky, Uno, Rebert, vations have been extended to victims of traumatic events & Finch, 1990), suggesting a possible mechanism for some not related to combat trauma (Shalev, Orr, & Pitman, 1993; of the changes in memory function seen in PTSD. Reduced Blanchard, Hickling, & Taylor, 1991). hippocampal volume (as measured by magnetic resonance Many investigators have suggested that the psychophys-­ imaging) and memory deficits have been demonstrated in iological arousal found in PTSD is mediated by chronic ele­ veterans with combat-related PTSD (Bremner et aI., 1995) vations in both central and peripheral catecholamine func· and in patients with PTSD associated with childhood physi­ tion (see Charney et at, 1993 and Southwick ct aL, 1993, for cal and ~Kual abu~ (nremner et al., in pre~). reviews). In supportofthis idea, it has been shown thatacute Uncontrollable stress results in stress-induced analgesia stress in animals is associated with increased activity of neu­ in both animal model systems and in humans that is attribut· rons in the locus ceruleus. the midbrain nucleus which is cd to the release of endogenous opioids (Hemingway & the source ofwidespread adrenergic projections (Simson & Reigle, 1987; Willer, Dehen.&Cambier, 1981). Furthermore, Weiss, 1988), and is also

4 DISSOCIATION, Vol. IX, No I, MaTch 1996 CHU/I\IATTHEWS/FREY/ GANZEL

daloid projections to the hippocampus (McGaugh, ]989 & tion al any ofa number ofstages: attention and registering 1992) . ofthe events, formation ofthe initial memory trace in short· The long-term physiologic changes associated with term memory, association to othermemories leading to inter­ severe stress may be understood broadly as a form of 000­ pretation of the experience. conversion to stable memory, conscious or conditioned somatic memory, and may be the long-term memory consolidation. integration of the trau· basis ofcertain forms ofnon

5 DlSSOClmON. Vol. IX, No. I. Marclll996 difficult to access memories and experiences ofa different Types ofMemory state. Since the traumaticexperience inducesa marked phys­ The study ofmemory has produced descriptions ofsev­ iological arousal and altered neurohormonal state, it is pos­ eral fonos of memory. As described by Polster, Nadel, & sible that both lhe encodingand recall ofmemorr is specific Schacter (1991), psychological and medical researchers of to this state. This maycontribute to the phenomenaofamne­ the 19th century agreed that memory was nota unitary enti~ sia and dissociated memory in PTSIJ, since when not physi­ ty, but more likely a multidimensional function consisting ologicallyaroused, itmay be more difficulllO access the trau­ ofvarious domains and various representations of recollec­ matic state. Conversely, when presented with triggers tions. For example, in the late 19th and early 20th centuries, reminiscentofthe trauma, access to the u'aumatic state may French philosopher Maine de Biran suggested three mem­ be facilitated, leading to flashbacks and other reexperienc­ ory types: 1) the accumulation of motor habits or mechani­ ing phenomena (Rainey et a\., 1987; Southwick ct a1, 1993; cal memory, 2) memory that represented facts and evenL'l, van der Kolk & van der Han, 1991). and 3) memory for emotions and feelings (Polster et at, Finally, based on clinical observation, some investigators 1991). (Crabtree, 1992; Kolb, 1987; van der Kolk & Ducey, 1989; Much of the study of different memory processes has van der Kolk & van der Hart, 1991) have suggested that trau­ derived from the study of patients with amnesia. In 1911, matic memories are stored segregated from ordinarr nar­ Qaparede (in Rapaport, 1951) reponed his obscIVdtions of rative memory, and are less subject to ongoing modification a woman with Korsakoff's syndrome who consistently had in response lO new experiences. In contrast to narrative mem­ no memory of him within minutes of numerous introduc­ ories thatare integrative, malleable, and liued into the indi­ tions. Finally, upon one introduction, he shook her hand vidual's personal cognitive schemas, traumatic memories are with a pin hidden in his own and pricked her. Later, she still inflexible, non-narrative, automatic, triggered, and discon­ had no memory ofhim, but refused to shake his hand even­ nected from ordinaryexperience. Theysuggest that this non­ tuallyadmitting that pins are sometimes hidden in the hands integration is the basis for dissociated remembering through ofothers. She did not consciously remember Claparede, but behavioral reenactment, somatic sensation, or intrusive had some form of memory of the pain caused by the pin­ images which are disconnected from of handshake. In the modern era of memory research, neu­ events. Because the memories are unassimilated, they retain ropsychological studieson patients with amnesia have repeat­ their original force - "unremembered and therefore unfor­ edly shown that these patients could acquire various skills gettable M (van der Ko1k & Ducey, 1989). Ordinary narrative (e.g., in cognitive and perceptual taSks) in spite of having memory is dynamic and both changes and degrades over no memory of the episodes during which the skills were time. In contrast, tr.mmatic memory may be less changeable learned (Cohen & Squire, 1980; Daum, Channon, & Canavar, and has been described as "indelible" (LeDoux, 1992). 1989;Jacoby, Lindsay, & Toth, 1992;Jacoby& Witherspoon, 1982; Sartori, Masterson, & Job, 1987; Warrington & THE CONTRIBUTIONS OF MEMORY RESEARCH WeiskrantL, 1982). Subsequent research demonsuated sim­ ilar nonconscious learning and memory in normal subjects Research in the field of cognitive psychology has paral­ (Graf, Mandler, & Haden, 1982; Jacoby, Lindsay, & Toth, leled psychobiologic investigations of memory. In particu­ 1992; Jacoby & Witherspoon, 1982; Tulving, Schaeter, & lar, research concerning the types of memory and the mal­ Stark, 1982). leability of memory has been useful in elucidating the A diverse terminology has been used lO describe what particular nature oftraumatic memory. Much ofthe exper­ appears to be two separate and distinct memory systems. imental research and the more recentdebateabout traumatic Tulving (1972 & 1983) proposed that memoryoccurs in two memory has concerned concepts of unconscious memory. primary modes: episodic and semantic. It should be noted in comparing experimental findings to included autobiographical infonoation about past experi­ !.henries about trauma, that the teno "unconscious~hasbeen ences. referred to ageneral fund ofknowl­ used to describe both n,onconscious memory processes edge not necessarilyassociatedwith specific pastexperiences. demonstrated by laboratory investigations and the psycho­ Subsequent investigators described two memory systems dynamic unconscious as described by Freud. Both uses of labeled declarative and proceduraJ (Kihlstrom & Hoyt, the term imply nonconscious mental processes, outside of 1990). Declarative memory, similar to episodic, referred to conscious awareness, that may exert influence on behavior, memory for factual knowledge ofone's material world and thought, or experience. The psychoanalytic use ofthe term social experiences. Procedural memory, like semantic, unconscious has additional implications, i.e., memory that referred to the memory of abilities, rules, and schematic is suppressed by the active process of repression. approaches to dealing with the world. Schacter ultimately coined the currentlyaccepted descriptive distinctions oftwo primary memory systems: explicit and implicit (Graf & Schacter, 1985; Schacter, 1985, 1987, 1990 & 1992a). Explicit

6 DbSOClHlO\ 1011\ \0 I \1i<1(hl~ CUU/MATTUEWS/FREY/GANZEL

memory consists ofthe collection ofpriOf experiences with­ Sartori, Masterson, &.Job, 1987; Schwartz, Saffran, & Marin, in "intentional or conscious" recall and includes declarative 1980; Squire, 1992). Forexample, neuroimagingstudies with and episodic memories. Implicit memory refers to changes positron emission tomography (PET) scans suggest that the in performance or behavior based on priOf experiences of visual perceptual representation subsystem is located pri­ which one has no conscious recalL Implicit memorysubsumes marily in an area ofthe extrastriate occipital cortex (Zeti et the previous concepts of semantic and procedural memo­ aI., 1991), whereas semantic language processing localizes ries, as well as conditioned responses and cognitive priming to the temporal and parietal cortex (Frackowiak, 1994). (see below). Implicit memory may also be the active process The implications of research concerning the psychobi­ in affective and somatic memory (Erdelyi, 1990), which sup­ ology of memory and types of memory are indeed signifi­ ports the clinical observation in PTSD patients that these kinds cant, demonstrating the existence of nonconscious mental ofmemory may be experienced without conscious awareness processes, and contributing to an understanding of the of their origins (Chu, 1991; Braun, 1988). nature ofmemory. Memory and memory processing is high­ Considerable research has provided evidence that these ly complex, with multiple memory systems involved in the explicit and implicitforms ofmemory can be dissociated from acquisition, retention, and recall ofinformation, and these each other (Bower, 1990; Kihlstrom & Hoyt, 1990). Schacter systems are represented in various locations in the brain and (1987 & 1990) has cautioned that the distinction between function through a variety ofneurocognitive networks. explicit and implicit memories is descriptive rather than proof ofanatomically separate systems. However, currentwork on The MaUeability ojMemory the anatomy ofmemory supports the speculation that sepa­ In 1977, Brown and Kulick described so-called "flash­ rate anatomical systems may be involved in explicit and bulb" memory as a process in which precise details ofa trau­ implicit memory. Studiesofanimals with precise lesions have matic scene are permanently etched in memory in a poten­ confirmed that the hippocampus and closely related medi­ tially retrievable manner. In contrast, more recent studies al temporal lobe structures are ofcentral importance in the of memory suggest that such memories can be remarkably formation and consolidation ofexplicit memory (Schacter, inaccurate, particularlyconcerningperipheral details ofthe 1992b; Squire, 1986; Squire, 1992; Squire & Zola-Morgan, experience. Despite the difficulties ofsimulating traumatic 1991; Thompson, 1986). In contrast to explicit memory, experiences in the laboratory, investigations have studied the implicit memory is unaffected by lesions ofthe medial tem­ nature ofmemoryin stressful experiences. Experimental pro­ porallobe. Implicit memories seem to be stored in diverse cedures have included testing college students under neocortical andsubcortical systems. For example, motor con­ demanding conditions (Eriksen, 1952 & 1953; Tudor & ditioning dependson modification ofneuronal connections Holmes, 1973), and exposing subjects to shocking photo­ in the cerebellum (Thompson, 1986), and learning ofskills graphic material (Christianson- & Loftus, 1987; Kramer, and habits may be reflected in change in the neostriatum Buckout, Fox, Widman, & Tusche, 1991). Data from these (Heindel, Salmon, Shults, Walicke, & Butters, 1989). investigations show that participants are often remarkably Emotional conditioningappears to be localized in the amyg­ inaccurate in recounting details of their experience (e.g., dala (Davis, 1992; LeDoux et aI., 1990). who made critical statements to whom, where they were at Research on ~priming,"a type of implicit memory, has the time, what other people looked like, what time ofday it shed further light on the nature ofconscious and noncon­ was, etc.) (Christianson &Loftus, 1987 & 1991; Holmes, 1990; scious mental processes. Priming refers to facilitation of a Kramer etal., 1991). However, details ofthe experiences that simple cognitive task (e.g., object recognition orword com­ are central to the individual seem to be accurately retained. pletion) as a result of a prior encounter with the cue, and A number of investigators (e.g., Chistianson and Loftus independent of conscious recollection of that encounter [1991], and Holmes [1990]) suggest that an individual's (Schacter, 1992a). Research conducted on priming effects recall ofcentral detail is retained as a direct function ofthe has produced evidence ofa group ofmodality-specific mem­ intensity of the affect associated with the experience: the ory subsystems that function prescmantically and outside of more emotional the experience, the better selected central conscious awareness (Schacter, 1992a & b). For example, details are remembered. some of these subsystems are involved in the acquisition of The role ofsuggestion in the malleability ofmemory has the form and structure ofwords and objects, but not their also beenwell established in laboratory studies (Loftus, 1979; meaning and associative qualities. Thatis, they operate inde­ Loftus, Korf, & Schooler, 1989; Schooler, Gerhard, & Loftus, pendently of both the need to access meanings ofwords or 1986; Schumaker, 1991). In some protocols, participantsare objects, and of conscious memory of prior experiences. As shown pictures, slides, orvideotape ofan eventand are then with other types ofimplicitmemory, priming subsystems are asked to recall the event. When participants are given cues expressed by neurocognitive systems that are distinct both or suggestions regarding the event, they often make errors functionally and anatomically from the neurocognitive struc­ concerning peripheral details of the events. For example, tures that support explicit memory (Frackowiak, 1994; in one experiment (Schooler, Gerhard, & Loftus, 1986), par-

7 D1SS0CL\TION, Vol. IX, No. I, ~Iarch 1996 ticipanls were shown slides ofan automobile accident. For three interviews, approximately 6% ofpartidpants developed one set of participants, the slides contained a yield sign. For vivid pseudo-memories of false events as in the following another set of participants, the slides did notcontain a yield description (p. 191): sigo, butits existence was suggested in a questionnaire about the slides. When asked, many participants in both groups First Intennew reported seeing the sign and could provide a verbal descrip­ tion of the sign. These studies are important because they I: The nextone is attending a wedding. At age six demonstrate that memory is not a static phenomenon, but you attended a wedding reception and while can be influenced by a variety offactorsincluding the retrieval you were running around with some other kids context. you bumped into a table and turned over a Actual traumatic events can be misremembered. Studies punch bowl on a parent ofthe bride. ofmemory oEthe space shuttle Challenger explosion showed that many participants had many incorrect recollections of S: I have no clue. I have never heard that one the events (Neisser & Harsch, 1992; Warren & Swartwood, before. Age six? 1992). Moreover, participants' certainty that theywere accu­ rate in recall was not related to actual accuracy (Warren & I: Dh-huh. Swartwood, 1992). For example, Neisser and Harsch (1992) describe college students who were very confidentabout their S: No due. recall ofthe Challengerexplosion, butwho made manyerrors aboutwhen the eventoccurred,where they were at the time, I: Can you think ofany details? and how they heard about it. Loftus describes other situa­ tionswhere serious life-and-death situations such as war and S: Six years old, we would have been in Spokane, sports accidents were misremembered (Loftus, 1993). um, not at alL However, once again, the central features ofthe events (e.g., the fact of the Chalknger explosion, the bombing of Pearl Second Interview Harbor, and sports accidents) were accurately retained. Despite evidence thatmemory contentcan be influenced I: The next one was when you were six years old by suggestion, emotional arousal, and personal meaning, the and you were attending a wedding. bulk of memory research actually supports the accuracy of remembered events that are known to have occurred. S: The wedding was my best friend in Spokane, However, there is also evidence that persons can have mem­ T_. Her brother, older brother was getting ory for events that did not occur. One well-known personal married, and it was over here in P, pseudo-memory was described by the Swiss psychologist, Washington, because that's where her family Piaget (1962), the well-known theorist of cognitive devel­ was from and it was in the summer or spring opmentin childhood. For many years during his childhood, because itwas really hotoutside and itwas right Piaget had clear visual memory ofsomeone trying to kidnap on the water. It was an outdoor wedding and I him from his pram when he was two. The memory also think we were running around and knocked , involved his nanny chasingaway the potentialkidnapperand over like the punch bowl orsomething and urn then going home and telling (he family. Years later, when made a big mess and ofcourse got yelled at for Piaget was 15, the nanny returned to the Piaget family and it. But uh. confessed that the incident had never occurred. Her motive had been to enhance her position in the household, but she I: Do you remember anything else? subsequently had suffered guilt about the fabrication and about the watch she had received as a reward. S: No. Piaget's experience suggests that after being told about certain past events by a trusted individual or someone in a I: OK position ofauthority, persons may create pseudo-memories ofevents that never actually occurred. The "memories» may In a similar subsequent experiment, Hyman and seem valid, and persons may not recall the true source of Pentland (1996) found thatvivid pseudo-memories increased the information (so-called "source amnesia»). An experiment from 9% to 25% if participants were asked to imagine the by Hyman, Husband, and Billings (1995) attempted to false events in detaiL These studies support the contention implant false memories of childhood events in college stu­ that pseudo-memories can be induced, particularly with dents. Participants were asked to describe both real events repeated suggestion, rehearsal, and the use of imagery. It (from information supplied by parents) and false events. Over should be noted, however, that only a minority of partici- 8 - CHU/MATTHEWS/FREY/GANZEL

paulS responded to cues LO remember false events, suggest­ or even memory for hearing aoout or witnessing trauma. ing matcenain individuals may have more vulnerability than Experimental investigations oflraumatic memory are limit­ others lO creating pseudo-memories. ed by the ethical conslraintsofexposingsubjects to truly over­ The nowwell·known case ofPaul Ingram has added evi­ whelming or very prolonged traumatic events. Thus, results dence to the notion of the creation of pseudo-memory. As from experimental psychology may be limited in under­ described by Ofshe (1992) and Loftus (1993), Ingram, the standing the actual impactoflraumaticevents. Nonetheless. chairofhis countyRepublican partycommittee.wasaccused a clear understanding ofconlributions ofmemory research ofthe sexual abuse ofhis daughter and other children, and is important in evaluating clinical studies oftraumatic mem­ participation in Satanic cult activities including ritual sexu­ ory and clinical situations. As a whole, both experimental al abuse and murder. Atfirsl, hedenied everything. Howc\'cr. and clinical observations should be pan of an integrated after interrogation and pressure from a psychologist and understanding of traumatic memory. other advisors, Ingram began LO have vivid memories ofhis involvement in the alleged abuse. Ofshe, an expen witness, CLINICAL STUDIES OF TRAUMATIC MEMORY attempted to tCSt Ingram'ssuggestibility. He told Ingram that he had been accused offorcing his son and daughter to have Compared to laooratory memory research, there has sex together, an event that his children had agreed had not been relatively little clinical research concerning traumatic occurred. Ingram initially had no memory of this wevent,· memories originating in childhood. Until relatively recent­ but after being urged to think about the scene, he began to ly, the only published studyconcerning the nature ofamne­ vividly recall it. and eventually confessed to the allegedactiv­ sia for childhood abuse and validity ofrecovered memories ities. This apparent pseudo·memory does not necessarily was reported by Herman and Schatzow in 1987. Theirstudy invalidate Ingram's other recoUections. In fact, Peterson involved 53 women who had sought treatment in time-lim­ (1994), a psychologist involved with the case. reports that ited incest survivors' groups. A majorilY of these women Ingram was convictedofsix countsofchild molestation after reported that they had experienced complete or partial "care was taken to elimin~te those allegations thatcould have amnesia for theirsexual abuse atsome time in t.he past: 26% been contaminated by the investigator's questioning or by reported having had no memory for the abuse and 36% had contact with the daughters and Mr. Ingram." However. the remembered only some or parts ofthe events. More amne­ case does raise issues conceming the effect on memory of sia was related to early age of onset of the abuse. chronic questioning.suggestion, and interrogation in ooth legal and abuse, and severity ofahuse such as violent orsadistic abuse. clinical settings. Perhapseven more notable WdS that the overwhelming m~or­ Psychobiological and cognitive memory research has ityofthese women were able to find some corroboratingevi­ demonstrated the existence ofa variety ofdifferentand com­ dence of the abuse. Seventy-foUT p€rcent (74%) were able plex memory systems. The elucidation ofthese memory sys­ to find convincing evidence that the incest had occurred, tems, particularly nonconscious (implicit) memory, may pro­ such as a family member who confirmed it, or, in one case, vide an explanation ofhow traumatic experiencesare stored diaries and other evidence of a deceased brother who had and recalled. There is evidence that the central theme of been lhe abuse perpetrator. Another9% found family mem­ stressful events is preserved at least in some experimental bers who indicated that they thought the abuse had likely situations. However, depending on factors such as the cir­ occurred, bUl who could not confirm it. Eleven percent cumstances and severity ofstressful events, the accuracy of (II%) made no attempt to corroborate their abuse, leaving memory encoding and conscious recall may be affected. It only 6% who could find no validating evidence despite efforts is also clear that the mechanisms and context of memory to do so. Critiques ormis sludynote thata proportion ofthe retrieval may have a profound effect in influendng the con­ amnesiac subjects were very young and p€rhaps had normal tent of memory, particularly in susceptible individuals. childhood amnesia, and that clear, independent corrobo­ The contributions of memory research raise many ration ofabuse was notobtained (Oeshe & Singer, 1994; Pope thomyquestions.some which challenge clinical observations. & Hudson. 1995). Forexample, cognitive psychology research does notempir­ A study by Briere and Conte (I993) asked therapists to ically substantiate the existence of the psychoanalytic theo­ administer a questionnaire to their patients who reponed ry ofrepression, an active ego-defensive process. However. sexual abuse memories. Thequestionnaire consisted ofa vari­ it is problematic to eXlrapolate experimental fmdings to clin­ cLyofscales aboutcurrentsymptomatology and pasllife expe­ ical situations. As acknowledged by a number of investiga­ riences. Of the 450 subjects who reponed childhood sexu­ tors, there are ecological differences between experimental al abuse. approximately 54% reponed having had some conditions and aClual clinical situations (Erdelyi. 1985; . amnesia for the abuse between the time ofoccurrence and Holmes. 1974 & 1990; SchaCler, 1990). l.eaJning and recall age eighteen. Greaterlevels ofamnesia were correlated with that result from actual involvement in traumatic events may greater currenllevels ofpsychiatric symptoms. early age of be substantially different than memory for neutral events, onset and severity (e.g., multiple perpetrators, physical

9 DISSOChTIO,\. \01 IX, ~o I. \I.u,h 1996 injury, fear of death if they revealed the abuse). The of defining the nature of the "forgetfulness" (Pope & researchers also asked aboutfactors which were likely to pro­ Hudson, 1995). duce a greater level ofpsychological conflict such as enjoy­ All of the above studies have the disadvantage of being ment ofthe abuse, acceptance of bribes, feelings ofguilt or based on patients' self-repon. Three ofthe studies (Herman shame. These factors were notcorrelated with amnesia, sug­ & Schatzhow, 1987; Briere & Conte, 1993; Loftus etal., 1994) gesting that it may be the noxiousness ofthe experience itself are clearly retrospective in nature and rely on a clinical pop­ which produces amnesia, and not intrapsychic conflict. ulation seeking treatment for sexual abuse which may also Critiques of this study note methodological problems con­ limit the applicability ofthe findings. Williams' study (1994) cerning recruitmentand various interpretationsof"remem­ is perhaps the most persuasive in that it involves a non-clin­ bering~ (Loftus, 1993; Orslle & Singer, 1994; Pope &Hudson, ical population and prospectivelyfoUows a traumatized pop­ 1995). For example, Loftus (1993) notes that the question ulation. All of these studies and clinical observations when concerning "forgetting~ could be interpreted as volitional taken as a whole support the idea that traumatic experiences suppression of the memory, (e.g., ''There were times when may lead to profound alterations ofmental processes includ­ I could not remember because I could not remember with­ ing amnesia. However, as noted by Pope and Hudson (1995), out feeling terrible~). good clinical studies are still needed thatindependentlycor­ Williams (1994) has recently studied a non-clinical pop­ roborate the validity ofabuse and thatvictims ofabuse devel­ ulation. She contacted adult women who had been treated op clear amnesia. for sexual abuse seventeenyears earlier in a city hospital, and Some potentially relevant and coherentevidence comes asked them to participate in a study about hospital services. from Terr's (1979, 1983, 1985, 1988, 1991) pioneeringwork One hundred twenty-nine (129) women were included in with children subjected to psychic trauma. Although Terr's the study. Their age at the time ofabuse ranged from infan­ work has been faulted for the absence ofclearempirical data, cy to twelve years old. Thirty-eight percent (38%) ofthe sub­ her observations of hundreds ofchildren over decades has jectswere amnestic for the experiencesorchose not to report face validity. In an overview ofthe effects of trauma on chil­ them. Because many of the women who did not report the dren (Terr, 1981), she notes thatdistinct differences are seen abuse did disclose other intimate details about their lives in children who have experienced limited, circumscribed including subsequent sexual victimization, there is a strong trauma (Type I), versus those who have been subjected to implication that many were actually amnestic for the expe­ chronic traumatization (Type II). Terr's description of riences. There was correlation between amnesia and age at memory in children who have experienced limited trauma time of abuse, which would be expected since verbal recall certainlysuggests that traumatic mcmory has a quality which ofevents experienced prior to age three is limited. However, is different from normal memory: this factor alone could not explain the degree ofamnesia in the subject population. Few of the women had been under Verbal recollections of single shocks in an other­ three years ofage, and there was actually greater amnesia in wise trauma-free childhood are delivered in an the group that was aged four to six at the time ofabuse ver­ amazingly clear and detailed fashion .. A few details sus the under threegroup. More amnesiawas associated with from a traumatic event of childhood may be fac­ perpetrators being family members. Amnesia was not cor­ tuallywrong because the child initially misperceived related with any particular kind ofabuse or severity ofabuse or mistimed the sequence ofwhat happened. But (e.g., fondling versus penetration). Critical reviews of this children with Type 1 disorders seem to remember study warn against interpreting the data as representing the event and to give impressively clear, detailed amnesia since the subjects were not asked directly whether accounts of their experiences. This remarkable or not they remembered the abuse (Ofshe & Singer, 1994; retrieval offu11, precise, verbal memories ofalmost Pope & Hudwn, 1995). Thus, the absence ofresponses about all single-blow traumas makes one conclude that early abuse could be based on avoidance or normal forget­ these memories stay alive in a very special ting. way... (Terr, 1991, p. 14) A recent study by Loftus, Polonsky, and Fullilove (1994) reports more conservative estimates of amnesia for sexual In contrast, Terr has observed that chronically traumatized abuse ina clinical population. Asubstantial proportion (54%) children often experience extensive amnesia: of 105 women in outpatient treatment for substance abuse reported childhood sexual abuse. Most (81 %) reported Children who experienceType II traumas often for­ remembering partorall ofthe abuse, and 19% reported that get. They may forget whole segments ofchildhood they forgot the abuse for a period oftime. In this study, amne­ - from birth to age nine, for instance. Where one sia was notcorrelated with either severity ofabuse or intrafa­ sees the difference between these "forgetful" chil­ milial abuse. Critiquesofthis study note the absence ofinde­ dren and ordinaryyoungsters isin the multiply trau­ pendent corroboration and the methodological problems matized child's relative indifference to pain, lack

10 ----"------~- CHU/MATTHEWS/FREY/GANZEL

ofempathy, failure to define or acknowledge feel­ events they had aJways remembered, and thirteen (68%) con­ ings, and absolute avoidance ofpsychological inti­ firmed events (jrstremembered in therapy (recovered mem­ macy. Repeatedly brutalized, benumbed children ory). Both valid memories and pseudo-memories occurred employ massive deniaL. (Terr, 1991, p. 16) [wo patients. Interestingly, many valid recovered memories (85%) were accessed by , challenging the widely held Terr's clinical obsclVations demonstrate the existence belief that the use of hypnosis strongly contributes to the ofvaTiaus kinds ofmemory in response to traumatic events creation of pseud(~memories. in childhood. Jn one study of preschool children who had Our recentdata also supportthe validity forsome recov­ been subjected to known traumatic events, verbal recall of ered memo!)' of childhood abuse (Chu, Frey, Ganzel, & the events depended on the child's age when traumatized, Matthews, unpublished data). In a study of90 inpatients in and on the chronicity aCthe trauma (Terr, 1988). Children a trauma program, there was a substantial rate of episodes under 28 to 36 months of age tended to have less verbal of self·reported complete amnesia for childhood physical (explicit) memory oftheir experiences, a finding !.hat is con­ (20%) and sexual abuse (24%). The mean dissociative sistent with the development ofverbal abilities around this symptoms for all participants reporting abuse was elevated period (Terr, 1985; Miller, 1979). However, even some of and consistent with post-traumatic stress disorder. More these very young children appeared to have implicit mem­ amnesia was correlated with earlier age ofonset and greater ory of the traumatic events, eng-.tging in behavioral reen­ chronicity ofabuse. Most of the participants who reported acunents (e.g., traumatic play, fears, and dreams) of the a period ofcomplete amnesia for their abuse had attempt­ events despite having no conscious recall. Terr also noted ed to obtain corroboration ofthe events - 14 of20 for phys-­ that of thirteen children over the age of 28 months at the ical abuse and 19 of25 for sexual abuse. The ovelWhelming time of being traumatized, seven had experienced single, majority ofthose who attempted to corroborate theirabuse briefevents and generally had good verbal recall. The other - 13 of 14 for physical abuse and 17 of 19 for sexual abuse six children, who had been subjected to more chronic - found clear validation for their recovered memories. Of traumatization, generally had impaired verbal memoryofthe particular note is the descriptions ofa subsetofseverely and events, but engaged in behavioral reenactments. chronically abused participants with high rates ofamnesia. Thereare important implications from Terr's work which For the most part, these participants lost memory for whole begins to explain that both a heightened clarity ofmemory periods of their lives, recollecting neither traumatic events (hypermnesia) and impairment of memory (amnesia) can nor neutral or positive experiences. These descriptions are result from traumatization. She postulates a kind of hyper­ strikingly similar to Terr's observation of pervasive amnesia mnesia for traumatic events in situations that involve limit­ for chronically traumatized children, and suggest that the ed trauma, and she observes amnesia as a result of chronic underlying mechanism for this kind ofamnesia may not be traumatization. She also offers evidence that there may be repression of overwhelming experiences or selective inat­ nonconscious memory oftraumatic events even when there tention to noxious events. Instead, the massive failure to inte­ is no conscious recall. (Little is known about the malleabil­ grate entire periods of childhood strongly suggests that ity ofimplicit memory.) However, it should be emphasized intensely traumatic experiencesmay result in a different way that the accuracy of explicit memory, including recovered ofprocessing and storing information, supportingthe notion memory, following chronic traumatization is not well estab­ that traumatic memory is different from ordinary memory. lished. Given that chronically traumatized children use mas­ This model is also consistent with the concept of dissocia­ sive denial and dissociative defenses, these children may not tion in which various mentaJ contents exist in differentstates encode traumatic memories with the hypermnestic clarity held separately from each other. that is characteristic of single event traumas. Thus, chroni­ cally traumatized patients are most likely to suffer amnesia CONCLUSIONS AND IMPLICATIONS FOR for their abuse, and, given the level ofdenial and dissocia­ CLINICAL PRACTICE tive defenses they use, the accuracy ofrecovered memory in these patients may be most vulnerable to distortions and From both experimental investigations and clinical errors in recall. research, there appears to be substantial evidence to sup­ There have been recent studies concerning the nature port the existenceofboth conscious and nonconscious mem­ and validil}' of memory of childhood abuse. Kluft (1995) ory processes. Understressful ortraumaticconditions, there reviewed records of34 dissociative identity disorder patients is also ample evidence that the memorycan be affected with in his practice for evidence of confirmation or disconfir­ both hypermnesia and amnesia.. Psychobiologic investigations mation ofreco\'ered memory. A majority (19) had obtained ~nd studies ofboth clinical and non-dinical populationssug­ clearconfirmation ofchildhood abuse. Three (3) recovered gest that limited trauma can result in a kind memory "memories~ that were later disconfirmed. Of the nineteen enhancement, and that overwhelming or repetitive trauma patients who obtained confirmation, ten (53%) confirmed may result in psychogenic amnesia for the experiences. This

11 DlSSOClmo~. \01 IX, ~o I. \1mb J99ii TRAUMATIC MEMORIES OF CHILDHOOD ABUSE

lalter observation concerning chronic traumatization sup­ must be careful not to inquire about possible abuse in a way porlS the concept that overwhelming trauma may be disso­ that even subtly encourages a particular kind ofresponse. ciated from consciousness. There is also evidence that cor­ Therapists, particularly those who specialize in the treat­ relates amnesia for traumatic events with early age ofonset, ment ofsurvivors of abuse, must not impose any particular chronicity, severity, and family involvement Thus, children idiosyncratic model of understanding or treaunent on who experience abuse at vel)' young ages, who suffer multi­ patienlS, and must be open to understanding patients' dif­ ple kinds of abuse. whose abuse continues over years, and ficulties in a variety ofways. Fantasies aboutabuse, suspicions who are abused by family members are most likely to devel­ or partly formed ideas aboutabuse, and dreamsaboutabuse op serious dissociative symptoms, perhaps induding psy­ are not the same as the actuality of abuse. Especially when chogenic amnesia. Unfortunately, at least in many acutely memories are fr

12

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