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What if his patient’s weight was a psychological and emotional barrier, something protecting her from harm?
Felitti suspected that he might have glimpsed a hidden relationship between histories of abuse and obesity.
he now began asking people if they had a history of childhood sexual abuse. To his shock, it seemed as if every other patient acknowledged such a history.
he enlisted five colleagues to screen their next hundred weight patients for a history of abuse. When they turned up the same results, Felitti knew they had uncovered something big.
The questionnaire collected crucial information about what Felitti and Anda termed “adverse childhood experiences,” or ACEs.
Their goal was to determine each patient’s level of exposure by asking if he or she had experienced any of the ten categories before the age of eighteen.
First, they discovered that ACEs were astonishingly common—67 percent of the population had at least one category of ACE and 12.6 percent had four or more categories of ACEs.
We all have a stress-response system, and it is carefully calibrated and highly individualized by both genetics and early experiences.
When it’s in good working order, it can help save your life, but when it’s out of balance, it can shorten it.
you’ve probably come upon stories of superhuman strength:
the woman who fought off the mountain lion that was mauling her husband (that one really is true).
If you’ve ever wondered what makes a person able to achieve such feats,
it’s the elegantly designed, evolutionarily imperative stress-response system.
your brain sends a bunch of signals to your adrenal glands (perched on your kidneys) saying, “Release stress hormones! Adrenaline! Cortisol!” So your heart starts to pound, your pupils dilate, your airways open up, and you are ready to either fight the bear or run from the bear.
fight or flight.
evolved over millennia to sav...
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free...
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in the hopes that the bear will think ...
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stress-response system can go wrong or, as we doctors say, “become dysregulated,”
Adrenaline and noradrenaline are powerful stimulants, designed to help you think more clearly so that you can figure out the quickest path to safety. They also create feelings of euphoria, that adrenaline rush that makes you think you can conquer the world. But, like everything body-chemistry-related, it’s all about balance.
too much will mess up your ability to focus.
when you’re really scared, your fear center temporarily shuts down the thinking part of your brain—because you need to defy those odds.
So the amygdala activates neurons that link to the prefrontal cortex and temporarily turns it off, or at least turns it way, way down.
The SAM axis is a very short-acting (seconds or minutes) response that primes your body by making available what you need most: ...
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Essentially, cortisol helps the body adapt to repeated or long-term stressors, like living in bear-infested woods or handling prolonged food shortages.
raises blood pressure and blood sugar, inhibits cognition
(clear thinking), and destabilizes mood. It also disrupts sleep, which makes a lot of sense if you are living ...
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Over and over again in my practice I saw kids who had experienced terrifying situations.
For many of my patients, the stress response was activated dozens and sometimes hundreds of times a day.
In a 2009 study, they set out to determine if the adverse experiences of preschool-age foster children had an effect on the functioning of the stress-response system, specifically the HPA axis. To do this, they analyzed the cortisol levels of 117 foster kids and 60 low-income kids who were not maltreated.
What the research tells us is that those daily challenges can be overcome with the right support from a loving caregiver.
Positive stress response is a normal and essential part of healthy development, characterized by brief increases in heart rate and mild elevations in hormone levels. Some situations that might trigger a positive stress response are the first day with a new caregiver or receiving an injected immunization.
Tolerable stress response activates the body’s alert systems to a greater degree as a result of more severe, longer-lasting difficulties, such as the loss of a loved one, a natural disaster, or a frightening injury. If the activation is time-limited and buffered by relationships with adults who help the child adapt, the brain and other organs recover from what might otherwise be damaging effects.
the effects are temporary if a solid support network is in place.
Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress-response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.
Healthy development of the stress-response system requires that a child experience both positive and tolerable stress. This allows the SAM and HPA axes to be calibrated to react normally in the face of stressors. But for every ACE a child has, the risk of tolerable stress tipping over into toxic stress increases, as the system responds more frequently and intensely to multiple stressors.
children are particularly sensitive to repeated stress activation. High doses of adversity affect not only the brain structure and function but also the developing immune system and hormonal systems, and even the way DNA is read and transcribed.
The kids who had the worst responses were also the ones whose caregivers were the least likely to hug, kiss, sing to, or otherwise soothe their child. We heard a lot of “Hold him down!” and “I don’t have time for this, I have to be back at work in a half hour.”
profound aching in my heart for all the kids who were struggling in school but being told that they had ADHD or a “behavior problem” when these problems were directly correlated with toxic doses of adversity.
Similarly, if we see impulsivity and hyperactivity but discover that those symptoms are caused by a brain tumor, we can’t diagnose ADHD.
unlike ADHD, the diagnosis of toxic stress doesn’t yet exist in the medical literature.
In the 1980s, the medical world was confronted with a new epidemic.
doctors felt they had to get better and better at treating things like sores, hepatitis, and Kaposi’s sarcoma—a strategy that didn’t touch the underlying problem.
These were AIDS-defining diseases; they were conditions that needed intervention and symptoms pointing to an underlying biological problem with a very different prognosis and treatment: HIV/AIDS.
ACEs. For a patient with a high ACE score, it may not be the obesity that shortens his or her life but the underlying toxic stress that the obesity is signaling.
There wasn’t (and still isn’t) a clear set of diagnostic criteria or a blood test for toxic stress, and there is no drug cocktail to prescribe.
After all, if a dysregulated stress-response system was the source of the problem, it could have far-reaching effects. A disrupted stress response doesn’t affect only the neurological system, it affects the immune system, the hormonal system, and the cardiovascular system as well. Because everyone’s biological and genetic makeup is different, how that dysregulation manifests itself will be similarly diverse.
ACEs had an outsize effect on children’s rapidly developing brains.
we talked about the cast of characters in the stress response: the amygdala, the prefrontal cortex, the hippocampus, and the noradrenergic nucleus of the locus coeruleus (which we’ll refer to as the locus coeruleus from now on). Because these parts of the brain are on front lines of the stress response, it makes sense that a severe and prolonged
disruption of the norm would hit them hardest, changing how
