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Psychiatric Clinics of North America
, Volume 12, Number 2,
Pages 389-411,
June 1989.
The Compulsion to Repeat the
Trauma
Re-enactment, Revictimization, and
Masochism
Bessel A. van der Kolk, MD*
During the formative years of contemporary
psychiatry much attention was paid to the continuing
role of past traumatic experiences on the current lives
of people. Charcot, Janet, and Freud all noted that
fragmented memories of traumatic events dominated
the mental life of many of their patient and built their
theories about the nature and treatment of
psychopathology on this recognition. Janet75 thought
that traumatic memories of traumatic events persist
as unassimilated fixed ideas that act as foci for the
development of alternate states of consciousness,
including dissociative phenomena, such as fugue
states, amnesias, and chronic states of helplessness
and depression. Unbidden memories of the trauma
may return as physical sensations, horrific images or
nightmares, behavioral reenactments, or a
combination of these. Janet showed how traumatized
individuals become fixated on the trauma: difficulties
in assimilating subsequent experiences as well. It is
"as if their personality development has stopped at a
certain point and cannot expand anymore by the
addition or assimilation of new elements."76 Freud
independently came to similar conclusions.43,45 Initially,
he thought all hysterical symptoms were caused by
childhood sexual "seduction" of which unconscious
memories were activated, when during adolescence,
a person was exposed to situations reminiscent of the
original trauma. The trauma permanently disturbed
the capacity to deal with other challenges, and the
victim who did not integrate the trauma was doomed
to "repeat the repressed material as a contemporary
experience in instead or . . . remembering it as
something belonging to the past."44 In this article, I will
show how the trauma is repeated on behavioral,
emotional, physiologic, and neuroendocrinologic
levels, whose confluence explains the diversity of
repetition phenomena.
Many traumatized people expose themselves,
seemingly compulsively, to situations reminiscent of
the original trauma. These behavioral reenactments
are rarely consciously understood to be related to
earlier life experiences. This "repetition compulsion"
has received surprisingly little systematic exploration
during the 70 years since its discovery, though it is
regularly described in the clinical
literature.12,17,21,29,61,64,65,69,88,112,137 Freud thought that the
aim of repetition was to gain mastery, but clinical
experience has shown that this rarely happens;
instead, repetition causes further suffering for the
victims or for people in their surroundings.
Children seem more vulnerable than adults to
compulsive behavioral repetition and loss of
conscious memory of the trauma.70,136. However,
responses to projective tests show that adults, too,
are liable to experience a large range of stimuli
vaguely reminiscent of the trauma as a return of the
trauma itself, and to react accordingly.39,42
BEHAVIORAL RE-ENACTMENT
In behavioral re-enactment of the trauma, the self
may play the role of either victim or victimizer.
Harm to Others
Re-enactment of victimization is a major cause of
violence. Criminals have often been physically or
sexually abused as children.55,121 In a recent
prospective study of 34 sexually abused boys,
Burgess et al.20 found a link with drug abuse, juvenile
delinquency, and criminal behavior only a few year
later. Lewis89,91 has extensively studied the association
between childhood abuse and subsequent
victimization of others. Recently, she showed that of
14 juveniles condemned to death for murder in the
United States in 1987, 12 had been brutally physically
abused, and five had been sodomized by relatives.90
In a study of self-mutilating male criminals, Brach-y-
Rita7 concluded that "the constellation of withdrawal,
depressive reaction, hyperreactivity, stimulus-seeking
behavior, impaired pain perception, and violent
aggressive behavior directed at self or others may be
the consequence of having been reared under
conditions of maternal social deprivation. This
constellation of symptoms is a common phenomenon
among a member of environmentally deprived
animals."
Self-destructiveness
Self-destructive acts are common in abused
children. Green53,54 found that 41 per cent of his
sample of abused children engaged in headbanging,
biting, burning, and cutting. In a controlled, double-
blind study on traumatic antecedents of borderline
personality disorder, we found a highly significant
relationship between childhood sexual abuse and
various kinds of self-harm later in life, particularly
cutting and self-starving.143a Clinical reports also
consistently show that self-mutilators have childhood
histories of physical or sexual abuse, or repeated
surgery.52,106,118,126 Simpson and Porter126 found a
significant association between self-mutilation and
other forms of self-deprecation or self-destruction
such as alcohol and drug abuse and eating disorders.
They sum up the conclusions of many students of this
problem in stating that "self-destructive activities were
not primarily related to conflict, guilt and superego
pressure, but to more primitive behavior patterns
originating in painful encounters wih hostile
caretakers during the first years of life."
Revictimization
Revictimization is a consistent finding.35,47,61
Victims of rape are more likely to be raped and
women who were physically or sexually abused as
children are more likely to be abused as adults.
Victims of child sexual abuse are at high risk of
becoming prostitutes.38,72,125 Russell,120 in a very careful
study of the effects of incest on the life of women,
found that few women made a conscious connection
between their childhood victimization and their drug
abuse, prostitution, and suicide attempts. Whereas 38
per cent of a random sample of women reported
incidents of rape or attempted rape after age 14, 68
per cent of those with a childhood history of incest
did. Twice as many women with a history of physical
violence in their marriages (27 per cent), and more
than twice as many (53 per cent) reported unwanted
sexual advances by an unrelated authority figure such
as a teacher, clergyman, or therapist. Victims of
father-daughter incest were four times more likely
than nonincest victims to be asked to pose for
pornography.
RE-EXPERIENCING AFTER ADULT TRAUMA
There are sporadic clinical reports,12,59 but
systematic studies on re-enactment and
revictimization in traumatized adults are even scarcer
than in children. In one study of adults who who had
recently been in accidents,68 57 per cent showed
behavioral re-enactments, and 51 per cent had
recurrent intrusive images. In this study, the
frequency with which recurrent memories were
experienced on a somatic level, as panic and anxiety
attacks, was not examined. Studies of burned
children131 and adult survivors of natural and
manmade disasters67,124 show that, over time,
rucurrent symbolic or visual recollections and
behavioral re-enactments abate, but there is often
persistent chronic anxiety that can be interpreted as
partial somatosensory reliving, dissociated from visual
or linguistic representations of the trauma.141 There
are scattered clinical reports64,65,109 of people re-
enacting the trauma on its anniversary. For example,
we treated a Vietnam veteran who had lit a cigarette
at night and caused the death of a friend by a Viet
Cong sniper's bullet in 1968. From 1969 to 1986, on
the exact anniversary of the death, to the hour and
minute, he yearly committed "armed robbery" by
putting a finger in his pocket and staging a "holdup,"
in order to provoke gunfire from the police. The
compulsive re-enactment ceased when he came to
understand its meaning.
SOCIAL ATTACHMENT AND THE TRAUMA
RESPONSE
Human beings are strongly dependent on social
support for a sense of safety, meaning, power, and
control.14,15,93 Even our biologic maturation is strongly
influenced by the nature of early attachment bonds.137
Traumatization occurs when both internal and
external resources are inadequate to cope with
external threat. Physical and emotional maturation, as
well as innate variations in physiologic reactivity to
perceived danger, play important roles in the capacity
to deal with external threat.77 The presence of familiar
caregivers also plays an important role in helping
children modulate their physiologic arousal.146 In the
absence of a caregiver, children experience extremes
of under-and over arousal that are physiologically
aversive and disorganizing.38 The availability of a
caregiver who can be blindly trusted when their own
resources are inadequate is very important in coping
with threats. If the caregiver is rejecting and abusive,
children are likely to become hyperaroused. When the
persons who are supposed to be the sources of
safety and nurturance become simultaneously the
sources of danger against which protection is needed,
children maneuver to re-establish some sense of
safety. Instead of turning on their caregivers and
thereby losing hope for protection, they blame
themselves. They become fearfully and hungrily
attached and anxiously obedient.24 Bowlby16 calls this
"a pattern of behavior in which avoidance of them
competes with his desire for proximity and care and in
which angry behavior is apt to become prominent."
Studies by Bowlby and Ainsworth1 in humans,
and by Harlow and his heirs58,114 in other primates,
demonstrate the crucial role that a "safe base" plays
for normal social and biologic development. As
children mature, they continually acquire new
cognitive schemata in which to frame current life
experiences. These ever-expanding cognitive
schemes decrease their reliance on the environment
for soothing and increase their own capacity to
modulate physiologic arousal in the face of threat.
Thus, the cognitive preparedness (development) of an
individual interacts with the degree of physiologic
disorganization to determine the capacity for mental
processing of potentially traumatizing
experiences.137,141
SEX DIFFERENCES
The frequency with which abused children repeat
aggressive interactions has suggested to Green53 a
link between the compulsion to repeat and
identification with the aggressor, which replaces fear
and helplessness with a sense of omnipotence. There
are significant sex differences in the way trauma
victims incorporate the abuse experience. Studies by
Carmen et al.22,71 and others indicate that abused men
and boys tend to identify with the aggressor and later
victimize others wheras abused women are prone to
become attached to abusive men who allow
themselves and their offspring to be victimized further.
Reiker and colleagues113 have pointed out that
"confrontations with violence challenges one's most
basic assumptions about the self as invulnerable and
intrinsically worthy and about the world as orderly and
just. After abuse, the victim's view of self and world
can never be the same again: it must be
reconstructed to incorporate the abuse experience."
Assuming responsibility for the abuse allows feelings
of helplessness to be replaced with an illusion of
control. Ironically, victims of rape who blame
themselves have a better prognosis than those who
do not assume this false responsibility: it allows the
locus of control to remain internal and prevent
helplessness. Children are even more likely to blame
themselves: "The child needs to hold on to an image
of the parent as good in order to deal with the
intensity of fear and rage which is the effect of the
tormenting experiences."113 Anger directed against the
self or others is always a central problem in the life of
people who have been violated. Reikers concludes
that "this 'acting out' is seldom understood by either
victims or clinicians as being a repetitive re-enactment
of real events from the past."
THE SEPARATION REPONSE
Primates have evolved highly complex ways to
maintain attachment bonds; they are intensely
dependent on their caregivers at the start. In lower
primates, his dependency is principally expressed in
physical contact, in humans this is supplemented by
verbal communication. McLean93 suggests that
language is an evolutionary development from the
mammalian separation cry that induces caregivers to
provide safety, nurturance, and social stimulation.
Primates react to separation from attachment figures
as if they were directly threatened. Thus, small
children, unable to anticipate the future, experience
separation anxiety as soon as they lose sight of their
mothers. Bowlby has described the protest and
despair phases of this response in great detail.14,15 As
people mature, hey develop an ever-enlarging
repertoire of coping responses, but adults are still
intensely dependent upon social support to prevent
and overcome traumatization, and under threat they
still may cry out for their mothers.57 Sudden,
uncontrollable loss of attachment bonds is an
essential element in the development of post-
traumatic stress syndromes.45,88,92,138 On exposure to
extreme terror, even mature people have protest and
despair responses (anger and grief, intrusion and
numbing) that make them turn toward the nearest
available source of comfort to return to a state of both
psychological and physiologic calm. Thus, severe
external threat may result in renewed clinging and
neophobia in both children and adults.8,41,111 Because
the attachment system is so important, mobilization of
social supports is an important element in the
treatment of post-traumatic stress disorder (PTSD).
INCREASED ATTACHMENT IN THE FACE
OF DANGER
People in general, and children in particular, seek
increased attachment in the face of external danger.
Pain, fear, fatigue, and loss of loved ones and
protectors all evoke efforts to attract increased
care,8,41,111 and most cultures have rituals designed to
provide it. When there is no access to ordinary
sources of comfort, people may turn toward their
tormentors.14,38,80,102 Adults as well as children may
develop strong emotional ties with people who
intermittently harass, beat, and threaten them.
Hostages have put up bail for their captors, expressed
a wish to marry them, or had sexual relations with
them;31 abused children often cling to their parents
and resist being removed from the home;31,80 inmates
of Nazi prison camps sometimes imitated their
captors by sewing together clothing to copy SS
uniforms.11 When Harlow observed this in nonhuman
primates, he stated that "the immediate
consequences of maternal rejection is the
accentuation of proximity seeking on the part of the
infant."114
Walker145 and Dutton and Painter31 have noted
that the bond between batter and victim in abusive
marriages resembles the bond between captor and
hostage or cult leader and follower. Social workers,
police, and legal personnel are constantly frustrated
by the strength of this bond. The woman's longing for
the batterer soon prevails over memories of the terror,
and she starts to make excuses for his behavior. This
pattern is so common that women engaged in these
sorts of relationships become the recipients of intense
anger for social service personnel. They are then
called masochistic, and like other psychiatric terms,
this can be employed pejoratively rather than
conveying an understanding of the underlying causes
and treatment of the problem. Walker145 first applied
ethnology to the study of traumatic bonding in such
couples. A central component is captivity, the lack of
permeability, and the absence of outside support or
influence.31,62,119,145 The victim organizes her life
completely around pleasing her captor and his
demands. As Dutton and Painter point out, "her
compliance legitimates his demands, builds up a store
of repressed anger and frustration on her part (which
may surface in her goading him or fighting back
during an actual argument, leading to escalating
violence), and systematically eliminates opportunities
for her to build up a supportive network which could
eventually assist her in leaving the relationship."
Walker145 has clarified the operation of
intermittent reinforcement paradigms in such
relationships, applying the animal model of
punishment-indulgence patterns. In child abuse or
spouse battering, this mechanism is accentuated by
the extreme contrast of terror followed by submission
and reconciliation. When such negative reinforcement
occurs intermittently, the reinforced response
consolidates the attachment between victim and
victimizer. During the abuse, victims tend to
dissociate emotionally with a sense of disbelief that
the incident is really happening. This is followed by
the typical post-traumatic response of numbing and
constriction, resulting in inactivity, depression, self-
blame, and feelings of helplessness. Walker145
describes the process as follows: "tension gradually
builds" (during phase one), an explosive battering
incident occurs (during phase two), and a "calm,
loving respite follows phase three). The violence
allows intense emotional engagement and dramatic
scenes of forgiveness, reconciliation, and physical
contact that restores the fantasy of fusion and
symbiosis.87,140 Hence, there are two powerful sources
of reinforcement: the "arousal-jag" or excitement
before the violence and the peace of surrender
afterwards, Both of these responses, placed at
appropriate intervals, reinforce the traumatic bond
between victim and abuser.31,145 To varying degrees,
the memory of the battering incidents is state-
dependent or dissociated, and thus only comes back
in full force during renewed situations of terror. This
interferes with good judgment about the relationship
and allows longing for love an reconciliation to
overcome realistic fears.
VULNERABILITY TO DEVELOP
TRAUMATIC BONDING
At least four studies of family violence40,48,63,132
have found a direct relationship between the severity
of childhood physical abuse and later marital violence.
Interestingly, nonhuman primates subjected to early
abuse and deprivation also are more likely to engage
in violent relationships with their peers as adults.134 as
in humans, males tend to be hyperaggressive, and
females fail to protect themselves and their offspring
against danger. Neither sex develops the capacity for
sustained peaceful social interactions.134
People who are exposed early to violence or
neglect come to expect it as a way of life. They see
the chronic helplessness of their mothers and fathers'
alternating outbursts of affection and violence; they
learn that they themselves have no control. As adults
they hope to undo the past by love, competency, and
exemplary behavior.46,87,145 When they fail they are
likely to make sense out of this situation by blaming
themselves. When they have little experience with
nonviolent resolution of differences, partners in
relationships alternate between an expectation of
perfect behavior leading to perfect harmony and a
state of helplessness, in which all verbal
communication seems futile. A return to earlier coping
mechanisms, such as self-blame, numbing (by means
of emotional withdrawal or drugs or alcohol), and
physical violence sets the stage for a repetition of the
childhood trauma and "return of the repressed."1,42,46,137
BIOLOGIC RESPONSES TO
TRAUMATIZATION
Chronic physiologic hyperarousal to stimuli
reminiscent of the trauma is a cardinal feature of the
trauma response, well documented in a large variety
of traumatized individuals, including victims of child
abuse, burns, rape, natural disasters, and
war.2,78,84,107,133,142 Because of their decreased capacity
to modulate physiologic arousal, which leads to
reduced ability to utilize symbols and fantasy to cope
with stress, they tend to experience later stresses as
somatic states, rather than as specific events that
require specific means of coping.142 Thus, victims of
trauma respond to contemporary stimuli as if the
trauma had returned, without conscious awareness
that past injury rather than current stress is the basis
of their physiologic emergency responses. The
hyperarousal interferes with their ability to make calm
and rational assessments and prevents resolution and
integration of the trauma.142 They respond to threats
as emergencies requiring action rather than thought.
Chronic hyperarousal in response to new
challenges is also found in animals exposed to
inescapable shock.5 In fact, this phenomenon drew
our attention to the possibility of using this animal
model for the study of human traumatization.142
Human beings and other mammals are very similar
biologically in respect to such relatively uncomplicated
behaviors as fight, flight, and freeze responses.
Exposure to inescapable aversive events has
widespread behavioral and physiologic effects on
animals including (1) deficits in learning to escape
novel adverse situations, (2) decreased motivation for
learning new options, (3) chronic subjective distress,94
and (4) increased tumor genesis and
immunosuppression.143 All this is the result not of the
shock itself but of a helplessness syndrome that is a
result of the lack of control that the animal has in
terminating shock.
Several neurotransmitters have been shown to
be affected by inescapably fearful experiences in
animals; they have low resting cerebro-spinal fluid
(CSF) norepinephrine, but under stress they respond
with much higher elevations than other animals.
Something has disturbed the organisms capacity to
modulate the extent of arousal.37,95,115,116,142
Dysregulation of the serotonin system has been
implicated in this.123,139 Serotonin is thought to be the
neurotransmitter most involved in modulating the
actions of other neurotransmitters;19 it has also been
implicated in the fine tuning of emotional reactions,
particularly arousal and aggression.18 Traumatization
also causes dysregulation of the endogenous opioid
system in both animals and humans. We will discuss
this phenomenon and how this could explain the
clinical phenomenon of compulsive re-exposure to
trauma.
STATE-DEPENDENT LEARNING
Both Janet74 and Freud observed that early
memory traces can be activated by later events that
cause partial reliving of earlier traumas in the form of
affect states, anxiety, or re-enactments. Their patients
generally had a poor memory for traumatic childhood
events, until they were brought back, by means of
hypnosis, to a state of mind similar to the one they
were in at the time of the trauma. In the past few
decades, these notions have gained scientific
confirmation with the discovery of state-dependent
learning; for example what is learned under the
influence of a particular drug tends to become
dissociated and seemingly lost until return of the state
similar to the one in which the memory was stored.
State dependency can be roughly related to arousal
levels. For example, state-dependent learning in
humans is produced by both psychostimulants and
depressants: alcohol, marijuana, barbituates, and
amphetamines as well as other psychoactive
agents.32 Reactivation of past learning is relatively
automatic: contextual stimuli directly evoke memories
without conscious awareness of the transition. The
more similar are the contextual stimuli are to
conditions prevailing at the time of the original storage
of memories, the more likely the probability of
retrieval. Both internal states, such as particular
affects, or external events reminiscent of earlier
trauma thus can trigger a return to feeling as if victims
are back in their original traumatizing situation. Thus,
battered women who otherwise behave competently
may experience themselves within the battering
relationship like the terrified child they once were in a
violent or alcoholic home.119 Similarly, war veterans
may be asymptomatic until they become intimate with
a partner and start reliving feelings of loss, grief,
vulnerability, and revenge related to the death of a
comrade on the battlefield but that are now incorrectly
attributed to some element of the current relationship.
Disinhibition resulting from drugs or alcohol strongly
facilitates the occurrence of such reliving experiences,
which then may take the form of acting out violent or
sexual traumatic episodes.107
During states of massive autonomic arousal,
memories are laid down that powerfully influence later
actions and interpretations of events. Long-term
activation of memory tracts is observed in animals
exposed to a highly stressful stimulus.51,81 This
pheromenon has been attributed to massive
noradrenergic activity at the time of the stress.129 In
traumatized people, visual and motoric reliving
experiences, nightmares, flashbacks, and re-
enactments are generally preceded by physiologic
arousal.30 Activation of long-term augmented memory
tracts may explain why current stress is experienced
as a return of the trauma.
"RETURN OF THE REPRESSED" OCCURS
IN SITUATIONS
OF THREAT
Under ordinary conditions, most previously
traumatized individuals can adjust psychologically and
socially. Studies have shown this to be true of victims
of rape,82 battered women,63 and victims of child
abuse.53 Nonhuman primates subjected to extended
periods of isolation may later become reasonably well
integrated socially. However, they do not respond to
stress in the same ways as their nontraumatized
peers. Studies in the Wisconsin primate laboratory
have shown that, even after an initial good social
adjustment, heightened emotional or physical arousal
causes social withdrawal or aggression.86 Even
monkeys that recover in other respects tend to
respond inappropriately to sexual arousal and
misperceive social cues when threatened by a
dominant animal.4,95,101 Animals with a history of
trauma also have much more intense catecholamine
responses to stress85 and a blunted cortisol
response.25
Stress causes a return to earlier behavior
patterns throughout the animal kingdom. In
experiments in mice, Mitchell and colleagues98,99 found
that arousal state determines how an animal will react
to stimuli. In a state of low arousal, animals tend to be
curious and seek novelty. During high arousal, they
are frightened, avoid novelty, and perseverate in
familiar behavior regardless of the outcome. Under
ordinary circumstances, an animal will choose the
most pleasant of two alternatives. When
hyperaroused, it will seek the familiar, regardless of
the intrinsic rewards.99 Thus shocked animals
returned to the box in which they were originally
shocked, in preference to less familiar locations not
associated with punishment. Punished animals
actually increased their exposure to shock as the
trials continued.98 Mitchell concluded that this
perseveration is nonassociative, that is, if uncoupled
from the usual rewards systems, animals seek
optimal levels of arousal,10,122 and this mediates
patterns of alternation and perseveration. Because
novel stimuli cause arousal, an animal in a state of
high arousal will avoid even mildly novel stimuli even
if it would reduce exposure to pain.
"THE COSTS OF PLEASURE AND THE
BENEFITS OF PAIN'
Solomon127 proposes an "opponent process
theory of acquired motivation" to explain addictive
behavior that originates in frightening or painful
events. He points out that frequent exposure to
stimuli, pleasant or unpleasant, may lead to
habituation; the resulting withdrawal or abstinence
state can take on a powerful life of its own and may
become an effective source of motivation. In drug
addiction, for example, the motivation changes from
getting high (pleasure) to controlling a highly aversive
withdrawal state.
In contrast with drug taking, which initially is
pleasant, many initially aversive stimuli, such as
sauna bathing, marathon running, and parachute
jumping, may also be eventually perceived as highly
rewarding by people who have repeatedly exposed
themselves to these frightening or painful situations.
Parachute jumpers, sauna bathers, and marathon
runners all feel exhilaration and a sense of well-being
from the intially aversive activities. These new
sources of pleasure become independent of the fear
that was necessary to produce them in the first place.
Solomon concludes that certain behaviors can
become highly pleasurable: "if they are derived
from aversive processes they can provide a relatively
enduring source of positive hedonic tone following the
removal of the aversive reenforcer. Fear thus has its
positive conquences."127
Solomon and colleagues have applied these
observations to imprinting and social attachment.
Their research showed that young animals responded
with increasing distress to repeated separations.66
Habituation did not occur, and attachment in fact
increased, provided that the imprinting object was
presented at fairly regular intervals. Starr130
demonstrated that there is a critical decay duration,
the time that it takes for the withdrawal response to
the original stimulus to wear off. If the reinforcing
stimulus of the imprinting or attachment object is
presented at intervals greater than the critical decay
duration, increased attachment does not occur.
However, animals earlier exposed to repeated
separations are more vulnerable to increased distress
upon later separations: "repeated exposures to the
imprinting object took less time and fewer exposures
than did the original exposures." The strength of the
imprinting eventually decays by disuse, but some
residues of past experiences remain and facilitate the
reactivation of the temporarily dormant system.
Readdiction to nicotine and opiates occurs much
faster than the initial addiction. If Starr is correct,
similar processes account for social attachment to
aversive objects and thus "the law of social
attachment may be identical to the law of drug
addiction."130
Solomon and coworkers established
experimentally that animal and people become
habituated to the original stimulus, whether it is
morphine, parachute jumping or marathon running,
but the withdrawal syndromes that follow a large
number of arousing events retain their integrity over
time, and recur when the original stimuli are
reintroduced.127 Thus, the positive reinforcer loses
some of its power, but the negative reinforcer gains
power and lasts longer: parachute jumpers continued
to feel exhilarated after jumping, even when they feel
less year beforehand. Solomon hypothesized that
endorphins are secreted in response to certain
environmental stresses and play a role in the
opponent process. We have recently found evidence
that supports this view.
ADDICTION TO TRAUMA
Some traumatized people remain preoccupied
with the trauma at the expense of other life
experiences137,141 and continue to re-create it in some
form for themselves or for others. War veterans may
enlist as mercenaries,128 victims of incest may become
prostitutes,47,120,125 and victims of childhood physical
abuse seemingly provoke subsequent abuse in foster
families53 or become self-mutilators143a Still others
identify with the aggressor and do to others what was
done to them.21,39 Clinically, these people are
observed to have a vague sense of apprehension,
emptiness, boredom, and anxiety when not involved
in activities reminiscent of the trauma. There is no
evidence to support Freud's idea that repetition
eventually leads to mastery and resolution. In fact,
reliving the trauma repeatedly in psychotherapy may
serve to re-enforce the preoccupation and fixation.
Many observers of traumatic bonding have
speculated that victims become addicted to their
victimizers. Erschak33 asks why the batterer does not
stop when injury and pain are apparent and why does
the victim not leave? He answers that "they are
addicted to each other and to abuse. The system, the
interaction, the relation takes hold; the individuals are
as powerless as junkies."
ENDOGENOUS OPIATES AND
ATTACHMENT
Thus Starr,130 Solomon,127 Erschak and others
may be right in postulating that people can become
physiologically addicted to each other. There is now
considerable evidence that human attachment is, in
part, mediated by the endogenous opiate system.
Research in non-human primates shows that social
attachment is related to the development of core
neurobiologic functions in the primate brain. Early
disruption of the attachment bond causes longlasting
psychobiologic changes that not only reduce the
capacity to cope with subsequent social disruption but
also disturb parenting processes and create similar
vulnerability into the next generation. In recent years
knowledge about the brain circuits involved in the
maintenance of affliative behavior are precisely those
most richly endowed with opioid receptors.83
Behavioral studies show that the endogenous opioid
system plays an important role in the maintenance of
social attachment. According to Panksepp and
colleagues, the separation response in rats can be
inhibited with doses of neuroactive agents to have
yielded reliable behavioral effects. Minute injections of
morphine abolish both the separation cry in rate
infants and the maternal response to it.100,103-105
Morphine-treated mothers (1 mg per kg) disregard
male intruders, often attempting no defense of their
offspring at all. One mother permitted a male intruder
to eat her pups.
Blocking of opioid receptors with naloxone
causes increased huddling in nonhuman primates,
where as activation of brain opioid systems can
decrease gregariousness.34,104 Lack of caregiving
during the first few weeks of life decreases the
number of opioid receptors in the cingulate gyrus in
mice.13 Panksepp and colleagues have shown that the
loss of social support decreases brain opioid activity
and produces withdrawal symptoms; emotive circuits
mediating loneliness-panic states are apparently
activated or disinhibited. Re-establishment of social
contact may, among other neural changes, activate
endogenous opioid systems, alleviating separation
distress and strengthening social bonds.103 If brain
opioid activity fulfills social needs, opioid blockade
might be expected to influence such other forms of
gratification as sex. Indeed, opioid systems interact
with the brain systems that regulate sex-steroid
secretion,56 and naloxone facilitates sexual behavior
in some mammals.49,96
High levels of stress,3 including social stress,97
also activate opioid systems. Animals exposed to
inescapable shock develop stress-induced analgesia
(SIA) when re-exposed to stress shortly afterward.
This analgesic response is mediated by endogenous
opioids and is readily reversible by the opioid receptor
blocker naloxone.79 In humans elevations of
enkephalins and plasma beta endorphins have been
reported following a large variety of stressors.26,28,73 In
testing the generalizability of the phenomenon of SIA
to people, we found that seven of eight Vietnam
veterans with PTSD showed a 30 percent reduction in
perception of pain when viewing a movie depicting
combat in Vietnam. This analgesia can be reversed
with naloxone.107,143b This amount of analgesia
produced by watching 15 minutes of a combat movie
was equivalent to that which follows the injection of 8
mg. of morphine. We concluded that Beecher9 was
right when, after observing that wounded soldiers
require less morphine, he speculated that "strong
emotions can block pain" because of the release of
endogenous opioids. Our experiments show that even
in people traumatized as adults, re-exposure to
situations reminiscent of the trauma evokes as
endogenous opioid response analogous to that of
animals exposed to mild shock subsequent to
inescapable shock. Thus, re-exposure to stress may
have the same effect as the temporary application of
exogenous opioids, providing a similar relief from
anxiety.50
Field113 has suggested that normal play and
exploratory activity in infants are dependent on the
presence of a familiar attachment figure who
modulates physiologic arousal by providing a balance
between soothing and stimulation. She, Reite,115,116
and others have shown that in the absence of the
mother, an infant experiences by psychological
disorganizing extremes of under- and overarousal.
This soothing and arousal may be mediated by
alternate stimulation of different neurotransmitter
systems, in which the endogenous opioid system is
likely to play a role, especially in subjective
experience of safety and soothing. Endogenous
opioids decrease central noradrenergic activity,6 and
their activation may thus inhibit hyperarousal.
Childhood abuse and neglect may cause a long-term
vulnerability to be hyperaroused, expressed on a
social level as decreased ability to modulate strong
affect states. "On a continuum from low to high
physiologic arousal there is an optimal level for every
organism. The shape of an individual's optimal
stimulation curve may depend on the level of
stimulation received during early experience."37 As a
result, people who were neglected or abused as
children may require much higher external stimulation
of the endogenous opioid system for soothing than
those whose endogenous opioids can be more easily
activated by conditioned responses based on good
early caregiving experiences. These victimized people
neutralize their hyperarousal by a variety of addictive
behaviors including compulsive re-exposure to
situations reminiscent of the trauma.
CHILDHOOD TRAUMA, ENDOGENOUS
OPIOIDS, AND
SELF HARM
If recent animal research is any guide, people,
particularly children, who have been exposed to
severe, prolonged environmental stress will
experience extraordinary increases in both
catecholamine and endogenous opioid responses to
subsequent stress. The endogenous opioid response
may produce both dependence and withdrawal
phenomena resembling those of exogenous opiods.
This could explain, in part, why childhood trauma is
associated with subsequent self-destructive behavior.
Depending on which stimuli have come to condition
an opioid response, self-destructive behavior may
include chronic involvement with abusive partners,
sexual masochism, self-starvation, and violence
against self or others. In a recent study, we found that
patients' reports of early childhood physical and
sexual abuse were highly correlated with self-
mutilation and self-starvation in adulthood.143a This
controlled study supports numerous other clinical
reports about the relationship between childhood
abuse and self-destructive behavior.52,106,118 In these
people, self-mutilation is a common response to
abandonment; it is accompanied by both analgesia
and an altered state of consciousness, and it provides
relief and return to normality. The pain, cutting, and
burning are apparent attempts at "repairing the
cohesiveness of the self in the face of overwhelming
anxiety."35 This pattern is reminiscent of spouse abuse
described by Walker:145 "tension gradually builds, an
explosive battering (self-mutilating) incident occurs,
and a 'calm, loving respite' follows."
Bach-y-Rita7 studied men who were in prison
because they habitually took out their frustrations on
others violently. He found that they started to self-
mutilate in prison when no external object of violence
was available. Thus acts of violence that the
perpetrator regards as horrible may, in fact, produce
somatic calm.
The evidence for involvement of the endogenous
opioid system in self-mutilation is fairly good. A recent
study found increased levels of metenkephalins in
habitual self-mutilators during the active stage of self-
harm, but not 3 months later.27 Opioid receptor
blockade has been found to decrease self-
mutilation.60,117 The specific biologic factors that
account for the relief felt by these traumatized people
who habitually harm themselves or others are still
unknown.
TREATMENT IMPLICATIONS
Compulsive repetition of the trauma usually is an
unconscious process that, although it may provide a
temporary sense of mastery or even pleasure,
ultimately perpetuates chronic feelings of
helplessness and a subjective sense of being bad and
out of control. Gaining control over one's current life,
rather than repeating trauma in action, mood, or
somatic states, is the goal of treatment.
Although verbalizing the contextual elements of
the trauma is the essence of treatment of acute post-
traumatic stress, the essential elements of chronic
post-traumatic reactions generally are retrieved with
difficulty and often cannot be dealt with until
reasonable control over current behavior can assure
the safety of both the patient and those in the patient's
immediate surroundings. Failure to approach trauma-
related material very gradually leads to intensification
of the affects and physiologic states related to the
trauma, leading to increased repetitive phenomena. It
is important to keep in mind that the only reason to
uncover the trauma is to gain conscious control over
the unbidden re-experience or re-enactments. Prior to
unearthing the traumatic roots of current behavior,
people need to gain reasonable control over the
longstanding secondary defenses that were originally
elaborated to defend against being overwhelmed by
traumatic material such as alcohol and drug abuse
and violence against self or others. The trauma can
only be worked through after a secure bond is
established with another person. The presence of an
attachment figure provides people with the security
necessary to explore their life experiences and to
interrupt the inner or social isolation that keeps people
stuck in repetitive patterns. Both the etiology and the
cure of trauma-related psychological disturbance
depend fundamentally on security of interpersonal
attachments. Once the traumatic experiences have
been located in time and place, a person can start
making distinctions between current life stresses and
past trauma and decrease the impact of the trauma
on present experience.137
Self-help organizations for people with addictions
or with backgrounds that include childhood traumas or
parental addictions have elaborated a model of
treatment that appears to address many of the core
issues of repetitive traumatization. These groups
provide people with both human attachments and a
meaningful cognitive frame for dealing with the sense
of helplessness that is central to these problems..
They focus on the development of "serenity," which
can be understood both as a state of automatic
stability and of being at peace with one's
surroundings. These groups teach that the way to
gain this serenity is by learning to trust, by
surrendering, and by making contact and developing
interpersonal commitments. They provide a support
network that attempts to avoid the barriers that people
create to bolster their individual differences, and they
thus endeavor to circumvent the shame of being
helpless and vulnerable that perpetuates social
isolation. Shame and social isolation are thought to
promote regression to earlier states of anxious
attachment and to addictive involvements. In these
circles it is said that: "No pain is so devastating as the
pain a person refuses to face and no suffering is so
lasting as suffering left unacknowledged."23 There is
emphasis on living in the here and now, generally with
the acknowledgement that in contrast to victimized
children, adults can learn to protect themselves and
make a conscious choice about not engaging in
relationships or behaviors that are known to be
harmful. The underlying assumption is that
conclusions drawn from a child's perspective retain
their power into adulthood until verbalized and
examined. In a group context, victims can learn that
as children they were not responsible for the chaos,
violence and despair surrounding them, but that as
adults there are choices and consequences.23,137
These groups also teach that in order to avoid
repetition, one has to give up the behavior, drug, or
person involved in the addiction. Acknowledging the
addictive quality of the involvement is known as
overcoming denial. Avoiding acknowledging the
feelings promotes acting out. Traumatized people
need to understand that acknowledging feelings
related to the trauma does not bring back the trauma
itself, and its accompanying violence and
helplessness. There must be emphasis on finding
replacement activities and experiences that are more
rewarding, successful and powerful in the immediate
present. These may include being of help to victims of
similar traumas as one's own.
Psychotropic medicines may be of help to
decrease autonomic hypearousal and decrease all or
none responses. Lithium, beta blockers, and
serotonin reuptake blockers such as flouxetine, may
be particularly helpful. By decreasing hyperarousal,
one decreases the likelihood that current stress will
be experienced as a recurrence of past trauma. This
facilitates finding solutions appropriate to the current
stress rather than the past.139 The use of medications
that affect the opioid system should be regarded as
experimental and at this time needs to be avoided
except in life-threatening cases.
In our last study on patients with borderline
personality disorder Judith Herman and I
(unpublished data, 1988) asked our self-mutilating
subjects what had helped them most in overcoming
the impact of their childhood traumas, including their
self-mutilation. All subjects attributed their
improvement to having found a safe therapeutic
relationship in which they had been able to explore
the realities of their childhood experiences and their
reactions to them. All subjects reported that they had
been able to markedly decrease a variety of repetitive
behaviors, including habitual self-harm, after they had
established a relationship in which they felt safe to
acknowledge the realities of both their past and their
current lives.
SUMMARY
Trauma can be repeated on behavioral,
emotional, physiologic, and neuroendocriniologic
levels. Repetition on these different levels causes a
large variety of individual and social suffering. Anger
directed against the self or others is always a central
problem in the lives of people who have been violated
and this is itself a repetitive re-enactment of real
events from the past.
People need a "safe base" for normal social and
biologic development. Traumatization occurs when
both internal and external resources are inadequate
to cope with external threat. Uncontrolable disruptions
or distortions of attachment bonds precede the
development of post-traumatic stress syndromes.
People seek increased attachment in the face of
danger. Adults, as well as children, may develop
strong emotional ties with people whe intermittently
harass, beat, and, threaten them. The persistence of
these attachment bonds leads to confusion of pain
and love. Assaults lead to hyperarousal states for
which the memory can be state-dependent or
dissociated, and this memory only returns fully during
renewed terror. This interferes with good judgment
about these relationships and allows longing for
attachment to overcome realistic fears.
All primates subjected to early abuse and
deprivation are vulnerable to engage in violent
relationships with peers as adults. Males tend to be
hyperagressive, and females fail to protect
themselves and their offspring against danger.
Chronic physiologic hyperarousal persists, particularly
to stimuli reminiscent of the trauma. Later stresses
tend to be experienced as somatic states, rather than
as specific events that require specific means of
coping. Thus victims of trauma may respond to
contemporary stimuli as a return of the trauma,
without conscious awareness that past injury rather
than current stress is the basis of their physiologic
emergency responses. Hyperarousal interferes with
the ability to make rational assessments and prevents
resolution and integration of the trauma. Disturbances
in the catecholamine, serotonin, and endogenous
opioid systems have been implicated in this
persistenence of all-or-nothing responses.
People who have been exposed to highly
stressful stimuli develop long-term potentiation of
memory tracts that are reactivated at times of
subsequent arousal. This activation explains how
current stress is experienced as a return of the
trauma; it causes a return to earlier behavior patterns.
Ordinarily, people will choose the most pleasant of
two alternatives. High arousal causes people to
engage in familiar behavior, regardless of the
rewards. As novel stimuli are anxiety provoking, under
stress, previously traumatized people tend return to
familiar patterns, even if they cause pain.
The "opponent process theory of acquired
motivation" explains how fear may become a
pleasurable sensation and that "the laws of social
attachment may be identical to those of drug
addiction." Victims can become addicted to their
victimizers; social contact may activate endogenous
opioid systems, alleviating separation distress and
strengthening social bonds. High levels of social
stress activate opioid systems as well. Vietnam
veterans with PTSD show opiod-mediated reduction
in pain perception after re-exposure to a traumatic
stimulus. Thus re-exposure to stress can have the
same effect as taking exogenous opioids, providing a
similar relief from stress.
Childhood abuse and neglect enhance long-term
hyperarousal and decreased modulation of strong
affect states. Abused children may require much
higher external stimulation to affect the endogenous
opioid system for soothing than when the biologic
concomitants of comfort are easily activated by
conditioned responses based on good early
caregiving experiences. Victimized people may
neutralize their hyperarousal by a variety of addictive
behaviors, including compulsive re-exposure to
victimization of self and others. Gaining control over
one's current life, rather than repeating trauma in
action, mood, or somatic states, is the goal of
treatment. The only reason to uncover traumatic
material is to gain conscious control over unbidden re-
experiences or re-enactments. The presence of
strong attachments provides people with the security
necessary to explore their life experiences and to
interrupt the inner or social isolation that keeps them
stuck in repetitive patterns. In contrast with victimized
children, adults can learn to protect themselves and
make conscious choices about not engaging in
relationships or behaviors that are harmful.
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Massachusetts Mental Health Center
Harvard Medical School
74 Fenwood Road
Boston Massachusetts 02116
*Director, Trauma Center, Massachusetts Mental Health Center,
Harvard Medical School, Boston, Massachusetts
Cite as:
van der Kolk BA. The compulsion to repeat the trauma: re-enactment,
revictimization, and masochism.
Psychiatric Clinics of North America
1989;12(2):389-411.
