Nobody Talked About My Uncle Johnny – Lingering Questions About Adverse Childhood Experiences…

I never knew my Uncle Johnny.  He died when he was 7 years old – many years before I was born.  He was the second of 8 children born to my paternal grandparents.  They were immigrants from Croatia and Austria.  Croatia was one of several countries that eventually combined to form Yugoslavia and then became Croatia again when Yugoslavia broke up.  As I tried to follow my grandparent’s timeline in the 1920, 1930, and 1940 census my grandmother’s country of origin was listed as Croatia-> Yugoslavia-> Yugoslavia. I am trying to piece that all together from the usual genealogy sites.  Nobody in my family ever talked about Johnny.  I did not know he existed until 4 months ago.   I was trying to find information about my paternal grandfather and landed on the census that showed he had 3 children – 2 aunts familiar to me and Johnny.

We always knew that my father had a brother who died in childhood. We did not know how old he was when he died, but we knew it was a gruesome death.   I was told that “he was held over a fire by two kids and burned to death.”  I was also told that child’s name was George and my father and subsequently I was named after him.  I also heard a version of the story that he was named Nick after my grandfather.  I had an uncle who had Nick as a middle name.   

Once I found out that Johnny existed, I sent an email to the Wisconsin Historical Society to track down what happened to him and the date he died.  In Wisconsin you cannot get a death certificate unless you know the exact date of death. I was sent newspaper clippings from several Wisconsin newspapers. The basic story in those papers was that Johnny went down to a local coal dock to see an airplane with several other boys.  There was a bonfire next to the plane.  He sustained severe burns, and died 2 days later in a hospital.  In the hospital he told his father that he was pushed into the fire.  Subsequently there was another story that he was held over the fire.  The Police Chief investigated what happened.  Some of the boys were questioned. Several of them were named in the newspaper.   After the article about his death, there are no further articles about the outcome of that investigation or whether the death was ruled accidental or a crime.  At the time of his death my father was 1 year old and he had a 5 year old brother and 3 sisters ages 4, 6, and 9.  

As a physician from an acute care hospital just the thought of what happened to Johnny evokes anxiety, anger, and hopelessness.  There was no burn care in 1925.  I did psychiatric consults on the burn unit at our modern trauma center for many years.  Burn care is emotionally demanding for both the patients and their physicians. Early on, one of the burn surgeons told me that he had informed consent discussions with severely burned patients and gave them all the option to choose no care except pain relief. It is difficult to imagine what the care must have been like in 1925 for my 7-year-old uncle during his last days. There were several statements about my grandfather seeking justice – but I am not sure whether that happened or not. 

There is a story that the boys involved did not do well as adults and that one of them may have died by suicide. At this point I cannot corroborate the outcome of the police investigation.  The local police department does not have records that old. I have requested the extended fact of death certificate to see if a specific cause of the severe burn injury is listed.  Local officials were initially unable to locate that death certificate until I discovered that the names of decedents were frequently misspelled – even official records (3,4).  I located a gravestone in the local cemetery marked John Dowson.  I sent that to the Register of Deeds and she was able to locate the death certificate under the name John Dosson. Given the age, date of death, and size of the town – it could not be anyone else.  It is also the first time I saw his date of birth.  

Given the historical limitations what were the potential impacts on the family?  Trauma is an overworked word these days in psychiatry and psychology.  Recent advocates of explaining nearly all psychopathology in terms of trauma and providing trauma informed care seem to have ignored the history of the field.  To cite a few examples – sexual trauma in children has been described back into the 19^th century by psychiatrists (1).  The trauma and biological effects of being raised in orphanages (psychosocial dwarfism) was described by psychiatrists (2).  Combat related trauma and PTSD was so well described that several of my mentors were placed in accelerated psychiatric residency programs to make sure the US Military had enough psychiatrists to treat the psychiatric complications of World War 2.  It is worth noting that before shell shock or the stress of combat was not seen as an etiology.  Soldiers exhibiting those symptoms were seen as morally deficient. In other words – the soldier was seen as flawed and combat exposure was incidental. In the early days of correcting that diagnosis the most frequent diagnosis in the German army was psychopathic personality suggesting an intrinsic susceptibility to overrespond to life threatening stressors.   

Over the span of my career I taught and practiced detailed phenomenological assessments that included every possible context that psychiatric disorders or symptoms occur in.  It was quite a shock when I started hearing about trauma informed care and started to see the iatrogenic problems associated with it. In the population I was treating at the time there were a significant number of immigrants from Africa, Russia, and Asia.  I routinely worked with 15 different language interpreters.  Many of the immigrants had been exposed to war and torture.  The prevalence of torture victims was so high that there is a  Center for Victims of Torture in Minnesota that was established in 1980.   

Despite those clear correlations the relationship between stressors or trauma and psychopathology is complex.  One of the primary problems is oversimplification. It is well known that people subjected to the similar catastrophic stressors do not respond in the same way (5,6)   This is due to several biological, environmental, and psychological factors that are typically called resilience.  More resilience translated to less maladaptive stress response.  In some cases, the stress response is very transient to nonexistent.  In others it follows a predictable course and in some it does not resolve without treatment.  The emphasis on identifiable stress response syndromes – Acute Stress Disorder and Post Traumatic Stress Disorder does not capture all the effects of these events.  It is clearly possible to have your life impacted by this kind of an event and not develop these full syndromes.

There have been efforts to more clearly correlate adverse life experiences with both physical and mental health.  The Adverse Childhood Experiences (ACEs) inventory was developed by the CDC and used to look at childhood adverse experience with subsequent problems.  The checklist is listed below and it was designed to be given only to adults over the age of 18. Inspecting those questions and the scoring it is apparent the focus is on physical, sexual, emotional, and verbal abuse and neglect.  There are four items on the lack of availability of a parent due to substance use, mental illness, separation or divorce, and/or incarceration.  The adverse experiences are all originating in a parent, caregiver, or person living in the same household.  Nothing about bad accidents originating outside the family or the death of a parent or sibling.

 The original CDC study of the ACES checklist was studied in a HMO sample (6) half of the 9,408 respondents reported at least one childhood exposure and a quarter reported more than or equal to 2 exposures.  This study also looked at correlations between ACES and adult risk behaviors and diseases and concluded there was a graded relationship.  That set the stage for subsequent studies that made similar claims.          

In the case of my Uncle Johnny – what was the impact of his death on the family?  Why was his name never used in discussions with his siblings?  Did it matter if the cause of death was never adequately resolved?  Did it lead to effects that are not typically considered as adverse childhood experiences?  None of his siblings knew his name.  The names passed on to the next generation were not accurate.  Why were his death and the associated circumstances never talked about in the family? 

Every family has characteristics that family members think about.   I can think of a few for mine.  We lived an isolated existence.  A typical family outing was a drive in the countryside.  We did not socialize with anyone.  Once or twice a year my father’s brother or brother-in-law would stop by.  Once or twice a year – we would stop by to see one of my father’s coworkers or a guy he used to play baseball with.  I did not know about the baseball connection until I found a picture of his team online – 40 years after he died. 

We would visit my maternal grandparents often.  It was one of the few places my father would smile.  He was typically very serious and showed emotions only during times of stress or if he was listening to opera or a comedian on TV.  I once asked him if I could play Little League baseball and he said: “As long as you know you are playing it for you and not for me.”  I got a similar reaction when I tried to give him a fishing rod for Father’s Day: “You just want me to take you fishing.  I don’t fish because when I was a kid we had to fish every day for food.”  His family home was right next to the coal dock where I usually went fishing.  The only consistent story we heard about his childhood was what it was like to grow up during the Great Depression.  One of the last events my father attended was a banquet for my high school football team.  It was an undefeated season and I was one of four sophomores.  He was at the event and seemed to enjoy himself – but never said a word about it to me.

If things got a little out of control – my father got angry.  I remember when one of us fell down a staircase.  He was clearly upset but it was mostly anger.  At times it came across like he was blaming the person who had the accident.  I found a box of rifle cartridges in the old horse barn modified to be our garage.  I put them in the trash burning pile that he attended next to our house every other night.  I still remember him dancing around when those cartridges went off. He showed plenty of restraint when I admitted doing it and that was the end of it.  I went out the next day and found the exploded cartridges in the ashes – the brass peeled back in a flower petal design.

There were many more situations that occurred between my father and I that I would consider unusual in retrospect.  There were only 5 children in our family and I cannot imagine what it would be like with three more. We lived “paycheck to paycheck” but never ran out of food.  There was not a lot of joy in the household. I worried about him and still have the mental image of him walking home in knee deep snow from work.  I worried because he told me that deep snow could get pulled into the air intake of his diesel locomotive and kill the engines.  In that blizzard he was leaning into the wind, covered in snow, wearing a flimsy fishing hat, and no gloves.  I was the only one up waiting for him at 11PM.  He walked in smelling like diesel oil and Lucky Strikes and shook off the snow.  He was freezing.  I was happy to see him.       

As I think about my Uncle Johnny and my family of origin there are more questions than answers.  Would things have been different for all of us if he had not been killed? Would my father have been a happier guy?  Would we have been less isolated?  Would the paternal side of the family have been less fragmented?  Can a catastrophic event like that have intergenerational effects?  There are only suggestions described by statistics at this point.  Studies like the impact of violence on mothers in families and the unique stressors that immigrants experience provide that data.

In an ideal world - the people closest to the incident have the greatest ability to process it and frame it for future generations.  They may not have the ability to do that but make no mistake about it – that is a very difficult task.  

 

George Dawson, MD, DFAPA

 

Supplementary 1:  The guidelines I used to write this essay:

1:  All of the principals in the generation of interest are deceased.  The general rule that I encountered from vital statistics government agencies for less stringent access to records was deceased for 50 years.

2:  I limited my remarks to personal observations in the subsequent generations and did not speculate about anyone else’s experience.

3:  I wrote only about observed behavior and did not speculate about intrapsychic states.

4:  I did not judge or assign blame to anyone – recognizing that this is a complex problem complicated by imperfect information. 

 

Supplementary 2:  Lessons about Vital Statistics

1:  The death certificate of my uncle was requested in an attempt to resolve a longstanding family mystery.  Starting in 1910 in the US the Standard Certificate of Death was supposed to include a manner of death (see section 37 below).  The manner of death is listed as accidental, suicide, homicide, natural causes, undetermined or under investigation.  The old death certificates did not have this section.

 

From my uncle’s death certificate, the cause of death was listed as:

“3^rd degree burns”

“1/2 of body involved”

From my grandfather’s death certificate, it read:

“cerebral thrombosis”

“arteriosclerosis”

Neither of them had manner of death listed.

An additional complication for my uncle was that I was sent 2 different death certificates with different dates, different spellings of his name, and different causes of death.  There were problems with the way this data was collected and reported in the past.  

Supplementary 3:  According to the 1920 Census my grandfather Dawson had been in the US for 17 years and his wife had been here for 7 years. Neither were US citizens at the time of the 1920 Census. My grandfather was working as a laborer on the railroad. Their official immigration status was listed as "papers had been filed for the process of naturalization".  Very fortunate that they were not involved in the immigration process today.  The Immigration Act of 1918 was designed to make it easier to deport anarchists, communists, and labor organizers.  It also removed protection from deportation for any non-citizen who had resided in the US for 5 or more years.  In the context of 4,000 arrests only 556 were deported. 

References:

1:  Esquirol JE.  Suicide in Dictionnaire des Sciences Medicales.  A Group of Physicians and Surgeons (eds).  1821: 219-220

French psychiatrist Jean-Étienne Dominique is credited with suggesting that suicide was associated with mental disorders and was not the result of moral weakness and therefore not a sin or a crime.  In this initial report he described and attempted sexual assault by the father on a 16-year-old daughter resulting in several suicide attempts.  I could not access the original Dictionnaire des Sciences Medicales - but found this interpretation in Peter Gay’s Freud – A Life for Our Time – page 95 footnote.

2:  Spitz RA. The role of ecological factors in emotional development in infancy. Child Development. 1949 Sep 1:145-55.

3:  McGivern L, Shulman L, Carney JK, Shapiro S, Bundock E. Death Certification Errors and the Effect on Mortality Statistics. Public Health Rep. 2017 Nov/Dec;132(6):669-675. doi: 10.1177/0033354917736514. Epub 2017 Nov 1. PMID: 29091542; PMCID: PMC5692167.

4:  Gamage USH, Adair T, Mikkelsen L, Mahesh PKB, Hart J, Chowdhury H, Li H, Joshi R, Senevirathna WMCK, Fernando HDNL, McLaughlin D, Lopez AD. The impact of errors in medical certification on the accuracy of the underlying cause of death. PLoS One. 2021 Nov 8;16(11):e0259667. doi: 10.1371/journal.pone.0259667. PMID: 34748575; PMCID: PMC8575485.

5:  Geoffrion S, Goncalves J, Robichaud I, Sader J, Giguère CÉ, Fortin M, Lamothe J, Bernard P, Guay S. Systematic Review and Meta-Analysis on Acute Stress Disorder: Rates Following Different Types of Traumatic Events. Trauma Violence Abuse. 2022 Jan;23(1):213-223. doi: 10.1177/1524838020933844. Epub 2020 Jun 26. PMID: 32588756.

6:  Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry. 2007 May;64(5):577-84. doi: 10.1001/archpsyc.64.5.577. PMID: 17485609.

7:  Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8. PMID: 9635069.

 

The Real Solution To Burnout

One of my favorite things these days is the concept (or is it diagnosis?) of burnout.  It seems to be a popular topic in medical and psychiatric news these days.  In the Psychiatric Times January 2016 edition, Editor in Chief Allan Tasman, MD published a column on burnout entitled My New Years Prescription for You.  He goes on to detail the syndrome and what can be done about it.  He points out the high prevalence of burnout in physicians including house staff, physicians in general and psychiatrists.  These studies generally depend on checklist surveys of symptoms suggestive of "burnout."  Dr. Tasman points out that they are relatively nonspecific and people may not see psychiatrists about burnout until there are more recognizable syndromes of anxiety or depression.

My problem with the concept of burnout is that it doesn't accurately describe the problem.  As I think back on some of my most engaging clinical rotations in training - the teams frequently worked to the point of exhaustion.  The attending came in the next day.  There was an air of collegiality and a lot of learning occurred.  There was a lot of dark humor on the part of house staff.  There was an understanding that all of this exhausting work would end some day when you made the transition to a staff or attending physicians and could work more normal hours.  That was the late 1980s and early 1990s.  As politicians and business people wrested control away from physicians, suddenly most physicians continue to work like they are house staff.  Senior physicians in their 60s are suddenly taking all night call and working 60-70 hours per week.  Hospitalist services were invented requiring physicians to work 7 days on and 7 days off - another exhausting schedule.  I have observed to many of these physicians that they are working like they did when they were house staff - interns and residents.  They numbly shake their heads in the affirmative when I ask them that question.  They also acknowledge the fact that by day 6, their cognitive capacity is markedly diminished.  Suddenly it takes them twice as long to do tasks especially all of the documentation.

The reference to Studer in the Tasman article is interesting.  I don't know if any other physicians have had to suffer through a business consultant-based inservice on how to improve "customer satisfaction scores".  There are discussions on how to introduce yourself to the "customer".  There are the usual business based mnemonics.  Physicians may actually have to demonstrate that they know how to introduce themselves to "customers"!  Think about that for a second, especially if you are a psychiatrist who was trained for years in how to interact with patients rather than customers.  If you are a psychiatrist who passed the oral boards,  you know that failing to make the appropriate introduction led to an immediate failure on that exam.  Now flash forward to the bizarre world where patients are "customers" and now there is a formula designed by business people who know relatively nothing about interacting with patients in a therapeutic manner.   You are expected to demonstrate competency in this shallow business paradigm that is setup to optimize results on customer satisfaction surveys.  This is a great example of how physicians are stressed on a regular basis in health care organizations and their time is wasted.  It is also a great example of how public relations, rather than the latest medical knowledge is the dominant performance metric for healthcare organizations.  If there is a recipe for burnout - this is it.

The dynamics of burnout are the dynamics of many clinical situations that psychiatrists try to address.  The referrals are people with chronic depression or depression that seems to have occurred as a result of a sudden change in their life circumstances.  A common scenario is an unreasonable employer or work supervisor.  I will understand it if the employers jump in here and say that they are entitled to tell people how they want them to work for their salary or that their employees are free to find another job.  Those are political arguments that I don't really care about.  Those arguments are also improbable ways of addressing burnout.

When I am faced with person who is chronically anxious and depressed, chronically sleep deprived due to forced swing shifts or double shifts, is dealing with an obnoxious demanding boss, and is not able to change jobs for economic or insurance reasons - I know the patient and I are up against a wall.  I speculate that there are millions of people in this situation who are diagnosed with one anxiety or depressive disorder or another or chronic insomnia and who are trying to get some kind of treatment to alleviate this stress.  There is no evidence that I am aware of that treatment that targets what is basically a chronic stress response is effective.  There may be some small incremental changes if people feel supported and are getting active feedback in therapy about how to deal with the stress in realistic ways, how the dynamics may have personal meaning, and how to reframe the stressful relationships but many people are likely to stay in treatment for the diagnosis for months or years and have little to show for it.  Many people have the expectation that there is a medication that will restore their ability to function in this situation and not require any significant changes on their part.  That is completely false.

That brings me to the issue of physician burnout.  Burnout is more than the clinical diagnoses that are used to describe people who are experiencing chronic workplace stress.  The current work environment for physicians is designed to produce burnout, anxiety, depression, and all of the associated comorbidity.  One of the central dynamics is administrators with no medical knowledge creating an environment that moves physicians away from patients and creates an onerous clerical and administrative burden.  The large increase in managers has created an environment that is both hostile and full of busy work.  The idea that this is something that can be overcome with medications, meditation, exercise, lifestyle management or psychotherapy leaves a lot to be desired.  It is time that psychiatrists focus on an optimized environment for mental and physical well being rather than than trying to treat the fallout from some of those horrific scenarios.

Addressing burnout in physicians is more than a health and wellness consult.  It is more than a weekend retreat to a local resort.  It is more than "lifestyle changes" when you don't have enough time to have a life.  It is a lot more than going on vacation and realizing that on the day you come back - it is like you never left.  Optimizing the work environment for physicians rather than treating burnout is a good place to start.  Recognizing this when it happens in our patients is also more useful than treating it like depression.



George Dawson, MD, DFAPA





  

No - I Don't Have Generalized Anxiety Disorder

I was reading a copy of JAMA the other day and a story written by a transplant surgeon Jeremy M. Blumberg, MD.  It was an excellent description of surgical training to the point of autonomy and then the nagging uncertainty of whether the surgery you have trained for years to do will go well.  Will you avoid mistakes?  He describes his first transplant as an attending:

"This operating room was new to me; the nurses were friendly but foreign.  The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect?  The patient's blood vessels were hard, thickened from years of dialysis and diabetes.  She bled more than usual when we reperfused the kidney.  It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...."  (p. 1676)

I hear you brother.  I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not.  In psychiatry a lot of it depends on the level of complexity that your patients have.  It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you.  Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem.  I have designed a hierarchy to illustrate what I mean.  It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top.  The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances.  The problems encompass both psychiatry and the medicine associated with psychiatry.

Let me provide an example of both.  In the case of the psychiatric problem the usual scenario is a case of impaired judgment.  Is the person at risk for death or self injury?  Are they able to cooperate with the assessment and treatment plan.  Do they seem changed to the point that you can no longer accept their responses as being accurate?  Are you treating them for acute and chronic suicidal ideation and behavior?  Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career.  It is often much more complex than an acute assessment.  Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken.  In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble.  I have not seen it studied but the stress of these situations for the psychiatrist involved is well known.   Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common.  In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.

The medical situations are as complex and they frequently have no clear solution.  A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking.  A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy.  The best example is bipolar disorder and lithium therapy.  Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective.  When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium.  Their functional capacity was restored and they were able to return to work and establish families.  In those early days, the issue of lithium nephrotoxicity was not clearly observed.  There was a major study of people on lithium maintenance for decades that showed no difference in renal function.  In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy.  In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good.  That translates to no hospitalizations in a long time to frequent hospitalizations every year.  Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.

In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable.  Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented.  But some sort of probability statement is inherent in all medical practice.  I would estimate it still happens to me about every three weeks.  Something isn't right and I don't have an exact answer.  It becomes an obsession to an extent.  Laying awake in bed.  Getting up to do some additional research but realizing ahead of time that the yield is low.  Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal.  You always get to the point where you  can feel the adrenaline molecules rushing and your heart pounding.  You know you are tense and starting to break into a light sweat.  You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack.  You might actually check your pulse and blood pressure and find that  they are elevated.  It goes on like this until something happens and the intellectual crisis abates.  Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.

No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.

George Dawson, MD, DFAPA