The Body Keeps the Score articulates new and better therapies for toxic stress based on a deep understanding of the effects of trauma on brain development and attachment systems. A book about understanding the impact of trauma by one of the true pioneers in the field.
PART FOUR
THE IMPRINT OF TRAUMA
PART FIVE
PATHS TO RECOVERY
PROLOGUE
FACING TRAUMA
Research from these new disciplines has revealed that trauma causes real physiological changes, including a recalibration of the brain's alarm system, an increase in stress hormone activity, and changes in the system that filters relevant information from irrelevant. Each of them can bring about profound changes, depending on the nature of the specific problem and the make-up of the individual person.
PART ONE
THE REDISCOVERY OF TRAUMA
LESSONS FROM VIETNAM VETERANS
In keeping with his family tradition of military service, he enlisted in the Marine Corps immediately after graduation. I had also participated in some early research into the beneficial effects of the psychoactive drugs that were just coming into use in the 1970s.
TRAUMA AND THE LOSS OF SELF
Perhaps even worse for Tom than the recurring flashbacks of the ambush was the memory of what happened next. One of the most difficult things for traumatized people is facing their shame about the way they behaved during a traumatic episode, whether or not they are.
NUMBING
Tom experienced Alex's death as if a part of him had been destroyed forever—the part that was good and honorable and trustworthy. Tom always showed up faithfully to his meetings, because I became his lifeline - the father he never had, Alex who survived the ambush.
THE REORGANIZATION OF PERCEPTION
It was like being in combat, he said - he felt completely alive and nothing else mattered. Looking at the second Rorschach card, Bill screamed in horror, “That's the kid I saw blown up in Vietnam.
STUCK IN TRAUMA
As moving as these experiences were, the limits of group therapy became apparent when I encouraged the men to talk about the problems they faced in their daily lives: their relationships with their wives, children, girlfriends, and family; interact with their bosses and find satisfaction in their work; their heavy alcohol consumption. Whether the trauma occurred ten years ago or more than forty years ago, my patients were unable to bridge the gap between their wartime lives.
DIAGNOSING POSTTRAUMATIC STRESS
While about a quarter of soldiers serving in war zones are expected to develop severe post-traumatic stress disorder10, the majority of Americans experience a violent crime at some point in their lives, and more accurate reporting has revealed that 12 million women in the country. More than half of all rapes occur on girls under the age of fifteen.11 For many people, the war begins at home: Every year, about three million children in the United States are reported as victims of child abuse and neglect.
A NEW UNDERSTANDING
We have learned that trauma is not just an event that happened sometime in the past; it is also the footprint he left. For real change to occur, the body must learn that the danger has passed and live in the reality of the present.
REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN
This has inspired hope that drugs can be developed to treat serious mental problems such as depression, panic, anxiety and mania, as well as to deal with some of the most distressing symptoms of schizophrenia. As an attendant I had nothing to do with the research aspect of the ward and was never told what treatment any of the patients were receiving.
TRAUMA BEFORE DAWN
Some of the women recalled lying awake, motionless, waiting for the inevitable – a brother or father coming in to molest them. Regardless of the symbolic meaning of many such hallucinations, most of them correspond to real sensations.2 This made me wonder: our patients were hallucinating—doctors routinely asked about them and noted them as signs of how anxious the patients were. .
MAKING SENSE OF SUFFERING
Allan Hobson discovered brain cells. responsible for generating dreams in a laboratory in the basement of the hospital while I trained there, and the first studies into the chemical underpinnings of depression were also conducted at MMHC. It was not until the nineteenth century that scientists in France and Germany began to investigate behavior as an adaptation to the complexity of the world.
INESCAPABLE SHOCK
The fight/flight/freeze signals continue after the danger has passed and, as in the case of dogs, do not return to normal. Instead, the constant release of stress hormones manifests as agitation and panic, wreaking havoc on their health in the long run.
ADDICTED TO TRAUMA: THE PAIN OF PLEASURE AND THE PLEASURE OF PAIN
Solomon hypothesized that endorphins—morphine-like chemicals the brain secretes in response to stress—play a role in the paradoxical addictions he described. We concluded that Beecher's speculation that "strong emotions can block pain" was the result of the release of morphine-like substances produced in the brain.
SOOTHING THE BRAIN
The first patient I saw that day was a young woman with a horrific history of child abuse, who was now struggling with bulimia; she spent much of her life binging and purging. On Thursday, she said: “I've had a very different time these past few days: I ate when I was hungry, and the rest of the time I did my schoolwork.” This was one of the most dramatic statements I had ever heard in my office.
THE TRIUMPH OF PHARMACOLOGY
The drug revolution that began with so much promise may have ended up doing as much harm as good. The new generation of antipsychotics, such as Abilify, Risperdal, Zyprexa and Seroquel, are the best-selling drugs in the United States.
ADAPTATION OR DISEASE?
Because drugs have become so profitable, major medical journals rarely publish studies on non-drug treatments of mental health problems.31 Practitioners who investigate treatments are typically marginalized as.
LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION
You and your younger brother and sister are huddled together at the top of the stairs. There were some confusing dots and colors on the scan, but the biggest area of brain activation - a large red dot in the lower right center of the brain, which is the limbic area or emotional brain - came as no surprise .
SPEECHLESS HORROR
This is an area in the visual cortex that registers images when they first enter the brain. We were surprised to see brain activation in this area so long after the original experience of the trauma.
SHIFTING TO ONE SIDE OF THE BRAIN
Under normal circumstances, the two sides of the brain work together more or less seamlessly, even in people who may be said to favor one side over the other. But because their left brain doesn't work very well, they may not be aware that they're reliving and reliving the past—they're just raging.
STUCK IN FIGHT OR FLIGHT
When something reminds traumatized people of the past, their right brain reacts as if the traumatic event happened in the present. Adrenaline is one of the hormones essential to helping us fight back or flee in the face of danger.
PART TWO
THIS IS YOUR BRAIN ON TRAUMA
RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL
But at the bottom of the picture he had drawn something else: a black circle at the foot of the buildings. He reproduced the image that haunted so many survivors – people jumping to escape the inferno – but with a life-saving addition: a trampoline at the bottom of the collapsing building.
ORGANIZED TO SURVIVE
This explains why it is crucial that trauma treatment involves the entire organism, body, mind and brain. When for some reason the normal response is blocked - for example when people are detained, imprisoned or otherwise prevented from taking effective action, whether in a war zone, a car accident, domestic violence or a rape is – the brain keeps moving. stress chemicals are secreted, and the brain's electrical circuits continue to fire in vain.2 Long after the actual event has passed, the brain may continue to send signals to the body to escape a threat that no longer exists.
THE BRAIN FROM BOTTOM TO TOP
Taken together, the reptilian brain and the limbic system form what I will call the “emotional brain” in this book.6 The emotional brain is the core of the central nervous system, and its main job is to care for your well-being. The ancient philosophers called seven years “the age of reason.” For us, first grade is the prelude to things to come, a life organized around the capabilities of the frontal lobe: sitting still; control sphincter muscles; being able to use words instead of actions;
MIRRORING EACH OTHER: INTERPERSONAL NEUROBIOLOGY
The frontal lobes are responsible for the features that make us unique in the animal kingdom.7 They allow us to use language and abstract thinking. The frontal lobes are critical to understanding trauma because they are also the seat of empathy – our ability to “feel” someone else.
IDENTIFYING DANGER: THE COOK AND THE SMOKE DETECTOR
By the time we realize what is happening, our bodies may already be in motion. When a threat is detected, the amygdala sends messages to the hypothalamus to secrete stress hormones to defend against that threat.
CONTROLLING THE STRESS RESPONSE: THE WATCHTOWER
Knowing the difference between top-down and bottom-up regulation is critical to understanding and treating traumatic stress. Bottom-up regulation involves recalibrating the autonomic nervous system (which, as we have seen, originates in the brainstem).
THE RIDER AND THE HORSE
When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight can silence it. I would like to conclude this chapter by examining two more brain scans that illustrate some core features of traumatic stress: timeless reliving;
STAN AND UTE’S BRAINS ON TRAUMA
Lanius used the same kind of script-driven imagery we used at Harvard, capturing the sights, sounds, smells, and other sensations that Stan and Ute experienced while trapped in the car. He came out of the scanner sweating, his heart pounding and his blood pressure sky high.
DISSOCIATION AND RELIVING
Veterans can react to the smallest signal—like hitting a bump in the road or seeing a child playing in the street—as if they were in a war zone. But in the lab we have no problem detecting their hearts and stress hormones coursing through their bodies.
THE SMOKE DETECTOR GOES ON OVERDRIVE
This is what trauma recovery looks like in the brain: the brightly lit area in the lower right corner, the lower left, and the four symmetrical white holes. It activated just as if the car accident was happening in the scanner, triggering powerful stress hormones and nervous system responses.
THE TIMEKEEPER COLLAPSES
Yes, you need to be able to tell if someone is upset with you, but if your amygdala goes into overdrive, you may become chronically afraid that people hate you or feel like they're out to get you. that's why the event is even registered in the brain as trauma—. Visiting the past in therapy should take place when people, biologically speaking, are firmly rooted in the present and feel as calm, safe and grounded as possible. Being anchored in the present when revisiting the trauma opens up the possibility of a deep awareness that the terrible events belong to the past.
THE THALAMUS SHUTS DOWN
Grounded” means you can feel your butt in your chair, see the light coming through the window, feel the tension in your calves, and hear the wind moving outside the tree.). The tragedy is that the price of closure also includes filtering out sources of pleasure and joy.
DEPERSONALIZATION: SPLIT OFF FROM THE SELF
Ute's father died when she was nine, and her mother was often nasty and humiliating to her afterwards. -five years later, when she was trapped in her wrecked car, Ute's brain automatically went into the same survival mode - she disappeared herself.
LEARNING TO LIVE IN THE PRESENT
BODY-BRAIN CONNECTIONS
When a man sneers or snarls at another, is the corner of his canine tooth or eye raised sideways in front of the man he is addressing? —Charles Darwin, 1872. Watch a movie in a language you don't know and you can still guess the quality of the relationship between the characters.
A WINDOW INTO THE NERVOUS SYSTEM
As we breathe, we are constantly accelerating and decelerating the heart, which is why the interval between two successive heartbeats is never exactly the same. A measurement called heart rate variability (HRV) can be used to test the flexibility of this system, and good HRV—the more fluctuation, the better—is a sign that the brake and accelerator in your arousal system are both functioning properly and in balance.
THE NEURAL LOVE CODE 7
He also suggested new approaches to healing that focus on strengthening the body's system for regulating arousal. When the message we get from another person is "You're safe with me," we relax.
SAFETY AND RECIPROCITY
Human beings are amazingly attuned to the subtle emotional shifts of the people (and animals) around them. The standard medical focus on finding the right drug to treat a particular "disorder" tends to distract us from dealing with how our problems affect our functioning as members of our tribe.
THREE LEVELS OF SAFETY
Any threat to our security or social connections triggers changes in the areas innervated by the VVC. When fight or flight fails to eliminate the threat, we activate the last resort – the reptilian brain, the ultimate emergency system.
HOW WE BECOME HUMAN
The more efficiently the VVC synchronizes the activity of the sympathetic and parasympathetic nervous systems, the better the physiology of each individual will be. Early in life, they are virtually at the mercy of the changing tides of their sympathetic and parasympathetic nervous systems, and their reptilian brain runs most of the show.
DEFEND OR RELAX?
NEW APPROACHES TO TREATMENT
It is true that we would probably have developed a therapeutic yoga program for women at some point, since yoga had proven so successful in helping them calm down and get in touch with their dissociated bodies. We would also have probably experimented with a theater program in Boston's inner-city schools, with a karate program for rape survivors called impact model robberies, and with play techniques and body modalities such as sensory stimulation that are now being used with community survivors. the world.
LOSING YOUR BODY, LOSING YOUR SELF
Over the years, our research team has repeatedly found that chronic emotional abuse and neglect can be just as devastating as physical abuse and sexual molestation.1 Sherry proved to be a living example of these findings: Not being seen, not knowing not becoming, and with nowhere to turn to feel safe, is devastating at any age, but it is especially devastating for young children, who are still trying to find their place in the world. The physical sensations made her feel more alive, but also deeply ashamed – she knew she was addicted to these actions, but couldn't stop them.
LOSING YOUR BODY
Each of these separate sensory experiences is transferred to a different part of the brain, which must then integrate them into a single perception. All this would be a small matter enough, but for its terrible result, which is the impossibility of any other kind of feeling and of any kind of enjoyment, even if I.
HOW DO WE KNOW WE’RE ALIVE?
The largest bright area at the back of the brain is the posterior cingulate, which gives us a physical sense of where we are - our internal GPS. Starting from the front of the brain (right), it consists of: the orbital prefrontal cortex, the medial prefrontal cortex, the anterior cingulate, the posterior cingulate and the insula.
THE SELF-SENSING SYSTEM
A neurologist who has treated hundreds of people with various forms of brain damage, he marveled at the awareness and identification of brain areas needed to know what you feel. As we have seen, the brain's job is to constantly monitor and evaluate what is happening in and around us.
THE SELF UNDER THREAT
How do people regain control when their animal brains are stuck in a fight for survival. If what goes on deep within our animal brains dictates how we feel, and if our body sensations are orchestrated by subcortical (subconscious) brain structures, how much control can we actually have over them.
AGENCY: OWNING YOUR LIFE
Our gut signals what is safe, life-sustaining, or threatening, even if we can't quite explain why we feel a certain way. Their bodies are constantly bombarded with visceral warning signs, and in an attempt to control these processes, they often become experts at ignoring their gut feelings and at silencing awareness of what is going on inside.
ALEXITHYMIA: NO WORDS FOR FEELINGS
One of the first people to teach me about alexithymia was psychiatrist Henry Krystal, who worked with more than a thousand. One of the participants said: “I don't know what I feel, it's like my head and body are not connected.
DEPERSONALIZATION
This research confirms what our patients tell us: that the self can detach from the body and live a phantom existence on its own. Frewen, as well as a group of researchers at the University of Groningen in the Netherlands,26 did brain scans of people dissociating their terror and found that the brain's fear centers simply shut down when they remembered the event.
BEFRIENDING THE BODY
Of course, medication only dulls sensations and does nothing to resolve them or turn them from toxic agents into allies. The mind must be reeducated to feel physical sensations, and the body must be helped to tolerate and enjoy the ease of touch.
CONNECTING WITH YOURSELF, CONNECTING WITH OTHERS
This made it possible to compare the effects of direct eye contact on brain activation with those of averted gaze.28. To have true relationships, you must be able to experience others as separate individuals, each with his or her own particular motives and goals.
PART THREE THE MINDS OF
CHILDREN
GETTING ON THE SAME
WAVELENGTH: ATTACHMENT AND ATTUNEMENT
She was fascinated by my stories about war veterans because they reminded her of the troubled kids she worked with in the Boston public schools. In this light, the strange behavior of the children at the children's clinic made perfect sense.2.
MEN WITHOUT MOTHERS
To my amazement, staff discussions on the unit rarely mentioned the children's horrific real-life experiences and the impact of these traumas on their emotions, thinking and self-regulation. Born into an aristocratic family (his father was a surgeon in the royal household), he trained in psychology, medicine and psychoanalysis at the temples of the British establishment.
A SECURE BASE
He saw this innate capacity as a product of evolution, essential to the survival of these helpless creatures. Bowlby regularly visited Regent's Park in London, where he would make systematic observations of the interactions between children and their mothers.
THE DANCE OF ATTUNEMENT
When a baby is in sync with its caregiver, its sense of joy and connection is reflected in its steady heartbeat and breathing, and a low level of stress hormones. Well-connected children learn the difference between situations they can control and situations where they need help.
BECOMING REAL
They learn to live within a shared understanding of the world and are likely to become valued members of the community. He told me with glee in his voice that when the cops saw him standing in the middle of the living room, they yelled, "Oh my God, it's Jack again, that little dick."
LIVING WITH THE PARENTS YOU HAVE
In one pattern, called "avoidant attachment," the babies appear as if nothing really bothers them: they don't cry when their mother leaves and ignore her when she returns. Anxious toddlers tend to grow into anxious adults, while avoidant toddlers are likely to become adults who are out of touch with their own feelings and those of others.
BECOMING DISORGANIZED WITHIN
The critical issue appears to be that the caregivers themselves were a source of distress or terror to the children. 16. Children from lower socioeconomic groups are more likely to be disorganized,22 with parents often severely stressed by economic and family instability.
THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT
If you do not have the inner sense of security, it is difficult to distinguish between security and danger. After all, raising healthy offspring is at the core of our human sense of purpose and meaning.
DISSOCIATION: KNOWING AND NOT KNOWING
Emotional distance and role reversal (in which mothers expected the children to care for them) were specifically linked to aggressive behavior towards themselves and others in the young adults. Bowlby wrote: "What cannot be communicated to the [m]other cannot be communicated to the self."38 If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.39 Perhaps the most devastating long-term effect of this closure is not really felt from the inside, a condition that we saw in the children in the Children's Clinic and that we see in the children and adults who come to the Trauma Center.
RESTORING SYNCHRONY
TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT
After he left, Marilyn sat on her bed for hours, stunned by what had happened. Therapy often begins with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when someone looks you in the eye, being covered in blood after cutting yourself with a piece of glass have, or deliberately throw up every meal.
TERROR AND NUMBNESS
I stepped in to help her set some boundaries about what she would talk about and she began to settle down. I told them Marilyn's story, showed them the picture she had drawn, and asked them to collaborate on a study.
A TORN MAP OF THE WORLD
This information is incorporated into the warp and woof of our brain circuitry and forms the template for how we think about ourselves and the world around us. Our maps of the world are encoded in the emotional brain, and changing them means reorganizing that part of the central nervous system, the subject of the treatment section of this book.
LEARNING TO REMEMBER
She brought her trauma back into her life, but had no narrative to refer to. She realized that this was what she had focused on when her father raped her when she was eight years old.
HATING YOUR HOME
Marilyn herself later realized that as an adult, she continued to float to the ceiling when she found herself in a sexual situation. She usually did not remember what happened, but sometimes she became angry and aggressive.
REPLAYING THE TRAUMA
I had to use every ounce of strength I had to keep from yelling, 'NONONONONONO',' as I stood over the sink. She went to bed and fell asleep, but woke up every two hours like clockwork the rest of the night. Like so many survivors of childhood abuse, Marilyn exemplified the power of the life force, the will to live and to own one's life, the energy that counteracts the obliteration of trauma.
WHAT’S LOVE GOT TO DO WITH IT?
Understanding what is "wrong" with people right now is more a matter of doctor mindset (and what insurance companies will pay for) than verifiable, objective facts. The manual has become a virtual industry that has generated more than $100 million for the American Psychiatric Association.1 The question is whether it has provided comparable benefits to the patients it is intended for.
HOW DO YOU TAKE A TRAUMA HISTORY?
Many of the patients reported moving frequently, requiring them to change schools mid-year. There we found a huge pile of prints, on which Chris had placed a Gary Larson cartoon of a group of scientists studying dolphins and being amazed by "those strange 'aw blah es span yol' sounds." The data had convinced him that you You can't really understand BPD unless you understand the language of trauma and abuse.
SELF-HARM
THE POWER OF DIAGNOSIS
Each major diagnosis in the DSM had a task force responsible for proposing revisions for a new edition. Complex PTSD” for short.12,13 Then, in May 1994, we eagerly awaited the publication of DSM-IV.
THE HIDDEN EPIDEMIC
With an ACE score of zero, the prevalence of rape was 5 percent; and 33 percent with a rating of four or more. Finally, there was a staggering toll of major health problems: those with an ACE score of six or higher had 15 percent or
WHEN PROBLEMS ARE REALLY SOLUTIONS
CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM
DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC
She had gotten pregnant by a drunken boyfriend who left her when she told him she was carrying his child. After other approaches failed, she was placed in an equine therapy program, where she groomed her horse daily and learned simple dressage.
BAD GENES?
They develop thicker connections in the hippocampus, a key center for learning and memory, and they perform better in an important rodent skill: finding their way through mazes. In Szyf's words: “Major changes can be made to our bodies not only by chemicals and toxins, but also in the way the social world talks to the wired.
MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE VERSUS NURTURE
If the babies survive, their mothers usually prevent them from making friends with their peers. Young monkeys, who are removed from their mothers at birth and raised only with their peers, bond intensely with them.
THE NATIONAL CHILD TRAUMATIC STRESS NETWORK
Their serotonin metabolism is even more abnormal than that of the monkeys who are genetically prone to aggression, but who were raised by their own mothers. Monkeys and humans share the same two variants of the serotonin gene (known as the short and long serotonin transporter alleles).
HOW RELATIONSHIPS SHAPE DEVELOPMENT
There were clear patterns: The children who received consistent care became well-regulated children, while erratic care produced children who were chronically physiologically agitated. The children of unpredictable parents often screamed for attention and became intensely frustrated in the face of small challenges.
THE LONG-TERM EFFECTS OF INCEST
A remarkable 96 percent of the girls, now grown women, have remained in the study since its inception. Their biology matched their observed responses: During the first assessment all the girls showed an increase in the stress hormone cortisol; three years later, cortisol decreased in abused girls as they reported on the most stressful event of the previous year.
THE DSM-5: A VERITABLE SMORGASBORD OF
They can't keep up with the normal envy-driven inclusion/exclusion games where players have to keep their cool under stress. Like so many of the young people we see, Ayesha can't articulate what she wants or needs and can't think through how to protect herself.
DIAGNOSES”
The most stunning rejection of DSM-5 came from the National Institute of Mental Health, which funds most psychiatric research in. For example, one of the NIMH domains is “Arousal/Modulatory Systems (Arousal, Circadian Rhythm, Sleep and Wakefulness),” which is disturbed to varying degrees in many patients.
