The Body Keeps the Score

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255

Content

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Full Title

The Body Keeps the Score

Author

Bessel van der Kolk

Samenvatting

"The Body Keeps the Score" by Bessel van der Kolk explores the profound impact of trauma on the mind, body, and relationships. It discusses how traumatic experiences leave lasting imprints that affect emotional regulation and self-perception, emphasizing the importance of addressing both the psychological and physiological aspects of trauma for effective healing.

As human beings we belong to an extremely resilient species. Since time immemorial we have rebounded from our relentless wars, countless disasters (both natural and man-made), and the violence and betrayal in our own lives. But traumatic experiences do leave traces, whether on a large scale (on our histories and cultures) or close to home, on our families, with dark secrets being imperceptibly passed down through generations. They also leave traces on our minds and emotions, on our capacity for joy and intimacy, and even on our biology and immune systems. (Location 161)

Trauma affects not only those who are directly exposed to it, but also those around them. (Location 165)

Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability. (Location 168)

It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability. (Location 170)

While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial. Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones. (Location 171)

Note: Trauma - vulnerable

Research from these new disciplines has revealed that trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant. (Location 187)

We now know that their behaviors are not the result of moral failings or signs of lack of willpower or bad character—they are caused by actual changes in the brain. (Location 191)

There are fundamentally three avenues: 1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma. Which one of these is best for any particular survivor is an empirical question. Most people I have worked with require a combination. (Location 195)

The challenge is: How can people gain control over the residues of past trauma and return to being masters of their own ship? Talking, understanding, and human connections help, and drugs can dampen hyperactive alarm systems. But we will also see that the imprints from the past can be transformed by having physical experiences that directly contradict the helplessness, rage, and collapse that are part of trauma, and thereby regaining self-mastery. (Location 208)

Some people’s lives seem to flow in a narrative; mine had many stops and starts. That’s what trauma does. It interrupts the plot. . . . It just happens, and then life goes on. No one prepares you for it.—Jessica Stern, Denial: A Memoir of Terror (Location 222)

How could the man I heard quietly going down the stairs every morning to pray and read the Bible while the rest of the family slept have such a terrifying temper? How could someone whose life was devoted to the pursuit of social justice be so filled with anger? (Location 252)

That morning I realized I would probably spend the rest of my professional life trying to unravel the mysteries of trauma. How do horrific experiences cause people to become hopelessly stuck in the past? What happens in people’s minds and brains that keeps them frozen, trapped in a place they desperately wish to escape? (Location 273)

Kardiner noted that sufferers from traumatic neuroses develop a chronic vigilance for and sensitivity to threat. His summation especially caught my eye: “The nucleus of the neurosis is a physioneurosis.” 2 In other words, posttraumatic stress isn’t “all in one’s head,” as some people supposed, but has a physiological basis. Kardiner understood even then that the symptoms have their origin in the entire body’s response to the original trauma. (Location 296)

The lack of literature on the topic was a handicap, but my great teacher, Elvin Semrad, had taught us to be skeptical about textbooks. We had only one real textbook, he said: our patients. We should trust only what we could learn from them—and from our own experience. (Location 301)

I remember him saying: “The greatest sources of our suffering are the lies we tell ourselves.” (Location 304)

It is hard enough for observers to bear witness to pain. Is it any wonder, then, that the traumatized individuals themselves cannot tolerate remembering it and that they often resort to using drugs, alcohol, or self-mutilation to block out their unbearable knowledge? (Location 309)

Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships. After you have experienced something so unspeakable, how do you learn to trust yourself or anyone else again? Or, conversely, how can you surrender to an intimate relationship after you have been brutally violated? (Location 334)

It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances. They despise themselves for how terrified, dependent, excited, or enraged they felt. (Location 344)

Something about the diagnosis didn’t sound right. I asked Bill if I could talk with him, and after hearing his story, I unwittingly paraphrased something Sigmund Freud had said about trauma in 1895: “I think this man is suffering from memories.” (Location 379)

We learned from these Rorschach tests that traumatized people have a tendency to superimpose their trauma on everything around them and have trouble deciphering whatever is going on around them. There appeared to be little in between. We also learned that trauma affects the imagination. The five men who saw nothing in the blots had lost the capacity to let their minds play. But so, too, had the other sixteen men, for in viewing scenes from the past in those blots they were not displaying the mental flexibility that is the hallmark of imagination. They simply kept replaying an old reel. Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word—all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities—it is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach. (Location 405)

Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word—all the things that make life interesting. (Location 409)

They insisted that I had to be part of their newfound unit and gave me a Marine captain’s uniform for my birthday. In retrospect that gesture revealed part of the problem: You were either in or out—you either belonged to the unit or you were nobody. After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers. Later I led another group, this time for veterans of Patton’s army—men now well into their seventies, all old enough to be my father. We met on Monday mornings at eight o’clock. In Boston winter snowstorms occasionally paralyze the public transit system, but to my amazement all of them showed up even during blizzards, some of them trudging several miles through the snow to reach the VA Clinic. For Christmas they gave me a 1940s GI-issue wristwatch. As had been the case with my group of Marines, I could not be their doctor unless they made me one of them. (Location 427)

Whether the trauma had occurred ten years in the past or more than forty, my patients could not bridge the gap between their wartime experiences and their current lives. Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past. (Location 439)

For most people the memory of an unpleasant event eventually fades or is transformed into something more benign. But most of our patients were unable to make their past into a story that happened long ago. (Location 453)

For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action. 12 In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. (Location 479)

We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present. Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think. (Location 488)

The act of telling the story doesn’t necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present. (Location 492)

The greater the doubt, the greater the awakening; the smaller the doubt, the smaller the awakening. No doubt, no awakening.—C.-C. Chang, The Practice of Zen (Location 498)

We now know that more than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their families. (Location 531)

I was often surprised by the dispassionate way patients’ symptoms were discussed and by how much time was spent on trying to manage their suicidal thoughts and self-destructive behaviors, rather than on understanding the possible causes of their despair and helplessness. I was also struck by how little attention was paid to their accomplishments and aspirations; whom they cared for, loved, or hated; what motivated and engaged them, what kept them stuck, and what made them feel at peace—the ecology of their lives. (Location 533)

Note: Ecology

Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes. (Location 553)

There was no question that many patients on the ward engaged in violent, bizarre, and self-destructive behaviors, particularly when they felt frustrated, thwarted, or misunderstood. (Location 556)

Sylvia was a gorgeous nineteen-year-old Boston University student who usually sat alone in the corner of the ward, looking frightened to death and virtually mute, but whose reputation as the girlfriend of an important Boston mafioso gave her an aura of mystery. After she refused to eat for more than a week and rapidly started to lose weight, the doctors decided to force-feed her. It took three of us to hold her down, another to push the rubber feeding tube down her throat, and a nurse to pour the liquid nutrients into her stomach. Later, during a midnight confession, Sylvia spoke timidly and hesitantly about her childhood sexual abuse by her brother and uncle. I realized then our display of “caring” must have felt to her much like a gang rape. This experience, and others like it, helped me formulate this rule for my students: If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past. (Location 562)

Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people “acknowledge, experience, and bear” the reality of life—with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves,” he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel. (Location 585)

You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions. (Location 591)

The way medicine approaches human suffering has always been determined by the technology available at any given time. (Location 597)

Now that scientists were finding evidence that abnormal levels of norepinephrine were associated with depression, and of dopamine with schizophrenia, there was hope that we could develop drugs that target specific brain abnormalities. That hope was never fully realized, but our efforts to measure how drugs could affect mental symptoms led to another profound change in the profession. Researchers’ need for a precise and systematic way to communicate their findings resulted in the development of the so-called Research Diagnostic Criteria, to which I contributed as a lowly research assistant. These eventually became the basis for the first systematic system to diagnose psychiatric problems, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which is commonly referred to as the “bible of psychiatry.” The foreword to the landmark 1980 DSM-III was appropriately modest and acknowledged that this diagnostic system was imprecise—so imprecise that it never should be used for forensic or insurance purposes. 8 As we will see, that modesty was tragically short-lived. (Location 628)

After administering several courses of electric shock, the researchers opened the doors of the cages and then shocked the dogs again. A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open—they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom. Like Maier and Seligman’s dogs, many traumatized people simply give up. Rather than risk experimenting with new options they stay stuck in the fear they know. I was riveted by Maier’s account. What they had done to these poor dogs was exactly what had happened to my traumatized human patients. They, too, had been exposed to somebody (or something) who had inflicted terrible harm on them—harm they had no way of escaping. I made a rapid mental review of the patients I had treated. Almost all had in some way been trapped or immobilized, unable to take action to stave off the inevitable. Their fight/ flight response had been thwarted, and the result was either extreme agitation or collapse. (Location 644)

Ideally our stress hormone system should provide a lightning-fast response to threat, but then quickly return us to equilibrium. In PTSD patients, however, the stress hormone system fails at this balancing act. Fight/ flight/ freeze signals continue after the danger is over, and, as in the case of the dogs, do not return to normal. Instead, the continued secretion of stress hormones is expressed as agitation and panic and, in the long term, wreaks havoc with their health. (Location 659)

I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control? What if they could be taught to physically move to escape a potentially threatening situation that was similar to the trauma in which they had been trapped and immobilized? (Location 666)

Scared animals return home, regardless of whether home is safe or frightening. (Location 673)

Freud had a term for such traumatic reenactments: “the compulsion to repeat.” He and many of his followers believed that reenactments were an unconscious attempt to get control over a painful situation and that they eventually could lead to mastery and resolution. There is no evidence for that theory—repetition leads only to further pain and self-hatred. In fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation. (Location 690)

Having observed that 75 percent of severely wounded soldiers on the Italian front did not request morphine, a surgeon by the name of Henry K. Beecher speculated that “strong emotions can block pain.” 16 Were Beecher’s observations relevant to people with PTSD? Mark Greenberg, Roger Pitman, Scott Orr, and I decided to ask eight Vietnam combat veterans if they would be willing to take a standard pain test while they watched scenes from a number of movies. The first clip we showed was from Oliver Stone’s graphically violent Platoon (1986), and while it ran we measured how long the veterans could keep their right hands in a bucket of ice water. We then repeated this process with a peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their hands in the painfully cold water 30 percent longer during Platoon. We then calculated that the amount of analgesia produced by watching fifteen minutes of a combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain. (Location 705)

The drug revolution that started out with so much promise may in the end have done as much harm as good. The theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs has become broadly accepted, by the media and the public as well as by the medical profession. 22 In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues. (Location 774)

The SSRIs can be very helpful in making traumatized people less enslaved by their emotions, but they should only be considered adjuncts in their overall treatment. 23 After conducting numerous studies of medications for PTSD, I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems. (Location 781)

Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered. (Location 812)

The brain-disease model overlooks four fundamental truths: (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive. When we ignore these quintessential dimensions of humanity, we deprive people of ways to heal from trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self. (Location 814)

Broca’s area is one of the speech centers of the brain, which is often affected in stroke patients when the blood supply to that region is cut off. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. In other words, we had visual proof that the effects of trauma are not necessarily different from—and can overlap with—the effects of physical lesions like strokes. (Location 892)

All trauma is preverbal. (Location 896)

Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies reexperience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate. (Location 900)

This doesn’t mean that people can’t talk about a tragedy that has befallen them. Sooner or later most survivors, like the veterans in chapter 1, come up with what many of them call their “cover story” that offers some explanation for their symptoms and behavior for public consumption. These stories, however, rarely capture the inner truth of the experience. (Location 903)

Note: Cover story

When words fail, haunting images capture the experience and return as nightmares and flashbacks. (Location 908)

Similar sensations often trigger a flashback that brings them back into consciousness, apparently unmodified by the passage of time. (Location 914)

Under ordinary circumstances the two sides of the brain work together more or less smoothly, even in people who might be said to favor one side over the other. However, having one side or the other shut down, even temporarily, or having one side cut off entirely (as sometimes happened in early brain surgery) is disabling. Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. (Broca’s area, which blacks out during flashbacks, is on the left side.) Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future. People who are very upset sometimes say they are “losing their minds.” In technical terms they are experiencing the loss of executive functioning. (Location 931)

When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present. But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they are just furious, terrified, enraged, ashamed, or frozen. After the emotional storm passes, they may look for something or somebody to blame for it. They behaved the way they did way because you were ten minutes late, or because you burned the potatoes, or because you “never listen to me.” Of course, most of us have done this from time to time, but when we cool down, we hopefully can admit our mistake. Trauma interferes with this kind of awareness, and, over time, our research demonstrated why. (Location 938)

The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli. The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability, and sleep disorders. They also contribute to many long-term health issues, depending on which body system is most vulnerable in a particular individual. (Location 951)

For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we’ve seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them—to tell a story of victimization and revenge—than to notice, feel, and put into words the reality of their internal experience. (Location 967)

During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars. (Location 996)

traumatized people become stuck, stopped in their growth because they can’t integrate new experiences into their lives. I was very moved when the veterans of Patton’s army gave me a World War II army-issue watch for Christmas, but it was a sad memento of the year their lives had effectively stopped: 1944. Being traumatized means continuing to organize your life as if the trauma were still going on—unchanged and immutable—as every new encounter or event is contaminated by the past. (Location 1005)

After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases. This explains why it is critical for trauma treatment to engage the entire organism, body, mind, and brain. (Location 1012)

Effective action versus immobilization. Effective action (the result of fight/ flight) ends the threat. Immobilization keeps the body in a state of inescapable shock and learned helplessness. (Location 1025)

If for some reason the normal response is blocked—for example, when people are held down, trapped, or otherwise prevented from taking effective action, be it in a war zone, a car accident, domestic violence, or a rape—the brain keeps secreting stress chemicals, and the brain’s electrical circuits continue to fire in vain. 2 Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists. (Location 1030)

The most important job of the brain is to ensure our survival, even under the most miserable conditions. Everything else is secondary. In order to do that, brains need to: (1) generate internal signals that register what our bodies need, such as food, rest, protection, sex, and shelter; (2) create a map of the world to point us where to go to satisfy those needs; (3) generate the necessary energy and actions to get us there; (4) warn us of dangers and opportunities along the way; and (5) adjust our actions based on the requirements of the moment. 4 And since we human beings are mammals, creatures that can only survive and thrive in groups, all of these imperatives require coordination and collaboration. Psychological problems occur when our internal signals don’t work, when our maps don’t lead us where we need to go, when we are too paralyzed to move, when our actions do not correspond to our needs, or when our relationships break down. (Location 1041)

Our rational, cognitive brain is actually the youngest part of the brain and occupies only about 30 percent of the area inside our skull. (Location 1049)

It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal. Any effective treatment for trauma has to address these basic housekeeping functions of the body. (Location 1063)

The limbic system is shaped in response to experience, in partnership with the infant’s own genetic makeup and inborn temperament. (Location 1068)

Taken together the reptilian brain and limbic system make up what I’ll call the “emotional brain” throughout this book. 6 The emotional brain is at the heart of the central nervous system, and its key task is to look out for your welfare. If it detects danger or a special opportunity—such as a promising partner—it alerts you by releasing a squirt of hormones. The resulting visceral sensations (ranging from mild queasiness to the grip of panic in your chest) will interfere with whatever your mind is currently focused on and get you moving—physically and mentally—in a different direction. Even at their most subtle, these sensations have a huge influence on the small and large decisions we make throughout our lives: what we choose to eat, where we like to sleep and with whom, what music we prefer, whether we like to garden or sing in a choir, and whom we befriend and whom we detest. (Location 1080)

The emotional brain’s cellular organization and biochemistry are simpler than those of the neocortex, our rational brain, and it assesses incoming information in a more global way. As a result, it jumps to conclusions based on rough similarities, in contrast with the rational brain, which is organized to sort through a complex set of options. (Location 1086)

The emotional brain initiates preprogrammed escape plans, like the fight-or-flight responses. These muscular and physiological reactions are automatic, set in motion without any thought or planning on our part, leaving our conscious, rational capacities to catch up later, often well after the threat is over. (Location 1089)

Crucial for understanding trauma, the frontal lobes are also the seat of empathy—our ability to “feel into” someone else. (Location 1104)

One writer compared mirror neurons to “neural WiFi” 9—we pick up not only another person’s movement but her emotional state and intentions as well. When people are in sync with each other, they tend to stand or sit similar ways, and their voices take on the same rhythms. But our mirror neurons also make us vulnerable to others’ negativity, so that we respond to their anger with fury or are dragged down by their depression. I’ll have more to say about mirror neurons later in this book, because trauma almost invariably involves not being seen, not being mirrored, and not being taken into account. (Location 1113)

The brain develops from the bottom up. The reptilian brain develops in the womb and organizes basic life sustaining functions. It is highly responsive to threat throughout our entire life span. The limbic system is organized mainly during the first six years of life but continues to evolve in a use-dependent manner. Trauma can have a major impact of its functioning throughout life. The prefrontal cortex develops last, and also is affected by trauma exposure, including being unable to filter out irrelevant information. Throughout life it is vulnerable to go off-line in response to threat. (Location 1120)

Our frontal lobes can also (sometimes, but not always) stop us from doing things that will embarrass us or hurt others. We don’t have to eat every time we’re hungry, kiss anybody who rouses our desires, or blow up every time we’re angry. But it is exactly on that edge between impulse and acceptable behavior where most of our troubles begin. The more intense the visceral, sensory input from the emotional brain, the less capacity the rational brain has to put a damper on it. (Location 1129)

Danger is a normal part of life, and the brain is in charge of detecting it and organizing our response. Sensory information about the outside world arrives through our eyes, nose, ears, and skin. These sensations converge in the thalamus, an area inside the limbic system that acts as the “cook” within the brain. The thalamus stirs all the input from our perceptions into a fully blended autobiographical soup, an integrated, coherent experience of “this is what is happening to me.” 10 The sensations are then passed on in two directions—down to the amygdala, two small almond-shaped structures that lie deeper in the limbic, unconscious brain, and up to the frontal lobes, where they reach our conscious awareness. The neuroscientist Joseph LeDoux calls the pathway to the amygdala “the low road,” which is extremely fast, and that to the frontal cortex the “high road,” which takes several milliseconds longer in the midst of an overwhelmingly threatening experience. However, processing by the thalamus can break down. Sights, sounds, smells, and touch are encoded as isolated, dissociated fragments, and normal memory processing disintegrates. Time freezes, so that the present danger feels like it will last forever. (Location 1133)

The central function of the amygdala, which I call the brain’s smoke detector, is to identify whether incoming input is relevant for our survival. (Location 1142)

If the amygdala senses a threat—a potential collision with an oncoming vehicle, a person on the street who looks threatening—it sends an instant message down to the hypothalamus and the brain stem, recruiting the stress-hormone system and the autonomic nervous system (ANS) to orchestrate a whole-body response. Because the amygdala processes the information it receives from the thalamus faster than the frontal lobes do, it decides whether incoming information is a threat to our survival even before we are consciously aware of the danger. By the time we realize what is happening, our body may already be on the move. (Location 1145)

The emotional brain has first dibs on interpreting incoming information. Sensory Information about the environment and body state received by the eyes, ears, touch, kinesthetic sense, etc., converges on the thalamus, where it is processed, and then passed on to the amygdala to interpret its emotional significance. This occurs with lightning speed. If a threat is detected the amygdala sends messages to the hypothalamus to secrete stress hormones to defend against that threat. (Location 1150)

While the smoke detector is usually pretty good at picking up danger clues, trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe. You can get along with other people only if you can accurately gauge whether their intentions are benign or dangerous. Even a slight misreading can lead to painful misunderstandings in relationships at home and at work. (Location 1161)

Faulty alarm systems lead to blowups or shutdowns in response to innocuous comments or facial expressions. (Location 1165)

If the amygdala is the smoke detector in the brain, think of the frontal lobes—and specifically the medial prefrontal cortex (MPFC), 12 located directly above our eyes—as the watchtower, (Location 1167)

As long as you are not too upset, your frontal lobes can restore your balance by helping you realize that you are responding to a false alarm and abort the stress response. (Location 1171)

Being able to hover calmly and objectively over our thoughts, feelings, and emotions (an ability I’ll call mindfulness throughout this book) and then take our time to respond allows the executive brain to inhibit, organize, and modulate the hardwired automatic reactions preprogrammed into the emotional brain. (Location 1173)

Neuroimaging studies of human beings in highly emotional states reveal that intense fear, sadness, and anger all increase the activation of subcortical brain regions involved in emotions and significantly reduce the activity in various areas in the frontal lobe, particularly the MPFC. When that occurs, the inhibitory capacities of the frontal lobe break down, and people “take leave of their senses”: They may startle in response to any loud sound, become enraged by small frustrations, or freeze when somebody touches them. (Location 1185)

Effectively dealing with stress depends upon achieving a balance between the smoke detector and the watchtower. If you want to manage your emotions better, your brain gives you two options: You can learn to regulate them from the top down or from the bottom up. (Location 1189)

Knowing the difference between top down and bottom up regulation is central for understanding and treating traumatic stress. Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations. Mindfulness meditation and yoga can help with this. Bottom-up regulation involves recalibrating the autonomic nervous system, (which, as we have seen, originates in the brain stem). We can access the ANS through breath, movement, or touch. Breathing is one of the few body functions under both conscious and autonomic control. (Location 1191)

For now I want to emphasize that emotion is not opposed to reason; our emotions assign value to experiences and thus are the foundation of reason. Our self-experience is the product of the balance between our rational and our emotional brains. When these two systems are in balance, we “feel like ourselves.” However, when our survival is at stake, these systems can function relatively independently. (Location 1196)

Psychologists usually try to help people use insight and understanding to manage their behavior. However, neuroscience research shows that very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention. When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it. (Location 1208)

Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed. (Location 1241)

Flashbacks and reliving are in some ways worse that the trauma itself. A traumatic event has a beginning and an end—at some point it is over. But for people with PTSD a flashback can occur at any time, whether they are awake or asleep. There is no way of knowing when it’s going to occur again or how long it will last. (Location 1246)

If elements of the trauma are replayed again and again, the accompanying stress hormones engrave those memories ever more deeply in the mind. Ordinary, day-to-day events become less and less compelling. Not being able to deeply take in what is going on around them makes it impossible to feel fully alive. It becomes harder to feel the joys and aggravations of ordinary life, harder to concentrate on the tasks at hand. Not being fully alive in the present keeps them more firmly imprisoned in the past. (Location 1252)

Intense and barely controllable urges and emotions make people feel crazy—and makes them feel they don’t belong to the human race. Feeling numb during birthday parties for your kids or in response to the death of loved ones makes people feel like monsters. As a result, shame becomes the dominant emotion and hiding the truth the central preoccupation. (Location 1262)

The trauma that started “out there” is now played out on the battlefield of their own bodies, usually without a conscious connection between what happened back then and what is going on right now inside. The challenge is not so much learning to accept the terrible things that have happened but learning how to gain mastery over one’s internal sensations and emotions. Sensing, naming, and identifying what is going on inside is the first step to recovery. (Location 1267)

It’s important to have an efficient smoke detector: You don’t want to get caught unawares by a raging fire. But if you go into a frenzy every time you smell smoke, it becomes intensely disruptive. Yes, you need to detect whether somebody is getting upset with you, but if your amygdala goes into overdrive, you may become chronically scared that people hate you, or you may feel like they are out to get you. (Location 1278)

Both Stan and Ute had become hypersensitive and irritable after the accident, suggesting that their prefrontal cortex was struggling to maintain control in the face of stress. (Location 1282)

Two brain systems are relevant for the mental processing of trauma: those dealing with emotional intensity and context. Emotional intensity is defined by the smoke alarm, the amygdala, and its counterweight, the watchtower, the medial prefrontal cortex. The context and meaning of an experience are determined by the system that includes the dorsolateral prefrontal cortex (DLPFC) and the hippocampus. The DLPFC is located to the side in the front brain, while the MPFC is in the center. The structures along the midline of the brain are devoted to your inner experience of yourself, those on the side are more concerned with your relationship with your surroundings. The DLPFC tells us how our present experience relates to the past and how it may affect the future—you can think of it as the timekeeper of the brain. Knowing that whatever is happening is finite and will sooner or later come to an end makes most experiences tolerable. The opposite is also true—situations become intolerable if they feel interminable. (Location 1286)

Trauma is the ultimate experience of “this will last forever.” (Location 1294)

Stan’s scan reveals why people can recover from trauma only when the brain structures that were knocked out during the original experience—which is why the event registered in the brain as trauma in the first place—are fully online. (Location 1295)

Visiting the past in therapy should be done while people are, biologically speaking, firmly rooted in the present and feeling as calm, safe, and grounded as possible. (Location 1296)

Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past. For that to happen, the brain’s watchtower, cook, and timekeeper need to be online. (Location 1299)

Therapy won’t work as long as people keep being pulled back into the past. (Location 1300)

Breakdown of the thalamus explains why trauma is primarily remembered not as a story, a narrative with a beginning middle and end, but as isolated sensory imprints: images, sounds, and physical sensations that are accompanied by intense emotions, usually terror and helplessness. 17 In normal circumstances the thalamus also acts as a filter or gatekeeper. This makes it a central component of attention, concentration, and new learning—all of which are compromised by trauma. (Location 1304)

People with PTSD have their floodgates wide open. Lacking a filter, they are on constant sensory overload. In order to cope, they try to shut themselves down and develop tunnel vision and hyperfocus. (Location 1312)

Anyone who deals with traumatized men, women, or children is sooner or later confronted with blank stares and absent minds, the outward manifestation of the biological freeze reaction. Depersonalization is one symptom of the massive dissociation created by trauma. (Location 1323)

After seeing Ute’s scan, I started to take a very different approach toward blanked-out patients. With nearly every part of their brains tuned out, they obviously cannot think, feel deeply, remember, or make sense out of what is going on. Conventional talk therapy, in those circumstances, is virtually useless. (Location 1329)

This is where a bottom-up approach to therapy becomes essential. The aim is actually to change the patient’s physiology, his or her relationship to bodily sensations. (Location 1337)

Numbing is the other side of the coin in PTSD. Many untreated trauma survivors start out like Stan, with explosive flashbacks, then numb out later in life. While reliving trauma is dramatic, frightening, and potentially self-destructive, over time a lack of presence can be even more damaging. (Location 1341)

The challenge of trauma treatment is not only dealing with the past but, even more, enhancing the quality of day-to-day experience. One reason that traumatic memories become dominant in PTSD is that it’s so difficult to feel truly alive right now. When you can’t be fully here, you go to the places where you did feel alive—even if those places are filled with horror and misery. (Location 1345)

We must most of all help our patients to live fully and securely in the present. In order to do that, we need to help bring those brain structures that deserted them when they were overwhelmed by trauma back. (Location 1350)

Life is about rhythm. We vibrate, our hearts are pumping blood. We are a rhythm machine, that’s what we are.—Mickey Hart (Location 1355)

For Darwin mammalian emotions are fundamentally rooted in biology: They are the indispensable source of motivation to initiate action. Emotions (from the Latin emovere—to move out) give shape and direction to whatever we do, and their primary expression is through the muscles of the face and body. These facial and physical movements communicate our mental state and intention to others: Angry expressions and threatening postures caution them to back off. Sadness attracts care and attention. Fear signals helplessness or alerts us to danger. (Location 1375)

We instinctively read the dynamic between two people simply from their tension or relaxation, their postures and tone of voice, their changing facial expressions. (Location 1379)

Darwin goes on to observe that the fundamental purpose of emotions is to initiate movement that will restore the organism to safety and physical equilibrium. Here is his comment on the origin of what today we would call PTSD: Behaviors to avoid or escape from danger have clearly evolved to render each organism competitive in terms of survival. But inappropriately prolonged escape or avoidance behavior would put the animal at a disadvantage in that successful species preservation demands reproduction which, in turn, depends upon feeding, shelter and mating activities all of which are reciprocals of avoidance and escape. 3 In other words: If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love. For us humans, it means that as long as the mind is defending itself against invisible assaults, our closest bonds are threatened, along with our ability to imagine, plan, play, learn, and pay attention to other people’s needs. (Location 1381)

How many mental health problems, from drug addiction to self-injurious behavior, start as attempts to cope with the unbearable physical pain of our emotions? If Darwin was right, the solution requires finding ways to help people alter the inner sensory landscape of their bodies. (Location 1398)

The sympathetic nervous system (SNS) is responsible for arousal, including the fight-or-flight response (Darwin’s “escape or avoidance behavior”). Almost two thousand years ago the Roman physician Galen gave it the name “sympathetic” because he observed that it functioned with the emotions (sym pathos). The SNS moves blood to the muscles for quick action, partly by triggering the adrenal glands to squirt out adrenaline, which speeds up the heart rate and increases blood pressure. The second branch of the ANS is the parasympathetic (“ against emotions”) nervous system (PNS), which promotes self-preservative functions like digestion and wound healing. It triggers the release of acetylcholine to put a brake on arousal, slowing the heart down, relaxing muscles, and returning breathing to normal. (Location 1409)

There is a simple way to experience these two systems for yourself. Whenever you take a deep breath, you activate the SNS. The resulting burst of adrenaline speeds up your heart, which explains why many athletes take a few short, deep breaths before starting competition. Exhaling, in turn, activates the PNS, which slows down the heart. If you take a yoga or a meditation class, your instructor will probably urge you to pay particular attention to the exhalation, since deep, long breaths out help calm you down. As we breathe, we continually speed up and slow down the heart, and because of that the interval between two successive heartbeats is never precisely 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. (Location 1416)

It clarified why knowing that we are seen and heard by the important people in our lives can make us feel calm and safe, and why being ignored or dismissed can precipitate rage reactions or mental collapse. It helped us understand why focused attunement with another person can shift us out of disorganized and fearful states. 8 In short, Porges’s theory made us look beyond the effects of fight or flight and put social relationships front and center in our understanding of trauma. (Location 1431)

Note: Polyvagal theory

Human beings are astoundingly attuned to subtle emotional shifts in the people (and animals) around them. Slight changes in the tension of the brow, wrinkles around the eyes, curvature of the lips, and angle of the neck quickly signal to us how comfortable, suspicious, relaxed, or frightened someone is. 9 Our mirror neurons register their inner experience, and our own bodies make internal adjustments to whatever we notice. Just so, the muscles of our own faces give others clues about how calm or excited we feel, whether our heart is racing or quiet, and whether we’re ready to pounce on them or run away. When the message we receive from another person is “You’re safe with me,” we relax. If we’re lucky in our relationships, we also feel nourished, supported, and restored as we look into the face and eyes of the other. (Location 1435)

Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe. We are part of that tribe even when we are by ourselves, whether listening to music (that other people created), watching a basketball game on television (our own muscles tensing as the players run and jump), or preparing a spreadsheet for a sales meeting (anticipating the boss’s reactions). Most of our energy is devoted to connecting with others. (Location 1442)

If we look beyond the list of specific symptoms that entail formal psychiatric diagnoses, we find that almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (as in the case of habitually becoming enraged, shut down, overexcited, or disorganized). Usually it’s a combination of both. The standard medical focus on trying to discover the right drug to treat a particular “disorder” tends to distract us from grappling with how our problems interfere with our functioning as members of our tribe. (Location 1445)

Note: Tribe

Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma. Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart. (Location 1452)

For our physiology to calm down, heal, and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities. (Location 1456)

Many traumatized people find themselves chronically out of sync with the people around them. Some find comfort in groups where they can replay their combat experiences, rape, or torture with others who have similar backgrounds or experiences. Focusing on a shared history of trauma and victimization alleviates their searing sense of isolation, but usually at the price of having to deny their individual differences: Members can belong only if they conform to the common code. (Location 1459)

Isolating oneself into a narrowly defined victim group promotes a view of others as irrelevant at best and dangerous at worst, which eventually only leads to further alienation. Gangs, extremist political parties, and religious cults may provide solace, but they rarely foster the mental flexibility needed to be fully open to what life has to offer and as such cannot liberate their members from their traumas. Well-functioning people are able to accept individual differences and acknowledge the humanity of others. (Location 1462)

After trauma the world is experienced with a different nervous system that has an altered perception of risk and safety. Porges coined the word “neuroception” to describe the capacity to evaluate relative danger and safety in one’s environment. When we try to help people with faulty neuroception, the great challenge is finding ways to reset their physiology, so that their survival mechanisms stop working against them. (Location 1470)

Porges’s theory provides an explanation: The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time. Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse. This is where the many-branched vagus nerve comes in, and I’ll describe its anatomy briefly because it’s central to understanding how people deal with trauma. The social-engagement system depends on nerves that have their origin in the brain stem regulatory centers, primarily the vagus—also known as the tenth cranial nerve—together with adjoining nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx. When the “ventral vagal complex” (VVC) runs the show, we smile when others smile at us, we nod our heads when we agree, and we frown when friends tell us of their misfortunes. When the VVC is engaged, it also sends signals down to our heart and lungs, slowing down our heart rate and increasing the depth of breathing. As a result, we feel calm and relaxed, centered, or pleasurably aroused. The many-branched vagus. The vagus nerve (which Darwin called the pneumogastric nerve) registers heartbreak and gut-wrenching feelings. When a person becomes upset, the throat gets dry, the voice becomes tense, the heart speeds up, and respiration becomes rapid and shallow. COURTESY OF NED KALIN, MD Three responses to threat. 1. The soci...

...al engagement system: an alarmed monkey signals danger and calls for help. VVC. 2. Fight or flight: Teeth bared, the face of rage and terror. SNS. 3. Collapse: The body signals defeat and withdraws. DVC. Any threat to our safety or social connections triggers changes in the areas innervated by the VVC. When something distressing happens, we automatically signal our upset in our facial expressions and tone of voice, changes meant to beckon others to come to our assistance. 11 However, if no one responds to our call for help, the threat increases, and the older limbic brain jumps in. The sympathetic nervous system takes over, mobilizing muscles, heart, and lungs for fight or flight. 12 Our voice becomes faster and more strident and our heart starts pumping faster. If a dog is in the room, she will stir and growl, because she can smell the activation of our sweat glands. Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart “drop”), we can’t breathe, and our gut stops working or empties (literally “scaring the shit out of” us). This is the point at which we disengage, collapse, and freeze. (Location 1479)

Danger turns off our social-engagement system, decreases our responsiveness to the human voice, and increases our sensitivity to threatening sounds. (Location 1517)

Collapse and disengagement are controlled by the DVC, an evolutionarily ancient part of the parasympathetic nervous system that is associated with digestive symptoms like diarrhea and nausea. It also slows down the heart and induces shallow breathing. Once this system takes over, other people, and we ourselves, cease to matter. Awareness is shut down, and we may no longer even register physical pain. (Location 1523)

Newborn babies are not very social; they sleep most of the time and wake up when they’re hungry or wet. After having been fed they may spend a little time looking around, fussing, or staring, but they will soon be asleep again, following their own internal rhythms. Early in life they are pretty much at the mercy of the alternating tides of their sympathetic and parasympathetic nervous systems, and their reptilian brain runs most of the show. But day by day, as we coo and smile and cluck at them, we stimulate the growth of synchronicity in the developing VVC. These interactions help to bring our babies’ emotional arousal systems into sync with their surroundings. The VVC controls sucking, swallowing, facial expression, and the sounds produced by the larynx. When these functions are stimulated in an infant, they are accompanied by a sense of pleasure and safety, which helps create the foundation for all future social behavior. 14 As my friend Ed Tronick taught me a long time ago, the brain is a cultural organ—experience shapes the brain. (Location 1531)

Immobilization is at the root of most traumas. When that occurs the DVC is likely to take over: Your heart slows down, your breathing becomes shallow, and, zombielike, you lose touch with yourself and your surroundings. You dissociate, faint and collapse. (Location 1544)

DEFEND OR RELAX? Steve Porges helped me realize that the natural state of mammals is to be somewhat on guard. However, in order to feel emotionally close to another human being, our defensive system must temporarily shut down. In order to play, mate, and nurture our young, the brain needs to turn off its natural vigilance. Many traumatized individuals are too hypervigilant to enjoy the ordinary pleasures that life has to offer, while others are too numb to absorb new experiences—or to be alert to signs of real danger. When the smoke detectors of the brain malfunction, people no longer run when they should be trying to escape or fight back when they should be defending themselves. (Location 1546)

It is especially challenging for traumatized people to discern when they are actually safe and to be able to activate their defenses when they are in danger. This requires having experiences that can restore the sense of physical safety, (Location 1557)

From simple, rhythmically attuned movements, Steve had created a small, safe place where the social-engagement system could begin to reemerge. In the same way, severely traumatized people may get more out of simply helping to arrange chairs before a meeting or joining others in tapping out a musical rhythm on the chair seats than they would from sitting in those same chairs and discussing the failures in their life. (Location 1566)

One thing is certain: Yelling at someone who is already out of control can only lead to further dysregulation. (Location 1569)

Just as your dog cowers if you shout and wags his tail when you speak in a high singsong, we humans respond to harsh voices with fear, anger, or shutdown and to playful tones by opening up and relaxing. (Location 1570)

We simply cannot help but respond to these indicators of safety or danger. Sadly, our educational system, as well as many of the methods that profess to treat trauma, tend to bypass this emotional-engagement system and focus instead on recruiting the cognitive capacities of the mind. (Location 1571)

The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement. When children are oppositional, defensive, numbed out, or enraged, it’s also important to recognize that such “bad behavior” may repeat action patterns that were established to survive serious threats, even if they are intensely upsetting or off-putting. (Location 1574)

The body keeps the score: 17 If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/ muscular problems, and if mind/ brain/ visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions. (Location 1588)

Be patient toward all that is unsolved in your heart and try to love the questions themselves. . . . Live the questions now. Perhaps you will gradually, without noticing it, live along some distant day into the answer.—Rainer Maria Rilke, Letters to a Young Poet (Location 1593)

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. (Location 1605)

Not being seen, not being known, and having nowhere to turn to feel safe is devastating at any age, but it is particularly destructive for young children, who are still trying to find their place in the world. (Location 1607)

However, in my experience, patients who cut themselves or pick at their skin like Sherry, are seldom suicidal but are trying to make themselves feel better in the only way they know. This is a difficult concept for many people to understand. As I discussed in the previous chapter, the most common response to distress is to seek out people we like and trust to help us and give us the courage to go on. We may also calm down by engaging in a physical activity like biking or going to the gym. We start learning these ways of regulating our feelings from the first moment someone feeds us when we’re hungry, covers us when we’re cold, or rocks us when we’re hurt or scared. But if no one has ever looked at you with loving eyes or broken out in a smile when she sees you; if no one has rushed to help you (but instead said, “Stop crying, or I’ll give you something to cry about”), then you need to discover other ways of taking care of yourself. (Location 1617)

Sherry was one of the first patients who taught me about the extreme disconnection from the body that so many people with histories of trauma and neglect experience. I discovered that my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves. Sherry knew that picking her skin was a destructive thing to do and that it was related to her mother’s neglect, but understanding the source of the impulse made no difference in helping her control it. LOSING YOUR BODY Once I was alerted to this, I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. (Location 1629)

Recognizing an object in the palm of your hand requires sensing its shape, weight, temperature, texture, and position. Each of those distinct sensory experiences is transmitted to a different part of the brain, which then needs to integrate them into a single perception. McFarlane found that people with PTSD often have trouble putting the picture together. (Location 1638)

When our senses become muffled, we no longer feel fully alive. (Location 1641)

What is your brain doing when you have nothing in particular on your mind? It turns out that you pay attention to yourself: The default state activates the brain areas that work together to create your sense of “self.” (Location 1658)

Markeren(geel) - 6. LOSING YOUR BODY, LOSING YOUR SELF > Locatie 1676 (Location 1666)

In response to the trauma itself, and in coping with the dread that persisted long afterward, these patients had learned to shut down the brain areas that transmit the visceral feelings and emotions that accompany and define terror. Yet in everyday life, those same brain areas are responsible for registering the entire range of emotions and sensations that form the foundation of our self-awareness, our sense of who we are. (Location 1676)

The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction. I used to be surprised by how often my patients asked me for advice about the most ordinary things, and then by how rarely they followed it. (Location 1680)

The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror. Brain scans show that this is not the result of mere inattention: The structures in charge of self-recognition may be knocked out along with the structures related to self-experience. (Location 1684)

The implications are clear: to feel present you have to know where you are and be aware of what is going on with you. If the self-sensing system breaks down we need to find ways to reactivate it. (Location 1689)

The Feeling of What Happens is, for me, his most important book, and reading it was a revelation. 5 Damasio starts by pointing out the deep divide between our sense of self and the sensory life of our bodies. As he poetically explains, “Sometimes we use our minds not to discover facts, but to hide them. . . . One of the things the screen hides most effectively is the body, our own body, by which I mean the ins of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day.” (Location 1699)

We need to register and act on our physical sensations to keep our bodies safe. (Location 1725)

It is not possible to manage life and maintain homeostatic balance without data on the current state of the organism’s body.” 9 Damasio calls these housekeeping areas of the brain the “proto-self,” because they create the “wordless knowledge” that underlies our conscious sense of self. (Location 1730)

THE SELF UNDER THREAT In 2000 Damasio and his colleagues published an article in the world’s foremost scientific publication, Science, which reported that reliving a strong negative emotion causes significant changes in the brain areas that receive nerve signals from the muscles, gut, and skin—areas that are crucial for regulating basic bodily functions. The team’s brain scans showed that recalling an emotional event from the past causes us to actually reexperience the visceral sensations felt during the original event. (Location 1732)

The elementary self system in the brain stem and limbic system is massively activated when people are faced with the threat of annihilation, which results in an overwhelming sense of fear and terror accompanied by intense physiological arousal. To people who are reliving a trauma, nothing makes sense; they are trapped in a life-or-death situation, a state of paralyzing fear or blind rage. Mind and body are constantly aroused, as if they are in imminent danger. They startle in response to the slightest noises and are frustrated by small irritations. Their sleep is chronically disturbed, and food often loses its sensual pleasures. This in turn can trigger desperate attempts to shut those feelings down by freezing and dissociation. (Location 1741)

“Agency” is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances. (Location 1749)

Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilize to manage them. But we can’t do this unless our watchtower, the MPFC, learns to observe what is going on inside us. This is why mindfulness practice, which strengthens the MPFC, is a cornerstone of recovery from trauma. (Location 1753)

Many of my patients have survived trauma through tremendous courage and persistence, only to get into the same kinds of trouble over and over again. Trauma has shut down their inner compass and robbed them of the imagination they need to create something better. (Location 1762)

Our gut feelings signal what is safe, life sustaining, or threatening, even if we cannot quite explain why we feel a particular way. Our sensory interiority continuously sends us subtle messages about the needs of our organism. Gut feelings also help us to evaluate what is going on around us. (Location 1770)

If you have a comfortable connection with your inner sensations—if you can trust them to give you accurate information—you will feel in charge of your body, your feelings, and your self. However, traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves. (Location 1773)

The more people try to push away and ignore internal warning signs, the more likely they are to take over and leave them bewildered, confused, and ashamed. People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic—they develop a fear of fear itself. We now know that panic symptoms are maintained largely because the individual develops a fear of the bodily sensations associated with panic attacks. The attack may be triggered by something he or she knows is irrational, but fear of the sensations keeps them escalating into a full-body emergency. “Scared stiff” and “frozen in fear” (collapsing and going numb) describe precisely what terror and trauma feel like. They are its visceral foundation. The experience of fear derives from primitive responses to threat where escape is thwarted in some way. People’s lives will be held hostage to fear until that visceral experience changes. (Location 1777)

The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation—from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others. (Location 1784)

Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body. (Location 1792)

three years she was my patient. Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. (Location 1795)

Her body felt the sadness that her mind couldn’t register—she was leaving our young family, her closest living relatives. Psychiatrists call this phenomenon alexithymia—Greek for not having words for feelings. Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean. They may look furious but deny that they are angry; they may appear terrified but say that they are fine. Not being able to discern what is going on inside their bodies causes them to be out of touch with their needs, and they have trouble taking care of themselves, whether it involves eating the right amount at the right time or getting the sleep they need. Like my aunt, alexithymics substitute the language of action for that of emotion. (Location 1806)

They tend to register emotions as physical problems rather than as signals that something deserves their attention. (Location 1814)

Krystal, himself a concentration camp survivor, found that many of his patients were professionally successful, but their intimate relationships were bleak and distant. Suppressing their feelings had made it possible to attend to the business of the world, but at a price. They learned to shut down their once overwhelming emotions, and, as a result, they no longer recognized what they were feeling. (Location 1821)

Frewen and his colleague Ruth Lanius found that the more people were out of touch with their feelings, the less activity they had in the self-sensing areas of the brain. 22 Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming “spaced out” or with excessive anger. (Location 1827)

People with alexithymia can get better only by learning to recognize the relationship between their physical sensations and their emotions, much as colorblind people can only enter the world of color by learning to distinguish and appreciate shades of gray. (Location 1833)

One step further down on the ladder to self-oblivion is depersonalization—losing your sense of yourself. (Location 1837)

Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. (Location 1856)

In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past. How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them. Noticing sensations for the first time can be quite distressing, and it may precipitate flashbacks in which people curl up or assume defensive postures. These are somatic reenactments of the undigested trauma and most likely represent the postures they assumed when the trauma occurred. (Location 1858)

Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies. The most natural way for human beings to calm themselves when they are upset is by clinging to another person. (Location 1871)

The mind needs to be reeducated to feel physical sensations, and the body needs to be helped to tolerate and enjoy the comforts of touch. (Location 1873)

Many patients who come to my office are unable to make eye contact. I immediately know how distressed they are by their difficulty meeting my gaze. (Location 1879)

The most striking difference between normal controls and survivors of chronic trauma was in activation of the prefrontal cortex in response to a direct eye gaze. The prefrontal cortex (PFC) normally helps us to assess the person coming toward us, and our mirror neurons help to pick up his intentions. However, the subjects with PTSD did not activate any part of their frontal lobe, which means they could not muster any curiosity about the stranger. (Location 1886)

Note: Curiosity

In response to being looked at they simply went into survival mode. (Location 1891)

While you need to be able to stand up for yourself, you also need to recognize that other people have their own agendas. Trauma can make all that hazy and gray. (Location 1894)

The roots of resilience . . . are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other.—Diana Fosha (Location 1899)

We could only conclude that for abused children, the whole world is filled with triggers. As long as they can imagine only disastrous outcomes to relatively benign situations, anybody walking into a room, any stranger, any image, on a screen or on a billboard might be perceived as a harbinger of catastrophe. In this light the bizarre behavior of the kids at the children’s clinic made perfect sense. (Location 1947)

To my amazement, staff discussions on the unit rarely mentioned the horrific real-life experiences of the children and the impact of those traumas on their feelings, thinking, and self-regulation. Instead, their medical records were filled with diagnostic labels: “conduct disorder” or “oppositional defiant disorder” for the angry and rebellious kids; or “bipolar disorder.” ADHD was a “comorbid” diagnosis for almost all. Was the underlying trauma being obscured by this blizzard of diagnoses? (Location 1951)

We are profoundly social creatures; our lives consist of finding our place within the community of human beings. I love the expression of the great French psychiatrist Pierre Janet: “Every life is a piece of art, put together with all means available.” (Location 1979)

Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage—a kind of buffer against the worst that fate can hand them. (Location 1983)

The more responsive the adult is to the child, the deeper the attachment and the more likely the child will develop healthy ways of responding to the people around him. (Location 1988)

When infants and young children notice that their mothers are not fully engaged with them, they become nervous. (Location 1993)

Bowlby saw attachment as the secure base from which a child moves out into the world. (Location 1995)

From the intimate give-and-take of the attachment bond children learn that other people have feelings and thoughts that are both similar to and different from theirs. In other words, they get “in sync” with their environment and with the people around them and develop the self-awareness, empathy, impulse control, and self-motivation that make it possible to become contributing members of the larger social culture. (Location 1996)

Children become attached to whoever functions as their primary caregiver. But the nature of that attachment—whether it is secure or insecure—makes a huge difference over the course of a child’s life. Secure attachment develops when caregiving includes emotional attunement. Attunement starts at the most subtle physical levels of interaction between babies and their caretakers, and it gives babies the feeling of being met and understood. (Location 2000)

Imitation is our most fundamental social skill. It assures that we automatically pick up and reflect the behavior of our parents, teachers, and peers. (Location 2010)

Tronick and other researchers have now shown that when infants and caregivers are in sync on an emotional level, they’re also in sync physically. 6 Babies can’t regulate their own emotional states, much less the changes in heart rate, hormone levels, and nervous-system activity that accompany emotions. When a child is in sync with his caregiver, his sense of joy and connection is reflected in his steady heartbeat and breathing and a low level of stress hormones. His body is calm; so are his emotions. The moment this music is disrupted—as it often is in the course of a normal day—all these physiological factors change as well. You can tell equilibrium has been restored when the physiology calms down. (Location 2021)

We soothe newborns, but parents soon start teaching their children to tolerate higher levels of arousal, a job that is often assigned to fathers. (I once heard the psychologist John Gottman say, “Mothers stroke, and fathers poke.”) Learning how to manage arousal is a key life skill, and parents must do it for babies before babies can do it for themselves. (Location 2027)

Associating intense sensations with safety, comfort, and mastery is the foundation of self-regulation, self-soothing, and self-nurture, a theme to which I return throughout this book. A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life. 7 Securely attached children learn what makes them feel good; they discover what makes them (and others) feel bad, and they acquire a sense of agency: that their actions can change how they feel and how others respond. Securely attached kids learn the difference between situations they can control and situations where they need help. They learn that they can play an active role when faced with difficult situations. (Location 2031)

The way a mother holds her child underlies “the ability to feel the body as the place where the psyche lives.” 8 This visceral and kinesthetic sensation of how our bodies are met lays the foundation for what we experience as “real.” 9 Winnicott thought that the vast majority of mothers did just fine in their attunement to their infants—it does not require extraordinary talent to be what he called a “good enough mother.” 10 But things can go seriously wrong when mothers are unable to tune in to their baby’s physical reality. If a mother cannot meet her baby’s impulses and needs, “the baby learns to become the mother’s idea of what the baby is.” Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose, and direction. (Location 2041)

Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync. Dr. Seth Pollak of the University of Wisconsin showed a series of faces to a group of normal eight-year-olds and compared their responses with those of a group of abused children the same age. Looking at this spectrum of angry to sad expressions, the abused kids were hyperalert to the slightest features of anger. 11 COPYRIGHT © 2000, AMERICAN PSYCHOLOGICAL ASSOCIATION This is one reason abused children so easily become defensive or scared. Imagine what it’s like to make your way through a sea of faces in the school corridor, trying to figure out who might assault you. Children who overreact to their peers’ aggression, who don’t pick up on other kids’ needs, who easily shut down or lose control of their impulses, are likely to be shunned and left out of sleepovers or play dates. Eventually they may learn to cover up their fear by putting up a tough front. Or they may spend more and more time alone, watching TV or playing computer games, falling even further behind on interpersonal skills and emotional self-regulation. The need for attachment never lessens. Most human beings simply cannot tolerate being disengaged from others for any length of time. People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation. (Location 2058)

Children have a biological instinct to attach—they have no choice. Whether their parents or caregivers are loving and caring or distant, insensitive, rejecting, or abusive, children will develop a coping style based on their attempt to get at least some of their needs met. (Location 2078)

Ainsworth created a research tool called the Strange Situation, which looks at how an infant reacts to temporary separation from the mother. Just as Bowlby had observed, securely attached infants are distressed when their mother leaves them, but they show delight when she returns, and after a brief check-in for reassurance, they settle down and resume their play. But with infants who are insecurely attached, the picture is more complex. Children whose primary caregiver is unresponsive or rejecting learn to deal with their anxiety in two distinct ways. The researchers noticed that some seemed chronically upset and demanding with their mothers, while others were more passive and withdrawn. In both groups contact with the mothers failed to settle them down—they did not return to play contentedly, as happens in secure attachment. In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.” 12 Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies. (Location 2082)

another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.” 13 They seem to have concluded that unless they make a spectacle, nobody is going to pay attention to them. They become enormously upset when they do not know where their mother is but derive little comfort from her return. And even though they don’t seem to enjoy her company, they stay passively or angrily focused on her, even in situations when other children would rather play. 14 Attachment researchers think that the three “organized” attachment strategies (secure, avoidant, and anxious) work because they elicit the best care a particular caregiver is capable of providing. (Location 2093)

Attachment patterns often persist into adulthood. 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. (Location 2100)

But there is another group that is less stably adapted, a group that makes up the bulk of the children we treat and a substantial proportion of the adults who are seen in psychiatric clinics. Some twenty years ago, Mary Main and her colleagues at Berkeley began to identify a group of children (about 15 percent of those they studied) who seemed to be unable to figure out how to engage with their caregivers. The critical issue turned out to be that the caregivers themselves were a source of distress or terror to the children. 16 Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear. 17 They “can neither approach (the secure and ambivalent ‘strategies’), shift [their] attention (the avoidant ‘strategy’), nor flee.” 18 If you observe such children in a nursery school or attachment laboratory, you see them look toward their parents when they enter the room and then quickly turn away. Unable to choose between seeking closeness and avoiding the parent, they may rock on their hands and knees, appear to go into a trance, freeze with their arms raised, or get up to greet their parent and then fall to the ground. Not knowing who is safe or whom they belong to, they may be intensely affectionate with strangers or may trust nobody. Main called this pattern “disorganized attachment.” Disorganized attachment is “fright without solution.” (Location 2105)

With “good enough” caregivers, children learn that broken connections can be repaired. The critical issue is whether they can incorporate a feeling of being viscerally safe with their parents or other caregivers. (Location 2122)

Kids from lower socioeconomic groups are more likely to be disorganized, 22 with parents often severely stressed by economic and family instability. (Location 2128)

Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems. (Location 2129)

Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection. (Location 2135)

In practice it often is difficult to distinguish the problems that result from disorganized attachment from those that result from trauma: They are often intertwined. (Location 2148)

Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are. (Location 2155)

Markeren(geel) - 7. GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT > Locatie 2165 (Location 2157)

If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. (Location 2165)

Disorganized attachment showed up in two different ways: One group of mothers seemed to be too preoccupied with their own issues to attend to their infants. They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs. Another group of mothers seemed helpless and fearful. They often came across as sweet or fragile, but they didn’t know how to be the adult in the relationship and seemed to want their children to comfort them. They failed to greet their children after having been away and did not pick them up when the children were distressed. The mothers didn’t seem to be doing these things deliberately—they simply didn’t know how to be attuned to their kids and respond to their cues and thus failed to comfort and reassure them. The hostile/ intrusive mothers were more likely to have childhood histories of physical abuse and/ or of witnessing domestic violence, while the withdrawn/ dependent mothers were more likely to have histories of sexual abuse or parental loss (but not physical abuse). 35 I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse. (Location 2174)

Karlen and her colleagues had expected that hostile/ intrusive behavior on the part of the mothers would be the most powerful predictor of mental instability in their adult children, but they discovered otherwise. Emotional withdrawal had the most profound and long-lasting impact. Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults. (Location 2190)

Lyons-Ruth concludes that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and to see.” (Location 2197)

Infants who live in secure relationships learn to communicate not only their frustrations and distress but also their emerging selves—their interests, preferences, and goals. (Location 2199)

Dissociation means simultaneously knowing and not knowing. (Location 2203)

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 Maybe the most devastating long-term effect of this shutdown is not feeling real inside, a condition we saw in the kids in the Children’s Clinic and that we see in the children and adults who come to the Trauma Center. When you don’t feel real nothing matters, which makes it impossible to protect yourself from danger. (Location 2204)

Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults. 40 Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. The critical underlying issue was that these patients didn’t know how to feel safe. (Location 2210)

This does not imply that child abuse is irrelevant41, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas. 42 For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation. (Location 2215)

Early attachment patterns create the inner maps that chart our relationships throughout life, not only in terms of what we expect from others, but also in terms of how much comfort and pleasure we can experience in their presence. (Location 2219)

The “night sea journey” is the journey into the parts of ourselves that are split off, disavowed, unknown, unwanted, cast out, and exiled to the various subterranean worlds of consciousness. . . . The goal of this journey is to reunite us with ourselves. Such a homecoming can be surprisingly painful, even brutal. In order to undertake it, we must first agree to exile nothing.—Stephen Cope (Location 2238)

Note: Reunite

It takes time and patience to allow the reality behind such symptoms to reveal itself. (Location 2255)

As the poet W. H. Auden wrote: Truth, like love and sleep, resents Approaches that are too intense. (Location 2273)

I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know. (Location 2276)

Was this some sort of “conversion reaction,” in which patients express their conflicts by losing function in some part of their body? (Location 2286)

Still, as a physician, I wasn’t about to conclude without further assessment that this was “all in her head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary and asked them to do a very thorough workup. Several weeks later the tests came back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was eroding her vision, and she would need immediate treatment. I was appalled: Marilyn was the third person that year whom I’d suspected of having an incest history and who was then diagnosed with an autoimmune disease—a disease in which the body starts attacking itself. (Location 2289)

When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA-to-RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA-to-RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells. Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety. (Location 2298)

When I first encountered patients like Marilyn, I used to challenge their thinking and try to help them see the world in a more positive, flexible way. One day a woman named Kathy set me straight. (Location 2324)

When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.” I genuinely thanked her for her feedback, and I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world. (Location 2333)

Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time. This doesn’t mean, however, that our maps can’t be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs. (Location 2338)

Generally the rational brain can override the emotional brain, as long as our fears don’t hijack us. (Location 2352)

Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable. (Location 2355)

Children have no choice who their parents are, nor can they understand that parents may simply be too depressed, enraged, or spaced out to be there for them or that their parents’ behavior may have little to do with them. Children have no choice but to organize themselves to survive within the families they have. (Location 2410)

Children sense—even if it they are not explicitly threatened—that if they talked about their beatings or molestation to teachers they would be punished. Instead, they focus their energy on not thinking about what has happened and not feeling the residues of terror and panic in their bodies. Because they cannot tolerate knowing what they have experienced, they also cannot understand that their anger, terror, or collapse has anything to do with that experience. They don’t talk; they act and deal with their feelings by being enraged, shut down, compliant, or defiant. Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror. (Location 2413)

Nothing feels safe—least of all your own body. (Location 2428)

In order to know who we are—to have an identity—we must know (or at least feel that we know) what is and what was “real.” We must observe what we see around us and label it correctly; we must also be able trust our memories and be able to tell them apart from our imagination. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called “soul murder.” Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust. (Location 2438)

Trauma is not stored as a narrative with an orderly beginning, middle, and end. (Location 2453)

I gradually came to realize that the only thing that makes it possible to do the work of healing trauma is awe at the dedication to survival that enabled my patients to endure their abuse and then to endure the dark nights of the soul that inevitably occur on the road to recovery. (Location 2458)

The way we define their problems, our diagnosis, will determine how we approach their care. Such patients typically receive five or six different unrelated diagnoses in the course of their psychiatric treatment. If their doctors focus on their mood swings, they will be identified as bipolar and prescribed lithium or valproate. If the professionals are most impressed with their despair, they will be told they are suffering from major depression and given antidepressants. If the doctors focus on their restlessness and lack of attention, they may be categorized as ADHD and treated with Ritalin or other stimulants. And if the clinic staff happens to take a trauma history, and the patient actually volunteers the relevant information, he or she might receive the diagnosis of PTSD. None of these diagnoses will be completely off the mark, and none of them will begin to meaningfully describe who these patients are and what they suffer from. Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts. (Location 2468)

A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo. (Location 2486)

All too often diagnoses are mere tallies of symptoms, (Location 2491)

We were struck by how many of our patients who were diagnosed with borderline personality disorder (BPD) told us horror stories about their childhoods. (Location 2500)

Keeping in mind that people universally feel ashamed about the traumas they have experienced, we designed an interview instrument, the Traumatic Antecedents Questionnaire (TAQ). 3 The interview started with a series of simple questions: “Where do you live, and who do you live with?”; “Who pays the bills and who does the cooking and cleaning?” It progressed gradually to more revealing questions: (Location 2510)

Our patients did not have the option to run away or escape; they had nobody to turn to and no place to hide. Yet they somehow had to manage their terror and despair. They probably went to school the next morning and tried to pretend that everything was fine. Judy and I realized that the BPD group’s problems—dissociation, desperate clinging to whomever might be enlisted to help—had probably started off as ways of dealing with overwhelming emotions and inescapable brutality. (Location 2531)

As we later reported in the American Journal of Psychiatry, 81 percent of the patients diagnosed with BPD at Cambridge Hospital reported severe histories of child abuse and/ or neglect; in the vast majority the abuse began before age seven. 4 This finding was particularly important because it suggested that the impact of abuse depends, at least in part, on the age at which it begins. Later research by Martin Teicher at McLean Hospital showed that different forms of abuse have different impacts on various brain areas at different stages of development. (Location 2540)

When children are pervasively filled with rage, it is due to rejection or harsh treatment. (Location 2551)

Bowlby noticed that when children must disown powerful experiences they have had, this creates serious problems, including “chronic distrust of other people, inhibition of curiosity, distrust of their own senses, and the tendency to find everything unreal.” 7 As we will see, this has important implications for treatment. (Location 2553)

Our study showed that having a history of childhood sexual and physical abuse was a strong predictor of repeated suicide attempts and self-cutting. (Location 2562)

if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop. (Location 2572)

Our study also confirmed that there was a traumatized population quite distinct from the combat soldiers and accident victims for whom the PTSD diagnosis had been created. People like Marilyn and Kathy, as well as the patients Judy and I had studied, and the kids in the outpatient clinic at MMHC that I described in chapter 7, do not necessarily remember their traumas (one of the criteria for the PTSD diagnosis) or at least are not preoccupied with specific memories of their abuse, but they continue to behave as if they were still in danger. (Location 2576)

Not having a diagnosis now confronts therapists with a serious dilemma: How do we treat people who are coping with the fall-out of abuse, betrayal and abandonment when we are forced to diagnose them with depression, panic disorder, bipolar illness, or borderline personality, which do not really address what they are coping with? (Location 2603)

To this day, after twenty years and four subsequent revisions, the DSM and the entire system based on it fail victims of child abuse and neglect—just as they ignored the plight of veterans before PTSD was introduced back in 1980. (Location 2608)

One day a twenty-eight-year-old nurse’s aide showed up in his office. Felitti accepted her claim that obesity was her principal problem and enrolled her in the program. Over the next fifty-one weeks her weight dropped from 408 pounds to 132 pounds. However, when Felitti next saw her a few months later, she had regained more weight than he thought was biologically possible in such a short time. What had happened? It turned out that her newly svelte body had attracted a male coworker, who started to flirt with her and then suggested sex. She went home and began to eat. She stuffed herself during the day and ate while sleepwalking at night. When Felitti probed this extreme reaction, she revealed a lengthy incest history with her grandfather. This was only the second case of incest Felitti had encountered in his twenty-three-year medical practice, and yet about ten days later he heard a similar story. As he and his team started to inquire more closely, they were shocked to discover that most of their morbidly obese patients had been sexually abused as children. They also uncovered a host of other family problems. (Location 2614)

The ACE study revealed that traumatic life experiences during childhood and adolescence are far more common than expected. The study respondents were mostly white, middle class, middle aged, well educated, and financially secure enough to have good medical insurance, and yet only one-third of the respondents reported no adverse childhood experiences. (Location 2633)

In short, Felitti and his team had found that adverse experiences are interrelated, even though they’re usually studied separately. People typically don’t grow up in a household where one brother is in prison but everything else is fine. (Location 2648)

Incidents of abuse are never stand-alone events. (Location 2650)

Antidepressant drugs and painkillers constitute a significant portion of our rapidly rising national health-care expenditures. 16 (Ironically, research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds. 17) (Location 2660)

Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation.—Katie Cannon (Location 3336)

Give sorrow words; the grief that does not speak knits up the o’er wrought heart and bids it break.—William Shakespeare, Macbeth (Location 4159)