Note 1: this book is not a light read. It contains graphic descriptions of horrible events, e.g. childhood sexual abuse, and the effects of traumatizing events.

Note 2: Bessel van der Kolk cites hundreds of scientific studies throughout his book. He also uses footnotes extensively throughout his book to indicate the sources from which he draws various statistics, empirical results, observations, etc. Reproducing all the footnotes and cited studies from Kolk's book here would make this already-long section even longer, so for now I am not going to do so. However, you can of course go check them yourself (and doing so is of course good epistemic practice.) You can get the book here on Amazon.
 

• Prologue - Facing Trauma
  • "Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beaten by a parent to the point of a mark being left on their body; and one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives, and one out of eight witnessed their mother being beaten or hit."
  • "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."
  • "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. 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. This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions. These posttraumatic reactions feel incomprehensible and overwhelming. Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption."
  • "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. We now know that trauma compromises the brain area that communicates the physical, embodied feeling of being alive. These changes explain why traumatized individuals become hypervigilant to threat at the expense of spontaneously engaging in their day-to-day lives. They also help us understand why traumatized people so often keep repeating the same problems and have such trouble learning from experience. We now know that their behaviors are not the result of moral failing."
• Chapter 1 - Lessons From Vietnam Veterans
  • "Kardiner reported the same phenomena I was seeing: After the war his patients {World War I veterans} were overtaken by a sense of futility; they became withdrawn and detached, even if they had functioned well before. What Kardiner called “traumatic neuroses,” today we call posttraumatic stress disorder—PTSD. 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. ” 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."
  • "Working at the VA {Boston Veterans Administration Clinic} I soon discovered how excruciating it can be to face reality. This was true both for my patients and for myself. We don’t really want to know what soldiers go through in combat. We do not really want to know how many children are being molested and abused in our own society or how many couples—almost a third, as it turns out—engage in violence at some point during their relationship. We want to think of families as safe havens in a heartless world and of our own country as populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places like Darfur or the Congo. 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?"
  • "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?"
  • "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. In later years I encountered a similar phenomenon in victims of child abuse: Most of them suffer from agonizing shame about the actions they took to survive and maintain a connection with the person who abused them. This was particularly true if the abuser was someone close to the child, someone the child depended on, as is so often the case. The result can be confusion about whether one was a victim or a willing participant, which in turn leads to bewilderment about the difference between love and terror; pain and pleasure."
  • "Experiencing Bill’s flashback firsthand in my office helped me realize the agony that regularly visited the veterans I was trying to treat and helped me appreciate again how critical it was to find a solution. The traumatic event itself, however horrendous, had a beginning, a middle, and an end, but I now saw that flashbacks could be even worse. You never know when you will be assaulted by them again and you have no way of telling when they will stop...When we gave the Rorschach test to twenty-one additional veterans, the response was consistent: Sixteen of them, on seeing the second card, reacted as if they were experiencing a wartime trauma. The second Rorschach card is the first card that contains color and often elicits so-called color shock in response. The veterans interpreted this card with descriptions like “These are the bowels of my friend Jim after a mortar shell ripped him open” and “This is the neck of my friend Danny after his head was blown off by a shell while we were eating lunch. ” None of them mentioned dancing monks, fluttering butterflies, men on motorcycles, or any of the other ordinary, sometimes whimsical images that most people see. While the majority of the veterans were greatly upset by what they saw, the reactions of the remaining five were even more alarming: They simply went blank. “This is nothing, ” one observed, “just a bunch of ink. ” They were right, of course, but the normal human response to ambiguous stimuli is to use our imagination to read something into them. 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...The Rorschach tests also taught us that traumatized people look at the world in a fundamentally different way from other people. For most of us a man coming down the street is just someone taking a walk. A rape victim, however, may see a person who is about to molest her and go into a panic. A stern schoolteacher may be an intimidating presence to an average kid, but for a child whose stepfather beats him up, she may represent a torturer and precipitate a rage attack or a terrified cowering in the corner."
  • "In those early days at the VA, we labeled our veterans with all sorts of diagnoses—alcoholism, substance abuse, depression, mood disorder, even schizophrenia—and we tried every treatment in our textbooks. But for all our efforts it became clear that we were actually accomplishing very little. The powerful drugs we prescribed often left the men in such a fog that they could barely function. When we encouraged them to talk about the precise details of a traumatic event, we often inadvertently triggered a full-blown flashback, rather than helping them resolve the issue. Many of them dropped out of treatment because we were not only failing to help but also sometimes making things worse...A turning point arrived in 1980, when a group of Vietnam veterans, aided by the New York psychoanalysts Chaim Shatan and Robert J. Lifton, successfully lobbied the American Psychiatric Association to create a new diagnosis: posttraumatic stress disorder (PTSD), which described a cluster of symptoms that was common, to a greater or lesser extent, to all of our veterans. Systematically identifying the symptoms and grouping them together into a disorder finally gave a name to the suffering of people who were overwhelmed by horror and helplessness. With the conceptual framework of PTSD in place, the stage was set for a radical change in our understanding of our patients. This eventually led to an explosion of research and attempts at finding effective treatments. Inspired by the possibilities presented by this new diagnosis, I proposed a study on the biology of traumatic memories to the VA. Did the memories of those suffering from PTSD differ from those of others? 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."
  • "In my new job {psychopharmacology at the Massachussetts Mental Health Center, beginning 1982} I was confronted on an almost daily basis with issues I thought I had left behind at the VA. My experience with combat veterans had so sensitized me to the impact of trauma that I now listened with a very different ear when depressed and anxious patients told me stories of molestation and family violence. I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women. Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital. Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology. ” My patients with incest histories were hardly free of “subsequent psychopathology” —they were profoundly depressed, confused, and often engaged in bizarrely self-harmful behaviors, such as cutting themselves with razor blades. The textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world. ” In fact, as it turned out, incest had devastating effects on women’s well-being. In many ways these patients were not so different from the veterans I had just left behind at the VA. They also had nightmares and flashbacks. They also alternated between occasional bouts of explosive rage and long periods of being emotionally shut down. Most of them had great difficulty getting along with other people and had trouble maintaining meaningful relationships. As we now know, war is not the only calamity that leaves human lives in ruins. While about a quarter of the soldiers who serve in war zones are expected to develop serious posttraumatic problems, the majority of Americans experience a violent crime at some time during their lives, and more accurate reporting has revealed that twelve million women in the United States have been victims of rape. More than half of all rapes occur in girls below age fifteen. 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. In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers."
  • "In the three decades since I met Tom, we have learned an enormous amount not only about the impact and manifestations of trauma but also about ways to help traumatized people find their way back. Since the early 1990s brain-imaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the damage inflicted by trauma and has guided us to formulate entirely new avenues of repair. We have also begun to understand how overwhelming experiences affect our innermost sensations and our relationship to our physical reality—the core of who we are. 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. We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful, but usually it is not enough. 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. Our search to understand trauma has led us to think differently not only about the structure of the mind but also about the processes by which it heals."
• Chapter 2 - Revolutions in Understanding Mind and Brain
  • "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. But such experiences seemed to be off the table during rounds. 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."
  • "This made me wonder: Our patients had hallucinations—the doctors routinely asked about them and noted them as signs of how disturbed the patients were. But if the stories I’d heard in the wee hours were true, could it be that these “hallucinations” were in fact the fragmented memories of real experiences? Were hallucinations just the concoctions of sick brains? 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."
  • "In my role as recreation leader I noticed other things: As a group the patients were strikingly clumsy and physically uncoordinated. When we went camping, most of them stood helplessly by as I pitched the tents. We almost capsized once in a squall on the Charles River because they huddled rigidly in the lee, unable to grasp that they needed to shift position to balance the boat. In volleyball games the staff members invariably were much better coordinated than the patients. Another characteristic they shared was that even their most relaxed conversations seemed stilted, lacking the natural flow of gestures and facial expressions that are typical among friends. The relevance of these observations became clear only after I’d met the body-based therapists Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about how trauma is held in people’s bodies."
  • "INESCAPABLE SHOCK -- Preoccupied with so many lingering questions about traumatic stress, I became intrigued with the idea that the nascent field of neuroscience could provide some answers and started to attend the meetings of the American College of Neuropsychopharmacology (ACNP). In 1984 the ACNP offered many fascinating lectures about drug development, but it was not until a few hours before my scheduled flight back to Boston that I heard a presentation by Steven Maier of the University of Colorado, who had collaborated with Martin Seligman of the University of Pennsylvania. His topic was learned helplessness in animals. Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.” Being a dog lover, I realized that I could never have done such research myself, but I was curious about how this cruelty would affect the animals. 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. Maier and Seligman also found that traumatized dogs secreted much larger amounts of stress hormones than was normal. This supported what we were beginning to learn about the biological underpinnings of traumatic stress. A group of young researchers, among them Steve Southwick and John Krystal at Yale, Arieh Shalev at Hadassah Medical School in Jerusalem, Frank Putnam at the National Institute of Mental Health (NIMH), and Roger Pitman, later at Harvard, were all finding that traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount Sinai in New York confronted us with her seemingly paradoxical findings that the levels of the stress hormone cortisol are low in PTSD. Her discoveries only started to make sense when her research clarified that cortisol puts an end to the stress response by sending an all-safe signal, and that, in PTSD, the body’s stress hormones do, in fact, not return to baseline after the threat has passed. 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."
  • "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. In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues. Antidepressants can make all the difference in the world in helping with day-to-day functioning, and if it comes to a choice between taking a sleeping pill and drinking yourself into a stupor every night to get a few hours of sleep, there is no question which is preferable. For people who are exhausted from trying to make it on their own through yoga classes, workout routines, or simply toughing it out, medications often can bring life-saving relief. 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. 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. Over the past three decades psychiatric medications have become a mainstay in our culture, with dubious consequences. Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants...Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems. Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. 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."
• Chapter 3 - Looking Into the Brain: The Neuroscience Revolution
  • "In the early 1990s novel brain-imaging techniques opened up undreamed-of capacities to gain a sophisticated understanding about the way the brain processes information. Gigantic multimillion-dollar machines based on advanced physics and computer technology rapidly made neuroscience into one of the most popular areas for research. Positron emission tomography (PET) and, later, functional magnetic resonance imaging (fMRI) enabled scientists to visualize how different parts of the brain are activated when people are engaged in certain tasks or when they remember events from the past. For the first time we could watch the brain as it processed memories, sensations, and emotions and begin to map the circuits of mind and consciousness. The earlier technology of measuring brain chemicals like serotonin or norepinephrine had enabled scientists to look at what fueled neural activity, which is a bit like trying to understand a car’s engine by studying gasoline. Neuroimaging made it possible to see inside the engine. By doing so it has also transformed our understanding of trauma...I had just finished a study on how trauma is remembered (to be discussed in chapter 12), in which participants repeatedly told me how upsetting it was to be suddenly hijacked by images, feelings, and sounds from the past. When several said they wished they knew what trick their brains were playing on them during these flashbacks, I asked eight of them if they would be willing to return to the clinic and lie still inside a scanner (an entirely new experience that I described in detail) while we re-created a scene from the painful events that haunted them. To my surprise, all eight agreed, many of them expressing their hope that what we learned from their suffering could help other people. My research assistant, Rita Fisler, who was working with us prior to entering Harvard Medical School, sat down with every participant and carefully constructed a script that re-created their trauma moment to moment. We deliberately tried to collect just isolated fragments of their experience—particular images, sounds, and feelings—rather than the entire story, because that is how trauma is experienced...I was standing outside the scanner as Marsha underwent the procedure and could follow her physiological reactions on a monitor. The moment we turned on the tape recorder, her heart started to race, and her blood pressure jumped. Simply hearing the script activated the same physiological responses that had occurred during the accident thirteen years earlier. After the recorded script concluded and Marsha’s heart rate and blood pressure returned to normal, we played her second script: getting out of bed and brushing her teeth. This time her heart rate and blood pressure did not change...There were some puzzling dots and colors on the scan, but the biggest area of brain activation—a large red spot in the right lower center of the brain, which is the limbic area, or emotional brain—came as no surprise. It was already well known that intense emotions activate the limbic system, in particular an area within it called the amygdala. We depend on the amygdala to warn us of impending danger and to activate the body’s stress response. Our study clearly showed that when traumatized people are presented with images, sounds, or thoughts related to their particular experience, the amygdala reacts with alarm—even, as in Marsha’s case, thirteen years after the event. Activation of this fear center triggers the cascade of stress hormones and nerve impulses that drive up blood pressure, heart rate, and oxygen intake— preparing the body for fight or flight. The monitors attached to Marsha’s arms recorded this physiological state of frantic arousal, even though she never totally lost track of the fact that she was resting quietly in the scanner. Our most surprising finding was a white spot in the left frontal lobe of the cortex, in a region called Broca’s area. In this case the change in color meant that there was a significant decrease in that part of the brain. 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. All trauma is preverbal. Shakespeare captures this state of speechless terror in Macbeth, after the murdered king’s body is discovered: “Oh horror! horror! horror! Tongue nor heart cannot conceive nor name thee! Confusion now hath made his masterpiece!” Under extreme conditions people may scream obscenities, call for their mothers, howl in terror, or simply shut down. Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children “lose their tongues” and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void. 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. Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past. 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, 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. It is enormously difficult to organize one’s traumatic experiences into a coherent account—a narrative with a beginning, a middle, and an end. Even a seasoned reporter like the famed CBS correspondent Ed Murrow struggled to convey the atrocities he saw when the Nazi concentration camp Buchenwald was liberated in 1945: “I pray you believe what I have said. I reported what I saw and heard, but only part of it. For most of it I have no words.” When words fail, haunting images capture the experience and return as nightmares and flashbacks. In contrast to the deactivation of Broca’s area, another region, Brodmann’s area 19, lit up in our participants. This is a region in the visual cortex that registers images when they first enter the brain. We were surprised to see brain activation in this area so long after the original experience of the trauma. Under ordinary conditions raw images registered in area 19 are rapidly diffused to other brain areas that interpret the meaning of what has been seen. Once again, we were witnessing a brain region rekindled as if the trauma were actually occurring. As we will see in chapter 12, which discusses memory, other unprocessed sense fragments of trauma, like sounds and smells and physical sensations, are also registered separately from the story itself. Similar sensations often trigger a flashback that brings them back into consciousness, apparently unmodified by the passage of time...The scans also revealed that during flashbacks, our subjects’ brains lit up only on the right side...our scans clearly showed that images of past trauma activate the right hemisphere of the brain and deactivate the left. We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical. While the left half of the brain does all the talking, the right half of the brain carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing, or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants. We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experiences to others. The left and right sides of the brain also process the imprints of the past in dramatically different ways. The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, smell, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past. What it recalls feels like intuitive truth—the way things are. Even as we enumerate a loved one’s virtues to a friend, our feelings may be more deeply stirred by how her face recalls the aunt we loved at age four. 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. 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 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. What had happened to Marsha in the scanner gradually started to make sense. Thirteen years after her tragedy we had activated the sensations—the sounds and images from the accident— that were still stored in her memory. When these sensations came to the surface, they activated her alarm system, which caused her to react as if she were back in the hospital being told that her daughter had died. The passage of thirteen years was erased. Her sharply increased heart rate and blood pressure readings reflected her physiological state of frantic alarm. Under normal conditions people react to a threat with a temporary increase in their stress hormones. As soon as the threat is over, the hormones dissipate and the body returns to normal. 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. We now know that there is another possible response to threat, which our scans aren’t yet capable of measuring. Some people simply go into denial: Their bodies register the threat, but their conscious minds go on as if nothing has happened. However, even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don’t stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score...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. Our scans had revealed how their dread persisted and could be triggered by multiple aspects of daily experience. They had not integrated their experience into the ongoing stream of their life. They continued to be “there” and did not know how to be “here” —fully alive in the present."
• Chapter 4 -- Running For Your Life: The Anatomy of Survival
  • "But Noam’s experience allows us to see in outline two critical aspects of the adaptive response to threat that is basic to human survival. At the time the disaster occurred, he was able to take an active role by running away from it, thus becoming an agent in his own rescue. And once he had reached the safety of home, the alarm bells in his brain and body quieted. This freed his mind to make some sense of what had happened and even to imagine a creative alternative to what he had seen—a lifesaving trampoline. In contrast to Noam, 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. -- Trauma affects the entire human organism—body, mind, and brain. In PTSD the body continues to defend against a threat that belongs to the past. Healing from PTSD means being able to terminate this continued stress mobilization and restore the entire organism to safety. -- 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 life. 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...When the brain’s alarm system is turned on, it automatically triggers preprogrammed physical escape plans in the oldest parts of the brain. As in other animals, the nerves and chemicals that make up our basic brain structure have a direct connection with our body. When the old brain takes over, it partially shuts down the higher brain, our conscious mind, and propels the body to run, hide, fight, or, on occasion, freeze. By the time we are fully aware of our situation, our body may already be on the move. If the fight/flight/freeze response is successful and we escape the danger, we recover our internal equilibrium and gradually “regain our senses." 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. Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists. Since at least 1889, when the French psychologist Pierre Janet published the first scientific account of traumatic stress, it has been recognized that trauma survivors are prone to “continue the action, or rather the (futile) attempt at action, which began when the thing happened.” Being able to move and do something to protect oneself is a critical factor in determining whether or not a horrible experience will leave long-lasting scars."
  • "Our rational, cognitive brain is actually the youngest part of the brain and occupies only about 30 percent of the area inside our skull. The rational brain is primarily concerned with the world outside us: understanding how things and people work and figuring out how to accomplish our goals, manage our time, and sequence our actions. Beneath the rational brain lie two evolutionarily older, and to some degree separate, brains, {1. the "ancient animal brain" (aka reptilian brain), 2. the limbic system (aka mammalian brain)} which are in charge of everything else: the moment-by-moment registration and management of our body’s physiology and the identification of comfort, safety, threat, hunger, fatigue, desire, longing, excitement, pleasure, and pain. The brain is built from the bottom up. It develops level by level within every child in the womb, just as it did in the course of evolution. The most primitive part, the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain. It is located in the brain stem, just above the place where our spinal cord enters the skull. The reptilian brain is responsible for all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating. The brain stem and the hypothalamus (which sits directly above it) together control the energy levels of the body. They coordinate the functioning of the heart and lungs and also the endocrine and immune systems, ensuring that these basic life-sustaining systems are maintained within the relatively stable internal balance known as homeostasis. Breathing, eating, sleeping, pooping, and peeing are so fundamental that their significance is easily neglected when we’re considering the complexities of mind and behavior. However, if your sleep is disturbed or your bowels don’t work, or if you always feel hungry, or if being touched makes you want to scream (as is often the case with traumatized children and adults), the entire organism is thrown into disequilibrium. It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal."
  • "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.” 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."
  • "STAN AND UTE’S BRAINS ON TRAUMA -- On a fine September morning in 1999, Stan and Ute Lawrence, a professional couple in their forties, set out from their home in London, Ontario, to attend a business meeting in Detroit. Halfway through the journey they ran into a wall of dense fog that reduced visibility to zero in a split second. Stan immediately slammed on the brakes, coming to a standstill sideways on the highway, just missing a huge truck. An eighteen-wheeler went flying over the trunk of their car; vans and cars slammed into them and into each other. People who got out of their cars were hit as they ran for their lives. The ear-splitting crashes went on and on—with each jolt from behind they felt this would be the one that killed them. Stan and Ute were trapped in car number thirteen of an eighty-seven-car pileup, the worst road disaster in Canadian history. Then came the eerie silence. Stan struggled to open the doors and windows, but the eighteen-wheeler that had crushed their trunk was wedged against the car. Suddenly, someone was pounding on their roof. A girl was screaming, “Get me out of here—I’m on fire!” Helplessly, they saw her die as the car she’d been in was consumed by flames. The next thing they knew, a truck driver was standing on the hood of their car with a fire extinguisher. He smashed the windshield to free them, and Stan climbed through the opening. Turning around to help his wife, he saw Ute sitting frozen in her seat. Stan and the truck driver lifted her out and an ambulance took them to an emergency room. Aside from a few cuts, they were found to be physically unscathed. At home that night, neither Stan nor Ute wanted to go to sleep. They felt that if they let go, they would die. They were irritable, jumpy, and on edge. That night, and for many to come, they drank copious quantities of wine to numb their fear. They could not stop the images that were haunting them or the questions that went on and on: What if they’d left earlier? What if they hadn’t stopped for gas? After three months of this, they sought help from Dr. Ruth Lanius, a psychiatrist at the University of Western Ontario. Dr. Lanius, who had been my student at the Trauma Center a few years earlier, told Stan and Ute she wanted to visualize their brains with an fMRI scan before beginning treatment. The fMRI measures neural activity by tracking changes in blood flow in the brain, and unlike the PET scan, it does not require exposure to radiation. Dr. Lanius used the same kind of script- driven imagery we had used at Harvard, capturing the images, sounds, smells, and other sensations Stan and Ute had experienced while they were trapped in the car. Stan went first and immediately went into a flashback, just as Marsha had in our Harvard study. He came out of the scanner sweating, with his heart racing and his blood pressure sky high. “This was just the way I felt during the accident, ” he reported. “I was sure I was going to die, and there was nothing I could do to save myself. ” Instead of remembering the accident as something that had happened three months earlier, Stan was reliving it."
  • "DISSOCIATION AND RELIVING -- 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. Unlike Stan, however, many people may not be aware of the connection between their “crazy” feelings and reactions and the traumatic events that are being replayed. They have no idea why they respond to some minor irritation as if they were about to be annihilated. 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. People who suffer from flashbacks often organize their lives around trying to protect against them. They may compulsively go to the gym to pump iron (but finding that they are never strong enough), numb themselves with drugs, or try to cultivate an illusory sense of control in highly dangerous situations (like motorcycle racing, bungee jumping, or working as an ambulance driver). Constantly fighting unseen dangers is exhausting and leaves them fatigued, depressed, and weary. 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. Triggered responses manifest in various ways. Veterans may react to the slightest cue—like hitting a bump in the road or seeing a kid playing in the street—as if they were in a war zone. They startle easily and become enraged or numb. Victims of childhood sexual abuse may anesthetize their sexuality and then feel intensely ashamed if they become excited by sensations or images that recall their molestation, even when those sensations are the natural pleasures associated with particular body parts. If trauma survivors are forced to discuss their experiences, one person’s blood pressure may increase while another responds with the beginnings of a migraine headache. Still others may shut down emotionally and not feel any obvious changes. However, in the lab we have no problem detecting their racing hearts and the stress hormones churning through their bodies. These reactions are irrational and largely outside people’s control. 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. They are rarely in touch with the origins of their alienation. That is where therapy comes in —is the beginning of bringing the emotions that were generated by trauma being able to feel, the capacity to observe oneself online. However, the bottom line is that the threat-perception system of the brain has changed, and people’s physical reactions are dictated by the imprint of the past. 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."
  • "THE TIMEKEEPER COLLAPSES -- 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. Stan’s flashback precipitated a more extreme reaction. The two white areas in the front of the brain (on top in the picture) are the right and left dorsolateral prefrontal cortex. When those areas are deactivated, people lose their sense of time and become trapped in the moment, without a sense of past, present, or future."
  • "THE THALAMUS SHUTS DOWN -- Look again at the scan of Stan’s flashback and you can see two more white holes in the lower half of the brain. These are his right and left thalamus—blanked out during the flashback as they were during the original trauma. As I’ve said, the thalamus functions as a “cook” —a relay station that collects sensations from the ears, eyes, and skin and integrates them into the soup that is our autobiographical memory. 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. 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. As you sit here reading, you may hear music in the background or traffic rumbling by or feel a faint gnawing in your stomach telling you it’s time for a snack. If you are able to stay focused on this page, your thalamus is helping you distinguish between sensory information that is relevant and information that you can safely ignore...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. If they can’t shut down naturally, they may enlist drugs or alcohol to block out the world. The tragedy is that the price of closing down includes filtering out sources of pleasure and joy, as well."
• Chapter 5 - Body-Brain Connections
  • "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...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...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. For our physiology to calm down, heal, and grow we need a visceral feeling of safety...Many traumatized people find themselves chronically out of sync with the people around them...After trauma the world is experienced with a different nervous system that has an altered perception of risk and safety....For many people panic and rage are preferable to the opposite: shutting down and becoming dead to the world. Activating flight/flight at least makes them feel energized. That is why so many abused and traumatized people feel fully alive in the face of actual danger, while they go numb in situations that are more complex but objectively safe, like birthday parties or family dinners. When fighting or running does not take care of the threat, we activate the last resort—the reptilian brain, the ultimate emergency system. This system is most likely to engage when we are physically immobilized, as when we are pinned down by an attacker or when a child has no escape from a terrifying caregiver. 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...When you beg for your life, but the assailant ignores your pleas; when you are a terrified child lying in bed, hearing your mother scream as her boyfriend beats her up; when you see your buddy trapped under a piece of metal that you’re not strong enough to lift; when you want to push away the priest who is abusing you, but you’re afraid you’ll be punished. 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...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. The landmark ACE (Adverse Childhood Experiences) study, which I’ll discuss in more detail in chapter 9, showed that women who had an early history of abuse and neglect were seven times more likely to be raped in adulthood. Women who, as children, had witnessed their mothers being assaulted by their partners had a vastly increased chance to fall victim to domestic violence. Many people feel safe as long as they can limit their social contact to superficial conversations, but actual physical contact can trigger intense reactions. However, as Porges points out, achieving any sort of deep intimacy—a close embrace, sleeping with a mate, and sex —requires allowing oneself to experience immobilization without fear. 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, a topic to which we’ll return many times in the chapters that follow."
  • "Porges’s work has had a profound effect on how my Trauma Center colleagues and I organize the treatment of abused children and traumatized adults. It’s true that we would probably have developed a therapeutic yoga program for women at some point, given that yoga had proved so successful in helping them calm down and get in touch with their dissociated bodies."
  • "The body keeps the score: If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/emuscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions."
• Chapter 6 -- Losing Your Body, Losing Your Self
  • "As far back as Sherry could remember, her mother had run a foster home, and their house was often packed with as many as fifteen strange, disruptive, frightened, and frightening kids who disappeared as suddenly as they arrived. Sherry had grown up taking care of these transient children, feeling that there was no room for her and her needs. “I know I wasn’t wanted, ” she told me. “I’m not sure when I first realized that, but I’ve thought about things that my mother said to me, and the signs were always there. She’d tell me, ‘You know, I don’t think you belong in this family. I think they gave us the wrong baby. ’ And she’d say it with a smile on her face. But, of course, people often pretend to joke when they say something serious. ” 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. Sherry turned out to be a living example of these findings: 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. Sherry had graduated from college, but she now worked in a joyless clerical job, lived alone with her cats, and had no close friends. When I asked her about men, she told me that her only “relationship” had been with a man who’d kidnapped her while she was on a college vacation in Florida. He’d held her captive and raped her repeatedly for five consecutive days. She remembered having been curled up, terrified and frozen for most of that time, until she realized she could try to get away. She escaped by simply walking out while he was in the bathroom. When she called her mother collect for help, her mother refused to take the call...Sherry told me that she’d started to pick at her skin because it gave her some relief from feeling numb. The physical sensations made her feel more alive but also deeply ashamed—she knew she was addicted to these actions but could not stop them. She’d consulted many mental health professionals before me and had been questioned repeatedly about her “suicidal behavior"...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...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. You are likely to experiment with anything—drugs, alcohol, binge eating, or cutting—that offers some kind of relief...Struck by how frozen and uptight she was, I suggested that she see Liz, a massage therapist I had worked with previously. During their first meeting Liz positioned Sherry on the massage table, then moved to the end of the table and gently held Sherry’s feet. Lying there with her eyes closed, Sherry suddenly yelled in a panic: “Where are you?” Somehow Sherry had lost track of Liz, even though Liz was right there, with her hands on Sherry’s feet. 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. Sometimes I’d ask them to close their eyes and tell me what I had put into their outstretched hands. Whether it was a car key, a quarter, or a can opener, they often could not even guess what they were holding—their sensory perceptions simply weren’t working. I talked this over with my friend Alexander McFarlane in Australia, who had observed the same phenomenon. In his laboratory in Adelaide he had studied the question: How do we know without looking at it that we’re holding a car key? 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. When our senses become muffled, we no longer feel fully alive."
  • "HOW DO WE KNOW WE’RE ALIVE? Most early neuroimaging studies of traumatized people were like those we’ve seen in chapter 3; they focused on how subjects reacted to specific reminders of the trauma. Then, in 2004, my colleague Ruth Lanius, who scanned Stan and Ute Lawrence’s brains, posed a new question: What happens in the brains of trauma survivors when they are not thinking about the past? Her studies on the idling brain, the “default state network” (DSN), opened up a whole new chapter in understanding how trauma affects self-awareness, specifically sensory self-awareness. Dr. Lanius recruited a group of sixteen “normal” Canadians to lie in a brain scanner while thinking about nothing in particular...she asked them to focus their attention on their breathing and try to empty their minds as much as possible. She then repeated the same experiment with eighteen people who had histories of severe, chronic childhood abuse. 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.” When Ruth looked at the scans of her normal subjects, she found activation of DSN regions that previous researchers had described. I like to call this the Mohawk of self-awareness, the midline structures of the brain, starting out right above our eyes, running through the center of the brain all the way to the back. All these midline structures are involved in our sense of self. The largest bright region at the back of the brain is the posterior cingulate, which gives us a physical sense of where we are—our internal GPS. It is strongly connected to the medial prefrontal cortex (MPFC), the watchtower I discussed in chapter 4. (This connection doesn’t show up on the scan because the fMRI can’t measure it.) It is also connected with brain areas that register sensations coming from the rest of the body: the insula, which relays messages from the viscera to the emotional centers; the parietal lobes, which integrate sensory information; and the anterior cingulate, which coordinates emotions and thinking. All of these areas contribute to consciousness. The contrast with the scans of the eighteen chronic PTSD patients with severe early-life trauma was startling. There was almost no activation of any of the self-sensing areas of the brain: The MPFC, the anterior cingulate, the parietal cortex, and the insula did not light up at all; the only area that showed a slight activation was the posterior cingulate, which is responsible for basic orientation in space. There could be only one explanation for such results: 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. What we witnessed here was a tragic adaptation: In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive. 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. Now I understood that their relationship with their own inner reality was impaired. How could they make decisions, or put any plan into action, if they couldn’t define what they wanted or, to be more precise, what the sensations in their bodies, the basis of all emotions, were trying to tell them? 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."
  • "Our sensory world takes shape even before we are born. In the womb we feel amniotic fluid against our skin, we hear the faint sounds of rushing blood and a digestive tract at work, we pitch and roll with our mother’s movements. After birth, physical sensation defines our relationship to ourselves and to our surroundings. We start off being our wetness, hunger, satiation, and sleepiness. A cacophony of incomprehensible sounds and images presses in on our pristine nervous system. Even after we acquire consciousness and language, our bodily sensing system provides crucial feedback on our moment-to-moment condition. Its constant hum communicates changes in our viscera and in the muscles of our face, torso, and extremities that signal pain and comfort, as well as urges such as hunger and sexual arousal. What is taking place around us also affects our physical sensations. Seeing someone we recognize, hearing particular sounds—a piece of music, a siren—or sensing a shift in temperature all change our focus of attention and, without our being aware of it, prime our subsequent thoughts and actions. As we have seen, the job of the brain is to constantly monitor and evaluate what is going on within and around us. These evaluations are transmitted by chemical messages in the bloodstream and electrical messages in our nerves, causing subtle or dramatic changes throughout the body and brain. These shifts usually occur entirely without conscious input or awareness: The subcortical regions of the brain are astoundingly efficient in regulating our breathing, heartbeat, digestion, hormone secretion, and immune system. However, these systems can become overwhelmed if we are challenged by an ongoing threat, or even the perception of threat. This accounts for the wide array of physical problems researchers have documented in traumatized people...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. Each type of emotion produced a characteristic pattern, distinct from the others. For example, a particular part of the brain stem was “active in sadness and anger, but not in happiness or fear.” All of these brain regions are below the limbic system, to which emotions are traditionally assigned, yet we acknowledge their involvement every time we use one of the common expressions that link strong emotions with the body: “You make me sick”; “It made my skin crawl”; “I was all choked up”; “My heart sank”; “He makes me bristle. ” 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."
  • "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."
  • "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. 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. 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. Many of my patients respond to stress not by noticing and naming it but by developing migraine headaches or asthma attacks. Sandy, a middle-aged visiting nurse, told me she’d felt terrified and lonely as a child, unseen by her alcoholic parents. She dealt with this by becoming deferential to everybody she depended on (including me, her therapist). Whenever her husband made an insensitive remark, she would come down with an asthma attack. By the time she noticed that she couldn’t breathe, it was too late for an inhaler to be effective, and she had to be taken to the emergency room. Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body. Even though Sandy had learned to ignore her relationship problems and block out her physical distress signals, they showed up in symptoms that demanded her attention. Her therapy focused on identifying the link between her physical sensations and her emotions, and I also encouraged her to enroll in a kickboxing program. She had no emergency room visits during the three years she was my patient. Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. They can include chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma. Traumatized children have fifty times the rate of asthma as their nontraumatized peers. Studies have shown that many children and adults with fatal asthma attacks were not aware of having breathing problems before the attacks."
  • "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. When asked, “How would you feel if you saw a truck coming at you at eighty miles per hour?” most people would say, “I’d be terrified” or “I’d be frozen with fear. ” An alexithymic might reply, “How would I feel? I don’t know. . . . I’d get out of the way. ” They tend to register emotions as physical problems rather than as signals that something deserves their attention. Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found. About three quarters of patients with anorexia nervosa, and more than half of all patients with bulimia, are bewildered by their emotional feelings and have great difficulty describing them. When researchers showed pictures of angry or distressed faces to people with alexithymia, they could not figure out what those people were feeling."
• Chapter 7 - Getting on the Same Wavelength: Attachment and Attunement
  • "The former chairman of the Harvard psychology department, Henry Murray, one of the pioneers of personality theory...had, among other things, become famous for designing the widely used Thematic Apperception Test. The TAT is a so-called projective test, which uses a set of cards to discover how people’s inner reality shapes their view of the world. Unlike the Rorschach cards we used with the veterans, the TAT cards depict realistic but ambiguous and somewhat troubling scenes: a man and a woman gloomily staring away from each other, a boy looking at a broken violin. Subjects are asked to tell stories about what is going on in the photo, what has happened previously, and what happens next. In most cases their interpretations quickly reveal the themes that preoccupy them. Nina and I decided to create a set of test cards specifically for children, based on pictures we cut out of magazines in the clinic waiting room. Our first study compared twelve six- to eleven- year-olds at the children’s clinic with a group of children from a nearby school who matched them as closely as possible in age, race, intelligence, and family constellation. What differentiated our patients was the abuse they had suffered within their families. They included a boy who was severely bruised from repeated beatings by his mother; a girl whose father had molested her at the age of four; two boys who had been repeatedly tied to a chair and whipped; and a girl who, at the age of five, had seen her mother (a prostitute) raped, dismembered, burned, and put into the trunk of a car. The mother’s pimp was suspected of sexually abusing the girl. The children in our control group also lived in poverty in a depressed area of Boston where they regularly witnessed shocking violence. While the study was being conducted, one boy at their school threw gasoline at a classmate and set him on fire. Another boy was caught in crossfire while walking to school with his father and a friend. He was wounded in the groin, and his friend was killed. Given their exposure to such a high baseline level of violence, would their responses to the cards differ from those of the hospitalized children? One of our cards depicted a family scene: two smiling kids watching dad repair a car. Every child who looked at it commented on the danger to the man lying underneath the vehicle. While the control children told stories with benign endings—the car would get fixed, and maybe dad and the kids would drive to McDonald’s—the traumatized kids came up with gruesome tales. One girl said that the little girl in the picture was about to smash in her father’s skull with a hammer. A nine-year-old boy who had been severely physically abused told an elaborate story about how the boy in the picture kicked away the jack, so that the car mangled his father’s body and his blood spurted all over the garage. As they told us these stories, our patients got very excited and disorganized. We had to take considerable time out at the water cooler and going for walks before we could show them the next card. It was little wonder that almost all of them had been diagnosed with ADHD, and most were on Ritalin—though the drug certainly didn’t seem to dampen their arousal in this situation. The abused kids gave similar responses to a seemingly innocuous picture of a pregnant woman silhouetted against a window. When we showed it to the seven-year-old girl who’d been sexually abused at age four, she talked about penises and vaginas and repeatedly asked Nina questions like “How many people have you humped?” Like several of the other sexually abused girls in the study, she became so agitated that we had to stop. A seven-year-old girl from the control group picked up the wistful mood of the picture: Her story was about a widowed lady sadly looking out the window, missing her husband. But in the end, the lady found a loving man to be a good father to her baby. In card after card we saw that, despite their alertness to trouble, the children who had not been abused still trusted in an essentially benign universe; they could imagine ways out of bad situations. They seemed to feel protected and safe within their own families. They also felt loved by at least one of their parents, which seemed to make a substantial difference in their eagerness to engage in schoolwork and to learn. The responses of the clinic children were alarming. The most innocent images stirred up intense feelings of danger, aggression, sexual arousal, and terror. We had not selected these photos because they had some hidden meaning that sensitive people could uncover; they were ordinary images of everyday life. 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. 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?"
  • "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. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it. When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences."
  • "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). 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. About eighteen years later, when these kids were around twenty years old, Lyons-Ruth did a follow-up study to see how they were coping. Infants with seriously disrupted emotional communication patterns with their mothers at eighteen months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving, and binge eating), inappropriate and intense anger, and recurrent suicidal behavior. 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."
  • "Lyons-Ruth was particularly interested in the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down. She found a “striking and unexpected” relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood. 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. 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. Receiving a sympathetic response cushions infants (and adults) against extreme levels of frightened arousal. But if your caregivers ignore your needs, or resent your very existence, you learn to anticipate rejection and withdrawal. You cope as well as you can by blocking out your mother’s hostility or neglect and act as if it doesn’t matter, but your body is likely to remain in a state of high alert, prepared to ward off blows, deprivation, or abandonment. Dissociation means simultaneously knowing and not knowing. 37 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. Or you may resort to extremes in an effort to feel something—even cutting yourself with a razor blade or getting into fistfights with strangers."
• Chapter 8 - Trapped in Relationships: The Cost of Abuse and Neglect
  • "Marilyn was a tall, athletic-looking woman in her midthirties who worked as an operating- room nurse in a nearby town. She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her company, but she told herself he didn’t really know her. One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of Law & Order, they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!” Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks. My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself."
  • "TERROR AND NUMBNESS -- As we talked, Marilyn told me that Michael was the first man she’d taken home in more than five years, but this was not the first time she’d lost control when a man spent the night with her. She repeated that she always felt uptight and spaced out when she was alone with a man, and there had been other times when she’d “come to” in her apartment, cowering in a corner, unable to remember clearly what had happened. Marilyn also said she felt as if she was just “going through the motions” of having a life. Except for when she was at the club playing tennis or at work in the operating room, she usually felt numb. A few years earlier she’d found that she could relieve her numbness by scratching herself with a razor blade, but she had become frightened when she found that she was cutting herself more and more deeply, and more and more often, to get relief. She had tried alcohol, too, but that reminded her of her dad and his out-of-control drinking, which made her feel disgusted with herself. So, instead, she played tennis fanatically, whenever she could. That made her feel alive. When I asked her about her past, Marilyn said she guessed that she “must have had” a happy childhood, but she could remember very little from before age twelve. She told me she’d been a timid adolescent, until she had a violent confrontation with her alcoholic father when she was sixteen and ran away from home. She worked her way through community college and went on to get a degree in nursing without any help from her parents. She felt ashamed that during this time she’d slept around, which she described as “looking for love in all the wrong places.""

  • 

  • "As I often did with new patients, I asked her to draw a family portrait, and when I saw her drawing (reproduced above), I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but she could not allow herself to recognize what her own picture revealed. She had drawn a wild and terrified child, trapped in some kind of cage and threatened not only by three nightmarish figures—one with no eyes—but also by a huge erect penis protruding into her space. And yet this woman said she “must have had” a happy childhood."
  • "As the poet W. H. Auden wrote: Truth, like love and sleep, resents Approaches that are too intense. I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, 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. This may take weeks or even years."
  • "I decided to start Marilyn’s treatment by inviting her to join an established therapy group where she could find support and acceptance before facing the engine of her distrust, shame, and rage. As I expected, Marilyn arrived at the first group meeting looking terrified, much like the girl in her family portrait; she was withdrawn and did not reach out to anybody...Three months later Marilyn told the group that she had stumbled and fallen a few times on the sidewalk between the subway and my office. She worried that her eyesight was beginning to fail: She’d also been missing a lot of tennis balls recently. I thought again about her drawing and the wild child with the huge, terrified eyes. Was this some sort of “conversion reaction, ” in which patients express their conflicts by losing function in some part of their body? Many soldiers in both world wars had suffered paralysis that couldn’t be traced to physical injuries, and I had seen cases of “hysterical blindness” in Mexico and India. 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. After making sure that Marilyn was getting the proper medical care, I consulted with two of my colleagues at Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the immunology laboratory there. I told them Marilyn’s story, showed them the picture she’d drawn, and asked them to collaborate on a study. They generously volunteered their time and the considerable expense of a full immunology workup. We recruited twelve women with incest histories who were not taking any medications, plus twelve women who had never been traumatized and who also did not take meds—a surprisingly difficult control group to find. (Marilyn was not in the study; we generally do not ask our clinical patients to be part of our research efforts.) 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. This means that the imprint of past trauma does not consist only of distorted perceptions of information coming from the outside; the organism itself also has a problem knowing how to feel safe. The past is impressed not only on their minds, and in misinterpretations of innocuous events (as when Marilyn attacked Michael because he accidentally touched her in her sleep), but also on the very core of their beings: in the safety of their bodies."
  • "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. Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system, the subject of the treatment section of this book."
  • "LEARNING TO REMEMBER -- About a year into Marilyn’s group, another member, Mary, asked permission to talk about what had happened to her when she was thirteen years old. Mary worked as a prison guard, and she was involved in a sadomasochistic relationship with another woman. She wanted the group to know her background in the hope that they would become more tolerant of her extreme reactions, such as her tendency to shut down or blow up in response to the slightest provocation. Struggling to get the words out, Mary told us that one evening, when she was thirteen years old, she was raped by her older brother and a gang of his friends. The rape resulted in pregnancy, and her mother gave her an abortion at home, on the kitchen table. The group sensitively tuned in to what Mary was sharing and comforted her through her sobbing. I was profoundly moved by their empathy—they were consoling Mary in a way that they must have wished somebody had comforted them when they first confronted their traumas. When time ran out, Marilyn asked if she could take a few more minutes to talk about what she had experienced during the session. The group agreed, and she told us: “Hearing that story, I wonder if I may have been sexually abused myself.” My mouth must have dropped open. Based on her family drawing, I had always assumed that she was aware, at least on some level, that this was the case. She had reacted like an incest victim in her response to Michael, and she chronically behaved as if the world were a terrifying place. Yet even though she’d drawn a girl who was being sexually molested, she—or at least her cognitive, verbal self—had no idea what had actually happened to her. Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience. She reenacted her trauma in her life, but she had no narrative to refer to. As we will see in chapter 12, traumatic memory differs in complex ways from normal recall, and it involves many layers of mind and brain. Triggered by Mary’s story, and spurred on by the nightmares that followed, Marilyn began individual therapy with me in which she started to deal with her past. At first she experienced waves of intense, free-floating terror. She tried stopping for several weeks, but when she found she could no longer sleep and had to take time off from work, she continued our sessions. As she told me later: “My only criterion for whether a situation is harmful is feeling, 'This is going to kill me if I don’t get out.'" I began to teach Marilyn calming techniques, such as focusing on breathing deeply—in and out, in and out, at six breaths a minute—while following the sensations of the breath in her body. This was combined with tapping acupressure points, which helped her not to become overwhelmed. We also worked on mindfulness: Learning to keep her mind alive while allowing her body to feel the feelings that she had come to dread slowly enabled Marilyn to stand back and observe her experience, rather than being immediately hijacked by her feelings. She had tried to dampen or abolish those feelings with alcohol and exercise, but now she began to feel safe enough to begin to remember what had happened to her as a girl. As she gained ownership over her physical sensations, she also began to be able to tell the difference between past and present: Now if she felt someone’s leg brush against her in the night, she might be able to recognize it as Michael’s leg, the leg of the handsome tennis partner she’d invited to her apartment. That leg did not belong to anyone else, and its touch didn’t mean someone was trying to molest her. Being still enabled her to know—fully, physically know—that she was a thirty- four-year-old woman and not a little girl. When Marilyn finally began to access her memories, they emerged as flashbacks of the wallpaper in her childhood bedroom. She realized that this was what she had focused on when her father raped her when she was eight years old. His molestation had scared her beyond her capacity to endure, so she had needed to push it out of her memory bank. After all, she had to keep living with this man, her father, who had assaulted her. Marilyn remembered having turned to her mother for protection, but when she ran to her and tried to hide herself by burying her face in her mother’s skirt, she was met with only a limp embrace. At times her mother remained silent; at others she cried or angrily scolded Marilyn for “making Daddy so angry.” The terrified child found no one to protect her, to offer strength or shelter. As Roland Summit wrote in his classic study The Child Sexual Abuse Accommodation Syndrome: “Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. Any attempts by the child to divulge the secret will be countered by an adult conspiracy of silence and disbelief. ‘Don’t worry about things like that; that could never happen in our family. ’ ‘How could you ever think of such a terrible thing?’ ‘Don’t let me ever hear you say anything like that again!’ The average child never asks and never tells. ”3 After forty years of doing this work I still regularly hear myself saying, “That’s unbelievable,” when patients tell me about their childhoods. They often are as incredulous as I am—how could parents inflict such torture and terror on their own child? Part of them continues to insist that they must have made the experience up or that they are exaggerating. All of them are ashamed about what happened to them, and they blame themselves—on some level they firmly believe that these terrible things were done to them because they are terrible people. Marilyn now began to explore how the powerless child had learned to shut down and comply with whatever was asked of her. She had done so by making herself disappear: The moment she heard her father’s footsteps in the corridor outside her bedroom, she would “put her head in the clouds. ” Another patient of mine who had a similar experience made a drawing that depicts how that process works. When her father started to touch her, she made herself disappear; she floated up to the ceiling, looking down on some other little girl in the bed. She was glad that it was not really her—it was some other girl who was being molested."

  • 

  • "Looking at these heads separated from their bodies by an impenetrable fog really opened my eyes to the experience of dissociation, which is so common among incest victims. Marilyn herself later realized that, as an adult, she had continued to float up to the ceiling when she found herself in a sexual situation. In the period when she’d been more sexually active, a partner would occasionally tell her how amazing she’d been in bed—that he’d barely recognized her, that she’d even talked differently. Usually she did not remember what had happened, but at other times she’d become angry and aggressive. She had no sense of who she really was sexually, so she gradually withdrew from dating altogether—until Michael."
  • "HATING YOUR HOME -- 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. Unlike adults, they have no other authorities to turn to for help—their parents are the authorities. They cannot rent an apartment or move in with someone else: Their very survival hinges on their caregivers. Children sense—even if 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. I have never met a child below the age of ten who was tortured at home (and who had broken bones and burned skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; victims of domestic violence often cover up for their abusers. Judges often tell me how humiliated they feel when they try to protect victims of domestic violence by issuing restraining orders, only to find out that many of them secretly allow their partners to return. It took Marilyn a long time before she was ready to talk about her abuse: She was not ready to violate her loyalty to her family—deep inside she felt that she still needed them to protect her against her fears. The price of this loyalty is unbearable feelings of loneliness, despair, and the inevitable rage of helplessness. Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions. One of my patients told me, “It is like hating your home, your kitchen and pots and pans, your bed, your chairs, your table, your rugs. ” Nothing feels safe—least of all your own body."
  • "REPLAYING THE TRAUMA -- One memory of Marilyn’s childhood trauma came to her in a dream in which she felt as if she were being choked and was unable to breathe. A white tea towel was wrapped around her hands, and then she was lifted up with the towel around her neck, so that she could not touch the ground with her feet. She woke in a panic, thinking that she was surely going to die. Her dream reminded me of the nightmares war veterans had reported to me: seeing the precise, unadulterated images of faces and body parts they had encountered in battle. These dreams were so terrifying that they tried to not fall asleep at night; only daytime napping, which was not associated with nocturnal ambushes, felt halfway safe. During this stage of therapy Marilyn was repeatedly flooded with images and sensations related to the choking dream. She remembered sitting in the kitchen as a four-year-old with swollen eyes, a sore neck, and a bloody nose, while her father and brother laughed at her and called her a stupid, stupid girl. One day Marilyn reported, “As I was brushing my teeth last evening, I was overcome with feelings of thrashing around. I was like a fish out of water, violently turning my body as I fought against the lack of air. I sobbed and choked as I brushed my teeth. Panic was rising up out of my chest with the feeling of thrashing. I had to use every bit of strength I had not to scream, ‘NONONONONONO,’ as I stood over the sink.” She went to bed and fell asleep but woke up like clockwork every two hours during the rest of the night. Trauma is not stored as a narrative with an orderly beginning, middle, and end. As I’ll discuss in detail in chapters 11 and 12, memories initially return as they did for Marilyn: as flashbacks that contain fragments of the experience, isolated images, sounds, and body sensations that initially have no context other than fear and panic. When Marilyn was a child, she had no way of giving voice to the unspeakable, and it would have made no difference anyway— nobody was listening."
• Chapter 9 - What's Love Got To Do With It?
  • "How do we organize our thinking with regard to individuals like Marilyn, Mary, and Kathy, and what can we do to help them? 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."
  • "The first serious attempt to create a systematic manual of psychiatric diagnoses occurred in 1980, with the release of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the official list of all mental diseases recognized by the American Psychiatric Association (APA). The preamble to the DSM-III warned explicitly that its categories were insufficiently precise to be used in forensic settings or for insurance purposes. Nonetheless it gradually became an instrument of enormous power: Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories...The manual has become a virtual industry that has earned the American Psychiatric Association well over $100 million...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...In this chapter, and the next, I will discuss the chasm between official diagnoses and what our patients actually suffer from and discuss how my colleagues and I have tried to change the way patients with chronic trauma histories are diagnosed...In 1985 I started to collaborate with psychiatrist Judith Herman, whose first book, Father-Daughter Incest, had recently been published. We were both working at Cambridge Hospital (one of Harvard’s teaching hospitals) and, sharing an interest in how trauma had affected the lives of our patients, we began to meet regularly and compare notes. We were struck by how many of our patients who were diagnosed with borderline personality disorder (BPD) told us horror stories about their childhoods. BPD is marked by clinging but highly unstable relationships, extreme mood swings, and self-destructive behavior, including self-mutilation and repeated suicide attempts. In order to uncover whether there was, in fact, a relationship between childhood trauma and BPD, we designed a formal scientific study and sent off a grant proposal to the National Institutes of Health. It was rejected. Undeterred, Judy and I decided to finance the study ourselves, and we found an ally in Chris Perry, the director of research at Cambridge Hospital, who was funded by the National Institute of Mental Health to study BPD and other near neighbor diagnoses, so-called personality disorders, in patients recruited from the Cambridge Hospital. He had collected volumes of valuable data on these subjects but had never inquired about childhood abuse and neglect. Even though he did not hide his skepticism about our proposal, he was very generous to us and arranged for us to interview fifty-five patients from the hospital’s outpatient department, and he agreed to compare our findings with records in the large database he had already collected...Keeping in mind that people universally feel ashamed about the traumas they have experienced, we designed an interview instrument, the Traumatic Antecedents Questionnaire (TAQ). The interview started with a series of simple questions...It progressed gradually to more revealing questions...The questions continued: “Who made the rules at home and enforced the discipline?” “How were kids kept in line—by talking, scolding, spanking, hitting, locking you up?” “How did your parents solve their disagreements?” By then the floodgates had usually opened, and many patients were volunteering detailed information about their childhoods. One woman had witnessed her little sister being raped; another told us she’d had her first sexual experience at age eight—with her grandfather. Men and women reported lying awake at night listening to furniture crashing and parents screaming; a young man had come down to the kitchen and found his mother lying in a pool of blood. Others talked about not being picked up at elementary school or coming home to find an empty house and spending the night alone. One woman who made her living as a cook had learned to prepare meals for her family after her mother was jailed on a drug conviction. Another had been nine when she grabbed and steadied the car’s steering wheel because her drunken mother was swerving down a four-lane highway during rush hour. 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 whoever might be enlisted to help—had probably started off as ways of dealing with overwhelming emotions and inescapable brutality. 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. 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. Although numerous studies have since replicated our findings, I still regularly get scientific papers to review that say things like “It has been hypothesized that borderline patients may have histories of childhood trauma.” When does a hypothesis become a scientifically established fact?"
  • "THE POWER OF DIAGNOSIS -- 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. They go from one extreme to the other; they have trouble staying on task, and they continually lash out against themselves and others. To some degree their problems do overlap with those of combat soldiers, but they are also very different in that their childhood trauma has prevented them from developing some of the mental capacities that adult soldiers possessed before their traumas occurred. After we realized this, a group of us went to see Robert Spitzer, who, after having guided the development of the DSM-III, was in the process of revising the manual. He listened carefully to what we told him. He told us it was likely that clinicians who spend their days treating a particular patient population are likely to develop considerable expertise in understanding what ails them. He suggested that we do a study, a so-called field trial, to compare the problems of different groups of traumatized individuals. Spitzer put me in charge of the project. First we developed a rating scale that incorporated all the different trauma symptoms that had been reported in the scientific literature, then we interviewed 525 adult patients at five sites around the country to see if particular populations suffered from different constellations of problems. Our populations fell into three groups: those with histories of childhood physical or sexual abuse by caregivers; recent victims of domestic violence; and people who had recently been through a natural disaster. There were clear differences among these groups, particularly those on the extreme ends of the spectrum: victims of child abuse and adults who had survived natural disasters. The adults who had been abused as children often had trouble concentrating, complained of always being on edge, and were filled with self-loathing. They had enormous trouble negotiating intimate relationships, often veering from indiscriminate, high-risk, and unsatisfying sexual involvements to total sexual shutdown. They also had large gaps in their memories, often engaged in self- destructive behaviors, and had a host of medical problems. These symptoms were relatively rare in the survivors of natural disasters. Each major diagnosis in the DSM had a workgroup responsible for suggesting revisions for the new edition. I presented the results of the field trial to our DSM-IV PTSD work group, and we voted nineteen to two to create a new trauma diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short. We then eagerly anticipated the publication of the DSM-IV in May 1994. But much to our surprise the diagnosis that our work group had overwhelmingly approved did not appear in the final product. None of us had been consulted. This was a tragic exclusion. It meant that large numbers of patients could not be accurately diagnosed and that clinicians and researchers would be unable to scientifically develop appropriate treatments for them. You cannot develop a treatment for a condition that does not exist. 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? The consequences of caretaker abuse and neglect are vastly more common and complex than the impact of hurricanes or motor vehicle accidents. Yet the decision makers who determined the shape of our diagnostic system decided not to recognize this evidence. 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."
  • "In 1985 Felitti was chief of Kaiser Permanente’s Department of Preventive Medicine in San Diego...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...In 1990 Felitti went to Atlanta to present data from the team’s first 286 patient interviews at a meeting of the North American Association for the Study of Obesity. He was stunned by the harsh response of some experts: Why did he believe such patients? Didn’t he realize they would fabricate any explanation for their failed lives? However, an epidemiologist from the Centers for Disease Control and Prevention (CDC) encouraged Felitti to start a much larger study, drawing on a general population, and invited him to meet with a small group of researchers at the CDC. The result was the monumental investigation of Adverse Childhood Experiences (now know at the ACE study), a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD, and Vincent Felitti, MD, as co–principal investigators. More than fifty thousand Kaiser patients came through the Department of Preventive Medicine annually for a comprehensive evaluation, filling out an extensive medical questionnaire in the process. Felitti and Anda spent more than a year developing ten new questions covering carefully defined categories of adverse childhood experiences, including physical and sexual abuse, physical and emotional neglect, and family dysfunction, such as having had parents who were divorced, mentally ill, addicted, or in prison. They then asked 25,000 consecutive patients if they would be willing to provide information about childhood events; 17,421 said yes. Their responses were then compared with the detailed medical records that Kaiser kept on all patients. 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. One out of ten individuals responded yes to the question “Did a parent or other adult in the household often or very often swear at you, insult you, or put you down?” More than a quarter responded yes to the questions “Did one of your parents often or very often push, grab, slap, or throw something at you?” and “Did one of your parents often or very often hit you so hard that you had marks or were injured?” In other words, more than a quarter of the U.S. population is likely to have been repeatedly physically abused as a child. To the questions “Did an adult or person at least 5 years older ever have you touch their body in a sexual way?” and “Did an adult or person at least 5 years older ever attempt oral, anal, or vaginal intercourse with you?” 28 percent of women and 16 percent of men responded affirmatively. One in eight people responded positively to the questions: “As a child, did you witness your mother sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her?” “As a child, did you witness your mother sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Each yes answer was scored as one point, leading to a possible ACE score ranging from zero to ten. For example, a person who experienced frequent verbal abuse, who had an alcoholic mother, and whose parents divorced would have an ACE score of three. Of the two-thirds of respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher. 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. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases...When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically. For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. The likelihood of being on antidepressant medication or prescription painkillers also rose proportionally. As Felitti has pointed out, we may be treating today experiences that happened fifty years ago—at ever-increasing cost. 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) Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts...Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent. Why are abused or neglected girls so much more likely to be raped later in life? The answers to this question have implications far beyond rape. For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold. More than 12 percent of study participants had seen their mothers being battered. The list of high-risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and sexually transmitted diseases. Finally, the toll of major health problems was striking: Those with an ACE score of six or above had a 15 percent or greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four times as likely to have emphysema. The ongoing stress on the body keeps taking its toll."
  • "CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM -- The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular health. But when the ACE study data started to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. 20 It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration. When the surgeon general’s report on smoking and health was published in 1964, it unleashed a decades-long legal and medical campaign that has changed daily life and long-term health prospects for millions. The number of American smokers fell from 42 percent of adults in 1965 to 19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer were prevented between 1975 and 2000. 21 The ACE study, however, has had no such effect. Follow-up studies and papers are still appearing around the world, but the day-to-day reality of children like Marilyn and the children in outpatient clinics and residential treatment centers around the country remains virtually the same. Only now they receive high doses of psychotropic agents, which makes them more tractable but which also impairs their ability to feel pleasure and curiosity, to grow and develop emotionally and intellectually, and to become contributing members of society."
• Chapter 10 - Developmental Trauma: The Hidden Epidemic
  • "There are hundreds of thousands of children like the ones I am about to describe, and they absorb enormous resources, often without appreciable benefit. They end up filling our jails, our welfare rolls, and our medical clinics. Most of the public knows them only as statistics. Tens of thousands of schoolteachers, probation officers, welfare workers, judges, and mental health professionals spend their days trying to help them, and the taxpayer pays the bills."
  • "Recent research has swept away the simple idea that “having” a particular gene produces a particular result. It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation), making it more or less sensitive to messages from the body. While life events can change the behavior of the gene, they do not alter its fundamental structure. Methylation patterns, however, can be passed on to offspring—a phenomenon known as epigenetics. Once again, the body keeps the score, at the deepest levels of the organism. One of the most cited experiments in epigenetics was conducted by McGill University researcher Michael Meaney, who studies newborn rat pups and their mothers. He discovered that how much a mother rat licks and grooms her pups during the first twelve hours after their birth permanently affects the brain chemicals that respond to stress—and modifies the configuration of over a thousand genes. The rat pups that are intensively licked by their mothers are braver and produce lower levels of stress hormones under stress than rats whose mothers are less attentive. They also recover more quickly—an equanimity that lasts throughout their lives. They develop thicker connections in the hippocampus, a key center for learning and memory, and they perform better in an important rodent skill—finding their way through mazes. We are just beginning to learn that stressful experiences affect gene expression in humans, as well. Children whose pregnant mothers had been trapped in unheated houses in a prolonged ice storm in Quebec had major epigenetic changes compared with the children of mothers whose heat had been restored within a day. 6 McGill researcher Moshe Szyf compared the epigenetic profiles of hundreds of children born into the extreme ends of social privilege in the United Kingdom and measured the effects of child abuse on both groups. Differences in social class were associated with distinctly different epigenetic profiles, but abused children in both groups had in common specific modifications in seventy-three genes. In Szyf’s words, “Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world."
  • "The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, ” causing “intense fear, helplessness, or horror, ” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability). This description suggests a clear story line: A person is suddenly and unexpectedly devastated by an atrocious event and is never the same again. The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system. How relevant was this definition to the children we were seeing? After a single traumatic incident—a dog bite, an accident, or witnessing a school shooting—children can indeed develop basic PTSD symptoms similar to those of adults, even if they live in safe and supportive homes. As a result of having the PTSD diagnosis, we now can treat those problems quite effectively. In the case of the troubled children with histories of abuse and neglect who show up in clinics, schools, hospitals, and police stations, the traumatic roots of their behaviors are less obvious, particularly because they rarely talk about having been hit, abandoned, or molested, even when asked. Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD. Because they often are shut down, suspicious, or aggressive they now receive pseudoscientific diagnoses such as “oppositional defiant disorder,” meaning “This kid hates my guts and won’t do anything I tell him to do,” or “disruptive mood dysregulation disorder,” meaning he has temper tantrums. Having as many problems as they do, these kids accumulate numerous diagnoses over time. Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage."
  • "As the NCTSN treated more and more kids, it became increasingly obvious that we needed a diagnosis that captured the reality of their experience. We began with a database of nearly twenty thousand kids who were being treated in various sites within the network and collected all the research articles we could find on abused and neglected kids. These were winnowed down to 130 particularly relevant studies that reported on more than one hundred thousand children and adolescents worldwide. A core work group of twelve clinician/researchers specializing in childhood trauma then convened twice a year for four years to draft a proposal for an appropriate diagnosis, which we decided to call Developmental Trauma Disorder. As we organized our findings, we discovered a consistent profile: (1) a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3) difficulties getting along with themselves and others. These children’s moods and feelings rapidly shifted from one extreme to another—from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling. Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted. Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they cannot help but define themselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and overreacting to slight frustrations makes it difficult for them to make friends. We published the first articles about our findings, developed a validated rating scale, and collected data on about 350 kids and their parents or foster parents to establish that this one diagnosis, Developmental Trauma Disorder, captured the full range of what was wrong with these children. It would enable us to give them a single diagnosis, as opposed to multiple labels, and would firmly locate the origin of their problems in a combination of trauma and compromised attachment. In February 2009 we submitted our proposed new diagnosis of Developmental Trauma Disorder to the American Psychiatric Association, stating the following in a cover letter...I felt confident that this letter would ensure that the APA would take our proposal seriously, but several months after our submission, Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be included in the DSM-V. The consensus, he wrote, was that no new diagnosis was required to fill a “missing diagnostic niche. ” One million children who are abused and neglected every year in the United States a “diagnostic niche”? The letter went on: “The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. This statement is commonly made but cannot be backed up by prospective studies.” In fact, we had included several prospective studies in our proposal. Let’s look at just two of them here..."
  • "THE LONG-TERM EFFECTS OF INCEST -- In 1986 Frank Putnam and Penelope Trickett, his colleague at the National Institute of Mental Health, initiated the first longitudinal study of the impact of sexual abuse on female development. Until the results of this study came out, our knowledge about the effects of incest was based entirely on reports from children who had recently disclosed their abuse and on accounts from adults reconstructing years or even decades later how incest had affected them. No study had ever followed girls as they matured to examine how sexual abuse might influence their school performance, peer relationships, and self-concept, as well as their later dating life. Putnam and Trickett also looked at changes over time in their subjects’ stress hormones, reproductive hormones, immune function, and other physiological measures. In addition they explored potential protective factors, such as intelligence and support from family and peers. The researchers painstakingly recruited eighty-four girls referred by the District of Columbia Department of Social Services who had a confirmed history of sexual abuse by a family member. These were matched with a comparison group of eighty-two girls of the same age, race, socioeconomic status, and family constellation who had not been abused. The average starting age was eleven. Over the next twenty years these two groups were thoroughly assessed six times, once a year for the first three years and again at ages eighteen, nineteen, and twenty-five. Their mothers participated in the early assessments, and their own children took part in the last. A remarkable 96 percent of the girls, now grown women, have stayed in the study from its inception. The results were unambiguous: Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation. They dropped out of high school at a higher rate than the control group and had more major illnesses and health-care utilization. They also showed abnormalities in their stress hormone responses, had an earlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses. The follow-up research revealed many details of how abuse affects development. For example, each time they were assessed, the girls in both groups were asked to talk about the worst thing that had happened to them during the previous year. As they told their stories, the researchers observed how upset they became, while measuring their physiology. During the first assessment all the girls reacted by becoming distressed. Three years later, in response to the same question, the nonabused girls once again displayed signs of distress, but the abused girls shut down and became numb. Their biology matched their observable reactions: During the first assessment all of the girls showed an increase in the stress hormone cortisol; three years later cortisol went down in the abused girls as they reported on the most stressful event of the past year. Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action. Putnam’s study also captured the pervasive long-term effects of incest on friendships and partnering. Before the onset of puberty nonabused girls usually have several girlfriends, as well as one boy who functions as a sort of spy who informs them about what these strange creatures, boys, are all about. After they enter adolescence, their contacts with boys gradually increase. In contrast, before puberty the abused girls rarely have close friends, girls or boys, but adolescence brings many chaotic and often traumatizing contacts with boys. Lacking friends in elementary school makes a crucial difference. Today we’re aware how cruel third- , fourth- , and fifth-grade girls can be. It’s a complex and rocky time when friends can suddenly turn on one another and alliances dissolve in exclusions and betrayals. But there is an upside: By the time girls get to middle school, most have begun to master a whole set of social skills, including being able to identify what they feel, negotiating relationships with others, pretending to like people they don’t, and so on. And most of them have built a fairly steady support network of girls who become their stress-debriefing team. As they slowly enter the world of sex and dating, these relationships give them room for reflection, gossip, and discussion of what it all means. The sexually abused girls have an entirely different developmental pathway. They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress. Other kids usually don’t want anything to do with them—they simply are too weird. But that’s only the beginning of the trouble. The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group."
  • "THE DSM-V: A VERITABLE SMORGASBORD OF “DIAGNOSES” -- When DSM-V was published in May 2013 it included some three hundred disorders in its 945 pages. It offers a veritable smorgasbord of possible labels for the problems associated with severe early-life trauma, including some new ones such as Disruptive Mood Regulation Disorder, Non-suicidal Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement Disorder, and Disruptive Impulse Control Disorder. Before the late nineteenth century doctors classified illnesses according to their surface manifestations, like fevers and pustules, which was not unreasonable, given that they had little else to go on. This changed when scientists like Louis Pasteur and Robert Koch discovered that many diseases were caused by bacteria that were invisible to the naked eye. Medicine then was transformed by its attempts to discover ways to get rid of those organisms rather than just treating the boils and the fevers that they caused. With DSM-V psychiatry firmly regressed to early-nineteenth-century medical practice. Despite the fact that we know the origin of many of the problems it identifies, its “diagnoses” describe surface phenomena that completely ignore the underlying causes. Even before DSM-V was released, the American Journal of Psychiatry published the results of validity tests of various new diagnoses, which indicated that the DSM largely lacks what in the world of science is known as “reliability” —the ability to produce consistent, replicable results. In other words, it lacks scientific validity. Oddly, the lack of reliability and validity did not keep the DSM-V from meeting its deadline for publication, despite the near-universal consensus that it represented no improvement over the previous diagnostic system. Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-V (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system? Diagnostic reliability isn’t an abstract issue: If doctors can’t agree on what ails their patients, there is no way they can provide proper treatment. When there’s no relationship between diagnosis and cure, a mislabeled patient is bound to be a mistreated patient...In a statement released in June 2011, the British Psychological Society complained to the APA that the sources of psychological suffering in the DSM-V were identified “as located within individuals” and overlooked the “undeniable social causation of many such problems. ”30 This was in addition to a flood of protest from American professionals, including leaders of the American Psychological Association and the American Counseling Association. Why are relationships or social conditions left out? If you pay attention only to faulty biology and defective genes as the cause of mental problems and ignore abandonment, abuse, and deprivation, you are likely to run into as many dead ends as previous generations did blaming it all on terrible mothers."
• Chapter 11 - Uncovering Secrets: The Problem of Traumatic Memory
  • "In the spring of 2002 I was asked to examine a young man who claimed to have been sexually abused while he was growing up by Paul Shanley, a Catholic priest who had served in his parish in Newton, Massachusetts. Now twenty-five years old, he had apparently forgotten the abuse until he heard that the priest was currently under investigation for molesting young boys. The question posed to me was: Even though he had seemingly “repressed” the abuse for well over a decade after it ended, were his memories credible, and was I prepared to testify to that fact before a judge? I will share what this man, whom I’ll call Julian, told me, drawing on my original case notes. (Even though his real name is in the public record, I’m using a pseudonym because I hope that he has regained some privacy and peace with the passage of time. 1) His experiences illustrate the complexities of traumatic memory. The controversies over the case against Father Shanley are also typical of the passions that have swirled around this issue since **psychiatrists first described the unusual nature of traumatic memories in the final decades of the nineteenth century."
  • "FLOODED BY SENSATIONS AND IMAGES -- On February 11, 2001, Julian was serving as a military policeman at an air force base. During his daily phone conversation with his girlfriend, Rachel, she mentioned a lead article she’d read that morning in the Boston Globe. A priest named Shanley was under suspicion for molesting children. Hadn’t Julian once told her about a Father Shanley who had been his parish priest back in Newton? “Did he ever do anything to you?” she asked. Julian initially recalled Father Shanley as a kind man who’d been very supportive after his parents got divorced. But as the conversation went on, he started to go into a panic. He suddenly saw Shanley silhouetted in a doorframe, his hands stretched out at forty-five degrees, staring at Julian as he urinated. Overwhelmed by emotion, he told Rachel, “I’ve got to go.” He called his flight chief, who came over accompanied by the first sergeant. After he met with the two of them, they took him to the base chaplain. Julian recalls telling him: “Do you know what is going on in Boston? It happened to me, too.” The moment he heard himself say those words, he knew for certain that Shanley had molested him—even though he did not remember the details. Julian felt extremely embarrassed about being so emotional; he had always been a strong kid who kept things to himself. That night he sat on the corner of his bed, hunched over, thinking he was losing his mind and terrified that he would be locked up. Over the subsequent week images kept flooding into his mind, and he was afraid of breaking down completely. He thought about taking a knife and plunging it into his leg just to stop the mental pictures. Then the panic attacks started to be accompanied by seizures, which he called “epileptic fits.” He scratched his body until he bled. He constantly felt hot, sweaty, and agitated. Between panic attacks he “felt like a zombie”; he was observing himself from a distance, as if what he was experiencing were actually happening to somebody else...Julian was a popular athlete in high school. Although he had many friends, he felt pretty bad about himself and covered up for being a poor student by drinking and partying. He feels ashamed that he took advantage of his popularity and good looks by having sex with many girls. He mentioned wanting to call several of them to apologize for how badly he’d treated them. He remembered always hating his body. In high school he took steroids to pump himself up and smoked marijuana almost every day. He did not go to college, and after graduating from high school he was virtually homeless for almost a year because he could no longer stand living with his mother. He enlisted to try to get his life back on track. Julian met Father Shanley at age six when he was taking a CCD (catechism) class at the parish church. He remembered Father Shanley taking him out of the class for confession. Father Shanley rarely wore a cassock, and Julian remembered the priest’s dark blue corduroy pants. They would go to a big room with one chair facing another and a bench to kneel on. The chairs were covered with red and there was a red velvet cushion on the bench. They played cards, a game of war that turned into strip poker. Then he remembered standing in front of a mirror in that room. Father Shanley made him bend over. He remembered Father Shanley putting a finger into his anus. He does not think Shanley ever penetrated him with his penis, but he believes that the priest fingered him on numerous occasions. Other than that, his memories were quite incoherent and fragmentary. He had flashes of images of Shanley’s face and of isolated incidents: Shanley standing in the door of the bathroom; the priest going down on his knees and moving “it” around with his tongue. He could not say how old he was when that happened. He remembered the priest telling him how to perform oral sex, but he did not remember actually doing it. He remembered passing out pamphlets in church and then Father Shanley sitting next to him in a pew, fondling him with one hand and holding Julian’s hand on himself with the other. He remembered that, as he grew older, Father Shanley would pass close to him and caress his penis. Paul did not like it but did not know what to do to stop it. After all, he told me, “Father Shanley was the closest thing to God in my neighborhood.” In addition to these memory fragments, traces of his sexual abuse were clearly being activated and replayed. Sometimes when he was having sex with his girlfriend, the priest’s image popped into his head, and, as he said, he would “lose it.” A week before I interviewed him, his girlfriend had pushed a finger into his mouth and playfully said: “You give good head.” Julian jumped up and screamed, “If you ever say that again I’ll fucking kill you.” Then, terrified, they both started to cry. This was followed by one of Julian’s “epileptic fits,” in which he curled up in a fetal position, shaking and whimpering like a baby. While telling me this Julian looked very small and very frightened. Julian alternated between feeling sorry for the old man that Father Shanley had become and simply wanting to “take him into a room somewhere and kill him.” **He also spoke repeatedly of how ashamed he felt, how hard it was to admit that he could not protect himself...How do we make sense of a story like Julian’s: years of apparent forgetting, followed by fragmented, disturbing images, dramatic physical symptoms, and sudden reenactments? As a therapist treating people with a legacy of trauma, my primary concern is not to determine exactly what happened to them but to help them tolerate the sensations, emotions, and reactions they experience without being constantly hijacked by them. When the subject of blame arises, the central issue that needs to be addressed is usually self-blame—accepting that the trauma was not their fault, that it was not caused by some defect in themselves, and that no one could ever have deserved what happened to them. Once a legal case is involved, however, determination of culpability becomes primary, and with it the admissibility of evidence. I had previously examined twelve people who had been sadistically abused as children in a Catholic orphanage in Burlington, Vermont. They had come forward (with many other claimants) more than four decades later, and although none had had any contact with the others until the first claim was filed, their abuse memories were astonishingly similar: They all named the same names and the particular abuses that each nun or priest had committed—in the same rooms, with the same furniture, and as part of the same daily routines. Most of them subsequently accepted an out-of-court settlement from the Vermont diocese. Before a case goes to trial, the judge holds a so-called Daubert hearing to set the standards for expert testimony to be presented to the jury. In a 1996 case I had convinced a federal circuit court judge in Boston that it was common for traumatized people to lose all memories of the event in question, only to regain access to them in bits and pieces at a much later date. The same standards would apply in Julian’s case. While my report to his lawyer remains confidential, it was based on decades of clinical experience and research on traumatic memory, including the work of some of the great pioneers of modern psychiatry."
  • "NORMAL VERSUS TRAUMATIC MEMORY -- We all know how fickle memory is; our stories change and are constantly revised and updated. When my brothers, sisters, and I talk about events in our childhood, we always end up feeling that we grew up in different families—so many of our memories simply do not match. Such autobiographical memories are not precise reflections of reality; they are stories we tell to convey our personal take on our experience. The extraordinary capacity of the human mind to rewrite memory is illustrated in the Grant Study of Adult Development, which has systematically followed the psychological and physical health of more than two hundred Harvard men from their sophomore years of 1939–44 to the present. Of course, the designers of the study could not have anticipated that most of the participants would go off to fight in World War II, but we can now track the evolution of their wartime memories. The men were interviewed in detail about their war experiences in 1945/1946 and again in 1989/1990. Four and a half decades later, the majority gave very different accounts from the narratives recorded in their immediate postwar interviews: With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended. Whether we remember a particular event at all, and how accurate our memories of it are, largely depends on how personally meaningful it was and how emotional we felt about it at the time. The key factor is our level of arousal. We all have memories associated with particular people, songs, smells, and places that stay with us for a long time. Most of us still have precise memories of where we were and what we saw on Tuesday, September 11, 2001, but only a fraction of us recall anything in particular about September 10. Most day-to-day experience passes immediately into oblivion. On ordinary days we don’t have much to report when we come home in the evening. The mind works according to schemes or maps, and incidents that fall outside the established pattern are most likely to capture our attention. If we get a raise or a friend tells us some exciting news, we will retain the details of the moment, at least for a while. We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds. Even if the content of the remark fades, our dislike for the person who made it usually persists. When something terrifying happens, like seeing a child or a friend get hurt in an accident, we will retain an intense and largely accurate memory of the event for a long time. As James McGaugh and colleagues have shown, the more adrenaline you secrete, the more precise your memory will be. But that is true only up to a certain point. Confronted with horror—especially the horror of “inescapable shock” —this system becomes overwhelmed and breaks down. Of course, we cannot monitor what happens during a traumatic experience, but we can reactivate the trauma in the laboratory, as was done for the brain scans in chapters 3 and 4. When memory traces of the original sounds, images, and sensations are reactivated, the frontal lobe shuts down, including, as we’ve seen, the region necessary to put feelings into words, the region that creates our sense of location in time, and the thalamus, which integrates the raw data of incoming sensations. At this point the emotional brain, which is not under conscious control and cannot communicate in words, takes over. The emotional brain (the limbic area and the brain stem) expresses its altered activation through changes in emotional arousal, body physiology, and muscular action. Under ordinary conditions these two memory systems—rational and emotional—collaborate to produce an integrated response. But high arousal not only changes the balance between them but also disconnects other brain areas necessary for the proper storage and integration of incoming information, such as the hippocampus and the thalamus. As a result, the imprints of traumatic experiences are organized not as coherent logical narratives but in fragmented sensory and emotional traces: images, sounds, and physical sensations. Julian saw a man with outstretched arms, a pew, a staircase, a strip poker game; he felt a sensation in his penis, a panicked sense of dread. But there was little or no story."
  • "The greatest advances, however, came in the study of hysteria, a mental disorder characterized by emotional outbursts, susceptibility to suggestion, and contractions and paralyses of the muscles that could not be explained by simple anatomy. Once considered an affliction of unstable or malingering women (the name comes from the Greek word for “womb”), hysteria now became a window into the mysteries of mind and body. The names of some of the greatest pioneers in neurology and psychiatry, such as Jean-Martin Charcot, Pierre Janet, and Sigmund Freud, are associated with the discovery that trauma is at the root of hysteria, particularly the trauma of childhood sexual abuse...Pierre Janet...helped Charcot establish a research laboratory devoted to the study of hysteria at the Salpêtrière. In 1889...Janet published the first book-length scientific account of traumatic stress: L’automatisme psychologique. Janet proposed that at the root of what we now call PTSD was the experience of “vehement emotions,” or intense emotional arousal. This treatise explained that, after having been traumatized, people automatically keep repeating certain actions, emotions, and sensations related to the trauma...AMNESIA, DISSOCIATION, AND REENACTMENT -- Janet was the first to point out the difference between “narrative memory” —the stories people tell about trauma—and traumatic memory itself. One of his case histories was the story of Irène, a young woman who was hospitalized following her mother’s death from tuberculosis. Irène had nursed her mother for many months while continuing to work outside the home to support her alcoholic father and pay for her mother’s medical care. When her mother finally died...even after an aunt arrived and started preparing for the burial, Irène’s denial persisted...In addition to amnesia for her mother’s death, Irène suffered from another symptom: Several times a week she would stare, trancelike, at an empty bed, ignore whatever was going on around her, and begin to care for an imaginary person. She meticulously reproduced, rather than remembered, the details of her mother’s death. Traumatized people simultaneously remember too little and too much. On the one hand, Irène had no conscious memory of her mother’s death—she could not tell the story of what had happened. On the other she was compelled to physically act out the events of her mother’s death. Janet’s term “automatism” conveys the involuntary, unconscious nature of her actions. Janet treated Irène for several months, mainly with hypnosis. At the end he asked her again about her mother’s death. Irène started to cry and said, “Don’t remind me of those terrible things. . . . My mother was dead and my father was a complete drunk, as always. I had to take care of her dead body all night long. I did a lot of silly things in order to revive her. . . . In the morning I lost my mind. ” Not only was Irène able tell the story, but she had also recovered her emotions: “I feel very sad and abandoned. ” Janet now called her memory “complete” because it now was accompanied by the appropriate feelings. Janet noted significant differences between ordinary and traumatic memory. Traumatic memories are precipitated by specific triggers. In Julian’s case the trigger was his girlfriend’s seductive comments; in Irène’s it was a bed. When one element of a traumatic experience is triggered, other elements are likely to automatically follow. Traumatic memory is not condensed: It took Irène three to four hours to reenact her story, but when she was finally able to tell what had happened it took less than a minute. The traumatic enactment serves no function. In contrast, ordinary memory is adaptive; our stories are flexible and can be modified to fit the circumstances. Ordinary memory is essentially social; it’s a story that we tell for a purpose: in Irène’s case, to enlist her doctor’s help and comfort; in Julian’s case, to recruit me to join his search for justice and revenge. But there is nothing social about traumatic memory. Julian’s rage at his girlfriend’s remark served no useful purpose. Reenactments are frozen in time, unchanging, and they are always lonely, humiliating, and alienating experiences. Janet coined the term “dissociation” to describe the splitting off and isolation of memory imprints that he saw in his patients. He was also prescient about the heavy cost of keeping these traumatic memories at bay. He later wrote that when patients dissociate their traumatic experience, they become “attached to an insurmountable obstacle”: “[U]nable to integrate their traumatic memories, they seem to lose their capacity to assimilate new experiences as well. It is . . . as if their personality has definitely stopped at a certain point, and cannot enlarge any more by the addition or assimilation of new elements.” He predicted that unless they became aware of the split-off elements and integrated them into a story that had happened in the past but was now over, they would experience a slow decline in their personal and professional functioning. This phenomenon has now been well documented in contemporary research. 20 Janet discovered that, while it is normal to change and distort one’s memories, people with PTSD are unable to put the actual event, the source of those memories, behind them. Dissociation prevents the trauma from becoming integrated within the conglomerated, ever- shifting stores of autobiographical memory, in essence creating a dual memory system. Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others. But in Julian’s case, the sensations, thoughts, and emotions of the trauma were stored separately as frozen, barely comprehensible fragments. If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that “that was then, and this is now.”"
• Chapter 12 - The Unbearable Heaviness of Remembering
  • "While politics and medicine turned their backs on the returning soldiers, the horrors of the war were memorialized in literature and art. In All Quiet on the Western Front, a novel about the war experiences of frontline soldiers by the German writer Erich Maria Remarque, the book’s protagonist, Paul Bäumer, spoke for an entire generation: “I am aware that I, without realizing it, have lost my feelings—I don’t belong here anymore, I live in an alien world. I prefer to be left alone, not disturbed by anybody. They talk too much—I can’t relate to them—they are only busy with superficial things. ” Published in 1929, the novel instantly became an international best seller, with translations in twenty-five languages. The 1930 Hollywood film version won the Academy Award for Best Picture. But when Hitler came to power a few years later, All Quiet on the Western Front was one of the first “degenerate” books the Nazis burned in the public square in front of Humboldt University in Berlin. Apparently awareness of the devastating effects of war on soldiers’ minds would have constituted a threat to the Nazis’ plunge into another round of insanity. Denial of the consequences of trauma can wreak havoc with the social fabric of society."
  • "THE SCIENCE OF REPRESSED MEMORY -- There have in fact been hundreds of scientific publications spanning well over a century documenting how the memory of trauma can be repressed, only to resurface years or decades later. Memory loss has been reported in people who have experienced natural disasters, accidents, war trauma, kidnapping, torture, concentration camps, and physical and sexual abuse. Total memory loss is most common in childhood sexual abuse, with incidence ranging from 19 percent to 38 percent. This issue is not particularly controversial: As early as 1980 the DSM-III recognized the existence of memory loss for traumatic events in the diagnostic criteria for dissociative amnesia: “an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness.” Memory loss has been part of the criteria for PTSD since that diagnosis was first introduced. One of the most interesting studies of repressed memory was conducted by Dr. Linda Meyer Williams, which began when she was a graduate student in sociology at the University of Pennsylvania in the early 1970s. Williams interviewed 206 girls between the ages of ten and twelve who had been admitted to a hospital emergency room following sexual abuse. Their laboratory tests, as well as the interviews with the children and their parents, were kept in the hospital’s medical records. Seventeen years later Williams was able to track down 136 of the children, now adults, with whom she conducted extensive follow-up interviews. More than a third of the women (38 percent) did not recall the abuse that was documented in their medical records, while only fifteen women (12 percent) said that they had never been abused as children. More than two-thirds (68 percent) reported other incidents of childhood sexual abuse. Women who were younger at the time of the incident and those who were molested by someone they knew were more likely to have forgotten their abuse. This study also examined the reliability of recovered memories. One in ten women (16 percent of those who recalled the abuse) reported that they had forgotten it at some time in the past but later remembered that it had happened. In comparison with the women who had always remembered their molestation, those with a prior period of forgetting were younger at the time of their abuse and were less likely to have received support from their mothers. Williams also determined that the recovered memories were approximately as accurate as those that had never been lost: All the women’s memories were accurate for the central facts of the incident, but none of their stories precisely matched every detail documented in their charts. Williams’s findings are supported by recent neuroscience research that shows that memories that are retrieved tend to return to the memory bank with modifications. As long as a memory is inaccessible, the mind is unable to change it. But as soon as a story starts being told, particularly if it is told repeatedly, it changes—the act of telling itself changes the tale. The mind cannot help but make meaning out of what it knows, and the meaning we make of our lives changes how and what we remember. Given the wealth of evidence that trauma can be forgotten and resurface years later, why did nearly one hundred reputable memory scientists from several different countries throw the weight of their reputations behind the appeal to overturn Father Shanley’s conviction, claiming that “repressed memories” were based on “junk science”? Because memory loss and delayed recall of traumatic experiences had never been documented in the laboratory, some cognitive scientists adamantly denied that these phenomena existed or that retrieved traumatic memories could be accurate. However, what doctors encounter in emergency rooms, on psychiatric wards, and on the battlefield is necessarily quite different from what scientists observe in their safe and well-organized laboratories. Consider what is known as the “lost in the mall” experiment, for example. Academic researchers have shown that it is relatively easy to implant memories of events that never took place, such as having been lost in a shopping mall as a child. About 25 percent of subjects in these studies later “recall” that they were frightened and even fill in missing details. But such recollections involve none of the visceral terror that a lost child would actually experience. Another line of research documented the unreliability of eyewitness testimony. Subjects might be shown a video of a car driving down a street and asked afterward if they saw a stop sign or a traffic light; children might be asked to recall what a male visitor to their classroom had been wearing. Other eyewitness experiments demonstrated that the questions witnesses were asked could alter what they claimed to remember. These studies were valuable in bringing many police and courtroom practices into question, but they have little relevance to traumatic memory. The fundamental problem is this: Events that take place in the laboratory cannot be considered equivalent to the conditions under which traumatic memories are created. The terror and helplessness associated with PTSD simply can’t be induced de novo in such a setting. We can study the effects of existing traumas in the lab, as in our script-driven imaging studies of flashbacks, but the original imprint of trauma cannot be laid down there. Dr. Roger Pitman conducted a study at Harvard in which he showed college students a film called Faces of Death, which contained newsreel footage of violent deaths and executions. This movie, now widely banned, is as extreme as any institutional review board would allow, but it did not cause Pitman’s normal volunteers to develop symptoms of PTSD. If you want to study traumatic memory, you have to study the memories of people who have actually been traumatized. Interestingly, once the excitement and profitability of courtroom testimony diminished, the “scientific” controversy disappeared as well, and clinicians were left to deal with the wreckage of traumatic memory.**"
  • "NORMAL VERSUS TRAUMATIC MEMORY -- In 1994 I and my colleagues at Massachusetts General Hospital decided to undertake a systematic study comparing how people recall benign experiences and horrific ones. We placed advertisements in local newspapers, in laundromats, and on student union bulletin boards that said: “Has something terrible happened to you that you cannot get out of your mind? Call 727- 5500; we will pay you $10.00 for participating in this study. ” In response to our first ad seventy- six volunteers showed up. 26 After we introduced ourselves, we started off by asking each participant: “Can you tell us about an event in your life that you think you will always remember but that is not traumatic?” One participant lit up and said, “The day that my daughter was born”; others mentioned their wedding day, playing on a winning sports team, or being valedictorian at their high school graduation. Then we asked them to focus on specific sensory details of those events, such as: “Are you ever somewhere and suddenly have a vivid image of what your husband looked like on your wedding day?” The answers were always negative. “How about what your husband’s body felt like on your wedding night?” (We got some odd looks on that one.) We continued: “Do you ever have a vivid, precise recollection of the speech you gave as a valedictorian?” “Do you ever have intense sensations recalling the birth of your first child?” The replies were all in the negative. Then we asked them about the traumas that had brought them into the study—many of them rapes. “Do you ever suddenly remember how your rapist smelled?” we asked, and, “Do you ever experience the same physical sensations you had when you were raped?” Such questions precipitated powerful emotional responses: “That is why I cannot go to parties anymore, because the smell of alcohol on somebody’s breath makes me feel like I am being raped all over again” or “I can no longer make love to my husband, because when he touches me in a particular way I feel like I am being raped again. ” There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events. In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events or other vital details (the first person who arrived to help, whether an ambulance or a police car took them to the hospital). We also asked the participants how they recalled their trauma at three points in time: right after it happened; when they were most troubled by their symptoms; and during the week before the study. All of our traumatized participants said that they had not been able to tell anybody precisely what had happened immediately following the event. (This will not surprise anyone who has worked in an emergency room or ambulance service: People brought in after a car accident in which a child or a friend has been killed sit in stunned silence, dumbfounded by terror.) Almost all had repeated flashbacks: They felt overwhelmed by images, sounds, sensations, and emotions. As time went on, even more sensory details and feelings were activated, but most participants also started to be able to make some sense out of them. They began to “know” what had happened and to be able to tell the story to other people, a story that we call “the memory of the trauma. ” Gradually the images and flashbacks decreased in frequency, but the greatest improvement was in the participants’ ability to piece together the details and sequence of the event. By the time of our study, 85 percent of them were able to tell a coherent story, with a beginning, a middle, and an end. Only a few were missing significant details. We noted that the five who said they had been abused as children had the most fragmented narratives—their memories still arrived as images, physical sensations, and intense emotions. In essence, our study confirmed the dual memory system that Janet and his colleagues at the Salpêtrière had described more than a hundred years earlier: Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography. Perhaps the most important finding in our study was that remembering the trauma with all its associated affects, does not, as Breuer and Freud claimed back in 1893, necessarily resolve it. Our research did not support the idea that language can substitute for action. Most of our study participants could tell a coherent story and also experience the pain associated with those stories, but they kept being haunted by unbearable images and physical sensations. Research in contemporary exposure treatment, a staple of cognitive behavioral therapy, has similarly disappointing results: The majority of patients treated with that method continue to have serious PTSD symptoms three months after the end of treatment. As we will see, finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries."
  • "LISTENING TO SURVIVORS -- Nobody wants to remember trauma. In that regard society is no different from the victims themselves. We all want to live in a world that is safe, manageable, and predictable, and victims remind us that this is not always the case. In order to understand trauma, we have to overcome our natural reluctance to confront that reality and cultivate the courage to listen to the testimonies of survivors. In his book Holocaust Testimonies: The Ruins of Memory (1991), Lawrence Langer writes about his work in the Fortunoff Video Archive at Yale University: “Listening to accounts of Holocaust experience, we unearth a mosaic of evidence that constantly vanishes into bottomless layers of incompletion. We wrestle with the beginnings of a permanently unfinished tale, full of incomplete intervals, faced by the spectacle of a faltering witness often reduced to a distressed silence by the overwhelming solicitations of deep memory.” As one of his witnesses says: “If you were not there, it’s difficult to describe and say how it was. How men function under such stress is one thing, and then how you communicate and express that to somebody who never knew that such a degree of brutality exists seems like a fantasy.” Another survivor, Charlotte Delbo, describes her dual existence after Auschwitz: “[T]he ‘self’ who was in the camp isn’t me, isn’t the person who is here, opposite you. No, it’s too unbelievable. And everything that happened to this other ‘self, ’ the one from Auschwitz, doesn’t touch me now, me, doesn’t concern me, so distinct are deep memory and common memory. . . . Without this split, I wouldn’t have been able to come back to life.” She comments that even words have a dual meaning: “Otherwise, someone [in the camps] who has been tormented by thirst for weeks would never again be able to say: ‘I’m thirsty. Let’s make a cup of tea. ’ Thirst [after the war] has once more become a currently used term. On the other hand, if I dream of the thirst I felt in Birkenau [the extermination facilities in Auschwitz], I see myself as I was then, haggard, bereft of reason, tottering.” Langer hauntingly concludes, “Who can find a proper grave for such damaged mosaics of the mind, where they may rest in pieces? Life goes on, but in two temporal directions at once, the future unable to escape the grip of a memory laden with grief.” The essence of trauma is that it is overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past.
  • "NANCY’S STORY Few patients have put that duality into words as vividly as Nancy, the director of nursing in a Midwestern hospital who came to Boston several times to consult with me. Shortly after the birth of her third child, Nancy underwent what is usually routine outpatient surgery, a laparoscopic tubal ligation in which the fallopian tubes are cauterized to prevent future pregnancies. However, because she was given insufficient anesthesia, she awakened after the operation began and remained aware nearly to the end, at times falling into what she called “a light sleep” or “dream,” at times experiencing the full horror of her situation. She was unable to alert the OR team by moving or crying out because she had been given a standard muscle relaxant to prevent muscle contractions during surgery. Some degree of “anesthesia awareness” is now estimated to occur in approximately thirty thousand surgical patients in the United States every year, 32 and I had previously testified on behalf of several people who were traumatized by the experience. Nancy, however, did not want to sue her surgeon or anesthetist. Her entire focus was on bringing the reality of her trauma to consciousness so that she could free herself from its intrusions into her everyday life. I’d like to end this chapter by sharing several passages from a remarkable series of e-mails in which she described her grueling journey to recovery. Initially Nancy did not know what had happened to her. “When we went home I was still in a daze, doing the typical things of running a household, yet not really feeling that I was alive or that I was real. I had trouble sleeping that night. For days, I remained in my own little disconnected world. I could not use a hair dryer, toaster, stove or anything that warmed up. I could not concentrate on what people were doing or telling me. I just didn’t care. I was increasingly anxious. I slept less and less. I knew I was behaving strangely and kept trying to understand what was frightening me so. “On the fourth night after the surgery, around 3 AM, I started to realize that the dream I had been living all this time related to conversations I had heard in the operating room. I was suddenly transported back into the OR and could feel my paralyzed body being burned. I was engulfed in a world of terror and horror.” From then on, Nancy says, memories and flashbacks erupted into her life. “It was as if the door was pushed open slightly, allowing the intrusion. There was a mixture of curiosity and avoidance. I continued to have irrational fears. I was deathly afraid of sleep; I experienced a sense of terror when seeing the color blue. My husband, unfortunately, was bearing the brunt of my illness. I would lash out at him when I truly did not intend to. I was sleeping at most 2 to 3 hours, and my daytime was filled with hours of flashbacks. I remained chronically hyperalert, feeling threatened by my own thoughts and wanting to escape them. I lost 23 pounds in 3 weeks. People kept commenting on how great I looked. “I began to think about dying. I developed a very distorted view of my life in which all my successes diminished and old failures were amplified. I was hurting my husband and found that I could not protect my children from my rage. “Three weeks after the surgery I went back to work at the hospital. The first time I saw somebody in a surgical scrubsuit was in the elevator. I wanted to get out immediately, but of course I could not. I then had this irrational urge to clobber him, which I contained with considerable effort. This episode triggered increasing flashbacks, terror and dissociation. I cried all the way home from work. After that, I became adept at avoidance. I never set foot in an elevator, I never went to the cafeteria, I avoided the surgical floors.” Gradually Nancy was able to piece together her flashbacks and create an understandable, if horrifying, memory of her surgery. She recalled the reassurances of the OR nurses and a brief period of sleep after the anesthesia was started. Then she remembered how she began to awaken. “The entire team was laughing about an affair one of the nurses was having. This coincided with the first surgical incision. I felt the stab of the scalpel, then the cutting, then the warm blood flowing over my skin. I tried desperately to move, to speak, but my body didn’t work. I couldn’t understand this. I felt a deeper pain as the layers of muscle pulled apart under their own tension. I knew I wasn’t supposed to feel this. ” Nancy next recalls someone “rummaging around” in her belly and identified this as the laparoscopic instruments being placed. She felt her left tube being clamped. “Then suddenly there was an intense searing, burning pain. I tried to escape, but the cautery tip pursued me, relentlessly burning through. There simply are no words to describe the terror of this experience. This pain was not in the same realm as other pain I had known and conquered, like a broken bone or natural childbirth. It begins as extreme pain, then continues relentlessly as it slowly burns through the tube. The pain of being cut with the scalpel pales beside this giant.” “Then, abruptly, the right tube felt the initial impact of the burning tip. When I heard them laugh, I briefly lost track of where I was. I believed I was in a torture chamber, and I could not understand why they were torturing me without even asking for information. . . . My world narrowed to a small sphere around the operating table. There was no sense of time, no past, and no future. There was only pain, terror, and horror. I felt isolated from all humanity, profoundly alone in spite of the people surrounding me. The sphere was closing in on me. “In my agony, I must have made some movement. I heard the nurse anesthetist tell the anesthesiologist that I was ‘light. ’ He ordered more meds and then quietly said, ‘There is no need to put any of this in the chart. ’ That is the last memory I recalled. ” In her later e-mails to me, Nancy struggled to capture the existential reality of trauma. “I want to tell you what a flashback is like. It is as if time is folded or warped, so that the past and present merge, as if I were physically transported into the past. Symbols related to the original trauma, however benign in reality, are thoroughly contaminated and so become objects to be hated, feared, destroyed if possible, avoided if not. For example, an iron in any form—a toy, a clothes iron, a curling iron, came to be seen as an instrument of torture. Each encounter with a scrub suit left me disassociated, confused, physically ill and at times consciously angry. “My marriage is slowly falling apart—my husband came to represent the heartless laughing people [the surgical team] who hurt me. I exist in a dual state. A pervasive numbness covers me with a blanket; and yet the touch of a small child pulls me back to the world. For a moment, I am present and a part of life, not just an observer. “Interestingly, I function very well at work, and I am constantly given positive feedback. Life proceeds with its own sense of falsity. “There is a strangeness, bizarreness to this dual existence. I tire of it. Yet I cannot give up on life, and I cannot delude myself into believing that if I ignore the beast it will go away. I’ve thought many times that I had recalled all the events around the surgery, only to find a new one. “There are so many pieces of that 45 minutes of my life that remain unknown. My memories are still incomplete and fragmented, but I no longer think that I need to know everything in order to understand what happened. “When the fear subsides I realize I can handle it, but a part of me doubts that I can. The pull to the past is strong; it is the dark side of my life; and I must dwell there from time to time. The struggle may also be a way to know that I survive—a re-playing of the fight to survive—which apparently I won, but cannot own.” An early sign of recovery came when Nancy needed another, more extensive operation. She chose a Boston hospital for the surgery, asked for a preoperative meeting with the surgeons and the anesthesiologist specifically to discuss her prior experience, and requested that I be allowed to join them in the operating room. For the first time in many years I put on a surgical scrub suit and accompanied her into the OR while the anesthesia was induced. This time she woke up to a feeling of safety. Two years later I wrote Nancy asking her permission to use her account of anesthesia awareness in this chapter. In her reply she updated me on the progress of her recovery: “I wish I could say that the surgery to which you were so kind to accompany me ended my suffering. That sadly was not the case. After about six more months I made two choices that proved provident. I left my CBT therapist to work with a psychodynamic psychiatrist and I joined a Pilates class. “In our last month of therapy, I asked my psychiatrist why he did not try to fix me as all other therapists had attempted, yet had failed. He told me that he assumed, given what I had be able to accomplish with my children and career, that I had sufficient resiliency to heal myself, if he created a holding environment for me to do so. This was an hour each week that became a refuge where I could unravel the mystery of how I had become so damaged and then re-construct a sense of myself that was whole, not fragmented, peaceful, not tormented. Through Pilates, I found a stronger physical core, as well as a community of women who willingly gave acceptance and social support that had been distant in my life since the trauma. This combination of core strengthening—psychological, social, and physical—created a sense of personal safety and mastery, relegating my memories to the distant past, allowing the present and future to emerge.”

• "Researchers estimate that, in our country, about 1 out of 6 boys and 1 out of 4 girls are sexually abused before the age 18."
• "About 30% of those who sexually abuse children are relatives of the child"
• "Some child sexual abuse survivors may show symptoms of PTSD, including agitated behavior, frightening dreams, and repetitive play in which aspects of the abuse are expressed. They might exhibit other fears and anxieties..."
• "If childhood sexual abuse is not effectively treated, long-term symptoms may persist into adulthood. These may include:
  • PTSD and/or anxiety
  • Depression and thoughts of suicide
  • Sexual anxiety and disorders, including promiscuity
  • Difficulty maintaining appropriate boundaries with others, including enmeshed or avoidant relationships
  • Poor body image and low self-esteem
  • The use of unhealthy behaviors, such as alcohol abuse, drug abuse, self-mutilation, or bingeing and purging, to help mask painful emotions related to the abuse"

• Tim Ferriss:
  • "I was routinely sexually abused from ages two to four—that seems to be accurate based on conversations with my mom about the timeline—by the son of a babysitter. So if you imagine sort of the most disgusting, repulsive activities that you might envision with that statement, that is what happened. And I don’t know if it was on a weekly basis. I don’t know if it was multiple times a week, but it was frequent over a period of two years. "
• Tim Ferriss:
  • "For a very long time, up until age 35 or so, I felt like I had no memories before age six or five. And this type of amnesia actually showed up a lot for me in the sense that whenever I had a very stressful set of circumstances, a crisis of some type, a severe injury. I would experience this dissociation and I would black out my memory for the next, let’s just call it two to five hours would disappear. I would have no recollection of what happened."
  • "And I didn’t have any memories I could recall or did recall about this abuse until five or six years ago when I had a number of experiences with a psychedelic combination of plants called ayahuasca. And for more on that, we can refer people to other podcasts where I’ve talked about this, but at the time, let’s just call it five years ago, for sake of simplicity, the memory came up—and psychedelics are well known, not necessarily in the scientific literature, although there are some recordings of this, but more anecdotally across thousands and tens of thousands and millions of users over time, hypermnesia. So the opposite of amnesia, remembering things that you haven’t thought of in decades—the color and texture of the corduroy couch you had when you were an infant, that type of thing—and about five years ago, I would say, I had these crystal clear memories of sexual abuse come to me. The layout of the house, the other kids who were being cared of, so to speak, at the house. What the mother looked like, what the son looked like, being led up the stairs to the upstairs bedroom, the floor plan of the house. I know exactly where the house is. I know the driveway, I know the names, these are all things that I know. And it came flooding back to me. And at the time I thought to myself, “Huh, that’s interesting. That definitely happened. I remember that happening.”"
  • "And it came back to me in high resolution, but I didn’t feel any suffering associated with it. And I tucked it away, I put it back in the box, locked the box. And that was that. Until I had my first 10-day Vipassana silent retreat. And thankfully, had Jack Kornfield there as one of the lead facilitators. And to increase the depth of the experience, I’d fast beforehand. So it was fasting for about five days. And then began to use increasing dosages of psilocybin mushrooms, which contains psilocybin. So I started at 300 milligrams, went up to 600, and ultimately landed at 900. And I want to say around day six of this silent retreat, all of this abuse came back to me like a tidal wave. And it was replaying as if I were wearing a virtual reality headset."
  • "I was immersed. I wasn’t an observer. I was actually being traumatized and re-traumatized 24/7 for this period of time. Any moment that I was awake, this movie was playing and I would sweat through my sheets at night, fall asleep for an hour or two, then wake up to go back into meditation and the movie would start again. And I was so distraught. There was so much anguish. And I felt like I was either already having a psychotic break, or certain to have a psychotic break and that I would not be able to manage life when I left the silent retreat that I sought out Jack as an emergency to spend time with him and speak with him."
  • "And it was at that point after that that Jack made a number of recommendations for resources that we’ll talk about later, but included books by Peter Levine, like Waking the Tiger, The Body Keeps the Score by Bessel van der Kolk and a handful of other things."
  • "It was at the tail end of that retreat that I realized these, let’s just call it 17 seemingly inexplicable behaviors of mine, these vicious cycles or triggers that I had been treating like separate things, separate problems to be solved, were all downstream of this trauma, if that makes any sense. I don’t know if you’ve had this experience, but I was like, “Oh, now that you click that puzzle piece into place, these really strange behaviors, this self-loathing, this rage that was seemingly so exaggerated and disproportionate, leading to the near suicide in college, which was as close as you can get to taking your life without actually doing it. All of these things fell into places making sense. And on one hand there was this relief that it made sense and that I wasn’t broken in all these different ways. I had just sort of suffered this acute trauma and blocked it."
  • "And it was also very overwhelming because I didn’t necessarily know how to work on this root cause, this trauma. And that’s when the direct work began. I cleared everything in my calendar and everything waited, everything that could wait, waited. And these memories at that point had started to trickle up to awareness. And I’ll just give another example that I’ve never spoken about publicly, which is in elementary school, feeling numb and priding myself on pain tolerance. This ability to dissociate and for whatever reason, really—well, for obvious reasons I guess, wanting to develop the ability to withstand pain. And for a very short period, I would bring this pocket knife to school and press it into the back of my left thumb, I remember this really clearly, until my thumb would start to bleed and then I’d move it a millimeter or two and then press it into my thumb and make it bleed. And do this over and over again without changing my facial expression. I’m in class, I’m sitting in math class doing this, looking at the blackboard tracking things."
• Tim Ferriss:
  • "And so I began working, this is a few years ago, on compiling this book on healing. And I’m very fortunate in the sense that this sexual trauma never seemed to affect my sex life, my sort of vitality in sex. It was one of the few places actually that I felt integrated and felt, period. Where I actually felt deeply without dissociating. And so I started working on this book, the healing book. And I was writing this chapter, drafting this chapter on the abuse."
• Tim Ferriss:
  • "Tim Ferriss: Totally. And I was chatting with a friend of mine before this call and I haven’t spoken to many people at all about any of this, but he also suffered quite a lot of trauma. And he said something to me, which I’ve also thought quite a bit in the last few years. And that is your childhood adaptive responses are perfect, that dissociation in a way is a miracle of evolution. The fact that we develop this ability to split our psyche, compartmentalize to survive, is really miraculous. And there just comes a point, at least for me, where these old adaptive coping mechanisms have outlived their usefulness. And that’s been a huge part of my journey. And telling my parents was also extremely difficult. I was worried about destroying them in a way, if that makes sense."
• Debbie Millman:
  • "we as a species have so much shame associated with this behavior that has been socialized, that somehow it is the victim’s fault. Just think about what rape victims go through when they report, how much they have to defend the believability of their story or what they might have done or not done to contribute. So you can only imagine how much shame there is for young people that don’t know what is happening to them or why it’s happening to them. So it’s pervasive in our world. And it is one of the most devastating behaviors that someone can enact on another at any age. If it happens before the age of 10, because we’re all still developing our brains, it changes the neural pathways in our brains to such an extent that the behaviors that I know we’re going to talk about that you’ve struggled with and that I’ve struggled with are just a normal way of responding once that kind of trauma occurs."
  • "And for me, my trauma began, my sexual trauma began when I was nine years old and continued until I was 12."
  • ...
  • "Your psyche is too strong to just take those experiences and sweep them under a rug and never ever look at them again. They come back...But back to my experience with you, I still, up until 2017 or 2018, when I was first on your show, I was very, very secretive about my past. I still felt an enormous amount of shame. I still felt that it made me damaged goods. I was not really willing to discuss it with anyone at any length, beyond my closest, closest friends and partners. And I hadn’t even talked about it at length with my family who didn’t really seem to want to know."
• Tim Ferriss:
  • "Hakomi therapy, H-A-K-O-M-I, which is something that I found very helpful for learning to feel again, after a lifetime of numbing and dissociation. So as a kid who is in retrospect, very, very, very sensitive, all of what happened was just such an utter assault on my senses that it obliterated my capacity or desire to feel anything. And it’s been a process to relearn how to feel, and to embrace that sensitivity as a gift and not just a liability."
  • ...
  • "In my case, I’m hyperreactive to any type of stressor. So I have a panic response, given my history, and there are other types of trauma that I’ve experienced. I was very badly physically bullied up until sixth grade. School was absolutely terrifying for me for a long time. That plus sexual trauma, plus other things, have led me to be very cardiac hyper-responsive. Even a minor disagreement or a loud noise can send my heart rate to a hundred plus beats per minute, where it will stay for hours."
• Debbie Millman:
  • "I think for me, and that’s so interesting the different responses people and bodies have to their trauma. I have often joked, and maybe it’s not really that funny, but I position it as a joke, that I am just a head. And then I’m not. I don’t know that my head is even still fully connected to my body. I am very cerebral. And my wife knows this, my former partner, Maria Popova. We joke about it all the time that I just love to talk. I am a talker. I like to analyze everything. And being connected to my body is much, much harder for me. I’m very comfortable face to face with someone, looking at them, looking into their eyes, and engaging intellectually and verbally."
• ...
• Tim Ferriss:
  • "Incredible, incredible teacher. Her book, Radical Acceptance, which has a very generic title, but very impactful content for me, at least. Radical Acceptance. And I’m going to come back to that word acceptance, because I think it’s critically important. She said or wrote at one point, and she was quoting some apocryphal sage, but that there’s only one question that really matters. And that is: what are you unwilling to feel?
  • I’ve thought about this a lot because the stories we tell ourselves, the life experiences, including trauma, that we’ve had drive our behavior and drive our reality, the stories that we tell. And what I realized about myself is that increasing my pain tolerance, focusing on honing myself as a weapon of competition, basically, was in large part a way to busy myself and overstimulate myself, including with caffeine and stimulants and so on, so that I wouldn’t feel certain things.
• Debbie Millman:
  • Absolutely.
• Tim Ferriss:
  • And this was subconscious. It was not something that was in my conscious awareness. It was subconscious. But in retrospect, that is what I was doing. I did not want to be in a room by myself with things bubbling to the surface. If I was at a slow simmer, I wanted to take something else that was boiling at a loud boil and pour it on top of that to create enough noise that I wouldn’t feel whatever needed to be felt.
• Debbie Millman:
  • That is so common. Absolutely. I did the exact same thing.
• Tim Ferriss:
  • Super common. And the part of the reason that Internal Family Systems, IFS as I mentioned, or something like it, in parts work has been so helpful to me, and Jack Kornfield is also very, very good at this type of parts work, and I’ll speak to something that I’ve done that has been very helpful in a minute, is recognizing and not hating or hurtfully judging your coping mechanisms.
  • I have historically had no tolerance for weakness, very little tolerance for weakness. So any type of fear, any type of shame was weakness and just was meant to be eradicated. And for me, I just had no tolerance for weakness. And as a result, I hated parts of myself, which ultimately just does not work. It just really, really does not work. And if you want to be a better competitor, by the way, this does not remove your edge. It actually gives you a greater awareness, and I think an ability to not leak energy all over the place that you could otherwise point at a worthwhile target.
  • So the parts practice in IFS has been a revelation. And I don’t use that word lightly. I’ve used it a few times, but I’m using it with very specific things that have actually warranted that type of word. Because the coping mechanisms, right? If you want to curl up in a fetal position and just let things happen, let things pass. If you have anger that you’ve suppressed and you judge that anger because it’s caused damage in certain areas of your life, these are very often what might be called protectors. These are things that allowed you to survive, and they’re like vestigial tails, they’re coping mechanisms that served a critical purpose at some point that perhaps are just now the only gear that you go to, or one of three default responses, reactions, I should say, that you have.
• ...
• Debbie Millman:
  • "It’s really quite extraordinary how plastic the brain actually is, and how you are able to, over time, create different neural pathways that allow you to respond differently than you may have in the past. And quite a lot of people that have experienced severe trauma do have that exaggerated panic response where something that might not ruffle someone else that hasn’t experienced severe trauma might see as a minor thing, that people that have experienced severe trauma will see as catastrophic. That if one small bad thing happens, that means that everything is fucked. That means that everything is screwed up. That means that you’re just terrible. And it’s more evidence that you’re not worthy of being alive or being happy."
• Debbie Millman:
  • "Yeah, but that is absolutely the way that people that have experienced severe trauma respond. It’s if you aren’t dealing with and experiencing and managing that trauma, you never get a place to detangle any future trauma to that past trauma, and so they become instantly attached. And that’s why that sort of giant feeling of everything being that globalizes that new trauma or that new frustration or that new paper cut, whatever it is to that past trauma happens. And I don’t know why in our DNA this isn’t better integrated in our daily lives and our experiences of ourselves, but humans metabolize our emotions fairly quickly in the grand scheme of things. We have the ability when were hot to take off our sweater, if we’re cold, we put it back on. When we’re hungry, we eat and we metabolize and digest our food and so forth. But when it comes to these types of traumas, there’s a fear that somehow reengaging with them will destroy us, and it won’t. If we have the right tools to help us through these things, they won’t."
• Debbie Millman:
  • "Yeah, I fantasize a lot because I do work with Mariska Hargitay and I have these sort of fantasies about sort of an SVU episode of vengeance. But I just don’t think I have it in me. That rage, I still do overreact to things. I still, when something bad will happen, I’ll feel doomed, but not anywhere as near what it was, what it used to be. And I have become so much more sensitive to life and to things that are living that I don’t think I have it in me anymore to do that, but I haven’t forgiven him. I’m wondering in the work that you’ve done, have you been able to forgive your perpetrator?"
• Tim Ferriss:
  • "Oh, so far, and the work is not done, and in a way I look forward to the work because as I do more work and learn more than I can hopefully share more. But I will say, just in the progress that I’ve made in the last handful of years I’ve realized through say the HRV training, looking at my cardiac hyper-reactivity to very small things, little noises, certainly different situations, tense conversations, I have a full blown panic response, even though I can keep a calm face, and part of that is retreating into stories. And this is something I repeat to myself, and this is while I’m sober, although it began as a realization in the space of working with psychedelics, is “Don’t retreat into story, don’t retreat into story.” And retreating into story means defaulting to these old stories that I’ve used for so long that I never, for decades, questioned them, right?"
  • "And one of the stories is related to personalizing things. So if somebody does something that I take to be a breach of trust, a betrayal of some type and I begin to spin this story and construct this narrative of how this person has completely betrayed me. I am unsafe. This person is dangerous, they are a threat. I have to cut them out of my life. It is very binary, black and white. And I think there’s a place for that, there is a place for that. I mean, the “Fool me once, shame on you, fool me twice, shame on me” type of mentality, I do think there is a place for that. But it has been such a default, like if you choose that as a response, that is fine. If it is a reaction, if you’re like a slug that’s getting poked with a stick and you’re just reacting, reacting, reacting, then I think it’s worthy of reexamination."
• Debbie Millman:
  • "Yeah, if you feel like it’s involuntary. Sometimes these responses, you almost feel like you don’t have any control over how you respond."
• Tim Ferriss:
  • "Yeah. And I would also say that looking at it through the lens, just as an exercise, of using physiology to change psychology, working on and training the heart as a muscle so that you can take what we think of as an autonomous function heartbeat and actually gain some control over it, shows me, at least in certain instances, that I’m not creating a story that then gives me a physical response. I’m having a nonverbal panic response to a perceived threat that is nowhere in my prefrontal cortex. I mean, this predates language. And then given that really strong physiological response, I’m crafting a story to justify it. Does that make sense?"
  • ...
  • "in my case, it has become clear, not always, but a lot of the time, I’m having this almost reptilian panic response. And then my prefrontal cortex kicks in, and within a nanosecond manufactures a story that justifies the huge physical response. And then my mind will find evidence to support that story."
• Debbie Millman:
  • "Yeah, absolutely. And you can’t control your reptilian brain. As hard as we try, you can’t will that adrenaline to kick in. It just doesn’t work that way."
• Tim Ferriss:
  • "Yeah. So it’s been fascinating to work at it from both ends, meaning working on the psychology, using words, using books, using resources, exercises that are clearly prefrontal cortex, to affect my physiology, to calm myself, to decrease hypervigilance, which is extremely energetically expensive. I mean, I’ve battled fatigue my whole life. And I think that’s a big part of it is that I’m always, as my friend Josh Waitzkin would put it, I’m always at a simmering six of sympathetic nervous system activation, like fight or flight. I’m always at a six."
  • "Yeah. And it’s just much more effective. It’s much more enjoyable to be at either a zero or a one, and then being able to jump to 10 when action is required. But if you’re constantly at a low boil, you’re just exhausted. So to work with words to decrease that hypervigilance and to change my physical response, and then also to work on the physical response directly to work on nonverbal, say somatic release and so on, to then relax the cognitive gum that keeps familiar stories playing as defaults. And so I’ve tried to work in both directions."
• Tim Ferriss:
  • "I absolutely think so, but what I think I’ve become aware of as a question is—again, it’s very basic, but what are you unwilling to feel? And the reason I bring that up in the context of, let’s just say work, is if there’s something, and again, much of this is subconscious that I don’t want to feel, or that I’m finding very uncomfortable, I will plunge into projects and work."
  • "Yeah, as a way to just overwhelm whatever the truth of that experience might be otherwise. And the truth of an experience—I’ve mentioned the word revelation a few times. Sometimes the truth and the solution is put right in your face. It’s a gigantic billboard put in your face, and the message is obvious. But very often for me, the truth and the solution, and maybe the alternative to your old stories and patterns, is a whisper from across the room, and you really have to pay attention to get the message. And if you’re not subconsciously or consciously ready to do that, well, going through 1,000 emails and having 15 conference calls and committing to three new projects, well, turn on the music in the room to such a high volume that you’re never going to hear the whisper. And I think I’ve voluntarily drowned out the signal as a coping mechanism."

• "Dissociation during and after the trauma: Children may daydream during inappropriate sexual encounters as a coping mechanism to escape the reality of the situation. After the event, feelings of depersonalization, reduced responsiveness to surroundings, and detachment from others is common. Poor integration of trauma memories can result in flashbacks that progress to PTSD."
• "Anxiety or arousal responses when recalling the trauma: PTSD sufferers have a higher baseline sympathetic nervous system (SNS) activity than most people. SNS activation, otherwise known as the “fight or flight” response, occurs when a person is first attacked. The stress hormone cortisol floods the system, leading to increases in blood pressure, muscle tenseness, rapid breathing, and reduced perception of pain. The parasympathetic nervous system, or “learning” brain, shuts down almost entirely, along with any non-essential neural circuits. Feelings of anxiety, nervousness, and depression may surface along with stress. While we need our SNS to survive life-threatening situations, these pathways can become too deepened in the mind, causing the brain to have trouble distinguishing a true emergency from a partner’s embrace, a news story about rape, or a nightmare. Many sexual trauma survivors with PTSD experience sexual inhibition and the inability to become aroused with a sexual partner."
• "Intrusive thoughts, followed by cognitive suppression: The trouble with dissociation and extreme anxiety is that these mental conditions interfere with the coding, storage, and retrieval of traumatic memories. Survivors may experience amnesia in the immediate aftermath, only for severely disturbing memories to resurface later on.  A person with PTSD could experience a memory that is simultaneously vivid and vague. Fear structures in the brain linking sensory details of the abuse together can become triggered, causing intense unpleasant emotions to flood the system."
• "Avoidant coping such as denial or minimizing: Once the abuse has occurred, many survivors deny that a problem, symptom, feeling, or need exists. They may blame themselves, seek rationalization for what happened, or assure themselves they’re fine. They may come to admit what happened, but deny the consequences and avoid seeking help. Sexual abuse survivors sometimes engage in behavioral strategies designed to reduce or avoid unpleasant thoughts and emotions associated with their traumatic experiences—excessive worrying, abuse of drugs or alcohol, self-harming, or engaging in promiscuous acts. Some survivors retreat in social isolation and depression to avoid any potential hurt."
• "Re-experiencing: Some survivors feel like they are reliving childhood trauma all over again through flashbacks, dreams, or intrusive thoughts. Certain people, places, life events, or news stories can serve as triggers, bringing unwanted memories or sensations back to their present thoughts."
• "Survivors frequently encounter waves of depression, anger, guilt, shame, and distrust. They may mourn the “death” of the innocent child who existed before the trauma occurred. Their opinions, perspectives, and personalities typically remain forever shaped by what happened to them. Family and friends may notice irritability, anger, or numbness. The ability to maintain steady employment and relationships can be seriously hindered in some cases."
• "Avoidance is the most significant factor in prolonging and intensifying trauma-related PTSD. This short-term strategy for resolving distress may seem to confirm that you are in control of your mind, but research shows that 70% of sexual assault survivors experience moderate to severe distress, which is a larger percentage than for any other violent crime. Repressed memories have a way of coming back—sometimes when you least expect it and feel you’ve truly put the past behind you—for instance, when you’re about to get married or have your first child. Major life events commonly serve as emotional triggers. It can be difficult for even the most supportive family members and friends to comprehend."

• "One of the most distressing aspects of living with a trauma-related disorder is experiencing a flashback— a vivid experience in which you relive an aspect of a past traumatic event as if it is happening in the present. Some flashbacks involve reexperiencing the physical sensations or bodily responses associated with the original trauma. These bodily experiences, aptly known as somatic flashbacks, are more than a memory: they center on the physical sensations of past traumas."
• "Flashbacks can take various forms. For some people, they manifest as vivid visual images, almost like watching the traumatic event unfold in the theater of their mind. Others might encounter flashbacks through sounds, smells, or somatic sensations deeply linked to the trauma. As mentioned, a somatic flashback is a present reexperiencing of the physical sensations felt during past trauma. How a person physically experiences a somatic flashback depends greatly on the nature of their initial trauma."
• "To better understand somatic flashbacks, it is helpful to understand how trauma can be stored in the body as somatic memory. Somatic memory, also known as body memory, refers to the physical sensations of discomfort, unease, and pain that remain in the body after trauma. If not properly addressed, somatic memories can manifest over time through digestive issues, poor posture, chronic pain, fatigue, insomnia, and other physical sensations."
• "Somatic memories caused by trauma often exist below the level of consciousness but can be brought to the surface by various triggers, such as certain types of sights, touch, sounds, emotions, and situations. Somatic flashbacks can be understood as the vivid reawakening of your somatic memories."
• "Somatic flashbacks, though, are just that: momentary flashbacks. If someone experiences ongoing negative physical (or emotional) sensations long after a traumatic experience, they are likely not experiencing somatic flashbacks but rather dealing with an underlying trauma-related disorder. Unfortunately, for people with trauma-related disorders, the mental and physical manifestations of their traumatic experiences can continue long after the perceived threat is no longer present."
• "When we experience stress or trauma, our mind and body gear up to protect us from the perceived threat by engaging our natural survival mechanism. This mechanism, known as the trauma response, can include a range of reactions such as fight, flight, freeze, fawn, and flop."
• "Ideally, the trauma response is time-limited and self-regulating. In other words, our mind and body kick into high gear to face the challenging experience, and then we return to our baseline to properly process the events of the past. However, returning to the baseline can be more challenging for some people. Proponents of somatic therapy believe that the continuation of symptoms related to stress and trauma indicates the body’s inability to move through the course of its survival instinct fully. By this logic, somatic flashbacks may be caused by unresolved, underlying trauma."
• "The mind processes and stores information differently during trauma than under normal circumstances. Namely, during a traumatic event, the mind and body are focused on survival, not as much on processing and storing information. Once the traumatic event has passed, the mind and body attempt to process and store the event as a memory based on available information. Yet, depending on the severity of the traumatic event and the person’s ability to engage in a healthy way with their past experience, the event’s storing, processing, and recollection can be disordered, leading to somatic flashbacks and other mental health challenges."
• "During a somatic flashback, the brain and body have difficulty differentiating between the past and present. When a person who struggles with a trauma-related disorder or endured previous trauma is triggered, their body can be sent into a state of overdrive where the brain and body confuse the perceived present threat with the threat of past trauma—unnecessarily activating a trauma response."
• "The trauma response is the body’s way of protecting itself from a perceived threat. That being said, for people with trauma-related disorders, there is a dysregulation in the body’s natural response to stress, and they can experience disproportionate or inappropriate bodily reactions. Remember, somatic flashbacks differ from memories. More often than not, these flashbacks are not recalled consciously but occur in a way that is intrusive and outside of the individual’s control. Through various therapeutic modalities, it is possible to address this dysregulation and help the individual better manage the emotional and physical effects of stress."
• "Flashbacks are a common feature of both post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD). Depending on the situation and the person, flashbacks can occur with varying levels of frequency and intensity. During a flashback, some people completely relive their traumatic experience, while others more momentarily or partially relive just one aspect of the original experience."

• "One particularly harmful form of trauma is when a child is a victim of sexual abuse. Statistically, the majority of children know their abuser, and in approximately half of those situations the child is sexually abused by a peer or older child. These statistics highlight the close relationship children have to the person who abused them, which adds to the complexity of the trauma experience (experts often refer to this as betrayal trauma). It is often very confusing to a child who trusts—maybe even loves—someone who is sexually abusing them. Such conflicting emotions may cause the child to question their understanding of the situation, their ability to trust others, and their relationship with their own bodies."
• "When a child is hurt by someone who is supposed to be protecting them, it is difficult for their developing minds to sort through the experience and make sense of the situation. However, regardless of the child’s relationship to the person who abuses them, every child who is a victim of sexual abuse has experienced a trauma that no child should have to endure. (To learn more about our efforts to help parents and communities reduce the risk of child sexual abuse, visit Saprea Prevention.)"
• "The brain is a complex organ, and there’s still so much to learn about its functions, abilities, and health. Studies on trauma and its impacts on the brain, however, have helped us understand that there are two areas of the brain that are especially important in working with trauma survivors: the limbic system and the frontal lobe."
  • "What Is the Limbic System?"
    • "The limbic system plays an important role in our brain function: it alerts our bodies when it perceives a threat. It can help our bodies respond to a situation by urging us into fight, flight, or freeze mode."
    • "The limbic system will often go through the same cycle, trying to prepare the body to protect itself from the threat. In situations of sexual abuse, however, the body is often unable to escape. The alarmed limbic system ends up flooding the body with adrenaline that has nowhere to go. Instead, this unreleased stress can remain held in the body while the brain functions in a state of high alert, constantly on the lookout for signs of danger—even when the abuse is not happening. This continual hypervigilance creates a pattern in the child’s brain where their mind and body are nearly always preparing to respond to a potential threat."
    • "How does the limbic system try to protect me?
      • "In other cases, the brain may disrupt the memory of the events, or dissociate all together, leaving the child with periods of time that they won’t remember as they get older. Additionally, the brain may try to protect the body by experiencing physical pain, which can disrupt the hormones in a way that often leads to emotional and mental health challenges. The brain may also learn to associate smells or environments with the abuse, and so as the child encounters similar smells or environments in the future, the brain sends off warning signals (usually referred to as triggers)."
      • "For example, to help you survive the trauma of the abuse, your limbic system may have prompted your still-developing brain to dissociate while the abuse was happening. This means that you may have experienced the sensation of leaving your body and watching the abuse from a third-person point of view. This strategy was your limbic system’s way to help distance your brain from a situation that would’ve been otherwise unbearable. But while this strategy was useful—even essential—at that time in your life, it may no longer be the most helpful technique in adulthood. Now, dissociation may lead to you feeling disconnected from your body, detached from your own thoughts and emotions, or unable to fully engage with the present. It may be disrupting your daily life and providing additional challenges to your healing journey."
    • "The Limbic System and the Window of Tolerance"
      • "However, there are times when triggers, environmental stressors, or relationship stressors happen, and we find ourselves moving out of our window of tolerance and into states of hypoarousal or hyperarousal."
      • "Hyperarousal (Fight/Flight)"
        • "When we are in this state, it feels like what’s happening in the moment is too much for us and we can’t handle it anymore, causing our limbic system to go into fight or flight. Below is a list of common symptoms of hyperarousal."
          • "Self-judgment/self-criticism"
          • "Intrusive imagery/flashbacks"
          • "Need for control"
          • "Nightmares"
          • "Physical pain"
          • "Anxiety/panic"
          • "Obsessive compulsive behaviors/thoughts"
      • "Hypoarousal (Freeze)"
        • "Hypoarousal is the opposite of hyperarousal. It is also a stress response, but instead of engaging with the stress, we feel like we are shutting down. The body and brain become so overwhelmed by the stressor and, as a survival mechanism, it’s almost as though they refuse to acknowledge the presence of that stressor. Hypoarousal may even occur as a result of being in a hyperaroused state for too long. Below is a list of common symptoms of hypoarousal."
          • "Dissociation"
          • "Disconnection"
          • "Separation from self"
          • "Memory issues"
          • "Depression"
          • "Shame"
  • "What Is the Frontal Lobe?"
    • "The frontal lobe is the area of the brain where we employ strategies for evaluating, thinking critically, and choosing action. This is very much the “decision-making” center of the brain. And this part can learn, including learning new patterns of thought, behaviors, and strategies."
    • "The frontal lobe is actively developing in childhood (think about how much a baby changes during their first five years of life) and continues to develop well into adulthood. In fact, research suggests the frontal lobe is still growing into an adult’s late twenties or early thirties. What this means is that the limbic system, which is active from infancy, takes a more active role in responding to childhood sexual abuse; the frontal lobe, which needs much more information, experience, and time to grow, is unprepared to deal with sexual experiences at a young age, much less sexual abuse. (It is for these reasons that Saprea firmly asserts that a child cannot consent to sexual activity, especially in situations where sexual activity is with an adult or older child who is developmentally more advanced.)"
    • "What Is Neuroplasticity and How Can It Help Me Heal from Child Sexual Abuse?"
      • "That being said, neural pathways can be created for behaviors and habits that serve us well, as well as for behaviors and habits that impede our progress. Triggers are a great example of a disruptive, frustrating neural pathway. With a trigger, the limbic system learned to associate something (a smell, for example) with a traumatic event from the past. And every time the survivor encounters that smell, the limbic system goes down that familiar path and tells the body it’s in danger, which in turn engages the body’s survival response."

• "Methods: The authors draw from approximately 128 international scholarly articles on CSA published between 1979 and 2009."
• "Numerous studies suggest that sexual victimization in adolescence significantly increases the likelihood of sexual victimization in adulthood. Studies suggest that sexual victimization in childhood or adolescence increases the likelihood of sexual victimization in adulthood between 2 and 13.7 times."
• "Several researchers speculate that mediating factors caused by CSA contribute to higher risk of sexual revictimization. Childhood abuse may interfere with normal development of interpersonal relatedness and affect regulation, which in turn decrease abuse victims’ awareness of danger. Negative long-term effects of CSA may be attempts to avoid or cope with negative emotional states, but that such emotional avoidance can create challenges in recognizing danger cues. Some female CSA victims may associate sexuality with pain, punishment, and other negative outcomes, leading them to believe that coercion and trauma are “normal” aspects of sexual relations. This, in turn, would leave CSA victims with a “higher threshold of tolerance” for coercive or forceful sexual advances."

• "For several decades, some, studies have reported that about one-third of male abusers may have been a victim in their childhood (Finkelhor, 1979; Senn et al., 2012). Therefore, although it cannot be stated that there is intergenerational transmission of abuse, because the majority of victims are female and they do not subsequently become abusers, it is relatively common for abusers to have witnessed or suffered abuse during their childhood (Clayton et al., 2018)."
• "Sexual Revictimization"
  • "Suffering further episodes of sexual victimization during adolescence and early youth is common among victims of CSA. Authors such as Walker et al. (2017) concluded in their meta-analysis that the prevalence of revictimization reached almost 50% of the cases. Some studies have reported that female victims of CSA are three to five times more likely to suffer further sexual assault than those who have not suffered CSA (Pereda et al., 2016; Godbout et al., 2019)."

• "What Is a Flashback?"
  • "When we experience an event with powerful emotions or sensations (especially ones like fear, distress, or pain), sometimes our memories of that event are stored in a way that our brain can quickly access to remind us to avoid similar situations in the future."
  • "When these memories come back suddenly to our mind involuntarily and intrusively, they are described as flashbacks. Put another way, flashbacks consist of “the intrusive re-experiencing of traumatic experiences in the present."
  • "The neurological cause of flashbacks has not yet been determined. Nevertheless, for individuals who cope with the effects of past abuse, flashbacks can greatly disrupt their lives and interfere with wellbeing."
• "What Does Having a Flashback Feel Like?"
  • "Flashbacks and intrusive memories are experienced in a broad range of ways that are influenced by many factors. Some trauma survivors describe flashbacks as abrupt and frequent—sometimes like watching repeating images in their mind’s eye or recalling sounds from their memory. Others experience vivid recollections in which they, in a sense, relive parts of the traumatic event from their past. In these cases, survivors can even have difficulty distinguishing their memory from what is happening around them in the present moment."
  • "For many survivors, experiencing a flashback is extremely distressing. They are typically caused by triggers and can sometimes lead to other unsettling symptoms such as panic attacks or dissociation. Flashbacks may leave the survivor with feelings of fear, anxiety, shame, or uncertainty about how to prevent one from happening again. Whatever the outcome, these recurring intrusive memories of the traumatic events interrupt survivors’ lives and bring frequent reminders of the pain they continue to carry."
• "How Are Flashbacks Connected to Child Sexual Abuse?"
  • "It is quite common for survivors of childhood sexual abuse to endure flashbacks and sudden intense memories of their abuse, even after many years have passed from when the abuse occurred. This is because the trauma of the abuse continues to impact the brain, even after the abuse itself is no longer a part of the survivor’s life. It does so by keeping the limbic system, the part of the brain that seeks to avoid pain and find relief, in a state of hypervigilance. This hypervigilance first occurred during the abuse in childhood, when the limbic struggled to keep the survivor safe and to process what was happening."
  • "Since then, the limbic system—for many survivors—remains on edge, always on high alert for any signs of danger. And when it does associate a detail in the present with a traumatic memory, the limbic system can be triggered into fight, flight, or freeze mode. In these moments of heightened distress, the memory can become so vivid that the limbic system links the sensations of the past— such as sight, sound, and smell—with the sensations of the present. And the frontal lobe, the analytical part of the brain, struggles to catch up and communicate the separation between the past and present. The end result can escalate into a flashback, where the aspects of a traumatic memory can seem like they are playing out in real time."

• "Why Does My Relationship with My Body Matter?"
  • "And while everyone has felt some degree of displeasure or dissatisfaction towards their body, survivors of child sexual abuse can experience such tension and conflict on an entirely different level."
• "In What Ways Can Child Sexual Abuse Impact a Survivor’s Relationship with Their Body?"
  • "Trauma lives in both the brain and body. And for survivors of child sexual abuse, this trauma was instilled at a very young age, while the brain is still developing and the body is still maturing. In some cases, survivors endured their abuse before they had reached puberty. They may have been abused before they had any other experience with sexual intimacy or even had a full understanding of what sexual intimacy is. And even though our bodies are designed to respond to sexual stimuli, a survivor may still feel ashamed of or confused by how their body responded to the abuse, even though the body’s physiological reactions were perfectly normal."
  • "Whatever the age and maturity level when the abuse occurred, survivors of child sexual abuse experienced a violation of their bodily autonomy. While such a violation is no less devastating when experienced in adulthood, it can be especially confusing and disorienting for a child or teen who has yet to develop an understanding of or a relationship with their own body and how it functions."
  • "These feelings of confusion, shame, fear, and betrayal can live in the body for years and even decades after the abuse has stopped. Even into adulthood, the physical, emotional, and sexual trauma they endured as a youth can remain present and continue to affect their relationship with their own body."
  • "This complicated relationship between a survivor’s brain and their body can manifest in many ways. Below are some examples of how trauma can impact a survivor’s body:"
    • "Body ownership"
      • "Body ownership is about understanding that your body is your own. It does not belong to anyone else. At a young age, we are often taught this concept through the importance of setting boundaries, respecting others’ boundaries and understanding that others are not entitled to touch or see certain areas of our bodies just because they want to. Survivors may feel a lack of this body ownership from the unwanted experiences they endured and how severely their boundaries were violated. Such experiences might leave survivors with the impression that someone else is in charge of their body and that their own wants, needs, and autonomy are not worth considering."
    • "Body shame"
      • "Body shame occurs when you perceive your physical self as the cause of the experience you went through—either through the messaging of others or a perception that your body failed you in some way. For some survivors, this shame can manifest as feelings of betrayal toward their body because of how it responded to the abuse, how their body garnered the attention of the abuser, or because of their body’s response to the trauma (if, for example, it defaulted into freeze mode, rather than fight or flight). Though these are very normal responses to the trauma of sexual abuse, survivors may feel ashamed by what their body did or didn’t do during the abuse and towards the sense of helplessness that resulted."
    • "Body satisfaction"
      • "When a survivor’s early experiences with their body are tied to the trauma of sexual abuse, it can be more difficult for that survivor to have feelings of satisfaction or contentment with their body. Again, while it is common in our society to feel dissatisfied with our bodies or to fixate on what aspects of our bodies we think need to be improved, for survivors, this lack of body satisfaction can run on a much deeper level. And it can impact not only how survivors view their bodies but how they view their overall worth and ability."
    • "Body disconnection"
      • "For some survivors, the most formative memories of their own body are rooted in trauma. And in some instances, the body itself can feel like a reminder of that trauma. As a way for survivors to protect themselves from this trauma, they may start to distance themselves from their body’s experience, including what sensations their body may be feeling, what functions their body serves, or what physical needs they have. This survival response is known as body disconnection and may have first developed when the abuse began. However, survivors may continue to experience this disconnection from their bodies long after the abuse has stopped in order to avoid certain memories or triggers. And because the communication between the mind and body is so important, this disconnection can interrupt a survivor’s healing. It can also lead to additional health problems in cases where a survivor is so disconnected that they don’t notice pain or other problems their body is experiencing."
    • "Physical health"
      • "The trauma of sexual abuse can impact not only how a survivor views their own body but also what they physically experience. Sometimes when trauma lives in the body, it can contribute to other ailments, such as chronic pain, illnesses, injuries, or chronic health problems. The continual anxiety, fear, and/or hypervigilance a survivor may experience might manifest as physical symptoms such as nausea, shallow breathing, muscle tension, or tightness in the chest. In some instances, survivors may face difficulties with certain physical activities, as these activities require an engagement with the body that a survivor may try to avoid, especially if they’re feeling disconnected from the body. Avoidance of such physical activities can sometimes exacerbate health problems or other physical issues."
    • "Body Objectification"
      • "Because of how their body was treated by those who abused them, survivors may sometimes feel as though their body is nothing more than an object. It’s quite natural for a survivor to internalize the objectification they were submitted to at such a young age. These feelings of objectification can contribute to a survivor viewing their body as an object of disgust or shame, influencing their perceived desirability or potential to be loved and wanted by others. On the other hand, internalized objectification can contribute to a survivor feeling as though the only thing their body is good for is sex. They may pursue high-risk sexual situations or engage in compulsive sexual behavior."

• "What Is a Panic Attack?"
  • "A panic attack is a sudden episode of intense fear that triggers severe reactions when there is no real danger or apparent cause. Panic attacks are typically unexpected, coming on without any warning, and can last anywhere from a few seconds to several minutes. Although panic attacks are not life-threatening, they are often very frightening for those who experience them. In some cases, the overwhelming fear can be so intense that the individual might think they are suffering a heart attack or another health condition they may not surive."
• "What Causes a Panic Attack?"
  • "A tragic event"
  • "Memories of trauma"
  • "Chronic illnesses"
  • "Underlying anxiety or panic disorders"
• "What Does a Panic Attack Feel Like?"
  • "Accelerated heart rate"
  • "Fear of having no control"
  • "Fear of possibly dying"
• "Why Do Many Survivors of Child Sexual Abuse Have Panic Attacks?"
  • "As discussed above, there are a variety of stressors that can cause panic attacks. However, one cause that is more common among survivors of trauma is symptoms of post-traumatic stress. This can be especially true for survivors of child sexual abuse who experienced their trauma at a young age while the brain was still developing. Because even after the abuse stops, and the child or teen ages into an adult survivor, their limbic system can remain hyperalert, on constant lookout for any signs of danger. With the brain already in this heightened state of stress, a survivor may be more susceptible to panic attacks. They may also have more difficulty managing the symptoms should one occur."
• "Does a Panic Attack Mean I Was “Triggered”?"
  • In some cases, yes. Unfortunately, when the brain is always in a state of hypervigilance, it may react to something it thinks is a threat when, in actuality, what the brain reacted to was not a threat but a reminder of the very real threats of the past. These reminders of past trauma are what we call triggers. Triggers can be anything from a song to a scent to a ceiling fan to the appearance of a stranger in the store. However seemingly small or insignificant these reminders may be, they carry a strong enough connection to the past trauma for the hyper aroused brain to pick up on. The limbic system will then react to this connection by setting off alarm bells, believing you to be in danger. For instance, you may see a curtain pattern that reminds you of a room from your childhood where you were sexually abused. Making the connection, your limbic system might confuse the past with the present and perceive you to be in the same danger you experienced as a child.
  • And because the threat of danger can seem so real, your body may respond to these alarm bells in a number of ways. You might have a flashback, forget where you are, or feel a physical pain in your neck and shoulders. In some cases, you may zone out, which is called “dissociating.” And in other cases, you may experience a panic attack. In these instances, the survivor can be seized by a sudden panic, overcome by an intense fear and certainty that danger is imminent.

• Psychological
  • Child sexual abuse can result in both short-term and long-term harm, including psychopathology in later life.[12][26] Indicators and effects include depression,[8][27][28] anxiety,[10] eating disorders,[29] poor self-esteem,[29] somatization,[28] sleep disturbances,[30][31] and dissociative and anxiety disorders including post-traumatic stress disorder.[9][32] While children may exhibit regressive behaviours such as thumb sucking or bedwetting, the strongest indicator of sexual abuse is sexual acting out and inappropriate sexual knowledge and interest.[33][34] Victims may withdraw from school and social activities[33] and exhibit various learning and behavioural problems including cruelty to animals,[35][36][37][38] attention deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder (ODD).[29] Teenage pregnancy and risky sexual behaviors may appear in adolescence.[39] Child sexual abuse victims report almost four times as many incidences of self-inflicted harm.[40] Sexual assault among teenagers has been shown to lead to an increase in mental health problems, social exclusion and worse school performance.[41][42]
  • CSA is associated with experiencing additional victimization in adolescence and adulthood.[44][45] Correlations have been found between childhood sexual abuse and various adult psychopathologies, including crime and suicide,[18][46][47][48][49][50] in addition to alcoholism and drug abuse.[43][45][51] Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting.[33] A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.[28][52] Intergenerational effects have been noted, with the children of victims of child sexual abuse exhibiting more conduct problems, peer problems, and emotional problems than their peers.[53]
  • A specific characteristic pattern of symptoms has not been identified,[54] and there are several hypotheses about the causality of these associations.[8][55][56]
  • Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms.[48][57][58][59][60] The risk of harm is greater if the abuser is a relative, if the abuse involves intercourse or attempted intercourse, or if threats or force are used.[61] The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force.[12][26][62][63] The social stigma of child sexual abuse may compound the psychological harm to children,[63][64] and adverse outcomes are less likely for abused children who have supportive family environments.[65][66]
• Post-traumatic stress disorder
  • Main articles: Dissociation (psychology) and Post-traumatic stress disorder
  • Child abuse, including sexual abuse, especially chronic abuse starting at early ages, has been found to be related to the development of high levels of dissociative symptoms, which includes amnesia for abuse memories.[67] When severe sexual abuse (penetration, several perpetrators, lasting more than one year) had occurred, dissociative symptoms were even more prominent.[68] Recent research showed that females with high exposure to child sexual abuse (CSA) develop PTSD symptoms that are associated with poor social functioning, which is also supported by prior research studies.[69] The feeling of being "cut-off" from peers and "emotional numbness" are both results of CSA and highly inhibit proper social functioning. Furthermore, PTSD is associated with higher risk of substance abuse as a result of the "self-medication hypothesis" and the "high-risk and susceptibility hypothesis".[70]
  • Besides dissociative identity disorder (DID), post-traumatic stress disorder (PTSD), and complex post-traumatic stress disorder (C-PTSD), child sexual abuse survivors may present borderline personality disorder (BPD) and eating disorders such as bulimia nervosa.[71]