THE BODY REMEMBERS: The Psychophysiology of Trauma and Trauma Treatment

This book is phenomenal, provides so much information regarding how trauma an so adversely disrupt the nervous system than an individual would then develop Post-Traumatic Stress Disorder (PTSD). PTSD did not appear as an official diagnosis until the publication of the DSM-III in 1980. 

Below are my favorite things I learned from this book: 

When the limbic system activates the Autonomic Nervous System (ANS) to meet the threat of a traumatic event, it is a normal, healthy, adaptive survival response. When the ANS continues to be chronically aroused even though the threat has passed and has been survived, that is PTSD. 

Bessel van der Kolk’s seminal article, “The Body Keeps the Score”, in the Harvard Review of Psychiatry was the first connection the author had between the body-mind connection being legitimized in mainstream psychiatry. In addition, Antonio Damasio’s Descartes’ Error has been a great inspiration. This groundbreaking book presents a neurological, theoretical basis for the mind-body connection. 

Whether the hippocampi of those with PTSD have shrunk due to suppression of hippocampal activity by stress hormones or whether these individuals had smaller hippocampi to begin with is unknown. At any rate, it appears that smaller hippocampus size might interfere with the brain’s processing of stressful life events. 

For a piece of information to become a memory it must traverse at least 3 major steps: 

• Encoding (the process of recording or etching information onto the brain)
• Memory Storage (how and for how long that information is kept)
• Retrieval (access the stored information, bringing it back into conscious awareness)

Some types of information are more likely to be stored than others. The greater the significance, and the higher the emotional charge- both positive and negative- the more likely a piece of information will be stored. 

Two new types of memory are: EXPLICIT and IMPLICIT MEMORY

In Explicit Memory, also known as Declarative Memory, it is comprised of facts, concepts, and ideas. When a person thinks consciously about something and describes it with words- either aloud or in her head- she is using explicit memory. It is explicit memory that enables the telling of the story of one’s life, narrating events, putting experience into words, constructing a chronology, extracting a meaning. Explicit memory of a traumatic event (or any event for that matter) involves being able to recall and recount the event in a cohesive narrative. Another aspect of explicit storage involves historical placement of an event in the proper slot of one’s lifetime. 

In Implicit Memory the procedures and internal states are automatic. It operates unconsciously. It is also called Procedural or Nondeclarative Memory has to do with the storage and recall of learned procedures and behaviors. 

Classical Conditioning, discovered by Ivan Pavlov, involves pairing a known stimulus with a new, conditioned stimulus (CS) to elicit a new behavior called a conditioned response (CR). In Pavlov’s famous experiment, he taught a hungry dog to respond physiologically to a bell as though it were food. He repeatedly rang a bell (CS) just before presenting food (S) to the dog. Of course, it salivated- a normal response (R)- at the sight and smell of the food. That sequence was repeated many times. Eventually the bell became associated with the food. Pavlov then removed the stimulus of the food and only rang the bell. Again the dog would salivate (CR). It was no longer necessary to present the dog with food to elicit the now conditioned response. 

Operant Conditioning, known from the work of B.F. Skinner, involves shaping behavior through a cause and effect system of positive and/or negative reinforcement. Behavior modification is based on operant conditioning. In a typical Skinner-type experiment a bird is taught to depress a pedal with its beak to receive food. It is rewarded with a few grains each time it performs the desired behavior, in this case pedal pecking. Eventually the behavior becomes automatic. What starts out as a random occurrence-the first time the bird accidentally depressing the pedal- quickly becomes associated and learned through rewards of food. The bird is then able to deliberately depress the pedal when it wants more. 

Traumatic Dissociation and Traumatic Flashbacks are the 2 most salient features of PTSD. Both are at the root of its most distressing psychological and somatic symptoms. As mentioned before, dissociation might be a constant factor in every case of PTSD. Some form of flashback might also be a constant. These 2 aspects of PTSD often occur in tandem; it is not possible to have traumatic flashbacks without some form of traumatic dissociation also being operable, though dissociation can occur without flashbacks. 

Dissociation implies a splitting of awareness. During a traumatic incident, the victim may separate elements of the experience, effectively reducing the impact of the incident. The process of dissociation involves a partial or total separation of aspects of the traumatic experience- both narrative components of facts and sequence and also physiological and psychological reactions. Amnesia of varying degrees is the most familiar kind of dissociation. One person might become anesthetized and feel no pain. Another might cut off feeling emotions. Someone else might lose consciousness or feel as if he had become disembodied. The most extreme form of dissociation happens when whole personalities become separated from consciousness (dissociative identity disorder). One might continue to become anesthesized when under stress, be unable to access emotions, or feel disembodied when anxious. 

A flashback is a reexperiencing of the traumatic event in part or in its entirety. Most familiar are visual and auditory flashbacks, but the term flashback might also apply to somatic symptoms that replicate the traumatic event in some way. Whatever the sensory system involved, a flashback is highly distressing, because it feels as though the trauma is continuing or happening all over again. In people with PTSD, traumatic event(s) are remembered differently than nontraumatic events. They are not actually “remembered” in the normal sense. Usually, “memory” implies the relegation of an event into one’s history- a position on one’s lifeline. Memory puts an experience into the past, “I remember when…” With PTSD traumatic memories become dissociated, freefloating in time. They pounce into the present unbidden in the form of flashbacks. 

Individuals who report dissociative phenomena during traumatic incidents express it as: “It was like I left my body”. “Time slowed down”. “I went dead and could not feel any pain”. “All I could see was the gun, nothing else mattered”. After an event the victim can still feel dissociated, continuing to feel “beside oneself” long after the event is over. Following a traumatic event, dissociative phenomena can continue for years or even arise for the first time years later. They may be identified by numbing, flashbacks, depersonalization, partial or complete amnesia, out-of-body experiences, inability to feel emotion, unexplained “irrational” behaviors, and emotional reactions that seemingly have no basis in reality. It is likely that some form of dissociation is fueling every case of PTSD. 

Traumatic Flashbacks are similar. They can occur while awake or in the form of nightmares that disrupt sleep. Traumatic flashbacks are comprised of sensory experiences of terrible events replaced with such realism and intensity that they are difficult to distinguish from in-the-moment reality. It can easily be the case when someone can act in ways that seem to make no sense unless you know the trauma history. Flashbacks can be varied. They can involve the recall of implicit memory of a traumatic event in the absence of explicit memory, so that the references necessary to make sense of the memory or to put it in perspective are lacking. They can also involve explicit memory of the sequence of the whole or parts of the event. Flashbacks almost always include the emotional and sensory aspects of the traumatic experience; that is why they are so disturbing. 

Lenore Terr has distinguished two types of trauma victims, Type I and Type II. She originally made this distinction with regard to children. Type I refers to those who have experienced a single traumatic event.

Type II refers to those who have been repeatedly traumatized.

Type IIA are individuals with multiple traumas who have stable backgrounds that have imbued them with sufficient resources to be able to separate the individual traumatic events one from the other. This type of client can speak about a single trauma at a time and can, therefore, address one at a time.

Type IIB individuals are so overwhelmed with multiple traumas that they are unable to separate one traumatic event from the other. The Type IIB client begins talking about one trauma but quickly finds links to others- often the list goes on and on.

Type IIB clients can also be divided into 2 categories. The Type IIB(R) is someone with a stable background, but with a complexity of traumatic experiences so overwhelming that she could no longer maintain her resilience. Typical of this type of client are the Holocaust survivors described in the aforementioned Norwegian study by Malt and Weisaeth. Type IIB(nR) is someone who never developed resources for resilience. 

There is an additional type of client that is worthy of mention when discussing trauma clients. This is the client who has many symptoms of PTSD but reports no identifying event(s) that qualify him for that diagnosis. Scott and Stradling proposed an additional diagnostic category they call prolonged duress stress disorder (PDSD). Chronic, prolonged stress during the developmental years (from neglect, chronic illness, a dysfunctional family system) and how it takes a toll on the autonomic nervous system; just short of pushing it to the point of flight, fight, or freeze. 

It is not possible to resolve trauma when a client lives in an unsafe and/or traumatizing environment. Resolving trauma implies releasing the defenses that have helped to contain it. If one is still living in an unsafe or traumatic situation, this will not be possible or advisable. When that is the case, helping the client to be and/or feel safe must be the first step. 

Protocol for identifying triggers: 

• Notice what you feel in your body right now. Be as precise as possible, particularly with regard to disturbances in breathing, heart rate, and temperature. 
• Think back and identify when you were last feeling calm- that is point A. 
• Identify, approximately, when you began to feel disturbed- that is point B. 
• Shuttle back and forth between points A and B, taking note of all aspects of your environment: people, conversation, objects, behaviors. Recall, also, what you were thinking about each step of the way. Notice your body awareness as you focus on each aspect.

Remember, the body remembers traumatic events through the encoding in the brain of sensations, movements, and emotions that are associated with trauma. 

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