You are being pro­vid­ed with a book chap­ter by chap­ter. I will request you to read the book for me after each chap­ter. After read­ing the chap­ter, 1. short­en the chap­ter to no less than 300 words and no more than 400 words. 2. Do not change the name, address, or any impor­tant nouns in the chap­ter. 3. Do not trans­late the orig­i­nal lan­guage. 4. Keep the same style as the orig­i­nal chap­ter, keep it con­sis­tent through­out the chap­ter. Your reply must com­ply with all four require­ments, or it’s invalid.
I will pro­vide the chap­ter now.

O
CHAPTER 4
RUNNING FOR YOUR LIFE: THE
ANATOMY OF SURVIVAL
Pri­or to the advent of brain, there was no col­or and no sound in the
uni­verse, nor was there any fla­vor or aro­ma and prob­a­bly lit­tle
sense and no feel­ing or emo­tion. Before brains the uni­verse was
also free of pain and anx­i­ety.
—Roger Sperry1
n Sep­tem­ber 11, 2001, five-year-old Noam Saul wit­nessed the first
pas­sen­ger plane slam into the World Trade Cen­ter from the win­dows
of his first-grade class­room at PS 234, less than 1,500 feet away. He and his
class­mates ran with their teacher down the stairs to the lob­by, where most
of them were reunit­ed with par­ents who had dropped them off at school just
moments ear­li­er. Noam, his old­er broth­er, and their dad were three of the
tens of thou­sands of peo­ple who ran for their lives through the rub­ble, ash,
and smoke of low­er Man­hat­tan that morn­ing.
Ten days lat­er I vis­it­ed his fam­i­ly, who are friends of mine, and that
evening his par­ents and I went for a walk in the eerie dark­ness through the
still-smok­ing pit where Tow­er One once stood, mak­ing our way among the
res­cue crews who were work­ing around the clock under the blaz­ing klieg
lights. When we returned home, Noam was still awake, and he showed me a
pic­ture that he had drawn at 9:00 a.m. on Sep­tem­ber 12. The draw­ing
depict­ed what he had seen the day before: an air­plane slam­ming into the
tow­er, a ball of fire, fire­fight­ers, and peo­ple jump­ing from the tower’s
win­dows. But at the bot­tom of the pic­ture he had drawn some­thing else: a
black cir­cle at the foot of the build­ings. I had no idea what it was, so I asked
him. “A tram­po­line,” he replied. What was a tram­po­line doing there? Noam
explained, “So that the next time when peo­ple have to jump they will be
safe.” I was stunned: This five-year-old boy, a wit­ness to unspeak­able
may­hem and dis­as­ter just twen­ty-four hours before he made that draw­ing,
had used his imag­i­na­tion to process what he had seen and begin to go on
with his life.
Noam was for­tu­nate. His entire fam­i­ly was unharmed, he had grown up
sur­round­ed by love, and he was able to grasp that the tragedy they had
wit­nessed had come to an end. Dur­ing dis­as­ters young chil­dren usu­al­ly take
their cues from their par­ents. As long as their care­givers remain calm and
respon­sive to their needs, they often sur­vive ter­ri­ble inci­dents with­out
seri­ous psy­cho­log­i­cal scars.
Five-year-old Noam’s draw­ing made after he wit­nessed the World Trade Cen­ter attack on
9/11. He repro­duced the image that haunt­ed so many survivors—people jump­ing to escape
from the inferno—but with a life-sav­ing addi­tion: a tram­po­line at the bot­tom of the col­laps­ing
build­ing.
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 restor­ing 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 lives. These attempts to
main­tain con­trol over unbear­able phys­i­o­log­i­cal reac­tions can result in a
whole range of phys­i­cal symp­toms, includ­ing fibromyal­gia, chron­ic fatigue,
and oth­er autoim­mune dis­eases. This explains why it is crit­i­cal for trau­ma
treat­ment to engage the entire organ­ism, body, mind, and brain.
ORGANIZED TO SURVIVE
This illus­tra­tion on page 53 shows the whole-body response to threat.
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.”
AP PHOTO/PAUL HAWTHORNE
ILLINOISPHOTO.COM
Effec­tive action ver­sus immo­bi­liza­tion. Effec­tive action (the result of fight/flight) ends the
threat. Immo­bi­liza­tion keeps the body in a state of inescapable shock and learned help­less­ness.
Faced with dan­ger peo­ple auto­mat­i­cal­ly secrete stress hor­mones to fuel resis­tance and escape.
Brain and body are pro­grammed to run for home, where safe­ty can be restored and stress
hor­mones can come to rest. In these strapped-down men who are being evac­u­at­ed far from
home after Hur­ri­cane Kat­ri­na stress hor­mone lev­els remain ele­vat­ed and are turned against the
sur­vivors, stim­u­lat­ing ongo­ing fear, depres­sion, rage, and phys­i­cal dis­ease.
If for some rea­son the nor­mal response is blocked—for exam­ple, when
peo­ple are held down, trapped, or oth­er­wise pre­vent­ed from tak­ing effec­tive
action, be it in a war zone, a car acci­dent, domes­tic vio­lence, or a rape—the
brain keeps secret­ing stress chem­i­cals, and the brain’s elec­tri­cal cir­cuits
con­tin­ue to fire in vain.2 Long after the actu­al event has passed, the brain
may keep send­ing sig­nals to the body to escape a threat that no longer
exists. Since at least 1889, when the French psy­chol­o­gist Pierre Janet
pub­lished the first sci­en­tif­ic account of trau­mat­ic stress,3 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.
In this chap­ter I’m going to go deep­er into the brain’s response to
trau­ma. The more neu­ro­science dis­cov­ers about the brain, the more we
real­ize that it is a vast net­work of inter­con­nect­ed parts orga­nized to help us
sur­vive and flour­ish. Know­ing how these parts work togeth­er is essen­tial to
under­stand­ing how trau­ma affects every part of the human organ­ism and
can serve as an indis­pens­able guide to resolv­ing trau­mat­ic stress.
THE BRAIN FROM BOTTOM TO TOP
The most impor­tant job of the brain is to ensure our sur­vival, even under the
most mis­er­able con­di­tions. Every­thing else is sec­ondary. In order to do that,
brains need to: (1) gen­er­ate inter­nal sig­nals that reg­is­ter what our bod­ies
need, such as food, rest, pro­tec­tion, sex, and shel­ter; (2) cre­ate a map of the
world to point us where to go to sat­is­fy those needs; (3) gen­er­ate the
nec­es­sary ener­gy and actions to get us there; (4) warn us of dan­gers and
oppor­tu­ni­ties along the way; and (5) adjust our actions based on the
require­ments of the moment.4 And since we human beings are mam­mals,
crea­tures that can only sur­vive and thrive in groups, all of these imper­a­tives
require coor­di­na­tion and col­lab­o­ra­tion. Psy­cho­log­i­cal prob­lems occur when
our inter­nal sig­nals don’t work, when our maps don’t lead us where we
need to go, when we are too par­a­lyzed to move, when our actions do not
cor­re­spond to our needs, or when our rela­tion­ships break down. Every brain
struc­ture that I dis­cuss has a role to play in these essen­tial func­tions, and as
we will see, trau­ma can inter­fere with every one of them.
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, 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. Any effec­tive treat­ment for trau­ma has to
address these basic house­keep­ing func­tions of the body.
Right above the rep­til­ian brain is the lim­bic sys­tem. It’s also known as
the mam­malian brain, because all ani­mals that live in groups and nur­ture
their young pos­sess one. Devel­op­ment of this part of the brain tru­ly takes
off after a baby is born. It is the seat of the emo­tions, the mon­i­tor of dan­ger,
the judge of what is plea­sur­able or scary, the arbiter of what is or is not
impor­tant for sur­vival pur­pos­es. It is also a cen­tral com­mand post for
cop­ing with the chal­lenges of liv­ing with­in our com­plex social net­works.
The lim­bic sys­tem is shaped in response to expe­ri­ence, in part­ner­ship
with the infant’s own genet­ic make­up and inborn tem­pera­ment. (As all
par­ents of more than one child quick­ly notice, babies dif­fer from birth in the
inten­si­ty and nature of their reac­tions to sim­i­lar events.) What­ev­er hap­pens
to a baby con­tributes to the emo­tion­al and per­cep­tu­al map of the world that
its devel­op­ing brain cre­ates. As my col­league Bruce Per­ry explains it, the
brain is formed in a “use-depen­dent manner.”5 This is anoth­er way of
describ­ing neu­ro­plas­tic­i­ty, the rel­a­tive­ly recent dis­cov­ery that neu­rons that
“fire togeth­er, wire togeth­er.” When a cir­cuit fires repeat­ed­ly, it can become
a default setting—the response most like­ly to occur. If you feel safe and
loved, your brain becomes spe­cial­ized in explo­ration, play, and coop­er­a­tion;
if you are fright­ened and unwant­ed, it spe­cial­izes in man­ag­ing feel­ings of
fear and aban­don­ment.
As infants and tod­dlers we learn about the world by mov­ing, grab­bing,
and crawl­ing and by dis­cov­er­ing what hap­pens when we cry, smile, or
protest. We are con­stant­ly exper­i­ment­ing with our surroundings—how do
our inter­ac­tions change the way our bod­ies feel? Attend any two-year-old’s
birth­day par­ty and notice how lit­tle Kim­ber­ly will engage you, play with
you, flirt with you, with­out any need for lan­guage. These ear­ly explo­rations
shape the lim­bic struc­tures devot­ed to emo­tions and mem­o­ry, but these
struc­tures can also be sig­nif­i­cant­ly mod­i­fied by lat­er expe­ri­ences: for the
bet­ter by a close friend­ship or a beau­ti­ful first love, for exam­ple, or for the
worse by a vio­lent assault, relent­less bul­ly­ing, or neglect.
Tak­en togeth­er the rep­til­ian brain and lim­bic sys­tem make up what I’ll
call the “emo­tion­al brain” through­out this book.6 The emo­tion­al brain is at
the heart of the cen­tral ner­vous sys­tem, and its key task is to look out for
your wel­fare. If it detects dan­ger or a spe­cial opportunity—such as a
promis­ing partner—it alerts you by releas­ing a squirt of hor­mones. The
result­ing vis­cer­al sen­sa­tions (rang­ing from mild queasi­ness to the grip of
pan­ic in your chest) will inter­fere with what­ev­er your mind is cur­rent­ly
focused on and get you moving—physically and mentally—in a dif­fer­ent
direc­tion. Even at their most sub­tle, these sen­sa­tions have a huge influ­ence
on the small and large deci­sions we make through­out our lives: what we
choose to eat, where we like to sleep and with whom, what music we pre­fer,
whether we like to gar­den or sing in a choir, and whom we befriend and
whom we detest.
The emo­tion­al brain’s cel­lu­lar orga­ni­za­tion and bio­chem­istry are
sim­pler than those of the neo­cor­tex, our ratio­nal brain, and it assess­es
incom­ing infor­ma­tion in a more glob­al way. As a result, it jumps to
con­clu­sions based on rough sim­i­lar­i­ties, in con­trast with the ratio­nal brain,
which is orga­nized to sort through a com­plex set of options. (The text­book
exam­ple is leap­ing back in ter­ror when you see a snake—only to real­ize that
it’s just a coiled rope.) The emo­tion­al brain ini­ti­ates pre­pro­grammed escape
plans, like the fight-or-flight respons­es. These mus­cu­lar and phys­i­o­log­i­cal
reac­tions are auto­mat­ic, set in motion with­out any thought or plan­ning on
our part, leav­ing our con­scious, ratio­nal capac­i­ties to catch up lat­er, often
well after the threat is over.
Final­ly we reach the top lay­er of the brain, the neo­cor­tex. We share this
out­er lay­er with oth­er mam­mals, but it is much thick­er in us humans. In the
sec­ond year of life the frontal lobes, which make up the bulk of our
neo­cor­tex, begin to devel­op at a rapid pace. The ancient philoso­phers called
sev­en years “the age of rea­son.” For us first grade is the pre­lude of things to
come, a life orga­nized around frontal-lobe capac­i­ties: sit­ting still; keep­ing
sphinc­ters in check; being able to use words rather than act­ing out;
under­stand­ing abstract and sym­bol­ic ideas; plan­ning for tomor­row; and
being in tune with teach­ers and class­mates.
The frontal lobes are respon­si­ble for the qual­i­ties that make us unique
with­in the ani­mal kingdom.7 They enable us to use lan­guage and abstract
thought. They give us our abil­i­ty to absorb and inte­grate vast amounts of
infor­ma­tion and attach mean­ing to it. Despite our excite­ment about the
lin­guis­tic feats of chim­panzees and rhe­sus mon­keys, only human beings
com­mand the words and sym­bols nec­es­sary to cre­ate the com­mu­nal,
spir­i­tu­al, and his­tor­i­cal con­texts that shape our lives.
The frontal lobes allow us to plan and reflect, to imag­ine and play out
future sce­nar­ios. They help us to pre­dict what will hap­pen if we take one
action (like apply­ing for a new job) or neglect anoth­er (not pay­ing the rent).
They make choice pos­si­ble and under­lie our aston­ish­ing cre­ativ­i­ty.
Gen­er­a­tions of frontal lobes, work­ing in close col­lab­o­ra­tion, have cre­at­ed
cul­ture, which got us from dug-out canoes, horse-drawn car­riages, and
let­ters to jet planes, hybrid cars, and e‑mail. They also gave us Noam’s
life­sav­ing tram­po­line.
MIRRORING EACH OTHER: INTERPERSONAL
NEUROBIOLOGY
Cru­cial for under­stand­ing trau­ma, the frontal lobes are also the seat of
empathy—our abil­i­ty to “feel into” some­one else. One of the tru­ly
sen­sa­tion­al dis­cov­er­ies of mod­ern neu­ro­science took place in 1994, when in
a lucky acci­dent a group of Ital­ian sci­en­tists iden­ti­fied spe­cial­ized cells in
the cor­tex that came to be known as mir­ror neurons.8 The researchers had
attached elec­trodes to indi­vid­ual neu­rons in a monkey’s pre­mo­tor area, then
set up a com­put­er to mon­i­tor pre­cise­ly which neu­rons fired when the
mon­key picked up a peanut or grasped a banana. At one point an
exper­i­menter was putting food pel­lets into a box when he looked up at the
com­put­er. The monkey’s brain cells were fir­ing at the exact loca­tion where
the motor com­mand neu­rons were locat­ed. But the mon­key wasn’t eat­ing or
mov­ing. He was watch­ing the researcher, and his brain was vic­ar­i­ous­ly
mir­ror­ing the researcher’s actions.
Numer­ous oth­er exper­i­ments fol­lowed around the world, and it soon
became clear that mir­ror neu­rons explained many pre­vi­ous­ly unex­plain­able
aspects of the mind, such as empa­thy, imi­ta­tion, syn­chrony, and even the
devel­op­ment of lan­guage. One writer com­pared mir­ror neu­rons to “neur­al
WiFi”9—we pick up not only anoth­er person’s move­ment but her emo­tion­al
state and inten­tions as well. When peo­ple are in sync with each oth­er, they
tend to stand or sit sim­i­lar ways, and their voic­es take on the same rhythms.
But our mir­ror neu­rons also make us vul­ner­a­ble to oth­ers’ neg­a­tiv­i­ty, so that
we respond to their anger with fury or are dragged down by their
depres­sion. I’ll have more to say about mir­ror neu­rons lat­er in this book,
because trau­ma almost invari­ably involves not being seen, not being
mir­rored, and not being tak­en into account. Treat­ment needs to reac­ti­vate
the capac­i­ty to safe­ly mir­ror, and be mir­rored, by oth­ers, but also to resist
being hijacked by oth­ers’ neg­a­tive emo­tions.
The Tri­une (Three-part) Brain. The brain devel­ops from the bot­tom up. The rep­til­ian brain
devel­ops in the womb and orga­nizes basic life sus­tain­ing func­tions. It is high­ly respon­sive to
threat through­out our entire life span. The lim­bic sys­tem is orga­nized main­ly dur­ing the first six
years of life but con­tin­ues to evolve in a use-depen­dent man­ner. Trau­ma can have a major
impact of its func­tion­ing through­out life. The pre­frontal cor­tex devel­ops last, and also is
affect­ed by trau­ma expo­sure, includ­ing being unable to fil­ter out irrel­e­vant infor­ma­tion.
Through­out life it is vul­ner­a­ble to go off-line in response to threat.
As any­body who has worked with brain-dam­aged peo­ple or tak­en care
of dement­ed par­ents has learned the hard way, well-func­tion­ing frontal
lobes are cru­cial for har­mo­nious rela­tion­ships with our fel­low humans.
Real­iz­ing that oth­er peo­ple can think and feel dif­fer­ent­ly from us is a huge
devel­op­men­tal step for two- and three-year-olds. They learn to under­stand
oth­ers’ motives, so they can adapt and stay safe in groups that have
dif­fer­ent per­cep­tions, expec­ta­tions, and val­ues. With­out flex­i­ble, active
frontal lobes peo­ple become crea­tures of habit, and their rela­tion­ships
become super­fi­cial and rou­tine. Inven­tion and inno­va­tion, dis­cov­ery and
wonder—all are lack­ing.
Our frontal lobes can also (some­times, but not always) stop us from
doing things that will embar­rass us or hurt oth­ers. We don’t have to eat
every time we’re hun­gry, kiss any­body who rous­es our desires, or blow up
every time we’re angry. But it is exact­ly on that edge between impulse and
accept­able behav­ior where most of our trou­bles begin. The more intense the
vis­cer­al, sen­so­ry input from the emo­tion­al brain, the less capac­i­ty the
ratio­nal brain has to put a damper on it.
IDENTIFYING DANGER: THE COOK AND THE SMOKE
DETECTOR
Dan­ger is a nor­mal part of life, and the brain is in charge of detect­ing it and
orga­niz­ing our response. Sen­so­ry infor­ma­tion about the out­side world
arrives through our eyes, nose, ears, and skin. These sen­sa­tions con­verge in
the thal­a­mus, an area inside the lim­bic sys­tem that acts as the “cook” with­in
the brain. The thal­a­mus stirs all the input from our per­cep­tions into a ful­ly
blend­ed auto­bi­o­graph­i­cal soup, an inte­grat­ed, coher­ent expe­ri­ence of “this
is what is hap­pen­ing to me.”10 The sen­sa­tions are then passed on in two
directions—down to the amyg­dala, two small almond-shaped struc­tures that
lie deep­er in the lim­bic, uncon­scious brain, and up to the frontal lobes,
where they reach our con­scious aware­ness. The neu­ro­sci­en­tist Joseph
LeDoux calls the path­way to the amyg­dala “the low road,” which is
extreme­ly fast, and that to the frontal cor­tex the “high road,” which takes
sev­er­al mil­lisec­onds longer in the midst of an over­whelm­ing­ly threat­en­ing
expe­ri­ence. How­ev­er, pro­cess­ing by the thal­a­mus can break down. Sights,
sounds, smells, and touch are encod­ed as iso­lat­ed, dis­so­ci­at­ed frag­ments,
and nor­mal mem­o­ry pro­cess­ing dis­in­te­grates. Time freezes, so that the
present dan­ger feels like it will last for­ev­er.
The cen­tral func­tion of the amyg­dala, which I call the brain’s smoke
detec­tor, is to iden­ti­fy whether incom­ing input is rel­e­vant for our survival.11
It does so quick­ly and auto­mat­i­cal­ly, with the help of feed­back from the
hip­pocam­pus, a near­by struc­ture that relates the new input to past
expe­ri­ences. If the amyg­dala sens­es a threat—a poten­tial col­li­sion with an
oncom­ing vehi­cle, a per­son on the street who looks threatening—it sends an
instant mes­sage down to the hypo­thal­a­mus and the brain stem, recruit­ing
the stress-hor­mone sys­tem and the auto­nom­ic ner­vous sys­tem (ANS) to
orches­trate a whole-body response. Because the amyg­dala process­es the
infor­ma­tion it receives from the thal­a­mus faster than the frontal lobes do, it
decides whether incom­ing infor­ma­tion is a threat to our sur­vival even
before we are con­scious­ly aware of the dan­ger. By the time we real­ize what
is hap­pen­ing, our body may already be on the move.
The emo­tion­al brain has first dibs on inter­pret­ing incom­ing infor­ma­tion. Sen­so­ry
Infor­ma­tion about the envi­ron­ment and body state received by the eyes, ears, touch, kines­thet­ic
sense, etc., con­verges on the thal­a­mus, where it is processed, and then passed on to the
amyg­dala to inter­pret its emo­tion­al sig­nif­i­cance. This occurs with light­ning speed. If a threat is
detect­ed the amyg­dala sends mes­sages to the hypo­thal­a­mus to secrete stress hor­mones to
defend against that threat. The neu­ro­sci­en­tist Joseph LeDoux calls this the low road. The
sec­ond neur­al path­way, the high road, runs from the thal­a­mus, via the hip­pocam­pus and
ante­ri­or cin­gu­late, to the pre­frontal cor­tex, the ratio­nal brain, for a con­scious and much more
refined inter­pre­ta­tion. This takes sev­er­al microsec­onds longer. If the inter­pre­ta­tion of threat by
the amyg­dala is too intense, and/or the fil­ter­ing sys­tem from the high­er areas of the brain are
too weak, as often hap­pens in PTSD, peo­ple lose con­trol over auto­mat­ic emer­gency respons­es,
like pro­longed star­tle or aggres­sive out­bursts.
The amygdala’s dan­ger sig­nals trig­ger the release of pow­er­ful stress
hor­mones, includ­ing cor­ti­sol and adren­a­line, which increase heart rate,
blood pres­sure, and rate of breath­ing, prepar­ing us to fight back or run
away. Once the dan­ger is past, the body returns to its nor­mal state fair­ly
quick­ly. But when recov­ery is blocked, the body is trig­gered to defend
itself, which makes peo­ple feel agi­tat­ed and aroused.
While the smoke detec­tor is usu­al­ly pret­ty good at pick­ing up dan­ger
clues, trau­ma increas­es the risk of mis­in­ter­pret­ing whether a par­tic­u­lar
sit­u­a­tion is dan­ger­ous or safe. You can get along with oth­er peo­ple only if
you can accu­rate­ly gauge whether their inten­tions are benign or dan­ger­ous.
Even a slight mis­read­ing can lead to painful mis­un­der­stand­ings in
rela­tion­ships at home and at work. Func­tion­ing effec­tive­ly in a com­plex
work envi­ron­ment or a house­hold filled with ram­bunc­tious kids requires the
abil­i­ty to quick­ly assess how peo­ple are feel­ing and con­tin­u­ous­ly adjust­ing
your behav­ior accord­ing­ly. Faulty alarm sys­tems lead to blowups or
shut­downs in response to innocu­ous com­ments or facial expres­sions.
CONTROLLING THE STRESS RESPONSE: THE
WATCHTOWER
If the amyg­dala is the smoke detec­tor in the brain, think of the frontal lobes
—and specif­i­cal­ly the medi­al pre­frontal cor­tex (MPFC),12 locat­ed direct­ly
above our eyes—as the watch­tow­er, offer­ing a view of the scene from on
high. Is that smoke you smell the sign that your house is on fire and you
need to get out, fast—or is it com­ing from the steak you put over too high a
flame? The amyg­dala doesn’t make such judg­ments; it just gets you ready
to fight back or escape, even before the frontal lobes get a chance to weigh
in with their assess­ment. As long as you are not too upset, your frontal
lobes can restore your bal­ance by help­ing you real­ize that you are
respond­ing to a false alarm and abort the stress response.
Ordi­nar­i­ly the exec­u­tive capac­i­ties of the pre­frontal cor­tex enable
peo­ple to observe what is going on, pre­dict what will hap­pen if they take a
cer­tain action, and make a con­scious choice. Being able to hov­er calm­ly
and objec­tive­ly over our thoughts, feel­ings, and emo­tions (an abil­i­ty I’ll call
mind­ful­ness through­out this book) and then take our time to respond allows
the exec­u­tive brain to inhib­it, orga­nize, and mod­u­late the hard­wired
auto­mat­ic reac­tions pre­pro­grammed into the emo­tion­al brain. This capac­i­ty
is cru­cial for pre­serv­ing our rela­tion­ships with our fel­low human beings. As
long as our frontal lobes are work­ing prop­er­ly, we’re unlike­ly to lose our
tem­per every time a wait­er is late with our order or an insur­ance com­pa­ny
agent puts us on hold. (Our watch­tow­er also tells us that oth­er people’s
anger and threats are a func­tion of their emo­tion­al state.) When that sys­tem
breaks down, we become like con­di­tioned ani­mals: The moment we detect
dan­ger we auto­mat­i­cal­ly go into fight-or-flight mode.
Top down or bot­tom up. Struc­tures in the emo­tion­al brain decide what we per­ceive as
dan­ger­ous or safe. There are two ways of chang­ing the threat detec­tion sys­tem: from the top
down, via mod­u­lat­ing mes­sages from the medi­al pre­frontal cor­tex (not just pre­frontal cor­tex),
or from the bot­tom up, via the rep­til­ian brain, through breath­ing, move­ment, and touch.
In PTSD the crit­i­cal bal­ance between the amyg­dala (smoke detec­tor)
and the MPFC (watch­tow­er) shifts rad­i­cal­ly, which makes it much hard­er to
con­trol emo­tions and impuls­es. Neu­roimag­ing stud­ies of human beings in
high­ly emo­tion­al states reveal that intense fear, sad­ness, and anger all
increase the acti­va­tion of sub­cor­ti­cal brain regions involved in emo­tions
and sig­nif­i­cant­ly reduce the activ­i­ty in var­i­ous areas in the frontal lobe,
par­tic­u­lar­ly the MPFC. When that occurs, the inhibito­ry capac­i­ties of the
frontal lobe break down, and peo­ple “take leave of their sens­es”: They may
star­tle in response to any loud sound, become enraged by small frus­tra­tions,
or freeze when some­body touch­es them.13
Effec­tive­ly deal­ing with stress depends upon achiev­ing a bal­ance
between the smoke detec­tor and the watch­tow­er. If you want to man­age
your emo­tions bet­ter, your brain gives you two options: You can learn to
reg­u­late them from the top down or from the bot­tom up.
Know­ing the dif­fer­ence between top down and bot­tom up reg­u­la­tion is
cen­tral for under­stand­ing and treat­ing trau­mat­ic stress. Top-down reg­u­la­tion
involves strength­en­ing the capac­i­ty of the watch­tow­er to mon­i­tor your
body’s sen­sa­tions. Mind­ful­ness med­i­ta­tion and yoga can help with this.
Bot­tom-up reg­u­la­tion involves recal­i­brat­ing the auto­nom­ic ner­vous sys­tem,
(which, as we have seen, orig­i­nates in the brain stem). We can access the
ANS through breath, move­ment, or touch. Breath­ing is one of the few body
func­tions under both con­scious and auto­nom­ic con­trol. In part 5 of this
book we’ll explore spe­cif­ic tech­niques for increas­ing both top-down and
bot­tom-up reg­u­la­tion.
THE RIDER AND THE HORSE
For now I want to empha­size that emo­tion is not opposed to rea­son; our
emo­tions assign val­ue to expe­ri­ences and thus are the foun­da­tion of rea­son.
Our self-expe­ri­ence is the prod­uct of the bal­ance between our ratio­nal and
our emo­tion­al brains. When these two sys­tems are in bal­ance, we “feel like
our­selves.” How­ev­er, when our sur­vival is at stake, these sys­tems can
func­tion rel­a­tive­ly inde­pen­dent­ly.
If, say, you are dri­ving along, chat­ting with a friend, and a truck
sud­den­ly looms in the cor­ner of your eye, you instant­ly stop talk­ing, slam
on the brakes, and turn your steer­ing wheel to get out of harm’s way. If your
instinc­tive actions have saved you from a col­li­sion, you may resume where
you left off. Whether you are able to do so depends large­ly on how quick­ly
your vis­cer­al reac­tions sub­side to the threat.
The neu­ro­sci­en­tist Paul MacLean, who devel­oped the three-part
descrip­tion of the brain that I’ve used here, com­pared the rela­tion­ship
between the ratio­nal brain and the emo­tion­al brain to that between a more
or less com­pe­tent rid­er and his unruly horse.14 As long as the weath­er is
calm and the path is smooth, the rid­er can feel in excel­lent con­trol. But
unex­pect­ed sounds or threats from oth­er ani­mals can make the horse bolt,
forc­ing the rid­er to hold on for dear life. Like­wise, when peo­ple feel that
their sur­vival is at stake or they are seized by rages, long­ings, fear, or sex­u­al
desires, they stop lis­ten­ing to the voice of rea­son, and it makes lit­tle sense
to argue with them. When­ev­er the lim­bic sys­tem decides that some­thing is a
ques­tion of life or death, the path­ways between the frontal lobes and the
lim­bic sys­tem become extreme­ly ten­u­ous.
Psy­chol­o­gists usu­al­ly try to help peo­ple use insight and under­stand­ing
to man­age their behav­ior. How­ev­er, neu­ro­science research shows that very
few psy­cho­log­i­cal prob­lems are the result of defects in under­stand­ing; most
orig­i­nate in pres­sures from deep­er regions in the brain that dri­ve our
per­cep­tion and atten­tion. When the alarm bell of the emo­tion­al brain keeps
sig­nal­ing that you are in dan­ger, no amount of insight will silence it. I am
remind­ed of the com­e­dy in which a sev­en-time recidi­vist in an anger-
man­age­ment pro­gram extols the virtue of the tech­niques he’s learned:
“They are great and work terrific—as long as you are not real­ly angry.”
When our emo­tion­al and ratio­nal brains are in con­flict (as when we’re
enraged with some­one we love, fright­ened by some­one we depend on, or
lust after some­one who is off lim­its), a tug-of-war ensues. This war is
large­ly played out in the the­ater of vis­cer­al experience—your gut, your
heart, your lungs—and will lead to both phys­i­cal dis­com­fort and
psy­cho­log­i­cal mis­ery. Chap­ter 6 will dis­cuss how the brain and vis­cera
inter­act in safe­ty and dan­ger, which is key to under­stand­ing the many
phys­i­cal man­i­fes­ta­tions of trau­ma.
I’d like to end this chap­ter by exam­in­ing two more brain scans that
illus­trate some of the core fea­tures of trau­mat­ic stress: time­less reliv­ing;
reex­pe­ri­enc­ing images, sounds, and emo­tions; and dis­so­ci­a­tion.
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.15
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 a 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 SMOKE DETECTOR GOES ON OVERDRIVE
Stan’s brain scan shows his flash­back in action. This is what reliv­ing trau­ma
looks like in the brain: the bright­ly lit area in the low­er right-hand cor­ner,
the blanked-out low­er left side, and the four sym­met­ri­cal white holes
around the cen­ter. (You may rec­og­nize the lit-up amyg­dala and the off-line
left brain from the Har­vard study dis­cussed in chap­ter 3.) Stan’s amyg­dala
made no dis­tinc­tion between past and present. It acti­vat­ed just as if the car
crash were hap­pen­ing in the scan­ner, trig­ger­ing pow­er­ful stress hor­mones
and ner­vous-sys­tem respons­es. These were respon­si­ble for his sweat­ing and
trem­bling, his rac­ing heart and ele­vat­ed blood pres­sure: entire­ly nor­mal and
poten­tial­ly life­sav­ing respons­es if a truck has just smashed into your car.
Imag­ing a flash­back with fMRI. Notice how much more activ­i­ty appears on the right side
than on the left.
It’s impor­tant to have an effi­cient smoke detec­tor: You don’t want to
get caught unawares by a rag­ing fire. But if you go into a fren­zy every time
you smell smoke, it becomes intense­ly dis­rup­tive. Yes, you need to detect
whether some­body is get­ting upset with you, but if your amyg­dala goes into
over­drive, you may become chron­i­cal­ly scared that peo­ple hate you, or you
may feel like they are out to get you.
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.16
Two brain sys­tems are rel­e­vant for the men­tal pro­cess­ing of trau­ma:
those deal­ing with emo­tion­al inten­si­ty and con­text. Emo­tion­al inten­si­ty is
defined by the smoke alarm, the amyg­dala, and its coun­ter­weight, the
watch­tow­er, the medi­al pre­frontal cor­tex. The con­text and mean­ing of an
expe­ri­ence are deter­mined by the sys­tem that includes the dor­so­lat­er­al
pre­frontal cor­tex (DLPFC) and the hip­pocam­pus. The DLPFC is locat­ed to
the side in the front brain, while the MPFC is in the cen­ter. The struc­tures
along the mid­line of the brain are devot­ed to your inner expe­ri­ence of
your­self, those on the side are more con­cerned with your rela­tion­ship with
your sur­round­ings.
The DLPFC tells us how our present expe­ri­ence relates to the past and
how it may affect the future—you can think of it as the time­keep­er of the
brain. Know­ing that what­ev­er is hap­pen­ing is finite and will soon­er or lat­er
come to an end makes most expe­ri­ences tol­er­a­ble. The oppo­site is also true
—sit­u­a­tions become intol­er­a­ble if they feel inter­minable. Most of us know
from sad per­son­al expe­ri­ence that ter­ri­ble grief is typ­i­cal­ly accom­pa­nied by
the sense that this wretched state will last for­ev­er, and that we will nev­er get
over our loss. Trau­ma is the ulti­mate expe­ri­ence of “this will last for­ev­er.”
Stan’s scan reveals why peo­ple can recov­er from trau­ma only when the
brain struc­tures that were knocked out dur­ing the orig­i­nal expe­ri­ence—
which is why the event reg­is­tered in the brain as trau­ma in the first place—
are ful­ly online. Vis­it­ing the past in ther­a­py should be done while peo­ple
are, bio­log­i­cal­ly speak­ing, firm­ly root­ed in the present and feel­ing as calm,
safe, and ground­ed as pos­si­ble. (“Ground­ed” means that you can feel your
butt in your chair, see the light com­ing through the win­dow, feel the ten­sion
in your calves, and hear the wind stir­ring the tree out­side.) Being anchored
in the present while revis­it­ing the trau­ma opens the pos­si­bil­i­ty of deeply
know­ing that the ter­ri­ble events belong to the past. For that to hap­pen, the
brain’s watch­tow­er, cook, and time­keep­er need to be online. Ther­a­py won’t
work as long as peo­ple keep being pulled back into the past.
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.17
In nor­mal cir­cum­stances the thal­a­mus also acts as a fil­ter or gate­keep­er.
This makes it a cen­tral com­po­nent of atten­tion, con­cen­tra­tion, and new
learning—all of which are com­pro­mised by trau­ma. 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. In chap­ter 19, on neu­ro­feed­back, I’ll dis­cuss some of the tests we
use to mea­sure how well this gat­ing sys­tem works, as well as ways to
strength­en it.
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.
DEPERSONALIZATION: SPLIT OFF FROM THE SELF
Let’s now look at Ute’s expe­ri­ence in the scan­ner. Not all peo­ple react to
trau­ma in exact­ly the same way, but in this case the dif­fer­ence is
par­tic­u­lar­ly dra­mat­ic, since Ute was sit­ting right next to Stan in the wrecked
car. She respond­ed to her trau­ma script by going numb: Her mind went
blank, and near­ly every area of her brain showed marked­ly decreased
activ­i­ty. Her heart rate and blood pres­sure didn’t ele­vate. When asked how
she’d felt dur­ing the scan, she replied: “I felt just like I felt at the time of the
acci­dent: I felt noth­ing.”
Blank­ing out (dis­so­ci­a­tion) in response to being remind­ed of past trau­ma. In this case
almost every area of the brain has decreased acti­va­tion, inter­fer­ing with think­ing, focus, and
ori­en­ta­tion.
The med­ical term for Ute’s response is depersonalization.18 Any­one
who deals with trau­ma­tized men, women, or chil­dren is soon­er or lat­er
con­front­ed with blank stares and absent minds, the out­ward man­i­fes­ta­tion
of the bio­log­i­cal freeze reac­tion. Deper­son­al­iza­tion is one symp­tom of the
mas­sive dis­so­ci­a­tion cre­at­ed by trau­ma. Stan’s flash­backs came from his
thwart­ed efforts to escape the crash—cued by the script, all his dis­so­ci­at­ed,
frag­ment­ed sen­sa­tions and emo­tions roared back into the present. But
instead of strug­gling to escape, Ute had dis­so­ci­at­ed her fear and felt
noth­ing.
I see deper­son­al­iza­tion reg­u­lar­ly in my office when patients tell me
hor­ren­dous sto­ries with­out any feel­ing. All the ener­gy drains out of the
room, and I have to make a valiant effort to keep pay­ing atten­tion. A life­less
patient forces you to work much hard­er to keep the ther­a­py alive, and I
often used to pray for the hour to be over quick­ly.
After see­ing Ute’s scan, I start­ed to take a very dif­fer­ent approach
toward blanked-out patients. With near­ly every part of their brains tuned
out, they obvi­ous­ly can­not think, feel deeply, remem­ber, or make sense out
of what is going on. Con­ven­tion­al talk ther­a­py, in those cir­cum­stances, is
vir­tu­al­ly use­less.
In Ute’s case it was pos­si­ble to guess why she respond­ed so dif­fer­ent­ly
from Stan. She was uti­liz­ing a sur­vival strat­e­gy her brain had learned in
child­hood to cope with her mother’s harsh treat­ment. Ute’s father died when
she was nine years old, and her moth­er sub­se­quent­ly was often nasty and
demean­ing to her. At some point Ute dis­cov­ered that she could blank out
her mind when her moth­er yelled at her. Thir­ty-five years lat­er, when she
was trapped in her demol­ished car, Ute’s brain auto­mat­i­cal­ly went into the
same sur­vival mode—she made her­self dis­ap­pear.
The chal­lenge for peo­ple like Ute is to become alert and engaged, a
dif­fi­cult but unavoid­able task if they want to recap­ture their lives. (Ute
her­self did recover—she wrote a book about her expe­ri­ences and start­ed a
suc­cess­ful jour­nal called Men­tal Fit­ness.) This is where a bot­tom-up
approach to ther­a­py becomes essen­tial. The aim is actu­al­ly to change the
patient’s phys­i­ol­o­gy, his or her rela­tion­ship to bod­i­ly sen­sa­tions. At the
Trau­ma Cen­ter we work with such basic mea­sures as heart rate and
breath­ing pat­terns. We help patients evoke and notice bod­i­ly sen­sa­tions by
tap­ping acupressure19 points. Rhyth­mic inter­ac­tions with oth­er peo­ple are
also effective—tossing a beach ball back and forth, bounc­ing on a Pilates
ball, drum­ming, or danc­ing to music.
Numb­ing is the oth­er side of the coin in PTSD. Many untreat­ed trau­ma
sur­vivors start out like Stan, with explo­sive flash­backs, then numb out lat­er
in life. While reliv­ing trau­ma is dra­mat­ic, fright­en­ing, and poten­tial­ly self-
destruc­tive, over time a lack of pres­ence can be even more dam­ag­ing. This
is a par­tic­u­lar prob­lem with trau­ma­tized chil­dren. The act­ing-out kids tend