The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

by Bessel van der Kolk

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 their behaviors are not the result of moral failings or signs of lack of willpower or bad character—they are caused by actual changes in the brain.

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

What Kardiner called “traumatic neuroses,” today we call posttraumatic stress disorder—PTSD.

His summation especially caught my eye: “The nucleus of the neurosis is a physioneurosis.”2 In other words, posttraumatic stress isn’t “all in one’s head,” as some people supposed, but has a physiological basis.

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?

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.

As part of that study we gave our participants a Rorschach test.6

The Rorschach provides us with a unique way to observe how people construct a mental image from what is basically a meaningless stimulus: a blot of ink.

What people make out of these blots can tell us a lot about how their minds work.

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.

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),

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.7

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.8 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.

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.

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.11

For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action.12

In other words, for every soldier who serves in a war zone abroad, there are ten children who are e...

This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enem...

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.

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.

Eugen Bleuler’s 1911 textbook Dementia Praecox.

Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.”9

The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom.

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.

the amygdala, a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat.

the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.18

The theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs has become broadly accepted, by the media and the public as well as by the medical profession.22 In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues. 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.

These medications often are used to make abused and neglected children more tractable. In 2008 19,045 children age five and under were prescribed antipsychotics through Medicaid.28 One study, based on Medicaid data in thirteen states, found that 12.4 percent of children in foster care received antipsychotics, compared with 1.4 percent of Medicaid-eligible children in general.29

These medications make children more manageable and less aggressive, but they also interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society.

Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.

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.

Picturing the brain on trauma. Bright spots in (A) the limbic brain, and (B) the visual cortex, show heightened activation. In drawing (C) the brain’s speech center shows markedly decreased activation.

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.

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.

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.

Once again, we were witnessing a brain region rekindled as if the trauma were actually occurring.

our scans clearly showed that images of past trauma activate the right hemisphere of the brain and deactivate the left.

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.

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.

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.)

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.

Adrenaline is one of the hormones that are critical to help us fight back or flee in the face of danger.

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 ...

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.

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.