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

by Bessel van der Kolk

What accounts for this spectrum of responses: focused, collapsed, or frantic?

Porges’s theory provides an explanation: The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time.

Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preser...

This is where the many-branched vagus n...

The social-engagement system depends on nerves that have their origin in the brain stem regulatory centers, primarily the vagus—also known as the tenth cranial nerve—together with adjoining nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx.

When the “ventral vagal complex” (VVC) runs the show, we smile when others smile at us, we nod our heads when we agree, and we frown when friends tell us of their misfortunes.

However, if no one responds to our call for help, the threat increases, and the older limbic brain jumps in.

If a dog is in the room, she will stir and growl, because she can smell the activation of our sweat glands.

Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart “drop”), we can’t breathe, and our gut stops working or empties (literally “scaring the shit out of” us). This is the point at which we disengage, collapse, and freeze.

trauma is expressed not only as fight or flight but also as shutting down and failing to engage in the present. A different level of brain activity is involved for each response: the mammalian fight-or-flight system, which is protective and keeps us from shutting down, and the reptilian brain, which produces the collapse response.

Almost everyone knows what that quintessential fight/flight response, road rage, feels like: A sudden threat precipitates an intense impulse to move and attack. Danger turns off our social-engagement system, decreases our responsiveness to the human voice, and increases our sensitivity to threatening sounds.

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.

Once this system takes over, other people, and we ourselves, cease to matter. Awareness is shut down, and we may no longer even register physical pain.

Early in life they are pretty much at the mercy of the alternating tides of their sympathetic and parasympathetic nervous systems, and their reptilian brain runs most of the show. But day by day, as we coo and smile and cluck at them, we stimulate the growth of synchronicity in the developing VVC.

The VVC controls sucking, swallowing, facial expression, and the sounds produced by the larynx.

the brain is a cultural organ—experience shapes the brain.

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.

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.

From simple, rhythmically attuned movements, Steve had created a small, safe place where the social-engagement system could begin to reemerge.

One thing is certain: Yelling at someone who is already out of control can only lead to further dysregulation. Just as your dog cowers if you shout and wags his tail when you speak in a high singsong, we humans respond to harsh voices with fear, anger, or shutdown and to playful tones by opening up and relaxing. We simply cannot help but respond to these indicators of safety or danger.

Sadly, our educational system, as well as many of the methods that profess to treat trauma, tend to bypass this emotional-engagement system and focus instead on recruiting the cognitive capacities of the mind.

Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain...

The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving mo...

But the polyvagal theory helped us understand and explain why all these disparate, unconventional techniques worked so well. It enabled us to become more conscious of combining top-down approaches (to activate social engagement) with bottom-up methods (to calm the physical tensions in the body).

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

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

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.1

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.

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.

In an article called “What Is an Emotion?” (1884),3 William James, the father of American psychology, reported a striking case of “sensory insensibility” in a woman he interviewed:

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?

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.”

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.

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.

In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive.

The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror.

Antonio Damasio

The Feeling of What Happens is, for me, his most important book, and reading it was a revelation.

Damasio starts by pointing out the deep divide between our sense of self and the sensory life of our bodies. As he poetically explains, “Sometimes we use our minds not to discover facts, but to hide them. . . .

Building on the century-old work of William James, Damasio argues that the core of our self-awareness rests on the physical sensations that convey the inner states of the body:

All feelings of emotion are complex musical variations on primordial feelings.

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.

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.

If what goes on deep inside our animal brains dictates how we feel, and if our body sensations are orchestrated by subcortical (subconscious) brain structures, how much control over them can we actually have?

Knowing what we feel is the first step to knowing why we feel that way.