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

by Bessel van der Kolk

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.

Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body.

Traumatized children have fifty times the rate of asthma as their nontraumatized peers.

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.

Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found.

Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies.

In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on.

All too often, however, drugs such as Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills to deal with such distressing physical reactions. Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies.

To have genuine relationships you have to be able to experience others as separate individuals, each with his or her particular motivations and intentions. While you need to be able to stand up for yourself, you also need to recognize that other people have their own agendas. Trauma can make all that hazy and gray.

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?

By the late 1940s Bowlby had become persona non grata in the British psychoanalytic community, as a result of his radical claim that children’s disturbed behavior was a response to actual life experiences—to neglect, brutality, and separation—rather than the product of infantile sexual fantasies. Undaunted, he devoted the rest of his life to developing what came to be called attachment theory.

Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection.26,27 While all parents need all the help they can get to help raise secure children, traumatized parents, in particular, need help to be attuned to their children’s needs.

My colleague Rachel Yehuda studied rates of PTSD in adult New Yorkers who had been assaulted or raped.29 Those whose mothers were Holocaust survivors with PTSD had a significantly higher rate of developing serious psychological problems after these traumatic experiences. The most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it difficult for them to regain their equilibrium after being violated. Yehuda found a similar vulnerability in the children of pregnant women who were in the World Trade Center that fatal day in 2001.

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

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.

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.

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.

Being in synch with oneself and with others requires the integration of our body-based senses—vision, hearing, touch, and balance.

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.

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.

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.

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.

I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world.

But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation.

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.

In order to know who we are—to have an identity—we must know (or at least feel that we know) what is and what was “real.” We must observe what we see around us and label it correctly; we must also be able to trust our memories and be able to tell them apart from our imagination.

Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust.

Trauma is not stored as a narrative with an orderly beginning, middle, and end.

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 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. DSM labels quickly found their way into the larger culture as well.

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.

“Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives.

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.

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.

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.

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.

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.

Childhood abuse isn’t something you “get over.” It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence in this country.

After multiple suicide attempts Maria was placed in one of our residential treatment centers. Initially she was mute and withdrawn and became violent when people got too close to her. After other approaches failed to work, she was placed in an equine therapy program where she groomed her horse daily and learned simple dressage. Two years later I spoke with Maria at her high school graduation. She had been accepted by a four-year college. When I asked her what had helped her most, she answered, “The horse I took care of.” She told me that she first started to feel safe with her horse; he was there every day, patiently waiting for her, seemingly glad upon her approach. She started to feel a visceral connection with another creature and began to talk to him like a friend.

She came to our residential treatment program after thirteen crisis hospitalizations for suicide attempts. The staff described her as isolated, controlling, explosive, sexualized, intrusive, vindictive, and narcissistic. She described herself as disgusting and said she wished she were dead.

We can hope to solve the problems of these children only if we correctly define what is going on with them and do more than developing new drugs to control them or trying to find “the” gene that is responsible for their “disease.”

Finding a genetic link seemed particularly relevant for schizophrenia, a fairly common (affecting about 1 percent of the population), severe, and perplexing form of mental illness and one that clearly runs in families. And yet after thirty years and millions upon millions of dollars’ worth of research, we have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness, for that matter.

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.

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.

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.

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.

Monkeys and humans share the same two variants of the serotonin gene (known as the short and long serotonin transporter alleles). In humans the short allele has been associated with impulsivity, aggression, sensation seeking, suicide attempts, and severe depression. Suomi showed that, at least in monkeys, the environment shapes how these genes affect behavior. Monkeys with the short allele that were raised by an adequate mother behaved normally and had no deficit in their serotonin metabolism. Those who were raised with their peers became aggressive risk takers.

The conclusion is clear: Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem.

Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.15 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.