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

by Bessel van der Kolk

Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled).

Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be included in the DSM-V. The consensus, he wrote, was that no new diagnosis was required to fill a “missing diagnostic niche.” One million children who are abused and neglected every year in the United States a “diagnostic niche”?

Nothing was written in stone. Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament—including its activity level and reactivity to stress—predicted whether a child would develop serious behavioral problems in adolescence.20 The key issue, rather, was the nature of the parent-child relationship: how parents felt about and interacted with their kids. As with Suomi’s monkeys, the combination of vulnerable infants and inflexible caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior on the part of the parents at six months predicted hyperactivity and attention problems in kindergarten and beyond.

By far the most important predictor of how well his subjects coped with life’s inevitable disappointments was the level of security established with their primary caregiver during the first two years of life. Sroufe informally told me that he thought that resilience in adulthood could be predicted by how lovable mothers rated their kids at age two.

Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation.

For example, each time they were assessed, the girls in both groups were asked to talk about the worst thing that had happened to them during the previous year. As they told their stories, the researchers observed how upset they became, while measuring their physiology. During the first assessment all the girls reacted by becoming distressed. Three years later, in response to the same question, the nonabused girls once again displayed signs of distress, but the abused girls shut down and became numb. Their biology matched their observable reactions: During the first assessment all of the girls showed an increase in the stress hormone cortisol; three years later cortisol went down in the abused girls as they reported on the most stressful event of the past year. Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action.

The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group.

Trying to explain her behavior in terms of victim/perpetrator isn’t helpful, nor are labels like “depression,” “oppositional defiant disorder,” “intermittent explosive disorder,” “bipolar disorder,” or any of the other options our diagnostic manuals offer us.

With DSM-V psychiatry firmly regressed to early-nineteenth-century medical practice. Despite the fact that we know the origin of many of the problems it identifies, its “diagnoses” describe surface phenomena that completely ignore the underlying causes.

the DSM largely lacks what in the world of science is known as “reliability”—the ability to produce consistent, replicable results. In other words, it lacks scientific validity. Oddly, the lack of reliability and validity did not keep the DSM-V from meeting its deadline for publication, despite the near-universal consensus that it represented no improvement over the previous diagnostic system.29 Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-V (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system?

You would not want to have your appendix removed when you are suffering from a kidney stone, and you would not want to have somebody labeled as “oppositional” when, in fact, his behavior is rooted in an attempt to protect himself against real danger.

Like the DSM-V, the RDoC framework conceptualizes mental illnesses solely as brain disorders. This means that future research funding will explore the brain circuits “and other neurobiological measures” that underlie mental problems. Insel sees this as a first step toward the sort of “precision medicine that has transformed cancer diagnosis and treatment.” Mental illness, however, is not at all like cancer: Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength.

Recognizing the profound effects of trauma and deprivation on child development need not lead to blaming parents. We can assume that parents do the best they can, but all parents need help to nurture their kids. Nearly every industrialized nation, with the exception of the United States, recognizes this and provides some form of guaranteed support to families. James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.

Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.

Seventy percent of prisoners in California spent time in foster care while growing up.

His experiences illustrate the complexities of traumatic memory.

As a therapist treating people with a legacy of trauma, my primary concern is not to determine exactly what happened to them but to help them tolerate the sensations, emotions, and reactions they experience without being constantly hijacked by them.

We all know how fickle memory is; our stories change and are constantly revised and updated. When my brothers, sisters, and I talk about events in our childhood, we always end up feeling that we grew up in different families—so many of our memories simply do not match. Such autobiographical memories are not precise reflections of reality; they are stories we tell to convey our personal take on our experience.

The men were interviewed in detail about their war experiences in 1945/1946 and again in 1989/1990. Four and a half decades later, the majority gave very different accounts from the narratives recorded in their immediate postwar interviews: With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended.

When something terrifying happens, like seeing a child or a friend get hurt in an accident, we will retain an intense and largely accurate memory of the event for a long time. As James McGaugh and colleagues have shown, the more adrenaline you secrete, the more precise your memory will be.3 But that is true only up to a certain point. Confronted with horror—especially the horror of “inescapable shock”—this system becomes overwhelmed and breaks down.

The names of some of the greatest pioneers in neurology and psychiatry, such as Jean-Martin Charcot, Pierre Janet, and Sigmund Freud, are associated with the discovery that trauma is at the root of hysteria, particularly the trauma of childhood sexual abuse.8 These early researchers referred to traumatic memories as “pathogenic secrets”9 or “mental parasites,”10 because as much as the sufferers wanted to forget whatever had happened, their memories kept forcing themselves into consciousness, trapping them in an ever-renewing present of existential horror.

Charcot conducted meticulous studies of the physiological and neurological correlates of hysteria in both men and women, all of which emphasized embodied memory and a lack of language.

Janet proposed that at the root of what we now call PTSD was the experience of “vehement emotions,” or intense emotional arousal.

Janet was the first to point out the difference between “narrative memory”—the stories people tell about trauma—and traumatic memory itself.

Traumatized people simultaneously remember too little and too much.

Not only was Irène able to tell the story, but she had also recovered her emotions: “I feel very sad and abandoned.” Janet now called her memory “complete” because it now was accompanied by the appropriate feelings.

Janet noted significant differences between ordinary and traumatic memory. Traumatic memories are precipitated by specific triggers.

He later wrote that when patients dissociate their traumatic experience, they become “attached to an insurmountable obstacle”:

He predicted that unless they became aware of the split-off elements and integrated them into a story that had happened in the past but was now over, they would experience a slow decline in their personal and professional functioning. This phenomenon has now been well documented in contemporary research.

Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others. But in Julian’s case, the sensations, thoughts, and emotions of the trauma were stored separately as frozen, barely comprehensible fragments.

“Hysterics suffer mainly from reminiscences,” they proclaim, and go on to note that these memories are not subject to the “wearing away process” of normal memories but “persist for a long time with astonishing freshness.” Nor can traumatized people control when they will emerge: “We must . . . mention another remarkable fact . . . namely, that these memories, unlike other memories of their past lives, are not at the patients’ disposal. On the contrary, these experiences are completely absent from the patients’ memory when they are in a normal psychical state, or are only present in a highly summary form.

In 1896 Freud boldly claimed that “the ultimate cause of hysteria is always the seduction of the child by an adult.”22 Then, faced with his own evidence of an epidemic of abuse in the best families of Vienna—one, he noted, that would implicate his own father—he quickly began to retreat. Psychoanalysis shifted to an emphasis on unconscious wishes and fantasies, though Freud occasionally kept acknowledging the reality of sexual abuse.

Freud reaffirmed that lack of verbal memory is central in trauma and that, if a person does not remember, he is likely to act out: “[H]e reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.”

How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remembers? How can patients themselves identify the source of their behavior? If their history is not known, they are likely to be labeled as crazy or punished as criminals rather than helped to integrate the past.

Almost one hundred leading psychiatrists and psychologists from around the United States and eight foreign countries signed an amicus curiae brief stating that “repressed memory” has never been shown to exist and that it should not have been admitted as evidence.

the debate over repressed memory, which started with Freud, continues to be played out today.

Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation. —Katie Cannon

Caught between taking the suffering of their soldiers seriously and pursuing victory over the Germans, the British General Staff issued General Routine Order Number 2384 in June of 1917, which stated, “In no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.”

In November 1917 the General Staff denied Charles Samuel Myers, who ran four field hospitals for wounded soldiers, permission to submit a paper on shell shock to the British Medical Journal

In 1922 the British government issued the Southborough Report, whose goal was to prevent the diagnosis of shell shock in any future wars and to undermine any more claims for compensation.

when Hitler came to power a few years later, All Quiet on the Western Front was one of the first “degenerate” books the Nazis burned in the public square in front of Humboldt University in Berlin.10 Apparently awareness of the devastating effects of war on soldiers’ minds would have constituted a threat to the Nazis’ plunge into another round of insanity.

Denial of the consequences of trauma can wreak havoc with the social fabric of society.

The extortionate war reparations of the Treaty of Versailles further humiliated an already disgraced Germany. German society, in turn, dealt ruthlessly with its own traumatized war veterans, who were treated as inferior creatures.

Hollywood director John Huston’s documentary Let There Be Light (1946) shows the predominant treatment for war neuroses at that time: hypnosis.

While the World War I soldiers flail, have facial tics, and collapse with paralyzed bodies, the following generation talks and cringes.

Culture shapes the expression of traumatic stress.

when I started to work with Vietnam veterans, there was not a single book on war trauma in the library of the VA, but the Vietnam War inspired numerous studies, the formation of scholarly organizations, and the inclusion of a trauma diagnosis, PTSD, in the professional literature.

Judith Herman’s book Trauma and Recovery (1992),

Cautioned by history, I began to wonder if we were headed toward another backlash like those of 1895, 1917, and 1947 against acknowledging the reality of trauma.

a so-called False Memory Syndrome in which psychiatric patients supposedly manufactured elaborate false memories of sexual abuse, which they then claimed had lain dormant for many years before being recovered. What was striking about these articles was the certainty with which they stated that there was no evidence that people remember trauma any differently than they do ordinary events.