The Body Keeps the Score

by Bessel van der Kolk MD

  Everyone in the study—even those who had received the placebo—improved, at least to some degree. Most treatment studies of PTSD find a significant placebo effect. People who screw up their courage to participate in a study for which they aren’t paid, in which they’re repeatedly poked with needles, and in which they have only a fifty-fifty chance of getting an active drug are intrinsically motivated to solve their problem. Maybe their reward is only the attention paid to them, the opportunity to respond to questions about how they feel and think. But maybe the mother’s kisses that soothe her child’s scrapes are “just” a placebo as well.

  Prozac worked significantly better than the placebo for the patients from the Trauma Clinic. They slept more soundly; they had more control over their emotions and were less preoccupied with the past than those who received a sugar pill.20 Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged. These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modest improvements, most have not benefited at all. I have never been able to explain this, and I cannot accept the most common explanation: that receiving a pension or disability benefits prevents people from getting better. After all, the amygdala knows nothing of pensions—it just detects threats.

  Nonetheless, medications such as Prozac and related drugs like Zoloft, Celexa, Cymbalta, and Paxil, have made a substantial contribution to the treatment of trauma-related disorders. In our Prozac study we used the Rorschach test to measure how traumatized people perceive their surroundings. These data gave us an important clue to how this class of drugs (formally known as selective serotonin reuptake inhibitors, or SSRIs) might work. Before taking Prozac these patients’ emotions controlled their reactions. I think of a Dutch patient, for example (not in the Prozac study) who came to see me for treatment for a childhood rape and who was convinced that I would rape her as soon as she heard my Dutch accent. Prozac made a radical difference: It gave PTSD patients a sense of perspective21 and helped them to gain considerable control over their impulses. Jeffrey Gray must have been right: When their serotonin levels rose, many of my patients became less reactive.

  THE TRIUMPH OF PHARMACOLOGY

  It did not take long for pharmacology to revolutionize psychiatry. Drugs gave doctors a greater sense of efficacy and provided a tool beyond talk therapy. Drugs also produced income and profits. Grants from the pharmaceutical industry provided us with laboratories filled with energetic graduate students and sophisticated instruments. Psychiatry departments, which had always been located in the basements of hospitals, started to move up, both in terms of location and prestige.

  One symbol of this change occurred at MMHC, where in the early 1990s the hospital’s swimming pool was paved over to make space for a laboratory, and the indoor basketball court was carved up into cubicles for the new medication clinic. For decades doctors and patients had democratically shared the pleasures of splashing in the pool and passing balls down the court. I’d spent hours in the gym with patients back when I was a ward attendant. It was the one place where we all could restore a sense of physical well-being, an island in the midst of the misery we faced every day. Now it had become a place for patients to “get fixed.”

  The drug revolution that started out with so much promise may in the end have done as much harm as good. 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. For people who are exhausted from trying to make it on their own through yoga classes, workout routines, or simply toughing it out, medications often can bring life-saving relief. The SSRIs can be very helpful in making traumatized people less enslaved by their emotions, but they should only be considered adjuncts in their overall treatment.23

  After conducting numerous studies of medications for PTSD, I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems.

  Over the past three decades psychiatric medications have become a mainstay in our culture, with dubious consequences. Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants.24

  The new generation of antipsychotics, such as Abilify, Risperdal, Zyprexa, and Seroquel, are the top-selling drugs in the United States. In 2012 the public spent $1,526,228,000 on Abilify, more than on any other medication. Number three was Cymbalta, an antidepressant that sold well over a billion dollars’ worth of pills,25 even though it has never been shown to be superior to older antidepressants like Prozac, for which much cheaper generics are available. Medicaid, the government health program for the poor, spends more on antipsychotics than on any other class of drugs.26 In 2008, the most recent year for which complete data are available, it funded $3.6 billion for antipsychotic medications, up from $1.65 billion in 1999. The number of people under the age of twenty receiving Medicaid-funded prescriptions for antipsychotic drugs tripled between 1999 and 2008. On November 4, 2013, Johnson & Johnson agreed to pay more than $2.2 billion in criminal and civil fines to settle accusations that it had improperly promoted the antipsychotic drug Risperdal to older adults, children, and people with developmental disabilities.27 But nobody is holding the doctors who prescribed them accountable.

  Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines. 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. Children who take them are also at risk of becoming morbidly obese and developing diabetes. Meanwhile, drug overdoses involving a combination of psychiatric and pain medications continue to rise.30

  Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31 Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. 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.

  ADAPTATION OR DISEASE?

  The brain-disease model overlooks four fundamental truths: (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) la
nguage gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

  When we ignore these quintessential dimensions of humanity, we deprive people of ways to heal from trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self. Given the limitations of drugs, I started to wonder if we could find more natural ways to help people deal with their post-traumatic responses.

  CHAPTER 3

  LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION

  If we could look through the skull into the brain of a consciously thinking person, and if the place of optimal excitability were luminous, then we should see playing over the cerebral surface, a bright spot, with fantastic, waving borders constantly fluctuating in size and form, and surrounded by darkness, more or less deep, covering the rest of the hemisphere.

  —Ivan Pavlov

  You observe a lot by watching.

  —Yogi Berra

  In the early 1990s novel brain-imaging techniques opened up undreamed-of capacities to gain a sophisticated understanding about the way the brain processes information. Gigantic multimillion-dollar machines based on advanced physics and computer technology rapidly made neuroscience into one of the most popular areas for research. Positron emission tomography (PET) and, later, functional magnetic resonance imaging (fMRI) enabled scientists to visualize how different parts of the brain are activated when people are engaged in certain tasks or when they remember events from the past. For the first time we could watch the brain as it processed memories, sensations, and emotions and begin to map the circuits of mind and consciousness. The earlier technology of measuring brain chemicals like serotonin or norepinephrine had enabled scientists to look at what fueled neural activity, which is a bit like trying to understand a car’s engine by studying gasoline. Neuroimaging made it possible to see inside the engine. By doing so it has also transformed our understanding of trauma.

  Harvard Medical School was and is at the forefront of the neuroscience revolution, and in 1994 a young psychiatrist, Scott Rauch, was appointed as the first director of the Massachusetts General Hospital Neuroimaging Laboratory. After considering the most relevant questions that this new technology could answer and reading some articles I had written, Scott asked me whether I thought we could study what happens in the brains of people who have flashbacks.

  I had just finished a study on how trauma is remembered (to be discussed in chapter 12), in which participants repeatedly told me how upsetting it was to be suddenly hijacked by images, feelings, and sounds from the past. When several said they wished they knew what trick their brains were playing on them during these flashbacks, I asked eight of them if they would be willing to return to the clinic and lie still inside a scanner (an entirely new experience that I described in detail) while we re-created a scene from the painful events that haunted them. To my surprise, all eight agreed, many of them expressing their hope that what we learned from their suffering could help other people.

  My research assistant, Rita Fisler, who was working with us prior to entering Harvard Medical School, sat down with every participant and carefully constructed a script that re-created their trauma moment to moment. We deliberately tried to collect just isolated fragments of their experience—particular images, sounds, and feelings—rather than the entire story, because that is how trauma is experienced. Rita also asked the participants to describe a scene where they felt safe and in control. One person described her morning routine; another, sitting on the porch of a farmhouse in Vermont overlooking the hills. We would use this script for a second scan, to provide a baseline measurement.

  After the participants checked the scripts for accuracy (reading silently, which is less overwhelming than hearing or speaking), Rita made a voice recording that would be played back to them while they were in the scanner. A typical script:

  You are six years old and getting ready for bed. You hear your mother and father yelling at each other. You are frightened and your stomach is in a knot. You and your younger brother and sister are huddled at the top of the stairs. You look over the banister and see your father holding your mother’s arms while she struggles to free herself. Your mother is crying, spitting and hissing like an animal. Your face is flushed and you feel hot all over. When your mother frees herself, she runs to the dining room and breaks a very expensive Chinese vase. You yell at your parents to stop, but they ignore you. Your mom runs upstairs and you hear her breaking the TV. Your little brother and sister try to get her to hide in the closet. Your heart pounds and you are trembling.

  At this first session we explained the purpose of the radioactive oxygen the participants would be breathing: As any part of the brain became more or less metabolically active, its rate of oxygen consumption would immediately change, which would be picked up by the scanner. We would monitor their blood pressure and heart rate throughout the procedure, so that these physiological signs could be compared with brain activity.

  Several days later the participants came to the imaging lab. Marsha, a forty-year-old schoolteacher from a suburb outside of Boston, was the first volunteer to be scanned. Her script took her back to the day, thirteen years earlier, when she picked up her five-year-old daughter, Melissa, from day camp. As they drove off, Marsha heard a persistent beeping, indicating that Melissa’s seatbelt was not properly fastened. When Marsha reached over to adjust the belt, she ran a red light. Another car smashed into hers from the right, instantly killing her daughter. In the ambulance on the way to the emergency room, the seven-month-old fetus Marsha was carrying also died.

  Overnight Marsha had changed from a cheerful woman who was the life of the party into a haunted and depressed person filled with self-blame. She moved from classroom teaching into school administration, because working directly with children had become intolerable—as for many parents who have lost children, their happy laughter had become a powerful trigger. Even hiding behind her paperwork she could barely make it through the day. In a futile attempt to keep her feelings at bay, she coped by working day and night.

  I was standing outside the scanner as Marsha underwent the procedure and could follow her physiological reactions on a monitor. The moment we turned on the tape recorder, her heart started to race, and her blood pressure jumped. Simply hearing the script similar activated the same physiological responses that had occurred during the accident thirteen years earlier. After the recorded script concluded and Marsha’s heart rate and blood pressure returned to normal, we played her second script: getting out of bed and brushing her teeth. This time her heart rate and blood pressure did not change.

  As she emerged from the scanner, Marsha looked defeated, drawn out, and frozen. Her breathing was shallow, her eyes were opened wide, and her shoulders were hunched—the very image of vulnerability and defenselessness. We tried to comfort her, but I wondered if whatever we discovered would be worth the price of her distress.

  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.

  After all eight participants completed the procedure, Scott Rauch went to work with his mathematicians and statisticians to create composite images that compared the arousal created by a flashback with the brain in neutral. After a few weeks he sent me the results, which you see above. I taped the scans up on the refrigerator in my kitchen, and for the next few months I stared at them every eve
ning. It occurred to me that this was how early astronomers must have felt when they peered through a telescope at a new constellation.

  There were some puzzling dots and colors on the scan, but the biggest area of brain activation—a large red spot in the right lower center of the brain, which is the limbic area, or emotional brain—came as no surprise. It was already well known that intense emotions activate the limbic system, in particular an area within it called the amygdala. We depend on the amygdala to warn us of impending danger and to activate the body’s stress response. Our study clearly showed that when traumatized people are presented with images, sounds, or thoughts related to their particular experience, the amygdala reacts with alarm—even, as in Marsha’s case, thirteen years after the event. Activation of this fear center triggers the cascade of stress hormones and nerve impulses that drive up blood pressure, heart rate, and oxygen intake—preparing the body for fight or flight.1 The monitors attached to Marsha’s arms recorded this physiological state of frantic arousal, even though she never totally lost track of the fact that she was resting quietly in the scanner.

  SPEECHLESS HORROR

  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. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. 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.