The Body Keeps the Score

by Bessel van der Kolk MD

The neuroscience of selfhood and agency validates the kinds of somatic therapies that my friends Peter Levine13 and Pat Ogden14 have developed. I’ll discuss these and other sensorimotor approaches in more detail in part V, but in essence their aim is threefold:

  to draw out the sensory information that is blocked and frozen by trauma;

  to help patients befriend (rather than suppress) the energies released by that inner experience;

  to complete the self-preserving physical actions that were thwarted when they were trapped, restrained, or immobilized by terror.

  Our gut feelings signal what is safe, life sustaining, or threatening, even if we cannot quite explain why we feel a particular way. Our sensory interiority continuously sends us subtle messages about the needs of our organism. Gut feelings also help us to evaluate what is going on around us. They warn us that the guy who is approaching feels creepy, but they also convey that a room with western exposure surrounded by daylilies makes us feel serene. If you have a comfortable connection with your inner sensations—if you can trust them to give you accurate information—you will feel in charge of your body, your feelings, and your self.

  However, traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. 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.

  We now know that panic symptoms are maintained largely because the individual develops a fear of the bodily sensations associated with panic attacks. The attack may be triggered by something he or she knows is irrational, but fear of the sensations keeps them escalating into a full-body emergency. “Scared stiff” and “frozen in fear” (collapsing and going numb) describe precisely what terror and trauma feel like. They are its visceral foundation. The experience of fear derives from primitive responses to threat where escape is thwarted in some way. People’s lives will be held hostage to fear until that visceral experience changes.

  The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation—from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others.

  Many of my patients respond to stress not by noticing and naming it but by developing migraine headaches or asthma attacks.15 Sandy, a middle-aged visiting nurse, told me she’d felt terrified and lonely as a child, unseen by her alcoholic parents. She dealt with this by becoming deferential to everybody she depended on (including me, her therapist). Whenever her husband made an insensitive remark, she would come down with an asthma attack. By the time she noticed that she couldn’t breathe, it was too late for an inhaler to be effective, and she had to be taken to the emergency room.

  Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body. Even though Sandy had learned to ignore her relationship problems and block out her physical distress signals, they showed up in symptoms that demanded her attention. Her therapy focused on identifying the link between her physical sensations and her emotions, and I also encouraged her to enroll in a kickboxing program. She had no emergency room visits during the three years she was my patient.

  Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. They can include chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma.16 Traumatized children have fifty times the rate of asthma as their nontraumatized peers.17 Studies have shown that many children and adults with fatal asthma attacks were not aware of having breathing problems before the attacks.

  ALEXITHYMIA: NO WORDS FOR FEELINGS

  I had a widowed aunt with a painful trauma history who became an honorary grandmother to our children. She came on frequent visits that were marked by much doing—making curtains, rearranging kitchen shelves, sewing children’s clothes—and very little talking. She was always eager to please, but it was difficult to figure out what she enjoyed. After several days of exchanging pleasantries, conversation would come to a halt, and I’d have to work hard to fill the long silences. On the last day of her visits I’d drive her to the airport, where she’d give me a stiff good-bye hug while tears streamed down her face. Without a trace of irony she’d then complain that the cold wind at Logan International Airport made her eyes water. Her body felt the sadness that her mind couldn’t register—she was leaving our young family, her closest living relatives.

  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. They may look furious but deny that they are angry; they may appear terrified but say that they are fine. Not being able to discern what is going on inside their bodies causes them to be out of touch with their needs, and they have trouble taking care of themselves, whether it involves eating the right amount at the right time or getting the sleep they need.

  Like my aunt, alexithymics substitute the language of action for that of emotion. When asked, “How would you feel if you saw a truck coming at you at eighty miles per hour?” most people would say, “I’d be terrified” or “I’d be frozen with fear.” An alexithymic might reply, “How would I feel? I don’t know. . . . I’d get out of the way.”18 They tend to register emotions as physical problems rather than as signals that something deserves their attention. Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found. About three quarters of patients with anorexia nervosa, and more than half of all patients with bulimia, are bewildered by their emotional feelings and have great difficulty describing them.19 When researchers showed pictures of angry or distressed faces to people with alexithymia, they could not figure out what those people were feeling.20

  One of the first people who taught me about alexithymia was the psychiatrist Henry Krystal, who worked with more than a thousand Holocaust survivors in his effort to understand massive psychic trauma.21 Krystal, himself a concentration camp survivor, found that many of his patients were professionally successful, but their intimate relationships were bleak and distant. Suppressing their feelings had made it possible to attend to the business of the world, but at a price. They learned to shut down their once overwhelming emotions, and, as a result, they no longer recognized what they were feeling. Few of them had any interest in therapy.

  Paul Frewen at the University of Western Ontario did a series of brain scans of people with PTSD who suffered from alexithymia. One of the participants told him: “I don’t know what I feel, it’s like my head and body aren’t connected. I’m living in a tunnel, a fog, no matter what happens it’s the same reaction—numbness, nothing. Having a bubble bath and being burned or raped is the same feeling. My brain doesn’t feel.” Frewen and his colleague Ruth Lanius found that the more people were out of touch with their feelings, the less activity they had in the self-sensing areas of the brain.22

  Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming “spaced out” or with excessive anger. Whatever their response, they oft
en can’t tell what is upsetting them. This failure to be in touch with their bodies contributes to their well-documented lack of self-protection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning.

  People with alexithymia can get better only by learning to recognize the relationship between their physical sensations and their emotions, much as colorblind people can only enter the world of color by learning to distinguish and appreciate shades of gray. Like my aunt and Henry Krystal’s patients, they usually are reluctant to do that: Most seem to have made an unconscious decision that it is better to keep visiting doctors and treating ailments that don’t heal than to do the painful work of facing the demons of the past.

  DEPERSONALIZATION

  One step further down on the ladder to self-oblivion is depersonalization—losing your sense of yourself. Ute’s brain scan in chapter 4 is, in its very blankness, a vivid illustration of depersonalization. Depersonalization is common during traumatic experiences. I was once mugged late at night in a park close to my home and, floating above the scene, saw myself lying in the snow with a small head wound, surrounded by three knife-wielding teenagers. I dissociated the pain of their stab wounds on my hands and did not feel the slightest fear as I calmly negotiated for the return of my emptied wallet.

  I did not develop PTSD, partly, I think, because I was intensely curious about having an experience I had studied so closely in others, and partly because I had the delusion that I would be able make a drawing of my muggers to show to the police. Of course, they were never caught, but my fantasy of revenge must have given me a satisfying sense of agency.

  Traumatized people are not so fortunate and feel separated from their bodies. One particularly good description of depersonalization comes from the German psychoanalyst Paul Schilder, writing in Berlin in 1928:24 “To the depersonalized individual the world appears strange, peculiar, foreign, dream-like. Objects appear at times strangely diminished in size, at times flat. Sounds appear to come from a distance. . . . The emotions likewise undergo marked alteration. Patients complain that they are capable of experiencing neither pain nor pleasure. . . . They have become strangers to themselves.”

  I was fascinated to learn that a group of neuroscientists at the University of Geneva25 had induced similar out-of-body experiences by delivering mild electric current to a specific spot in the brain, the temporal parietal junction. In one patient this produced a sensation that she was hanging from the ceiling, looking down at her body; in another it induced an eerie feeling that someone was standing behind her. This research confirms what our patients tell us: that the self can be detached from the body and live a phantom existence on its own. Similarly, Lanius and Frewen, as well as a group of researchers at the University of Groningen in the Netherlands,26 did brain scans on people who dissociated their terror and found that the fear centers of the brain simply shut down as they recalled the event.

  BEFRIENDING THE BODY

  Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. Being frightened means that you live in a body that is always on guard. Angry people live in angry bodies. The bodies of child-abuse victims are tense and defensive until they find a way to relax and feel safe. In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past.

  How can people open up to and explore their internal world of sensations and emotions? 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. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them.

  Noticing sensations for the first time can be quite distressing, and it may precipitate flashbacks in which people curl up or assume defensive postures. These are somatic reenactments of the undigested trauma and most likely represent the postures they assumed when the trauma occurred. Images and physical sensations may deluge patients at this point, and the therapist must be familiar with ways to stem torrents of sensation and emotion to prevent them from becoming retraumatized by accessing the past. (Schoolteachers, nurses, and police officers are often very skilled at soothing terror reactions because many of them are confronted almost daily with out-of-control or painfully disorganized people.)

  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.

  The most natural way for human beings to calm themselves when they are upset is by clinging to another person. This means that patients who have been physically or sexually violated face a dilemma: They desperately crave touch while simultaneously being terrified of body contact. The mind needs to be reeducated to feel physical sensations, and the body needs to be helped to tolerate and enjoy the comforts of touch. Individuals who lack emotional awareness are able, with practice, to connect their physical sensations to psychological events. Then they can slowly reconnect with themselves.27

  CONNECTING WITH YOURSELF, CONNECTING WITH OTHERS

  I’ll end this chapter with one final study that demonstrates the cost of losing your body. After Ruth Lanius and her group scanned the idling brain, they focused on another question from everyday life: What happens in chronically traumatized people when they make face-to-face contact?

  Many patients who come to my office are unable to make eye contact. I immediately know how distressed they are by their difficulty meeting my gaze. It always turns out that they feel disgusting and that they can’t stand having me see how despicable they are. It never occurred to me that these intense feelings of shame would be reflected in abnormal brain activation. Ruth Lanius once again showed that mind and brain are indistinguishable—what happens in one is registered in the other.

  Ruth bought an expensive device that presents a video character to a person lying in a scanner. (In this case, the cartoon resembled a kindly Richard Gere.) The figure can approach either head on (looking directly at the person) or at a forty-five-degree angle with an averted gaze. This made it possible to compare the effects of direct eye contact on brain activation with those of an averted gaze.28

  The most striking difference between normal controls and survivors of chronic trauma was in activation of the prefrontal cortex in response to a direct eye gaze. The prefrontal cortex (PFC) normally helps us to assess the person coming toward us, and our mirror neurons help to pick up his intentions. However, the subjects with PTSD did not activate any part of their frontal lobe, which means they could not muster any curiosity about the stranger. They just reacted with intense activation deep inside their emotional brains, in the primitive areas known as the Periaqueductal Gray, which generates startle, hypervigilance, cowering, and other self-protective behaviors. There was no activation of any part of the brain involved in social engagement. In response to being looked at they simply went into survival mode.

  What does this mean for their ability to make friends and get along with others? What does it mean for their therapy? Can people with PTSD trust a therapist with their deepest fears? 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 hav
e their own agendas. Trauma can make all that hazy and gray.

  PART THREE

  THE MINDS OF CHILDREN

  CHAPTER 7

  GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT

  The roots of resilience . . . are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other.

  —Diana Fosha

  The Children’s Clinic at the Massachusetts Mental Health Center was filled with disturbed and disturbing kids. They were wild creatures who could not sit still and who hit and bit other children, and sometimes even the staff. They would run up to you and cling to you one moment and run away, terrified, the next. Some masturbated compulsively; others lashed out at objects, pets, and themselves. They were at once starving for affection and angry and defiant. The girls in particular could be painfully compliant. Whether oppositional or clingy, none of them seemed able to explore or play in ways typical for children their age. Some of them had hardly developed a sense of self—they couldn’t even recognize themselves in a mirror.

  At the time, I knew very little about children, apart from what my two preschoolers were teaching me. But I was fortunate in my colleague Nina Fish-Murray, who had studied with Jean Piaget in Geneva, in addition to raising five children of her own. Piaget based his theories of child development on meticulous, direct observation of children themselves, starting with his own infants, and Nina brought this spirit to the incipient Trauma Center at MMHC.

  Nina was married to the former chairman of the Harvard psychology department, Henry Murray, one of the pioneers of personality theory, and she actively encouraged any junior faculty members who shared her interests. She was fascinated by my stories about combat veterans because they reminded her of the troubled kids she worked with in the Boston public schools. Nina’s privileged position and personal charm gave us access to the Children’s Clinic, which was run by child psychiatrists who had little interest in trauma.