The Body Keeps the Score

by Bessel van der Kolk MD

  BRAIN-WAVE BASICS FROM SLOW TO FAST

  Each line on an EEG charts the activity in a different part of the brain: a mixture of different rhythms, ranged on a scale from slow to fast.12 The EEG consists of measurements of varying heights (amplitude) and wavelengths (frequency). Frequency refers to the number of times a waveform rises and falls in one second, and it is measured in hertz (Hz), or cycles per second (cps). Every frequency on the EEG is relevant to understanding and treating trauma, and the basics are relatively easy to grasp.

  Delta waves, the slowest frequencies (2–5 Hz) are seen most often during sleep. The brain is in an idling state, and the mind is turned inward. If people have too much slow-wave activity while they’re awake, their thinking is foggy and they exhibit poor judgment and poor impulse control. Eighty percent of children with ADHD and many individuals diagnosed with PTSD have excessive slow waves in their frontal lobes.

  The Electroencephalogram (EEG). While there is no typical signature for PTSD, many traumatized people have sharply increased activity in the temporal lobes, as this patient does (T3, T4, T5). Neurofeedback can normalize these abnormal brain patterns and thereby increase emotional stability.

  THE RATE OF BRAINWAVE FIRING IS RELATED TO OUR STATE OF AROUSAL

  Dreaming speeds up brain waves. Theta frequencies (5–8 Hz) predominate at the edge of sleep, as in the floating “hypnopompic” state I described in chapter 15 on EMDR; they are also characteristic of hypnotic trance states. Theta waves create a frame of mind unconstrained by logic or by the ordinary demands of life and thus open the potential for making novel connections and associations. One of the most promising EEG neurofeedback treatments for PTSD, alpha/theta training, makes use of that quality to loosen frozen associations and facilitate new learning. On the downside, theta frequencies also occur when we’re “out of it” or depressed.

  Alpha waves (8–12 Hz) are accompanied by a sense of peace and calm.13 They are familiar to anyone who has learned mindfulness meditation. (A patient once told me that neurofeedback worked for him “like meditation on steroids.”) I use alpha training most often in my practice to help people who are either too numb or too agitated to achieve a state of focused relaxation. Walter Reed National Military Medical Center recently introduced alpha-training instruments to treat soldiers with PTSD, but at the time of this writing the results are not yet available.

  Beta waves are the fastest frequencies (13–20 Hz). When they dominate, the brain is oriented to the outside world. Beta enables us to engage in focused attention while performing a task. However, high beta (over 20 Hz) is associated with agitation, anxiety, and body tenseness—in effect, we are constantly scanning the environment for danger.

  HELPING THE BRAIN TO FOCUS

  Neurofeedback training can improve creativity, athletic control, and inner awareness, even in people who already are highly accomplished.14 When we started to study neurofeedback, we discovered that sports medicine was the only department in Boston University that had any familiarity with the subject. One of my earliest teachers in brain physiology was the sports psychologist Len Zaichkowsky, who soon left Boston to train the Vancouver Canucks with neurofeedback.15

  Neurofeedback has probably been studied more thoroughly for performance enhancement than for psychiatric problems. In Italy the trainer for the soccer club AC Milan used it to help players remain relaxed and focused as they watched videos of their errors. Their increased mental and physiological control paid off when several players joined the Italian team that won the 2006 World Cup—and when AC Milan won the European championship the following year.16 Neurofeedback was also included in the science and technology component of Own the Podium, a $117 million, five-year plan engineered to help Canada dominate the 2010 Winter Olympics in Vancouver. The Canadians won the most gold medals and came in third overall.

  Musical performance has been shown to benefit as well. A panel of judges from Britain’s Royal College of Music found that students who were trained with ten sessions of neurofeedback by John Gruzelier of the University of London had a 10 percent improvement in the performance of a piece of music, compared with students who had not received neurofeedback. This represents a huge difference in such a competitive field.17

  Given its enhancement of focus, attention, and concentration, it’s not surprising that neurofeedback drew the attention of specialists in attention-deficit/hyperactivity disorder (ADHD). At least thirty-six studies have shown that neurofeedback can be an effective and time-limited treatment for ADHD—one that’s about as effective as conventional drugs.18 Once the brain has been trained to produce different patterns of electrical communication, no further treatment is necessary, in contrast to drugs, which do not change fundamental brain activity and work only as long as the patient keeps taking them.

  WHERE IS THE PROBLEM IN MY BRAIN?

  Sophisticated computerized EEG analysis, known as the quantitative EEG (qEEG), can trace brain-wave activity millisecond by millisecond, and its software can convert that activity into a color map that shows which frequencies are highest or lowest in key areas of the brain.19 The qEEG can also show how well brain regions are communicating or working together. Several large qEEG databases of both normal and abnormal patterns are available, which allows us to compare a patient’s qEEG with those of thousands of other people with similar issues. Last but not least, in contrast to fMRIs and related scans, the qEEG is both relatively inexpensive and portable.

  The qEEG provides compelling evidence of the arbitrary boundaries of current DSM diagnostic categories. DSM labels for mental illness are not aligned with specific patterns of brain activation. Mental states that are common to many diagnoses, such as confusion, agitation, or feeling disembodied, are associated with specific patterns on the qEEG. In general, the more problems a patient has, the more abnormalities show up in the qEEG.20

  Our patients find it very helpful to be able to see the patterns of localized electrical activity in their brains. We can show them the patterns that seem to be responsible for their difficulty focusing or for their lack of emotional control. They can see why different brain areas need to be trained to generate different frequencies and communication patterns. These explanations help them shift from self-blaming attempts to control their behavior to learning to process information differently.

  As Ed Hamlin, who trained us in interpreting the qEEG, recently wrote to me: “Many people respond to the training, but the ones that respond best and quickest are those that can see how the feedback is related to something they are doing. For example, if I’m attempting to help someone increase their ability to be present, we can see how they’re doing with it. Then the benefit really begins to accumulate. There is something very empowering about having the experience of changing your brain’s activity with your mind.”

  HOW DOES TRAUMA CHANGE BRAIN WAVES?

  In our neurofeedback lab we see individuals with long histories of traumatic stress who have only partially responded to existing treatments. Their qEEGs show a variety of different patterns. Often there is excessive activity in the right temporal lobe, the fear center of the brain, combined with too much frontal slow-wave activity. This means that their hyperaroused emotional brains dominate their mental life. Our research showed that calming the fear center decreases trauma-based problems and improves executive functioning. This is reflected not only in a significant decrease in patients’ PTSD scores but also in improved mental clarity and an increased ability to regulate how upset they become in response to relatively minor provocations.21

  Other traumatized patients show patterns of hyperactivity the moment they close their eyes: Not seeing what is going on around them makes them panic and their brain waves go wild. We train them to produce more relaxed brain patterns. Yet another group overreacts to sounds and light, a sign that the thalamus has difficulty filtering out irrelevant information. In those patients we focus on changing communication patterns at the back of
the brain.

  While our center is focused on finding optimal treatments for long-standing traumatic stress, Alexander McFarlane is studying how exposure to combat changes previously normal brains. The Australian Department of Defence asked his research group to measure the effects of deployment to combat duty in Iraq and Afghanistan on mental and biological functioning, including brain-wave patterns. In the initial phase McFarlane and his colleagues measured the qEEG in 179 combat troops four months prior to and four months after each successive deployment to the Middle East.

  They found that the total number of months in combat over a three-year period was associated with progressive decreases in alpha power at the back of the brain. This area, which monitors the state of the body and regulates such elementary processes as sleep and hunger, ordinarily has the highest level of alpha waves of any region in the brain, particularly when people close their eyes. As we have seen, alpha is associated with relaxation. The decrease in alpha power in these soldiers reflects a state of persistent agitation. At the same time the brain waves at the front of the brain, which normally have high levels of beta, show a progressive slowing with each deployment. The soldiers gradually develop frontal-lobe activity that resembles that of children with ADHD, which interferes with their executive functioning and capacity for focused attention.

  The net effect is that arousal, which is supposed to provide us with the energy needed to engage in day-to-day tasks, no longer helps these soldiers to focus on ordinary tasks. It simply makes them agitated and restless. At this stage of McFarlane’s study, it is too early to know if any of these soldiers will develop PTSD, and only time will tell to what degree these brains will readjust to the pace of civilian life.

  NEUROFEEDBACK AND LEARNING DISABILITIES

  Chronic abuse and neglect in childhood interfere with the proper wiring of sensory-integration systems. In some cases this results in learning disabilities, which include faulty connections between the auditory and word-processing systems, and poor hand-eye coordination. As long as they are frozen or explosive, it is difficult to see how much trouble the adolescents in our residential treatment programs have processing day-to-day information, but once their behavioral problems have been successfully treated, their learning disabilities often become manifest. Even if these traumatized kids could sit still and pay attention, many of them would still be handicapped by their poor learning skills.22

  Lisa described how trauma had interfered with the proper wiring of basic processing functions. She told me she “always got lost” going places, and she recalled having a marked auditory delay that kept her from being able to follow the instructions from her teachers. “Imagine being in a classroom,” she said, “and the teacher comes in and says, ‘Good morning. Turn to page two-seventy-two. Do problems one to five.’ If you’re even a fraction of a second off, it’s just a jumble. It was impossible to concentrate.”

  Neurofeedback helped her to reverse these learning disabilities. “I learned to keep track of things; for example, to read maps. Right after we started therapy, there was this memorable time when I was going from Amherst to Northampton [less than ten miles] to meet Sebern. I was supposed to take a couple of buses, but I ended up walking along the highway for a couple miles. I was that disorganized—I couldn’t read the schedule; I couldn’t keep track of the time. I was too jacked up and nervous, which made me tired all the time. I couldn’t pay attention and keep it together. I just couldn’t organize my brain around it.”

  That statement defines the challenge for brain and mind science: How can we help people learn to organize time and space, distance and relationships, capacities that are laid down in the brain during the first few years of life, if early trauma has interfered with their development? Neither drugs nor conventional therapy have been shown to activate the neuroplasticity necessary to bring those capacities online after the critical periods have passed. Now is the time to study whether neurofeedback can succeed where other interventions have failed.

  ALPHA-THETA TRAINING

  Alpha-theta training is a particularly fascinating neurofeedback procedure, because it can induce the sorts of hypnagogic states—the essence of hypnotic trance—that are discussed in chapter 15.23 When theta waves predominate in the brain, the mind’s focus is on the internal world, a world of free-floating imagery. Alpha brain waves may act as a bridge from the external world to the internal, and vice versa. In alpha-theta training these frequencies are alternately rewarded.

  The challenge in PTSD is to open the mind to new possibilities, so that the present is no longer interpreted as a continuous reliving of the past. Trance states, during which theta activity dominates, can help to loosen the conditioned connections between particular stimuli and responses, such as loud cracks signaling gunfire, a harbinger of death. A new association can be created in which that same crack can come to be linked to Fourth of July fireworks at the end of a day at the beach with loved ones.

  In the twilight states fostered by alpha/theta training, traumatic events may be safely reexperienced and new associations fostered. Some patients report unusual imagery and/or deep insights about their life; others simply become more relaxed and less rigid. Any state in which people can safely experience images, feelings, and emotions that are associated with dread and helplessness is likely to create fresh potential and a wider perspective.

  Can alpha-theta reverse hyperarousal patterns? The accumulated evidence is promising. Eugene Peniston and Paul Kulkosky, researchers at the VA Medical Center in Fort Lyon, Colorado, used neurofeedback to treat twenty-nine Vietnam veterans with a twelve- to- fifteen-year history of chronic combat-related PTSD. Fifteen of the men were randomly assigned to the EEG alpha-theta training and fourteen to a control group that received standard medical care, including psychotropic drugs and individual and group therapy. On average, participants in both groups had been hospitalized more than five times for their PTSD. The neurofeedback facilitated twilight states of learning by rewarding both alpha and theta waves. As the men lay back in a recliner with their eyes closed, they were coached to allow the neurofeedback sounds to guide them into deep relaxation. They were also asked to use positive mental imagery (for example, being sober, living confidently and happily) as they moved toward the trancelike alpha-theta state.

  This study, published in 1991, had one of the best outcomes ever recorded for PTSD. The neurofeedback group had a significant decrease in their PTSD symptoms, as well as in physical complaints, depression, anxiety, and paranoia. After the treatment phase the veterans and their family members were contacted monthly for a period of thirty months. Only three of the fifteen neurofeedback-treated veterans reported disturbing flashbacks and nightmares. All three chose to undergo ten booster sessions; only one needed to return to the hospital for further treatment. Fourteen out of fifteen were using significantly less medication.

  In contrast, every vet in the comparison group experienced an increase in PTSD symptoms during the follow-up period, and all of them required at least two further hospitalizations. Ten of the comparison group also increased their medication use.24 This study has been replicated by other researchers, but it has received surprisingly little attention outside the neurofeedback community.25

  NEUROFEEDBACK, PTSD, AND ADDICTION

  Approximately one-third to one-half of severely traumatized people develop substance abuse problems.26 Since the time of Homer, soldiers have used alcohol to numb their pain, irritability, and depression. In one recent study half of motor vehicle accident victims developed problems with drugs or alcohol. Alcohol abuse makes people careless and thus increases their chances of being traumatized again (although being drunk during an assault actually decreases the likelihood of developing PTSD).

  There is a circular relationship between PTSD and substance abuse: While drugs and alcohol may provide temporary relief from trauma symptoms, withdrawing from them increases hyperarousal, thereby intensifying nightmares, flashbacks, and
irritability. There are only two ways to end this vicious cycle: by resolving the symptoms of PTSD with methods such as EMDR or by treating the hyperarousal that is part of both PTSD and withdrawal from drugs or alcohol. Drugs such as naltrexone are sometimes prescribed to reduce hyperarousal, but this treatment helps in only some cases.

  One of the first women I trained with neurofeedback had a long-standing cocaine addiction, in addition to a horrendous childhood history of sexual abuse and abandonment. Much to my surprise, her cocaine habit cleared after the first two sessions and on follow-up five years later had not returned. I had never seen anyone recover this quickly from severe drug abuse, so I turned to the existing scientific literature for guidance.27 Most of the studies on this subject were done more than two decades ago; in recent years, very few neurofeedback studies for the treatment of addiction have been published, at least in the United States.

  Between 75 percent and 80 percent of patients who are admitted for detox and alcohol and drug abuse treatment will relapse. Another study by Peniston and Kulkosky—on the effects of neurofeedback training with veterans who had dual diagnoses of alcoholism and PTSD28—focused on this problem. Fifteen veterans received alpha-theta training, while the control group received standard treatment without neurofeedback. The subjects were followed up regularly for three years, during which eight members of neurofeedback group stopped drinking completely and one got drunk once but became sick and didn’t drink again. Most of them were markedly less depressed. As Peniston put it, the changes reported corresponded to being “more warmhearted, more intelligent, more emotionally stable, more socially bold, more relaxed and more satisfied.”29 In contrast, all of those given standard treatment were readmitted to the hospital within eighteen months.30 Since that time a number of studies on neurofeedback for addictions have been published,31 but this important application needs much more research to establish its potential and limitations.