The Body Keeps the Score

by Bessel van der Kolk MD

  13.A. Young, Harmony of Illusions. See also J. M. Charcot, Clinical Lectures on Certain Diseases of the Nervous System, vol. 3 (London: New Sydenham Society, 1888).

  14.http://en.wikipedia.org/wiki/File:Jean-Martin_Charcot_chronophotography.jpg

  15.P. Janet, L’Automatisme psychologique (Paris: Félix Alcan, 1889).

  16.Onno van der Hart introduced me to the work of Janet and probably is the greatest living scholar of his work. I had the good fortune of closely collaborating with Onno on summarizing Janet’s fundamental ideas. B. A. van der Kolk and O. van der Hart, “Pierre Janet and the Breakdown of Adaptation in Psychological Trauma,” American Journal of Psychiatry 146 (1989): 1530–40; B. A. van der Kolk and O. van der Hart, “The Intrusive Past: The Flexibility of Memory and the Engraving of Trauma,” Imago 48 (1991): 425–54.

  17.P. Janet, “L’amnésie et la dissociation des souvenirs par l’emotion” [Amnesia and the dissociation of memories by emotions], Journal de Psychologie 1 (1904): 417–53.

  18.P. Janet, Psychological Healing (New York: Macmillan, 1925); p 660.

  19.P. Janet, L’Etat mental des hystériques, 2nd ed. (Paris: Félix Alcan, 1911; repr. Marseille, France: Lafitte Reprints, 1983). P. Janet, The Major Symptoms of Hysteria (London and New York: Macmillan, 1907; repr. New York: Hafner, 1965); P. Janet, L’evolution de la memoire et de la notion du temps (Paris: A. Chahine, 1928).

  20.J. L. Titchener, “Post-traumatic Decline: A Consequence of Unresolved Destructive Drives,” Trauma and Its Wake 2 (1986): 5–19.

  21.J. Breuer, and S. Freud, “The Physical Mechanisms of Hysterical Phenomena.”

  22.S. Freud and J. Breuer, “The Etiology of Hysteria,” in the Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 3, ed. J. Strachy (London: Hogarth Press, 1962): 189–221.

  23.S. Freud, “Three Essays on the Theory of Sexuality,” in the Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 7 (London: Hogarth Press, 1962): 190: The reappearance of sexual activity is determined by internal causes and external contingencies . . . I shall have to speak presently of the internal causes; great and lasting importance attaches at this period to the accidental external [Freud’s emphasis] contingencies. In the foreground we find the effects of seduction, which treats a child as a sexual object prematurely and teaches him, in highly emotional circumstances, how to obtain satisfaction from his genital zones, a satisfaction which he is then usually obliged to repeat again and again by masturbation. An influence of this kind may originate either from adults or from other children. I cannot admit that in my paper on ‘The Aetiology of Hysteria’ (1896c) I exaggerated the frequency or importance of that influence, though I did not then know that persons who remain normal may have had the same experiences in their childhood, and though I consequently overrated the importance of seduction in comparison with the factors of sexual constitution and development. Obviously seduction is not required in order to arouse a child’s sexual life; that can also come about spontaneously from internal causes. S. Freud “Introductory Lectures in Psycho-analysis in Stand ard Edition (1916), 370: Phantasies of being seduced are of particular interest, because so often they are not phantasies but real memories.

  24.S. Freud, Inhibitions Symptoms and Anxiety (1914), 150. See also Strachey, Standard Edition of the Complete Psychological Works.

  25.B. A. van der Kolk, Psychological Trauma (Washington, D: American Psychiatric Press, 1986).

  26.B. A. Van der Kolk, “The Compulsion to Repeat the Trauma,” Psychiatric Clinics of North America 12, no. 2 (1989): 389–411.

  CHAPTER 12: THE UNBEARABLE HEAVINESS OF REMEMBERING

  1.A. Young, The Harmony of Illusions: Inventing Post-traumatic Stress Disorder (Princeton, NJ: Princeton University Press, 1997), 84.

  2.F. W. Mott, “Special Discussion on Shell Shock Without Visible Signs of Injury,” Proceedings of the Royal Society of Medicine 9 (1916): i–xliv. See also C. S. Myers, “A Contribution to the Study of Shell Shock,” Lancet 1 (1915): 316–20; T. W. Salmon, “The Care and Treatment of Mental Diseases and War Neuroses (“Shell Shock”) in the British Army,” Mental Hygiene 1 (1917): 509–47; and E. Jones and S. Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf (Hove, UK: Psychology Press, 2005).

  3.J. Keegan, The First World War (New York: Random House, 2011).

  4.A. D. Macleod, “Shell Shock, Gordon Holmes and the Great War.” Journal of the Royal Society of Medicine 97, no. 2 (2004): 86–89; M. Eckstein, Rites of Spring: The Great War and the Birth of the Modern Age (Boston: Houghton Mifflin, 1989).

  5.Lord Southborough, Report of the War Office Committee of Enquiry into “Shell-Shock” (London: His Majesty’s Stationery Office, 1922).

  6.Booker Prize winner Pat Barker has written a moving trilogy about the work of army psychiatrist W. H. R. Rivers: P. Barker, Regeneration (London: Penguin UK, 2008); P. Barker, The Eye in the Door (New York: Penguin, 1995); P. Barker, The Ghost Road (London: Penguin UK, 2008). Further discussions of the aftermath of World War I can be found in A. Young, Harmony of Illusions; and B. Shephard, A War of Nerves, Soldiers and Psychiatrists 1914–1994 (London: Jonathan Cape, 2000).

  7.J. H. Bartlett, The Bonus March and the New Deal (1937); R. Daniels, The Bonus March: An Episode of the Great Depression (1971).

  8.E. M. Remarque, All Quiet on the Western Front, trans. A. W. Wheen (London: GP Putnam’s Sons, 1929).

  9.Ibid., pp. 192–93.

  10.For an account, see http://motlc.wiesenthal.com/site/pp.asp?c=gvKVLcMVIuG&b=395007.

  11.C. S. Myers, Shell Shock in France 1914–1918 (Cambridge UK, Cambridge University Press, 1940).

  12.A. Kardiner, The Traumatic Neuroses of War (New York: Hoeber, 1941).

  13.http://en.wikipedia.org/wiki/Let_There_Be_Light_(film).

  14.G. Greer and J. Oxenbould, Daddy, We Hardly Knew You (London: Penguin, 1990).

  15.A. Kardiner and H. Spiegel, War Stress and Neurotic Illness (Oxford, England: Hoeber, 1947).

  16.D. J. Henderson, “Incest,” in Comprehensive Textbook of Psychiatry, 2nd ed., eds. A. M. Freedman and H. I. Kaplan (Baltimore: Williams & Wilkins, 1974), p. 1536.

  17.W. Sargent and E. Slater, “Acute War Neuroses,” The Lancet 236, no. 6097 (1940): 1–2. See also G. Debenham, et al., “Treatment of War Neurosis,” The Lancet 237, no. 6126 (1941): 107–9; and W. Sargent and E. Slater, “Amnesic Syndromes in War,” Proceedings of the Royal Society of Medicine (Section of Psychiatry) 34, no. 12 (October 1941): 757–64.

  18.Every single scientific study of memory of childhood sexual abuse, whether prospective or retrospective, whether studying clinical samples or general population samples, finds that a certain percentage of sexually abused individuals forget, and later remember, their abuse. See, e.g., B. A. van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8 (1995): 505–25; J. W. Hopper and B. A. van der Kolk, “Retrieving, Assessing, and Classifying Traumatic Memories: A Preliminary Report on Three Case Studies of a New Standardized Method,” Journal of Aggression, Maltreatment & Trauma 4 (2001): 33–71; J. J. Freyd and A. P. DePrince, eds., Trauma and Cognitive Science (Binghamton, NY: Haworth Press, 2001), 33–71; A. P. DePrince and J. J. Freyd, “The Meeting of Trauma and Cognitive Science: Facing Challenges and Creating Opportunities at the Crossroads,” Journal of Aggression, Maltreatment & Trauma 4, no. 2 (2001): 1–8; D. Brown, A. W. Scheflin, and D. Corydon Hammond, Memory, Trauma Treatment and the Law (New York: Norton, 1997); K. Pope and L. Brown, Recovered Memories of Abuse: Assessment, Therapy, Forensics (Washington: American Psychological Association, 1996); and L. Terr, Unchained Memories: True Stories of Traumatic Memories, Lost and Found (New York: Basic Books, 1994).

  19.E. F. Loftus, S. Polonsky, and M. T. Fullilove, “
Memories of Childhood Sexual Abuse: Remembering and Repressing,” Psychology of Women Quarterly 18, no. 1 (1994): 67–84. L. M. Williams, “Recall of Childhood Trauma: A Prospective Study of Women’s Memories of Child Sexual Abuse,” Journal of Consulting and Clinical Psychology 62, no. 6 (1994): 1167–76.

  20.L. M. Williams, “Recall of Childhood Trauma.”

  21.L. M. Williams, “Recovered Memories of Abuse in Women with Documented Child Sexual Victimization Histories,” Journal of Traumatic Stress 8, no. 4 (1995): 649–73.

  22.The prominent neuroscientist Jaak Panksepp states in his most recent book: “Abundant preclinical work with animal models has now shown that memories that are retrieved tend to return to their memory banks with modifications.” J. Panksepp and L. Biven, The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2012).

  23.E. F. Loftus, “The Reality of Repressed Memories,” American Psychologist 48, no. 5 (1993): 518–37. See also E. F. Loftus and K. Ketcham, The Myth of Repressed Memory: False Memories and Allegations of Sexual Abuse (New York: Macmillan, 1996).

  24.J. F. Kihlstrom, “The Cognitive Unconscious,” Science 237, no. 4821 (1987): 1445–52.

  25.E. F. Loftus, “Planting Misinformation in the Human Mind: A 30-Year Investigation of the Malleability of Memory,” Learning & Memory 12, no. 4 (2005): 361–66.

  26.B. A. Van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8, no. 4 (1995): 505–25.

  27.We will explore this further in chapter 14.

  28.L. L. Langer, Holocaust Testimonies: The Ruins of Memory (New Haven: Yale University Press, 1991).

  29.Ibid., p.5.

  30.L. L. Langer, op cit., p. 21.

  31.L. L. Langer, op cit., p. 34.

  32.J. Osterman and B. A. van der Kolk, “Awareness during Anaesthesia and Posttraumatic Stress Disorder,” General Hospital Psychiatry 20 (1998): 274-81. See also K. Kiviniemi, “Conscious Awareness and Memory During General Anesthesia,” Journal of the American Association of Nurse Anesthetists 62 (1994): 441–49; A. D. Macleod and E. Maycock, “Awareness During Anaesthesia and Post Traumatic Stress Disorder,” Anaesthesia and Intensive Care 20, no. 3 (1992) 378–82; F. Guerra, “Awareness and Recall: Neurological and Psychological Complications of Surgery and Anesthesia,” in International Anesthesiology Clinics, vol. 24. ed. B. T Hindman (Boston: Little Brown, 1986), 75–99; J. Eldor and D. Z. N. Frankel, “Intra-anesthetic Awareness,” Resuscitation 21 (1991): 113–19; J. L. Breckenridge and A. R. Aitkenhead, “Awareness During Anaesthesia: A Review,” Annals of the Royal College of Surgeons of England 65, no. 2 (1983), 93.

  CHAPTER 13: HEALING FROM TRAUMA: OWNING YOUR SELF

  1.“Self-leadership” is the term used by Dick Schwartz in internal family system therapy, the topic of chapter 17.

  2.The exceptions are Pesso’s and Schwartz’s work, detailed in chapters 17 and 18, which I practice, and from which I have personally benefited, but which I have not studied scientifically—at least not yet.

  3.A. F. Arnsten, “Enhanced: The Biology of Being Frazzled,” Science 280, no. 5370 (1998): 1711–12; A. Arnsten, “Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function,” Nature Reviews Neuroscience 10, no. 6 (2009): 410–22.

  4.D. J. Siegel, The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration (New York: WW Norton, 2010).

  5.J. E. LeDoux, “Emotion Circuits in the Brain,” Annual Review of Neuroscience 23, no. 1 (2000): 155–84. See also M. A. Morgan, L. M. Romanski, and J. E. LeDoux, “Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163, no. 1 (1993): 109–113; and J. M. Moscarello and J. E. LeDoux, “Active Avoidance Learning Requires Prefrontal Suppression of Amygdala-Mediated Defensive Reactions,” Journal of Neuroscience 33, no. 9 (2013): 3815–23.

  6.S. W. Porges, “Stress and Parasympathetic Control,” Stress Science: Neuroendocrinology 306 (2010). See also S. W. Porges, “Reciprocal Influences Between Body and Brain in the Perception and Expression of Affect,” in The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2009), 27.

  7.B. A. van der Kolk, et al., “Yoga As an Adjunctive Treatment for PTSD.” Journal of Clinical Psychiatry 75, no. 6 (June 2014): 559–65.

  8.Sebern F. Fisher, Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain. (New York: WW Norton & Company, 2014).

  9.R. P. Brown and P. L. Gerbarg, “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression—Part II: Clinical Applications and Guidelines,” Journal of Alternative & Complementary Medicine 11, no. 4 (2005): 711–17. See also C. L. Mandle, et al., “The Efficacy of Relaxation Response Interventions with Adult Patients: A Review of the Literature,” Journal of Cardiovascular Nursing 10 (1996): 4–26; and M. Nakao, et al., “Anxiety Is a Good Indicator for Somatic Symptom Reduction Through Behavioral Medicine Intervention in a Mind/Body Medicine Clinic,” Psychotherapy and Psychosomatics 70 (2001): 50–57.

  10.C. Hannaford, Smart Moves: Why Learning Is Not All in Your Head (Arlington, VA: Great Ocean Publishers, 1995), 22207–3746.

  11.J. Kabat-Zinn, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, 2013). See also D. Fosha, D. J. Siegel, and M. Solomon, eds., The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2011); and B. A. van der Kolk, “Posttraumatic Therapy in the Age of Neuroscience,” Psychoanalytic Dialogues 12, no. 3 (2002): 381–92.

  12.As we have seen in chapter 5, brain scans of people suffering from PTSD show altered activation in areas associated with the default network, which is involved with autobiographical memory and a continuous sense of self.

  13.P. A. Levine, In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness (Berkeley: North Atlantic, 2010).

  14.P. Ogden, Trauma and the Body (New York: Norton, 2009). See also A. Y. Shalev, “Measuring Outcome in Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 61, supp. 5 (2000): 33–42.

  15.I. Kabat-Zinn, Full Catastrophe Living. p. xx

  16.S. G. Hofmann, et al., “The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review,” Journal of Consulting and Clinical Psychology 78, no.2 (2010): 169–83; J. D. Teasdale, et al., “Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy,” Journal of Consulting and Clinical Psychology 68 (2000): 615–23. See also Britta K. Hölzel, et al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural Perspective.” Perspectives on Psychological Science 6, no. 6 (2011): 537–59; and P. Grossman, et al., “Mindfulness-Based Stress Reduction and Health Benefits: A Meta-Analysis,” Journal of Psychosomatic Research 57, no. 1 (2004): 35–43.

  17.The brain circuits involved in mindfulness meditation have been well established, and improve attention regulation and has a positive effect on the interference of emotional reactions with attentional performance tasks. See L. E. Carlson, et al., “One Year Pre-Post Intervention Follow-up of Psychological, Immune, Endocrine and Blood Pressure Outcomes of Mindfulness-Based Stress Reduction (MBSR) in Breast and Prostate Cancer Outpatients,” Brain, Behavior, and Immunity 21, no. 8 (2007): 1038–49; and R. J. Davidson, et al., “Alterations in Brain and Immune Function Produced by Mindfulness Meditation,” Psychosomatic Medicine 65, no. 4 (2003): 564–70.

  18.Britta Hölzel and her colleagues have done extensive research on meditation and brain function and have shown that it involves the dorsomedial P
FC, ventrolateral PFC, and rostral anterior congulate (ACC). See B. K. Hölzel, et al., “Stress Reduction Correlates with Structural Changes in the Amygdala,” Social Cognitive and Affective Neuroscience 5 (2010): 11–17; B. K. Hölzel, et al., “Mindfulness Practice Leads to Increases in Regional Brain Gray Matter Density,” Psychiatry Research 191, no. 1 (2011): 36–43; B. K. Hölzel, et al., “Investigation of Mindfulness Meditation Practitioners with Voxel-Based Morphometry,” Social Cognitive and Affective Neuroscience 3, no. 1 (2008): 55–61; and B. K. Hölzel, et al., “Differential Engagement of Anterior Cingulate and Adjacent Medial Frontal Cortex in Adept Meditators and Non-meditators,” Neuroscience Letters 421, no. 1 (2007): 16–21.

  19.The main brain structure involved in body awareness is the anterior insula. See A. D. Craig, “Interoception: The Sense of the Physiological Condition of the Body,” Current Opinion on Neurobiology 13 (2003): 500–505; Critchley, Wiens, Rotshtein, Ohman, and Dolan, 2004; N. A. S Farb, Z. V. Segal, H. Mayberg, J. Bean, D. McKeon, Z. Fatima, et al., “Attending to the Present: Mindfulness Meditation Reveals Distinct Neural Modes of Self-Reference,” Social Cognitive and Affective Neuroscience 2 (2007): 313–22.; J. A. Grant, J. Courtemanche, E. G. Duerden, G. H. Duncan, and P. Rainville, (2010). “Cortical Thickness and Pain Sensitivity in Zen Meditators,” Emotion 10, no. 1 (2010): 43–53.

  20.S. J. Banks, et al., “Amygdala-Frontal Connectivity During Emotion-Regulation,” Social Cognitive and Affective Neuroscience 2, no. 4 (2007): 303–12. See also M. R. Milad, et al., “Thickness of Ventromedial Prefrontal Cortex in Humans Is Correlated with Extinction Memory,” Proceedings of the National Academy of Sciences of the United States of America 102, no. 30 (2005): 10706–11; and S. L. Rauch, L. M. Shin, and E. A. Phelps, “Neurocircuitry Models of Posttraumatic Stress Disorder and Extinction: Human Neuroimaging Research—Past, Present, and Future,” Biological Psychiatry 60, no. 4 (2006): 376–82.

  21.A. Freud and D. T. Burlingham. War and Children (New York University Press, 1943).