EIGHT

The Trauma Spectrum

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Although the world is full of suffering, it is also full of the overcoming of it.

—Helen Keller

At no other time in written history have there been more people on the move as refugees, with many traumatized by war, famine, and genocide. The numbers are estimated to triple in the next thirty years, with climate change causing whole island nations to disappear and coastlines to move inland, all contributing the social chaos and trauma. These historical changes, combined with the ongoing trauma experienced by people who endure such disruptive events as domestic violence, rape, and auto accidents, make the next few decades extremely challenging for health care professionals.

Not all people respond to life-threatening situations in the same way. Some people are quite resilient, while others develop a wide spectrum of chronic anxiety, including posttraumatic stress disorder (PTSD) and depressive disorders. All the feedback loops addressed in previous chapters, including epigenetic, immune system, attachment, and social factors, play major roles in undermining or supporting “self”-organization and resiliency for people who endure traumatic experiences.

Linda had at least a few risk factors for PTSD before entering an abusive marriage. She suffered years of abuse from Steve before I met her. And it wasn’t her idea to seek therapy. Only after her third visit to the emergency department for bruises and a broken nose did she agree. The staff knew what was happening, despite her denials that she was the victim of domestic violence. I met her at 3 a.m. while on call to the emergency department. We arranged an immediate referral to a domestic violence program where I previously served on the board of directors. Perhaps it was because her broken nose was so obvious or my firsthand information about the program, but she showed minimal resistance to the placement.

Risk Factors for PTSD

After two weeks at the shelter she came to see me for follow-up as an outpatient. She noted that as soon as she began to feel understood by her peers in the support group, she became less hesitant about disclosing the extent of the beatings. Up to that point she had sought help for a wide spectrum of health problems, including obesity, type 2 diabetes, and high blood pressure, but not the domestic violence. She had had assumed that Steve would “take mercy” on her because she was too ill to abuse.

As a daughter of an alcoholic who beat not only her mother but also her, she seemed to have a marriage initially that was “somewhat normal.” In fact, Steve did not hit her until well after his “verbal tantrums” went on largely without protest. She explained that she spent much of their marriage “walking on eggshells,” because “there was no telling what would set him off.”

A person with a greater internal locus of control may be more durable and resilient in the face of trauma. In response to the first incident of verbal abuse and domestic violence she would have immediately set firm limits or gotten out of the marriage. In contrast, Linda had an external locus of control. She was more vulnerable to develop PTSD because she possessed fewer resources and less confidence. She doubted that she could deal with the traumatic stress and recover afterward.

With apparently less PFC development supporting affect regulation, her capacity to make and then follow through on practical goals was compromised, especially when she was stressed. In fact, she did not believe that her behaviors could prevent or protect herself from abuse. In short, she developed learned helplessness that contributed to not only depression but also the cycle of violence.

THE BREAKDOWN OF THE SYSTEMS

As noted in Chapter 7, our species evolved a multilevel stress response system. Given that we live in an extraordinarily complicated social environment, many of the stressors we encounter are social. If the danger we encounter is from other people, our first line of defense is the social engagement system. We talk, implore, and even beg for mercy if our life is in danger from others. If those maneuvers fail, we can revert to the fight-or-flight response. And if fleeing or fighting off a threat is not possible, and if the situation is hopeless, we may revert to the most primitive response of shutting down, becoming immobilized. People who have been traumatized may use any or a combination of these defensive responses.

Stages of Defense

  1. The social engagement system: the myelinated vagus
  2. Fight or flight: the sympathetic nervous system and hypothalamic-pituitary-adrenal axis
  3. Immobilization: freeze, collapse, and feigned death, in two stages—

Traumatic events provoke defensive behaviors that may work over the short term but not the long term. Linda’s neuroendrocrine system, sympathetic branch of the autonomic nervous system, and immune system became dysregulated in response to acute and chronic stress. When his rages went on for hours, she could not regain allostasis because the sustained effects of these hyperalert states led to the breakdown of her self-regulatory systems. Even when he was not posing imminent risk, she had difficulty falling or staying asleep and concentrating during the daytime. Her default-mode network activity centered on replaying traumatic autobiographical memories or fears of the future.

When Linda detected an immediate threat from Steve, her amygdala signaled the locus ceruleus to release norepinephrine and her adrenal medulla to release norepinephrine and epinephrine (adrenalin). Both neurotransmitters promote immediate hypervigilance, quicken heartbeat, and tighten muscles to prepare to flee from danger. Her quickened thoughts, centered on whether Steve would hurt her at that moment, were processed by her cortex, and memories about whether he did so in similar contexts before were processed by her hippocampus. If she determined that a real threat was imminent, her orbital frontal cortex disinhibited her amygdala to activate her neuroendrocrine system.

Whereas her sympathetic activity occurred immediately, her neuroendrocrine system (hypothalamic-pituitary-adrenal axis) added sustained alertness and energy, by her hypothalamus releasing corticotropin-releasing hormone within seconds of hearing his angry voice. Approximately fifteen seconds later her pituitary released adrenocorticotropic hormone, and within minutes her adrenal glands released cortisol to increase her metabolism to utilize glucose stores for more energy to deal with the danger at hand. Sometimes her stress systems were not amenable, and in response to the abuse she shut down into what she called her “deer-in-the-headlights” mode.

STABILIZING AND PREVENTING PTSD

There are significant differences in the potential consequences of experiencing a traumatic incident and experiencing several traumatic events. As described in Chapter 3, the greater the number of adverse childhood experiences endured by a person, the more health problems and the more vulnerability to subsequent trauma. Linda endured several adverse childhood experiences with complex trauma. In contrast, one discrete trauma, like a near-fatal auto accident, though not simple, is relatively less complicated.

Take Michael, for example, who suffered from the residual effects of a horrific auto accident that totaled his car and killed all drunk teenagers in the car that hit him. He became hyperconditioned to stimuli associated with automobiles. Because our brain abides by the evolutionary mandate of self-preservation, strong associations with a trauma are exceptionally resistant to extinction (Milad & Quirk, 2012). Accordingly, Michael felt compelled to avoid cars altogether.

Immediately after the accident Michael’s norepinephrine, adrenalin, cortisol, and pro-inflammatory cytokine levels were all elevated. Nightmares and hypervigilance plagued him during the first few weeks following the accident. Had he seen a psychologist initially after the accident, the therapeutic effort would have been directed toward stabilization so that less traumatic memory was encoded by lowering of elevated stress chemistry. Elevated levels of these neurochemicals, associated with the development of PTSD, serve to maintain intrusive thoughts and nightmares, as well as ramping up anxiety by unleashing the amygdala.

This potentially debilitating combination of factors emerging posttrauma demonstrates that therapy should be directed toward stabilization and prevention of PTSD. With this in mind, critical incident debriefing employed just after the trauma is largely considered countertherapeutic. Heightening stress neurochemistry by a premature review of the traumatic details accelerates the encoding of traumatic memory and actually primes the development of PTSD.

Therapeutic interventions should include those that stabilize and calm, to minimize the risk of developing PTSD. One of the principle goals of psychological first aid is to depathologize and normalize the initial hypervigilance and nightmares. If people are not forewarned, when they do experience those symptoms they become alarmed and frightened and overreact, making the symptoms worse.

A variety of feedforward factors encode the stress response into an enduring chaotic pattern that misreads safe conditions as danger. In fact, if one month after a traumatic event the levels of three neurochemicals are elevated—norepinephrine, high cortisol in the evening, and pro-inflammatory cytokines—there is a higher likelihood of transitioning from acute stress disorder to PTSD.

Neuroimaging studies involving PTSD symptom provocation have identified consistent findings (Bremner, 2002):

Reduced Activity

Increased Activity

These factors inhibited the capacity of Michael’s PFC for problem solving and rational behavior. Meanwhile, he was plagued by heightened startle response, vigilance, insomnia, flashbacks, intrusive memories of the accident, and increased fear conditioning, so that he even avoided riding in his car as a passenger.

The symptoms of trauma create a feedforward loop, driven by neuroplasticity, intensifying over time. Even when Michael watched movies that featured a scene with a car chase, the trauma felt like it was happening now. Each time this happened, it led to further priming and the potential for more flashbacks.

The three therapeutic phases applied to trauma are as follows:

Balancing Bottom-Up and Right/Left

The positive relationship among amygdala activity, hyperarousal, and startle response and the reduction in activity in the medial PFC represents a failure to exert appropriate top-down inhibition. The amygdala functions as the driving force (the accelerator) to defensive reactions, whereas the medial PFC regulates (applies the brakes) to the amygdala. This check-and-balance system is often impaired in people who have been traumatized, so there tends to be more acceleration and less braking for stress. Because the amygdala is part of a threat detection system that the cortex assembles into the conscious feeling of fear, Michael tended to feel threat when there was none. To make matters worse, the sustained high levels of cortisol impaired his hippocampus thermostat function, making him prone to hypervigilance and false positives for danger.

One of the goals in therapy was to shore up Michael’s PFC and its ability to dampen the hyperarousal and reexperiencing. This effort put more emphasis on the left PFC through establishing and working on concrete goals, over the tendency to withdraw, associated with the right PFC. The structure and follow-through on doable goals supported his self-efficacy and helped stabilize and prevent the development of PTSD.

Long-Term Dysregulations

Had Michael not sought out therapy, the unaddressed residual effects of the trauma would have contributed to the dysregulation of his immune system. That is what happened for Linda. Distant and persisting trauma may also result in inadequate cortisol; its natural anti-inflammatory effect evaporated, and she suffered from chronic inflammation and autoimmune diseases. While too much cortisol can suppress the immune system, too little can impair the ability to constrain inflammation. Chronic stress, depression, and PTSD are associated with hypoactivity of the cortisol system.

Complex trauma breaks down many of the homeostatic feedback systems. In addition to the cortisol receptors on the hippocampus, part of the hypothalamus called the paraventricular nucleus provides another negative feedback mechanism that inhibits further release of cortisol. As Linda endured acute stress and repeated traumas, these thermostat functions broke down. She was less able to shut down the stress response, so that even minor stress felt overwhelming.

High levels of stress for extended periods forces the body to do the following:

The stress-induced autonomic-inflammatory reflex contributes to the following disorders:

Acute and chronic stress, combined with depression, increases the risk for impaired immune system functioning, coronary heart disease, myocardial infarction, chronic pain syndromes, type 2 diabetes, and dementia. Acute stress contributes to activation of pro-inflammatory cytokines (Harbuz, Chover-Gonzalez, & Jessop, 2003). Accordingly, Linda suffered from chronic inflammation combined with elevated catecholamines, making her feel ill, depressed, and anxious at the same time. In response, she failed to maintain positive self-care behaviors, which further undermined her health and impaired her central nervous system, undermining her ability to manage stress. The cumulative effects contributed to more depression and exacerbated her autoimmune disorders.

These feedforward loops involving stress, depression, and autoimmune disorders illustrate how traumatized people not only tend to become stressed and depressed but also are more vulnerable to feel ill because they are stressed and depressed. The mediators of allostasis operate as a nonlinear network, so dysregulation of any of these networks leads to allostatic load.

Memory Integration

After Linda left Steve, her capacity to make use of safety-related information was obscured by intrusive trauma-related thoughts and feelings. Because at times she suffered from a fragmented sense of self and the loss of a cohesive experience of time, her traumatic past could instantaneously surge into the present, hijacking her sense of safety. Her emotions were fragmented from her cognitions, which all felt too overwhelming to put both into context together.

The therapeutic reconsolidation of her memory systems was key to her regaining a sense of self and capacity to regulate her affect. Because her implicit memory system was out of synch with her explicit memory system, surges of anxious feelings were triggered by sights, sounds, and smells. Her explicit memory system, a function of her cortex and hippocampus, was overwhelmed by the onslaught of dysregulated anxious feelings coming from her implicit memory system.

Implicit memories are more resistant to change and the passage of time, in contrast to explicit memories, which are modified over time. Implicit memories are difficult to update by purely verbally based approaches because they occur spontaneously through exposure to sights, smells, sounds, and emotions. The more complex and extended the traumatic experiences, the greater the tendency to code in a range of unregulated implicit memories.

The interaction between the explicit and implicit systems is influenced by the intensity of emotion. Because explicit memories depend on the hippocampal-frontal memory system, during periods of intense emotion they can be overtaken by amygdala-driven implicit memories. Intense emotion associated with trauma, combined with reduced hippocampal processing of explicit memory, tends to favor greater formation of implicit memory. Implicit system can contort the explicit system to code in threat-based memory. Avoidance of the traumatic memory cues maintains symptoms of trauma, whereas emotional engagement with traumatic memories neutralizes them and is critical to recovery.

Therapy with Michael involved helping him incrementally focus on the implicit memory content of the flashbacks without suppressing them. These exposure-based exercises included sitting in a car, driving it, and eventually driving past the location of the accident. He managed to depotentiate the timeless qualities of the implicit images and sensations so that they became linked with a spatial and temporal context monitored by his executive and salience networks. Consolidation of the implicit system with the explicit system frames traumatic memories in the past, where they belong, and that he is safe in the present.

The process of exposure and reconsolidating the implicit memories within the explicit system must be repeated multiple times to facilitate neuroplastic change. Through rehearsing the newly consolidated explicit memories with new narratives, Michael learned to say, “I felt that way right after the accident when the paramedics pulled me out of my mashed up car. But I’m in no danger now.” Through slow exposure to the previously frightening implicit memory cues, he brought them gradually under control so that they no longer triggered flashbacks. He simultaneously applied meaning, context, and realistic thoughts to seemingly chaotic sensations and emotions.

So-called hot spots represent brief moments of emotional intensity associated with flashbacks, such as when Michael drove into the neighborhood of the accident. These moments of dysregulation between the contents of implicit and explicit memory systems identified the focal points needing reconsolidation. His sustained attention to the implicit memory cues, such as the feelings of driving his car in that neighborhood again, strengthened his coping skills and enhanced his prefrontal circuit’s inhibitory control over the amygdala, diminishing flashbacks. Integration of his memory systems was framed by new narratives, such as “I will drive defensively, and that is the best I can do.” Therapy focused on reconsolidating traumatic memories from the accident into feelings of realistic self-efficacy.

This shift in activity within his salience network allowed his previously fragmented implicit memories to transform into an integrated sense of stability. The cognitive self-representations available for narrative expression either in the moment through executive network or in imagination through his default-mode network contained the disturbing emotional feelings that came up. Instead of reverting to overwhelming flashbacks, he could stay in the present and calm himself.

Memory integration necessitates the following steps:

  1. Assessing the current capacity of the explicit memory system to determine the pace in which integration of the implicit and explicit systems is possible.
  2. Identifying the cues that trigger flashbacks.
  3. Priming the integration by orchestrating a “safe emergency” within the window of tolerance to apply an exposure exercise to the implicit memory cues.
  4. Ensuring that integration is encoded through multiple processing channels, including somatic grounding.

Normally, the realm between explicit and implicit memory can be hazy. Especially for Linda, implicit memories seemed surreal and horrifying during flashbacks. Episodic (explicit) memory is relatively rational, due to its reliance on cortical-hippocampal networks. In contrast, emotional and procedural (implicit) memory is irrational and more dependent on subcortical networks. The dynamic interface between the contextually organized time-dependent episodic memory and the generalized, irrational, and timeless emotional memory was dysregulated. The integration of explicit and implicit memory slowly brought meaning and positive emotions to her life.

Though fragmented, her explicit memories of the trauma needed to be made cohesive and realistic so that she could explain the implicit feelings as they came up. For example, when Linda said, “My head is beginning to feel dizzy,” she was able to reframe the experience by saying, “This is how I used to feel when Steve was about to hit me. But he is not here now, and I am safe.” Therapy rebuilt her explicit memory system abilities of context and time and integrated them with implicit memories of the trauma, which had up to that point felt timeless. Because the trauma-related episodic memories were fused with negative valence, the feeling tones needed positive valence (Levine, 2012). For Linda it began with the belief that she was beginning to feel safe and in control of her own life.

Co-constructing a new narrative placed past events in the context of her new experiences within the supported environment of the domestic violence program. Though the process took considerable time, the benefit of living in a therapeutic community provided constant support and encouragement for her salience network to reconfigure a viable sense of self. She was slowly able to integrate past experiences into a cohesive sense of self which, though unfair, could be accepted as understandable. Therapy helped her construct a new adaptive narrative of being a survivor instead of a broken person. Ahmed, introduced in Chapter 7, also gained from a therapeutic community. He joined others who were suffering from the traumatic complexities of civil war. Like Linda, he developed a narrative consistent with conceptualizing himself as a survivor instead of damaged for life. But unlike Linda, he was plagued by secondary emotions.

SECONDARY EMOTIONS

Ahmed used his executive and default-mode networks to draw up memories from his explicit memory system to evaluate how the events could have been prevented and the implications to his self-worth. So-called secondary emotions associated with the episodic memory are not experienced at the time of the traumas. They include regret about risks he had taken or sadness and remorse at the loss. These emotions may involve shame and guilt about his failure. He felt tremendous shame for joining the army that supported a regime that killed his father. He finally deserted after witnessing more atrocities and the fear of being forced to participant in them in the future.

Secondary emotions can torment trauma survivors for their entire life. When I first heard about the tortured guilt and remorse experienced by my grandfather Missak, I was speechless, and my heart ached. He had witnessed the murder of his first wife and child while hiding in the woods. The Turks were gathering all the young Armenian men for labor camps, the army, or execution on the spot. Women and children up to that point had been spared. At that moment the Turks brutally shifted to outright genocide. The year was 1915. Though Missak managed to escape with his life, part of him never left that spot. The tormenting guilt and deep sadness he carried would periodically erupt in rage. Decades later he encountered two Turkish men in Pershing Square in Los Angeles. Trying to rise above his grief and reconcile the painful memories, he approached them, greeting them in Turkish. When they asked if he was Turkish, he could not resist responding, “No, I am one of the few Armenians that survived the genocide.” One of them shook his head in disgust and said, “What genocide!? You Armenians need to get over the past.” Missak had to be restrained from attacking the man. Later Missak explained: “It was as if it was all happening again.”

His story permeated my family. But he was not the only one to have experienced trauma. I learned that, like him, many of my maternal and paternal relatives carried with them similar horrific stories. The next generation and mine to follow carried an undercurrent of survivor’s guilt. This complicated mix of sadness and horror is made worse not just by a few men in a park in Los Angeles but by the continued organized program of denial of the genocide by the Turkish government.

For my grandfather, just hearing Turkish spoken in an angry voice instantly brought him back to that horrifying day. His implicit memory system contained information that had been obtained from sensations from the traumatic events, including the sound of a Turkish accent spoken in anger, which triggered bodily sensations such as increased heart rate, temperature, and pain. These implicit memories cued flashbacks that occurred immediately and involuntarily. This is why he said, “The past is always there . . . lingering, ready to bite. And it comes with a vengeance!” The raw, poorly organized, implicit situational reminders of the trauma, such as the physical sensations and horrifying emotions, never left him. Superimposed on the erratic implicit memories was a unintegrated layer of guilt and deep sadness.

MANAGING THE WINDOW OF TOLERANCE AND OPPORTUNITY

Like many people who have experienced complex trauma, Linda tended to be in a state of biphasic hypoarousal and hyperarousal. The cues for her flashbacks were often fragmented implicit memories that appeared sporadically and at times “out of nowhere.” On the other hand, at times she felt numb, blunted, and in a surreal world. A window of tolerance was available between these extremes. The task of therapy was to operate within that window. Implicit memory cues are difficult to neutralize without deliberate exposure in therapy. Yet, they are best approached through well-managed exposure within this window of tolerance to build the explicit memory system so that the implicit memory cues can be tolerated and integrated.

Prior to her time in the domestic violence program and therapy, Linda alternated between feeling overwhelmed with intense emotional states, such as sadness, despair, fear, and shame, overreacting to the world around, and feeling distant, numb, and as though little part of her had died. This oscillation of hypervigilance at one extreme and avoidance and emotional blunting at the other extreme undermined her sense of self-efficacy and control. Her window of tolerance represented the space between these two extremes, in which she could best achieve integration and positive therapeutic outcome.

Linda’s state-based implicit memories were cued by specific breathing patterns, muscle tensions, gastrointestinal sensations, heart rate, and the tone of my voice—any or all of these sensations served as implicit cues for a flashback. As with people with panic disorders, interoceptive exposure exercises served as access to these somatic sensations. The increase of implicit memories and the decrease of context-dependent explicit memories opened the gate for flashbacks triggered by sights, sounds, and smells, experienced as timeless threat.

Because her implicit memory system was nonconscious, it could be triggered by the fast track to her amygdala. The sensory information such as sounds went directly to her amygdala from her thalamus to signal a potential threat. Primed to activate the false-positive threats by elevated levels of cortisol and norepinephrine, her amygdala overwhelmed her hippocampus and PFC. Consequently, her executive network, which would normally restrict threat detection to realistic danger, was off-line. Therapy entailed balancing bottom-up and top-down circuits within the window of tolerance.

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Figure 8.1: The Window of Tolerance

“Figure 2.1 Window of Tolerance”, from TRAUMA AND THE BODY: A SENSORIMOTOR APPROACH TO PSYCHOTHERAPY by Pat Ogden, Kenkuni Minton, Clare Pain. Copyright © 2006 by Pat Ogden. Copyright (c) 2006 by W. W. Norton & Company, Inc. Used by permission of W. W. Norton & Company, Inc.

Integration of her implicitly generated arousal levels were carefully managed to help her affect stay within the therapeutic window so that she was not too hyper- or hypoaroused. Simultaneously, we made sure that the “safe emergency” of the exposure exercises utilized the moderatere level of arousal to maximize neuroplasticity. If her arousal levels were too low, traumatic memories would not be accessed. On the other hand, if arousal levels were too high, she would have been so overwhelmed with the traumatic memory that the effort would have become countertherapeutic and retraumatizing. She alternated between feeling too much or not enough emotion. The goal was to help her get back into the range of tolerance, back to dynamic equilibrium.

Because her hippocampal and PFC networks may have been compromised, therapy strengthened her executive network, carefully integrating implicit information such as seeing a brief angry facial expression within her explicit memory system denoting that there is a situation to be resolved. A moderate level of activation (a safe emergency) maximized the middle range of arousal and expanded the width of the therapeutic window.

Neurobiological Mechanisms of the Therapeutic Window

Michael’s exposure to the implicit and explicit cues of driving a car again triggered a range of memories of the traumatic event, especially when approaching traffic. These exercises were repeated and extended (prolonged) so that the cues could reconsolidate as routine stimuli that he needed to habituate to so that he could commute to work without feeling overwhelmed with anxiety. The duration of the exercises was at least twenty minutes to allow for the release of beta-endorphin to buffer the anxiety. Because flooding could retraumatize him, titration within the window of tolerance started low and went slow. The principle goal was for the traumatic memories to lose their power. He was taught that the exposure process could be understood in the phrase “cells that fire out of sync lose their link,” so that what was unnecessarily feared faded away. Of course, there was always the chance that another car would swerve into his lane or run a stoplight. The point is that he needed to adapt to a world of probabilities. Since driving at 2 a.m. on Sunday would increase the chances that drunk drivers were on the road, he drove defensively in the middle of the day when it was relatively safe.

The neurophysiological changes resulting from successful therapy:

Emotions as Cues

The emotions provoked during or after the trauma may later trigger a flashback. These conditioned emotional responses (CERs) can include fear, sadness, or horror (Briere, & Scott, 2015). For Michael fear and horror became associated with driving. Neutralizing the CERs required that they be activated, not reinforced, and then counterconditioned. Because the utility of perceiving, labeling, and accepting emotions can help diminish their intensity, therapy identified and modified the thoughts that exacerbated the CERs associated with the accident. Practical action through driving, in concert with purposeful thoughts about the necessity of getting to work, doing errands, and visiting friends, transformed into new meaning associated with those emotions. Therapy necessitated titrating the exposure to the CERs within the window of tolerance and at the middle of the arousal curve.

Neutralizing Conditioned Emotional Responses

Advise clients to do the following:

Therapy took advantage of the fact that, every time a memory is retrieved, the underlying memory trace becomes once again fragile so that it goes through another period of consolidation. An incremental approach worked best so that the traumatic implicit memories were dealt with in smaller units and in a hierarchy from less distressing to more distressing. We broke down the levels of distress into doable chunks so that the highest-intensity emotion occurred in the middle of the session and then the session ended with calm. Novel and distinctive explicit memories were co-constructed in therapy to facilitate greater access a wide range of PFC and hippocampal circuits so Michael could apply affective top-down inhibition, so that the flashbacks diminished in intensity.

In sum, traumatic CERs periodically and abruptly trigger flashbacks. They need to be integrated within the explicit memory system to make them coherent and better structured and to reduce the risk of unwanted intrusions. When those traumatic memories are reactivated through exposure and reconsolidation they become less distressing.

AVOIDANCE, DETACHMENT, AND DISSOCIATION

Linda had typically “checked out” during Steve’s abusive tirades. She said that the only way she could endure the beatings was to “go somewhere else.” This method of protecting her “self” began during childhood when her drunken father terrorized everyone in the household.

Like other species, in addition to the sympathetic and neuroendocrine systems we possess a primitive defense system made possible by the unmyelinated vagus. During extreme trauma the metaphors of “deer in the headlights” and “playing possum” represent actual self-protective responses to extreme life-threatening threats. The freeze, collapse, or feigned death reactions play many roles in the wild. For humans, the spectrum of primitive defenses includes mild, moderate, and extreme detachment. For example, if her other means of defense did not work, Linda became detached and immobilized in response to horrific pain that she could not stop.

Detachment can occur at different levels. With mild detachment, or absorption, she may experience a breakdown in the ability to notice outside events such as how Steve was handling her in the moment. Her executive network checked out while her default-mode network dominated. Her distorted perception at times extended to an altered sense of herself, with the salience network checking out, too. During moderate detachment she may tend to have feelings of depersonalization and derealization and see herself as if from afar, as an observer. Finally, in extreme detachment she may become unresponsive and catatonic and have no sense of self or time.

The “continuum of deattachment” in disassociation (Allen, 2001) includes the following:

Some people revert to these defenses more than others. Linda’s propensity to quickly revert to these primitive defenses occurred in absence of a coherent salience network. As described in Chapters 1 and 2, “self”-organization is promoted by an internal sense of safety and positive attachment, which would have permitted her adequate self-awareness. But she endured adverse childhood experiences and abuse, and her attention was drawn outward, away from the development of a durable salience network. Her internal representations were fragmented in favor of being hypervigilant for potential danger. Later, as an adult, in response to extreme stress she had difficulty feeling her body and differentiating emotions. When she encountered acute stress or life-threatening trauma with Steve, she tended to detach from the situation.

Therapy entailed helping her build a coherent salience network monitored by a well-functioning executive network. Building the capacity for self-reflection within her default-mode network helped her develop a coherent internal life by helping her identify, label, and accept feelings. Because her schemas were primed by situations and feeling states associated with the trauma, they needed reconditioning through activation and reconsolidation. This process took time and necessitated working within the implicit memory system because her reaction patterns did not contain the contextual representations of the past or were not realistically relevant to the present.

The Somatic Therapies

When I presented a seminar to Afghan government service workers on coping with stress, during a break Aamir told me that when he says goodbye to his children in the morning he does not know if he is going to see them in the evening. Car bombs and IEDs engineered by the Taliban are quite common in Kabul. His anxiety centered not only on his family but also on his own safety—two car bombs had exploded near his office. He was painfully aware that working for the government made him a target. One day on the way home from work the car in front of him hit an IED, killing everyone inside.

His implicit memory systems encoded traumas as a mix of procedural and emotional memories that fused specific body movements and sensations with emotions. For example, when someone in the lecture hall accidentally dropped his briefcase, making a loud bang, Aamir abruptly ducked his head, only to raise it again with intense fear on his face. His automatic avoidant behaviors such as ducking became part of an array of procedural and emotional memories that represented somatic action patterns. They offered an important focus in therapy because they formed a key mechanism underlying trauma (Levine, 2015). Intense emotions combined with procedural memories that served as a guide to protect and defend him became chronic and corrosive to his sense of self. The goal was to bring him back to a state of dynamic equilibrium.

Jean Martin Charcot and his student Pierre Janet were the first to identify the implicit-nonconscious procedural memory system as holding traumatic memory and experienced through the body. Charcot, a neurologist working at the Salpêtrière Hospital in Paris the late 1880s, described jerky movements, contracted postures, and the tendency to suddenly collapse in response to cues to traumatic memory. Janet followed by describing trauma as replayed and reenacted through body movements and visceral sensations. These physical manifestations occurred as if the trauma were happening in the present, not as thoughts and reflections of what had occurred in the past. As raw sensations, they bring the past into the present, often with horrifying emotion.

Therapy that emphasizes body sensations attempts to address procedural and emotional memory circuits, which can be cued and expressed somatically. Implicit traumatic memories are expressed by the “somatic narrative” in gesture, posture, facial expressions, speech prosody, eye gaze, and movement (Ogden & Fisher, 2015). The body, indeed, “keeps the score” (van der Kolk, 2015).

Somatic based therapies, including the so-called bilateral-reprocessing therapies such as Eye Movement Desensitization Reprocessing (EMDR) and the tapping therapies such as Emotional Freedom Therapy, as well as Sensorimotor Therapy and Somatic Experiencing, all utilize somatosensory factors. Integrating the implicit and explicit systems through the somatic techniques can accelerate the narrative reorganization and strengthening of explicit memories.

It is important to find the common factors among these approaches and shed elements of the approaches that are superfluous (Arden, 2015). Along those lines, dismantling studies have not demonstrated that the bilateral movements affect symptom reduction (Cahill, Carrigan, & Frueh, 1999). However, the somatic-based therapies do disrupt traumatic memories to help clients reconsolidate and integrate them.

How does the body keep the score? Because much of the memory of the trauma is implicit, coded in body movements and sensations, access to them must be somatic. These procedural memories have been dysregulated from explicit memories and conscious awareness. One of the goals of therapy is to integrate them so that the procedural memories do not erupt without warning to trigger flashbacks.

Somatic-based approaches place attention on the physical sensations and support the cortical containment of traumatic memories into general semantic networks (Stickgold, 2002). Orienting identifies and shapes the amount and quality of the information processed that all species use to guide their behavior (Sokolov, Spinks, Naatanen, & Heikki, 2002). Redirecting attention to personally relevant information, such as a novel stimulus, promotes the orienting reflex.

The initial discovery of orienting response dates back to Pavlov (a few decades after the research on classical conditioning). He argued that his dogs “lost their sense of purpose” after being traumatized after a flood. In recovery, he argued that the dogs reoriented themselves to a sense of safety by noting that a previously frightening stimulus was not dangerous after all. He suggested that they reframed the new, non-dangerous stimulus by reorienting to a new identification of it, explained in the phrase, Shto takoe? (Что такое? or What is it?).

For humans, the reorienting response provides a much greater shift in brain activity. A stimulus that prompts a person to notice what happens next primes PFC activity. Coding in novelty, essentially an unexpected somatic sensation, integrates PFC, anterior cingular cortex, hippocampus, and basal ganglia circuits by moderate bursts of dopamine, and in so doing, orienting serves as a sort of a kickstart to the connectivity between the executive and the salience networks. Even the most subtle of stimuli can prompt a shift to the executive network.

Pierre Janet proposed that trauma victims are stuck and cannot accumulate new experiences. Somatic-based therapies offer a kickstart to reopen the gate. Consider how an unexpected stimulus such as cat darting across the road or an unexpected omission of a stimulus, such as when the hum of the refrigerator motor that suddenly turns off, can evoke the orienting reflex. Whereas we had habituated to the sound of the refrigerator motor, when it turns off it becomes novel. The orienting reflex is evoked when there is a discrepancy between a person’s contextual expectations and a stimulus. Because one of the many functions of the hippocampus is as novelty detector, as well as a key part of the explicit memory system, novel somatic stimuli abruptly kindle the integration of the memory systems, which promotes affect-enhanced regulation.

Developing the flexibility of the top-down or bottom-up orienting and habituation responses helps us adapt to changing conditions. However, trauma victims may tend to dishabituate to a novel stimulus due to their hyper- or hypoarousal states. Whereas the bottom-up orienting reflex is reflexive, top-down orienting is cognitive. Being responsive to new information necessitates regaining a dynamic equilibrium in the attentional circuits and the mind’s operating networks. Activating the orienting response in therapy promotes the ability to attentionally orient toward stimuli related to recovery, which is congruent with a hopeful narrative.

Somatic stimulation, whether induced by eye movements, bilateral stimulation, tapping, acupressure, or acupuncture, induces a shift in attention involving the orientation response (Sokolov, 1990). The orientating response may induce an REM-like state, which facilitates the cortical integration of traumatic memories when PFC and hippocampus activity has shifted (Stickgold, 2002). The reorienting of attention occurs automatically when a sudden movement grabs the client’s attention, such as directed eye movements, taps, or intention movement of the body to specific postures. The reorienting of attention requires release of focus on one location or position so that attention can shift to a new location or position. Repeatedly reorienting attention from one location to another by somatic stimulation kindles the prefrontal and hippocampal networks to build here-now and top-down circuits of the executive network that put the past in the past. Though clients do not forget trauma, the power of the past becomes neutralized by the safe feelings coded in the salience network in the present moment.

In sum, somatic-type therapies evoke the orienting response to facilitate the integration of traumatic memories. Through focused therapeutic effort combined with somatic stimulation, these approaches activate the PFC and hippocampus. By combining exposure and somatic stimulation, the reconsolidation of implicit and explicit memory associated with the trauma reconsolidates by “safe emergencies” within the therapeutic alliance. Moderated degrees of anxiety within the window of tolerance facilitate the optimal conditions for therapeutic neuroplasticity.

POSTTRAUMATIC GROWTH

A major goal of therapy involves working with the client to develop a belief in a viable optimistic future that has meaning, to promote “posttraumatic growth.” The potential for positive growth to occur posttrauma has been exemplified by reports that up to half of trauma victims describe some sort of positive outcome posttrauma (Updegraff and Taylor, 2000). Linda gained posttraumatic growth through her peer counseling efforts with other victims of domestic violence and adult children of alcoholics. By helping her develop a sense of meaning to move beyond the traumatic events, her posttraumatic growth involved constructive changes to her sense of self, her relationships, and her philosophy of life (Tedeshi & Calhoun, 1996).

Though the traumatic events were behind her, they are never forgotten. Her “self”-organization involved leaps to higher levels of insight and affect regulation as she acknowledged her interdependence with the world. The “self”-organizing process associated with posttraumatic growth transcended the pain of the traumas as she embraced greater meaning to her life. Her posttraumatic growth involved acknowledging the illusion of invulnerability without hopelessness by embracing realistic optimism about her life. This paradoxical recognition of vulnerability and hope promoted better control and a realistic sense of strength. The changes to her relationships allowed her to deepen intimacy and share feelings about what happened, as well as aspirations for the future. Through posttraumatic growth her old sense of self (“old me”) transformed to a new sense of self (“new me”), with a recognition that there was no turning back to the old self. Her new sense of identity became wiser, and she used the opportunity to become more compassionate person. Her involvement as a support to others who had experienced trauma tapped into a natural inclination to gather with others for safety and healing. Increasing cognitive complexity and “self”-organization bolstered her resiliency as she expanded the number of different perspectives she had of herself to weather subsequent stressors.

The importance of developing meaning posttrauma was described in one of the most inspiring books in the mental health field, Man’s Search for Meaning by Victor Frankl. Despite enduring the horrors of Auschwitz, Frankl embraced a transcending sense of meaning, demonstrating that deeply traumatized people can move on to wisdom and growth. In fact, many people who have been horribly traumatized have gone on to gain a deep sense of meaning and satisfaction with life. My Armenian relatives, despite living through genocide, thrived in the United States and France. Posttraumatic growth for my grandfather was operationalized by education. He spoke five languages and until a week before his death taught himself six new words a day. He instilled in me a quest for knowledge. On a political level posttraumatic growth can affect millions of other people as well, as personified by Nelson Mandela’s expanding a sense of meaning and commitment to others.