PTSD Mini-Handbook

In Dr. Van der Kolk’s words, both from class and from other online interviews, trauma is “any experience that overwhelms our central nervous system’s ability to deal with it. Trauma is a serious event, creating suffering so great it cannot be expressed in words and therefore cannot be ‘recalled’. Trauma begins with the feeling of ‘Oh My God, my life is over’. No one wants to remember or acknowledge trauma; it is unbearable to stare it in the face because it fills you with shame and locks you inside yourself. Trauma leaves people stuck in a state of helplessness and terror.”

From my bodywork perspective, I would offer the following: trauma is an event, or series of events, that are life-threatening, or, most importantly, perceived or experienced by the BodyMindSpirit to be life-threatening. Thus, trauma is systemic destabilization.

Physiologically, trauma literally changes the way the brain is wired, and therefore, how it intakes, processes and acts upon information.

Thanks to technological advances in imaging, fMRI (functional Magnetic Resonance Imaging) in particular, we have a new window into the brain and how it works. We can observe not only how individual areas of the brain function and what they are responsible for, but also how the different areas work in tandem through neural pathways, and what traumatic changes look like in the underlying brain structures. fMRI is also shining a light on what interventions actually help the brain recover more normalized ways of functioning.

Bad stuff happens to almost all humans, and many experiences leave a lasting mark. But not all are “traumatic”, because not all change the underlying physiology of the central nervous system (brain and spinal cord). However, common usage of the word trauma has developed to include a wide array of difficult experiences, and it is almost never helpful to minimize someone’s pain by correcting their use of the word. Again, in my professional and personal experience, “trauma”, like most other experiences, occurs on a spectrum and is highly individualized. I imagine further research will continue to shine a light into this complex array of human experiences and responses, and perhaps both the usage and the understanding of the word trauma will change over time.

That said, universally recognized events deemed highly likely to create observable physiological brain changes include directly experiencing or witnessing abuse, neglect, violence, assault, terrorism, torture, war, accidents and/or natural disasters. The death of a loved one (including animals), depending on the circumstances, can also fall into this category. Trauma causes certain direct changes in the brain:

• The Broca’s area of the brain goes offline. This area, located in the left side of the brain produces speech. Hence, we are “speechless with terror.”
• The left side of the brain (thinking) is deactivated while the right side (feelings) is active. All we have are our feelings, and those feelings are being hard-wired. We are unable to think or reason. We simply react.
• We cannot organize ourselves.

In response, our brain sets off a response that floods our bodies with natural endorphins, to numb the pain.

These same brain and body responses occur subsequent to the initial trauma when the persons neurological system perceives a similar threat and reacts, even if the current situation poses no direct danger to them. We commonly refer to this as being “triggered”, a topic I will explore at length below. It is this re-wiring of the brain structures from an initial traumatic event that develops into Post-Traumatic Stress Disorder, or PTSD.

Interestingly, and surprising to me, not all traumatic experiences will result in PTSD. The two main risk factors for PTSD development are:

1. Being physically immobilized during the initial trauma and
2. A lack of caring, appropriate emotional support immediately afterwards. These are both linked to workings of the sympathetic arm of the autonomic nervous system (ANS).

The ANS controls our muscles that direct involuntary functions such as heart and breathing rates, digestive muscle tone, and glandular functions, among others. I like to think of the ANS as the “automatic” nervous system. The ANS itself has three components, the sympathetic, parasympathetic and enteric arms. The sympathetic arm is commonly called our “fight or flight” response since it prepares the body for action, while the parasympathetic arm is referred to as the “rest and digest” response. They work together, as opposites often do, to keep the body in overall balance. The enteric division is charged with regulating stomach activity and is rarely referenced at this time, though we are learning more and more about it.

This chart visually shows the different nervous system parts and how they are related.
First, the fight or flight response is designed specifically to make us MOVE our bodies. Therefore, if the power to save ourselves through fighting back or fleeing to safety is somehow lost, we are much more likely to develop PTSD. For example, if we are trapped in the car during an accident and have to wait for help to arrive. Or if we are held down during a rape or other violent assault.

Second, if someone is there to care for us in the aftermath the parasympathetic arm of the ANS kicks in and counteracts the fight or flight system so our nervous system calms down immediately and we are less likely to develop PTSD. For example, an empathetic nurse in the ER. Or a friend who holds your hand through a police report. If we can calm the fight or flight in a timely manner the neural system re-sets to a baseline. Otherwise, PTSD is a likely outcome.

Technically, Post-Traumatic Stress Disorder, or PTSD, is a mental health diagnosis outlined in the DSM (Diagnostic and Statistical Manual of Mental Disorders). The DSM includes these observed criteria for making a medical diagnosis. However, many cases of PTSD are never clinically diagnosed. PTSD can also co-exist with other mental or physical health disorders. These are complicated systems. Nothing is simple or linear.

In practice, PTSD is the ongoing, unresolved changes to the central nervous system as a result of the initial trauma. The brain has essentially adapted to a new way of being, to the environment it believes is real:

The World is a Dangerous Place.

Networks in our brains determine the relevance of incoming information, what we pay attention to and for how long, how we process information and our self-experience. In normalized brains all the parts are working together but in traumatized brains the parts are going in different directions.

A traumatized person lives in an alternate universe.

Ongoing traumatic changes hit hardest in the ANS, and those bodily functions we don’t need to think about consciously. Our levels of physiological arousal vs calmness, our ability to fall asleep, our patterns and quality of sleep, our breathing and heart rates and the chemical balances in our bodies are all deeply affected by PTSD.

In addition to the dysfunction of the ANS, and therefore interruptions to our basic biological bodily functions, the structural brain changes of PTSD can wreak havoc on an individual’s day-to-day activities. Consider the impact of any one of these changes, shared with us by Dr. Van der Kolk as a result of his research, by themselves, or as a whole:

• Our amygdala (part of the limbic brain focused on survival) becomes hyperactive. It reacts to stimuli it perceives to be dangerous (even if it isn’t, or others don’t think it is). This is also known as hyperarousal or hypervigilance. The amygdala has connections with the sympathetic arm of the ANS, thus its hyperactivity keeps the body aroused in a perpetual low-level state of preparation for action.
• We lose our ability to internally observe, and thus to know, ourselves.
• We lose our internal timekeeper. Thus, we lose the ability to wait in general, or, importantly, to know that “this too shall pass”. The ability to wait out unpleasant experiences or events is an act of resilience to life. When our timekeeper is gone, we cannot even differentiate the past from the present. Everything is happening now and must be solved NOW. We cannot bear the suffering one moment longer because we cannot anticipate its end.
• We become highly self-conscious in relation to others.
• We lose our ability to focus and/or filter relevant from irrelevant information. We cannot pay attention, or we pay attention to the “wrong” things. We become distracted easily. Filtering incoming sensory information is one of the most basic tools our brains use to navigate our surroundings and decide on a course of action.
• We lose our ability to know what our body needs – hunger, thirst, sleep. Bodily sensations are not safe, and so we choose not to pay attention to them.
• We lose our ability to feel; we become numb.
  We act inappropriately, either because we’ve lost our ability for impulse control or because we can’t assess the situation properly.
• We have trouble anticipating, planning or holding things in the context of time.
• We lose our capacity for empathy.
• We lose our internal map of the world, our internal GPS, and have trouble placing ourselves in the world, or understanding spatial relationships. This can manifest in myriad ways such as getting lost when driving, being accident prone, or misjudging personal space within relationships.
• We can’t take advice, or risks, or see different options or opportunities, or be open to new ideas or ways of doing things. We become inflexible and locked into old ways of thinking and being.
• We always think the worst is going to happen because it many ways it already has. Our brains are predisposed to assume the past predicts the future.
• We lose our sense of purpose, so we don’t know who we are or what we want.
• No amount of reasoning can override the fear center of our brain – we are what we feel.
• We can feel hatred toward and disgusted by the part that experienced the wounding (trauma) – self-hatred.
• Early childhood trauma or neglect leads to poor integration of sound, sight and body placement in the world.

Sitting through the course, I was shocked by this list and the realization of the breadth and depth PTSD can exert over even the most basic of life’s daily tasks. This is not only anecdotal evidence, but rather based on credible scientific research. In my experience recognizing that we are not alone, crazy, messed-up, failures, or any other hurtful beliefs we have about ourselves give us hope and encourage us to take any steps, even the smallest, to recovery. Hence, for those who have a trauma history, their reactions and responses are “normal” based on what they have experienced.

That bad stuff that happens to everyone? It can leave enduring marks, but that does not mean it is PTSD. The hallmark of trauma and PTSD are the significant structural changes they cause to the central nervous system. These changes to the brain’s structures, pathways and responses are hardwired and will endure until appropriate intervention occurs.

So, bottom line, you can’t will, wish, work or talk your way out of PTSD. You can’t just “move on” or “get over it”, no matter how many people in your life think you should, including yourself. Thus, my first conclusion – that in our everyday lives we can begin to ask, “what happened to that person” instead of “what’s wrong with that person,” and choose to practice empathy and compassion instead of judgment.

“The world is a dangerous place. Watch out.” – The traumatized brain

“No one wants to remember or acknowledge trauma; it is unbearable to stare it in the face because it fills you with shame and locks you inside yourself. Trauma leaves people stuck in a state of helplessness and terror.” – Dr. Bessel van der Kolk

Now that we have examined what trauma and PTSD are, and how they change the physiology of the brain itself, let’s look at some of the ways PTSD manifests in an individual’s life. Of course, each person’s experience is unique to them. Nevertheless, the new technology of fMRI is helping us understand the commonalities of brain structure function and dysfunction in regard to certain inputs.

Living with PTSD, in the words of Dr. Van der Kolk, is having “your behaviors annoy or frighten the people around you and make you feel ashamed of yourself”. I would extend this observation to include ourselves – most people I know who have PTSD would say their behaviors can annoy and frighten themselves. Living with PTSD means living with triggers, flashbacks and traumatic memories, along with their accompanying, often overpowering, emotions and behaviors. Living with PTSD means living with the consequences of these triggers and memories, and, often, a long list of coping mechanisms and avoidance behaviors.

What is a traumatic memory? A trigger? A flashback?

A trigger = any incoming sensory information that reminds the danger warning center of the brain (the amygdala) of the initial trauma.

A traumatic memory = any memory that is specific to the event and is stored differently in the brain because of it.

A flashback = one of the ways a traumatic memory is recalled where the recall is accompanied by “disassociation”.

Triggers can be anything and are everywhere because memories are everywhere. From the weather to a smell, from a bodily sensation to the look on someone’s face, the survival brain remembers it all. A trigger can release the stored traumatic memories and thus the person reacts. Because this response is driven by the unconscious physiological survival mechanisms of the brain, the person has little to no control over their reaction.

A traumatic memory is different than a non-traumatic memory in how it is stored in the brain. These two types of memory have also been called “narrative” and “implicit” to differentiate between them. Whereas non-traumatic memories are accompanied by a “story” that makes sense of the experience and can be “recalled” and rerun, like a sequential video, traumatic, or implicit, memories are stored more as individual snapshots, accompanied by real-time feelings and sensory information such as smells or bodily sensations. In other words, non-traumatic memory has an accompanying narrative and traumatic memory has no narrative. Instead, traumatic memory is behavioral, cognitive, emotional, sensory and physiological in nature. In addition, while the narrative linked to non-traumatic memory, and thus the memory itself, can change over time, traumatic memory NEVER deteriorates because it is linked to our survival.

Traumatic memories are related to fear, the fear you will not survive, and are hard-wired into the brain’s structures. The brain seems unable to integrate traumatic memories, and furthermore, also unable to integrate any other experiences that follow the traumatization. As mentioned before, a non-traumatized brain is working as a whole, whereas the parts of a traumatized brain are going in different directions.

Traumatic memories are recalled in three general ways:

• For some people, traumatic memories run like loops of an old movie in the persons head, as if the brain is replaying the scene and trying to change the outcome. A common term for this type of constant replay is “looping.” Looping can also take the form of speaking about or re-playing the event(s) over and over again, especially if the traumatized person is a child, or was a child when the initial trauma took place. Looping can even include having repetitive thoughts unrelated to the trauma. It’s as if the record is stuck on repeat.
• Other memories are buried, or hidden from the person’s consciousness, and require intervention or specific intention to access. Traumatic memories can manifest as nightmares; again, the brain seems be trying to process and make sense of the experience.
• The third type of traumatic recall is called a flashback. Flashbacks are accompanied by “disassociation” from the present reality; the brains timekeeper is disrupted and is in fact re-living the trauma as if it is happening RIGHT NOW. The person cannot tell the difference between past and present and so believe their life is again in danger. Flashbacks are accompanied by the overpowering emotions of the time and thus seem very real and are deeply disruptive and disturbing. We have all experienced this “losing track of time” – daydreaming is an example; it just doesn’t carry with it the same emotional impact as reliving a life-threatening event.

When the brain lives according to its new reality following trauma, that is, the world is a dangerous place, it becomes hyper-focused on watching for the next threat. When a threat is perceived by the limbic brain, the center of our survival instinct, it sends out hormones that set off a response in the ANS (autonomic nervous system). This cascades into several physiological changes that prime us to fight the threat, or run from it. The system is designed to make us MOVE toward or away from danger, the fight or flight response. The limbic system doesn’t differentiate the current event from the past traumatic event, so it reacts, regardless of whether the situation poses an immediate danger to us or not. As we are unable to reason, we are at the mercy of our physiology until the central nervous system is calmed. In addition to fighting or fleeing, the brain can decide in an instant that “freezing”, or mimicking a prey animals’ lifeless immobility, is the best pathway to survival.

The situation or sensory input that the brain interprets as dangerous we commonly call a “trigger,” since it triggers these physiological responses without conscious thought on our part. We’ve all heard those heroic stories about someone lifting a car off of a loved one or jumping out of the way of a falling tree they didn’t “see.” We’ve also questioned the apparent freezing, or inaction, of a policeman or firefighter when they were supposed to act and keep us safe. These are all examples of the fight, flight or freeze response of the ANS. Remember, it’s beyond our conscious control.

It is important to remember the brain learns from every experience we have and is always interpreting incoming data points, watching for threats and deviations from expected outcomes. Therefore, people can develop triggers even if they do not have a classic history of trauma or PTSD. In addition, one of the ways the brain copes with trauma is by repressing or suppressing memories of the event(s). This array of human experience and response may explain why some people are aware of their triggers, and speak openly about them, while denying any history of trauma. There are also many people who experience the effects of a trigger without any awareness of why they do what they do.

As I said before, after trauma the brain becomes highly focused watching for anything that could be a threat, and, once it finds it, the central nervous system explodes into fight or flight. Action comes next, sometimes with tragic consequences. Consider a war veteran who believes they are back in a war zone and hurts or kills someone they know but perceive to be the enemy. Heartbreaking. Even if the behavior is not this extreme, it is commonly confusing, scary or annoying to the person with PTSD or those around them.

Therefore, the FEAR of these trigger events and their possible fallout become their own source of trauma; individuals develop a myriad array of extensive coping mechanisms to avoid them. These recurring responses can actually re-traumatize people and impact their relationships, lives and daily function until intervention occurs. Voila, the cycle of danger/fear/response is etched further into the brain structure, creating more barriers to recovery.

The possible outward symptoms of these inward brain changes are innumerable but can include feelings of detachment (from your body, family or friends, society at large), being out of step or misunderstood, lost, unworthy, ungrounded, perpetually unsafe and on guard, overwhelmed, exhausted, anxious, disempowered or victimized, generally resistant/hesitant/inflexible. You can have trouble with emotional regulation, either “feeling too much” or not feeling at all, become hysterical or depressed for no “good” reason, have suicidal thoughts or illusions of grandeur. You may develop coping mechanisms that include isolation, addiction, obsessive/compulsive acts, cutting, eating disorders or other self-harming behaviors. You can disassociate – a mental process of disconnecting from one’s thoughts, feelings, memories, or sense of identity. During a trigger event or flashback, you may leave your body, feel light-headed, nauseous, fall asleep or even black out.

Furthermore, ongoing changes to the brain from unresolved trauma keep us trapped in the fight or flight response, with major health consequences. Again, recent neuroscience research is showing us the underlying physiology that explains the outward symptoms. Disruptions in the brain center find their way into the heart and the digestive system by way of the Vagus nerve. Unresolved traumatic brain changes have been found to negatively impact the immune system by making it more adept at turning the inflammatory response on and less adept at turning it off. Trauma affects heart function and morbidity through the ANS control of heart rate variations (HRV), the variation in the time interval between consecutive heartbeats in milliseconds. Proper digestion requires activation by the parasympathetic arm of the autonomic nervous system and can’t take place while the system is in fight or flight mode. Immune memory cell functions have been found to be changed in women with incest histories.

If you’re interested in exploring deeper, The National Institute of Health has an extensive article on the impact of trauma.
There is good news, however. Research continues to show us what interventions actually help the brain recover more normalized function.

Human Beings have two root needs. One is to receive safe, caring touch, and the other is to be in relationship to other humans where we are safe, seen and heard. Unfortunately, traumatic events often involve such extensive pain that the BodyMindSpirit doesn’t think it can, or even wants to, survive. Our brains re-wire in the wake of the trauma and they can no longer take advice, or risks, or see different options or opportunities, or be open to new ideas or ways of doing things. No amount of reasoning can override the hyperactivity of the brains’ fear center.

Of all the traumatic events that can lead to PTSD, child sexual abuse and child neglect are the two most complex to treat. We need to have certain input into our systems for that part of the brain to come online as we develop. In addition, in a healthy environment, babies develop a rhythm of engagement and disengagement, learn to attune to others, to mimic and to engage. Babies rely on voices and facial recognition to decide if the environment is “safe.” We’re highly attuned to both non-verbal cues. In a neglectful or abusive environment, the capacity to interact with others is highly impacted.
Intervention and recovery, then, can be challenging and frustrating, both to the individual and to those who want to help them. We are dealing with complex and interwoven systems. Healing is not linear. Compassion is a necessity.

If someone suffers from PTSD, diagnosed or otherwise, they will likely have trigger events or be generally anxious, fearful, agitated or angry in certain situations. In either case, is helpful to respond to them in a way that helps to calm them. It is important to remember that they have no control over what triggers a PTSD response, and little to no access to their reasoning, analytical brain nor their speech center as it is happening.

Since a trigger event is accompanied by physiological changes, you can often see it coming before it tips over and explodes into a full-on fight, flight or freeze catastrophe. Physiologically, blood rushes away from the digestive system and surface (leading to pale skin) and races to the arm and leg muscles, heart, and brain. Pupils dilate, heart rate and breathing rate increase, and muscle tension increases (sometimes this results in trembling). As stated in my first post, we become unable to reason, to speak, organize ourselves, and are inundated with numbing endorphins. Our brain thinks the past is the present and acts accordingly.

Again, in the words of Dr. Van der Kolk, we become “dull.” I would also use the word detached, while at the same time we may become physically agitated, pacing for example. Sometimes the person reacts immediately to a trigger, slapping a hand away, screaming, cursing, or throwing a punch. Sometimes they simply stop speaking or withdraw. Sometimes they drive recklessly or at high speeds. Sometimes they numb the pain with drugs, alcohol, cutting, or other self-destructive behaviors.

When you know or suspect someone is experiencing a full-on trigger event, or you are supporting them in general, helping to re-set patterns, the first priority is to help calm their nervous system. They need to be seen, heard, and cared for. These strategies can help:

• Listen without judgment, arguing or giving advice. They may repeat themselves, they may talk about the traumatic experience over and over, they may say things that sound “crazy”. Remember they are responding as if the experience is happening now. If they are acting like they are three years old, they are feeling the same emotions and re-acting as if they are three years old. Their brain cannot tell the difference.
• Ask them what you can do to help. This puts them in control of the situation. It may give them a way to press the “pause” button in their brain and bring them into the present.
• Ask if you can touch them in a caring way, perhaps hold their hand, or give them a hug. Respect their answer.
• Remind them to breathe, and breathe deeply with them. It is physiologically impossible for the fight or flight response to activate or escalate when we are concentrating on breathing deeply. Expiration (breathing out) is tied to activation of the parasympathetic (rest and digest) arm of the autonomic nervous system, so focus on exhaling deeply and for as long as possible.
• Don’t pressure them to speak until they are ready; remember the speech creation and processing area of the brain is off-line.
• Don’t minimize their feelings or experiences
• Let them lead and be in control as much as possible in situations you know create stress and anxiety.

What outside interventions help trauma recovery?

For our class, Dr. Van der Kolk defined recovery as “the integration of emotion and cognition; or what do we think about how we feel?”

Fortunately, there is hope, and, again, through recent technological advances and research, we are more clearly identifying what interventions change the brains physiology into more normalized and synchronous functionality. Basically, Dr. Van der Kolk expressed the idea that any therapy that allows for new possibilities and outcomes is good therapy, and that all good trauma therapy begins in an altered state (of consciousness). Not everything works for everyone so trying different approaches is important. Yet the traumatized brain has trouble doing so, or even understanding why it should want to. This can be frustrating for those surrounding the person and requires more patience and compassion.

On a professional level, the core objectives to trauma recovery include:

• Re-establishing community – helping people find a place where they feel seen, heard and cared for
• Dealing with “affect” (emotional) dysregulation – reducing acute stress and/or calming the nervous system. If you can regulate the brain stem the entire system calms down
• Accessing the emotional brain and integrating it with the cognitive brain.
• Giving people back a sense of “agency” or the power to be the director of their own lives and make decisions.
• Speaking the truth. Words come last in treatment, not first. All we know is what we feel, we have no “story” or narrative until we can integrate the experience. Further, that which cannot be communicated to someone else cannot be communicated to the Self, and so it “didn’t happen.”
• Accessing the emotional brain to know oneself – the only pathway to the emotional brain is through self-knowledge.

These goals can be achieved through:

• Bodywork. Safe, caring touch is core to being human. *In my own practice I find the techniques of Biodynamic Craniosacral Therapy to be the most powerful tool I have to calm the central nervous system.
• The arts – singing, playing music, theatre, and art
• Mindfulness and meditation practices (known in the Christian church as Contemplative and/or Centering prayer) – even more powerful when accompanied by self-compassion.
• Yoga and/or martial arts
• Sleep. REM (rapid eye movement) sleep aids in integration. Science has found a connection between REM periods of sleep and memory processing and integration.
  Play
• Sensory integration programs
• Developing competency at any one thing, no matter what it is
• Neuro/biofeedback. This field is very new and unregulated. There are many options; if you try one and it doesn’t help you may want to try a different type.
• All spiritual practices have been shown to raise heart rate variation, a measure of heart function, which correlates to increased positivity in life.
• EMDR – eye movement desensitization and reprocessing. This is a technique used by many therapists that incorporates the connection between eye movement and memory storage and processing in the brain. Research has shown EMDR is more effective at resolving adult-onset or single incident trauma (car accident) than childhood or ongoing trauma (abuse).
• Deep breathing techniques are especially helpful to calm agitation
• Writing and journaling.
• Psychodrama or other programs that promote a virtual reality experience and change the outcome of the event or lay down new memories.
• Any therapy that allows us to take the action we were prevented from taking at the time of the trauma.
• IFS, or Internal Family Systems therapy. The basis of IFS is that we are all made of up different cognitive “parts” that have different roles and they are not always working together or integrated. Traumatized people often have “exiled parts” – generally the parts that have directly experienced the trauma. These parts are denied, put away, or even hated and despised by the other parts. The intent of IFS is to integrate all the parts.
• Hypnosis.
• Chiropractic care – ongoing studies (not by van der Kolk) are looking at the benefits of chiropractic specifically for PTSD recovery, however, chiropractic is known to activate the parasympathetic nervous system and calm the fight or flight response.
• EFT – emotional freedom technique is commonly known as tapping. EFT is a type of non-invasive acupuncture, where a person uses their own fingers to activate certain energetic points on the body. Dr. Van der Kolk does not recommend this simply because he has not scientifically researched EFT’s efficacy. However, anecdotally it appears to be helpful.

Highly controlled studies are currently being done with psychedelic drugs such as ketamine, MDMA and psilocybin. I wonder where the results will lead.

Again, Dr. Van der Kolk expressed the idea that any therapy that allows for new possibilities and outcomes is good therapy, and that all good trauma therapy begins in an altered state (of consciousness). Therefore, there may be other modalities or healing techniques that have no scientific data showing their effectiveness as of yet but would be beneficial to certain people. Just as trauma and PTSD are individualized, so is each persons’ path to healing.

One therapy that has not been shown scientifically to be beneficial is simple cognitive brain therapy (CBT) or talk therapy. Recalling the trauma and relating the events repeatedly can trigger flashbacks and fight or flight responses and their re-traumatizing effects. However, CBT can be helpful when combined with any other intervention mentioned above.