All trauma is preverbal. Shakespeare captures this state of speechless terror in Macbeth, after the murdered king’s body is discovered: “Oh horror! horror! horror! Tongue nor heart cannot conceive nor name thee! Confusion now hath made his masterpiece!” Under extreme conditions people may scream obscenities, call for their mothers, howl in terror, or simply shut down. Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children “lose their tongues” and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void.
Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies reexperience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate. Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past.
This doesn’t mean that people can’t talk about a tragedy that has befallen them. Sooner or later most survivors, like the veterans in chapter 1, come up with what many of them call their “cover story” that offers some explanation for their symptoms and behavior for public consumption. These stories, however, rarely capture the inner truth of the experience. It is enormously difficult to organize one’s traumatic experiences into a coherent account—a narrative with a beginning, a middle, and an end. Even a seasoned reporter like the famed CBS correspondent Ed Murrow struggled to convey the atrocities he saw when the Nazi concentration camp Buchenwald was liberated in 1945: “I pray you believe what I have said. I reported what I saw and heard, but only part of it. For most of it I have no words.”
When words fail, haunting images capture the experience and return as nightmares and flashbacks. In contrast to the deactivation of Broca’s area, another region, Brodmann’s area 19, lit up in our participants. This is a region in the visual cortex that registers images when they first enter the brain. We were surprised to see brain activation in this area so long after the original experience of the trauma. Under ordinary conditions raw images registered in area 19 are rapidly diffused to other brain areas that interpret the meaning of what has been seen. Once again, we were witnessing a brain region rekindled as if the trauma were actually occurring.
As we will see in chapter 12, which discusses memory, other unprocessed sense fragments of trauma, like sounds and smells and physical sensations, are also registered separately from the story itself. Similar sensations often trigger a flashback that brings them back into consciousness, apparently unmodified by the passage of time.
SHIFTING TO ONE SIDE OF THE BRAIN
The scans also revealed that during flashbacks, our subjects’ brains lit up only on the right side. Today there’s a huge body of scientific and popular literature about the difference between the right and left brains. Back in the early nineties I had heard that some people had begun to divide the world between left-brainers (rational, logical people) and right-brainers (the intuitive, artistic ones), but I hadn’t paid much attention to this idea. However, our scans clearly showed that images of past trauma activate the right hemisphere of the brain and deactivate the left.
We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical. While the left half of the brain does all the talking, the right half of the brain carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing, or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants. We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experiences to others.
The left and right sides of the brain also process the imprints of the past in dramatically different ways.2 The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, smell, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past. What it recalls feels like intuitive truth—the way things are. Even as we enumerate a loved one’s virtues to a friend, our feelings may be more deeply stirred by how her face recalls the aunt we loved at age four.3
Under ordinary circumstances the two sides of the brain work together more or less smoothly, even in people who might be said to favor one side over the other. However, having one side or the other shut down, even temporarily, or having one side cut off entirely (as sometimes happened in early brain surgery) is disabling.
Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. (Broca’s area, which blacks out during flashbacks, is on the left side.) Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future. People who are very upset sometimes say they are “losing their minds.” In technical terms they are experiencing the loss of executive functioning.
When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present. But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they are just furious, terrified, enraged, ashamed, or frozen. After the emotional storm passes, they may look for something or somebody to blame for it. They behaved the way they did way because you were ten minutes late, or because you burned the potatoes, or because you “never listen to me.” Of course, most of us have done this from time to time, but when we cool down, we hopefully can admit our mistake. Trauma interferes with this kind of awareness, and, over time, our research demonstrated why.
STUCK IN FIGHT OR FLIGHT
What had happened to Marsha in the scanner gradually started to make sense. Thirteen years after her tragedy we had activated the sensations—the sounds and images from the accident—that were still stored in her memory. When these sensations came to the surface, they activated her alarm system, which caused her to react as if she were back in the hospital being told that her daughter had died. The passage of thirteen years was erased. Her sharply increased heart rate and blood pressure readings reflected her physiological state of frantic alarm.
Adrenaline is one of the hormones that are critical to help us fight back or flee in the face of danger. Increased adrenaline was responsible for our participants’ dramatic rise in heart rate and blood pressure while listening to their trauma narrative. Under normal conditions people react to a threat with a temporary increase in their stress hormones. As soon as the threat is over, the hormones dissipate and the body returns to normal. The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli. The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability, and sleep disorders. They also contribute to many long-term health issues, depending on which body system is most vulnerable in a particular individual.
We now know that there is another possible response to threat, which our scans aren’t yet capable of measuring. Some people simply go into denial: Their bodies register the threat, but their conscious minds go on as if nothing has happened. However, even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don’t stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand
notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.
We can interpret what happened to Marsha in the scanner from several different perspectives, each of which has implications for treatment. We can focus on the neurochemical and physiological disruptions that were so evident and make a case that she is suffering from a biochemical imbalance that is reactivated whenever she is reminded of her daughter’s death. We might then search for a drug or a combination of drugs that would damp down the reaction or, in the best case, restore her chemical equilibrium. Based on the results of our scans, some of my colleagues at MGH began investigating drugs that might make people less responsive to the effects of elevated adrenaline.
We can also make a strong case that Marsha is hypersensitized to her memories of the past and that the best treatment would be some form of desensitization.4 After repeatedly rehearsing the details of the trauma with a therapist, her biological responses might become muted, so that she could realize and remember that “that was then and this is now,” rather than reliving the experience over and over.
For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we’ve seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them—to tell a story of victimization and revenge—than to notice, feel, and put into words the reality of their internal experience.
Our scans had revealed how their dread persisted and could be triggered by multiple aspects of daily experience. They had not integrated their experience into the ongoing stream of their life. They continued to be “there” and did not know how to be “here”—fully alive in the present.
Three years after being a participant in our study Marsha came to see me as a patient. I successfully treated her with EMDR, the subject of chapter 15.
PART TWO
THIS IS YOUR BRAIN ON TRAUMA
CHAPTER 4
RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL
Prior to the advent of brain, there was no color and no sound in the universe, nor was there any flavor or aroma and probably little sense and no feeling or emotion. Before brains the universe was also free of pain and anxiety.
—Roger Sperry1
On September 11, 2001, five-year-old Noam Saul witnessed the first passenger plane slam into the World Trade Center from the windows of his first-grade classroom at PS 234, less than 1,500 feet away. He and his classmates ran with their teacher down the stairs to the lobby, where most of them were reunited with parents who had dropped them off at school just moments earlier. Noam, his older brother, and their dad were three of the tens of thousands of people who ran for their lives through the rubble, ash, and smoke of lower Manhattan that morning.
Ten days later I visited his family, who are friends of mine, and that evening his parents and I went for a walk in the eerie darkness through the still-smoking pit where Tower One once stood, making our way among the rescue crews who were working around the clock under the blazing klieg lights. When we returned home, Noam was still awake, and he showed me a picture that he had drawn at 9:00 a.m. on September 12. The drawing depicted what he had seen the day before: an airplane slamming into the tower, a ball of fire, firefighters, and people jumping from the tower’s windows. But at the bottom of the picture he had drawn something else: a black circle at the foot of the buildings. I had no idea what it was, so I asked him. “A trampoline,” he replied. What was a trampoline doing there? Noam explained, “So that the next time when people have to jump they will be safe.” I was stunned: This five-year-old boy, a witness to unspeakable mayhem and disaster just twenty-four hours before he made that drawing, had used his imagination to process what he had seen and begin to go on with his life.
Noam was fortunate. His entire family was unharmed, he had grown up surrounded by love, and he was able to grasp that the tragedy they had witnessed had come to an end. During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.
Five-year-old Noam’s drawing made after he witnessed the World Trade Center attack on 9/11. He reproduced the image that haunted so many survivors—people jumping to escape from the inferno—but with a life-saving addition: a trampoline at the bottom of the collapsing building.
But Noam’s experience allows us to see in outline two critical aspects of the adaptive response to threat that is basic to human survival. At the time the disaster occurred, he was able to take an active role by running away from it, thus becoming an agent in his own rescue. And once he had reached the safety of home, the alarm bells in his brain and body quieted. This freed his mind to make some sense of what had happened and even to imagine a creative alternative to what he had seen—a lifesaving trampoline.
In contrast to Noam, traumatized people become stuck, stopped in their growth because they can’t integrate new experiences into their lives. I was very moved when the veterans of Patton’s army gave me a World War II army-issue watch for Christmas, but it was a sad memento of the year their lives had effectively stopped: 1944. Being traumatized means continuing to organize your life as if the trauma were still going on—unchanged and immutable—as every new encounter or event is contaminated by the past.
Trauma affects the entire human organism—body, mind, and brain. In PTSD the body continues to defend against a threat that belongs to the past. Healing from PTSD means being able to terminate this continued stress mobilization and restoring the entire organism to safety.
After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases. This explains why it is critical for trauma treatment to engage the entire organism, body, mind, and brain.
ORGANIZED TO SURVIVE
This illustration on page 53 shows the whole-body response to threat.
When the brain’s alarm system is turned on, it automatically triggers preprogrammed physical escape plans in the oldest parts of the brain. As in other animals, the nerves and chemicals that make up our basic brain structure have a direct connection with our body. When the old brain takes over, it partially shuts down the higher brain, our conscious mind, and propels the body to run, hide, fight, or, on occasion, freeze. By the time we are fully aware of our situation, our body may already be on the move. If the fight/flight/freeze response is successful and we escape the danger, we recover our internal equilibrium and gradually “regain our senses.”
AP PHOTO/PAUL HAWTHORNE
ILLINOISPHOTO.COM
Effective action versus immobilization. Effective action (the result of fight/flight) ends the threat. Immobilization keeps the body in a state of inescapable shock and learned helplessness. Faced with danger people automatically secrete stress hormones to fuel resistance and escape. Brain and body are programmed to run for home, where safety can be restored and stress hormones can come to rest. In these strapped-down men who are being evacuated far from home after Hurricane Katrina stress hormone levels remain elevated and are turned against the survivors, stimulating ongoing fear, depression, rage, and physical disease.
If for some reason the normal response is blocked—for example, when people are held down, trapped, or otherwise prevented from taking effective action, be it in a war zone, a car accident, domestic violence, or a rape—the brain keeps secreting stress chemicals, and the brain’s electrical circuits continue to fire in vain.2 Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists. Since at least 1889, when the French psychologist Pierre Janet published the first scientific account of traumatic stress,3 it has been recognized that trauma survivors are prone to “continue the action, or rather the (futile) attempt at action, which began when the thing happened.” Being able to move and do something to protect oneself is a critical factor in determining whether or not a horrible experience will leave long-lasting scars.
In this chapter I’m going to go deeper into the brain’s response to trauma. The more neuroscience discovers about the brain, the more we realize that it is a vast network of interconnected parts organized to help us survive and flourish. Knowing how these parts work together is essential to understanding how trauma affects every part of the human organism and can serve as an indispensable guide to resolving traumatic stress.
The Body Keeps the Score Page 7