The Body Keeps the Score

by Bessel van der Kolk MD

  But if no one has ever looked at you with loving eyes or broken out in a smile when she sees you; if no one has rushed to help you (but instead said, “Stop crying, or I’ll give you something to cry about”), then you need to discover other ways of taking care of yourself. You are likely to experiment with anything—drugs, alcohol, binge eating, or cutting—that offers some kind of relief.

  While Sherry dutifully came to every appointment and answered my questions with great sincerity, I did not feel we were making the sort of vital connection that is necessary for therapy to work. Struck by how frozen and uptight she was, I suggested that she see Liz, a massage therapist I had worked with previously. During their first meeting Liz positioned Sherry on the massage table, then moved to the end of the table and gently held Sherry’s feet. Lying there with her eyes closed, Sherry suddenly yelled in a panic: “Where are you?” Somehow Sherry had lost track of Liz, even though Liz was right there, with her hands on Sherry’s feet.

  Sherry was one of the first patients who taught me about the extreme disconnection from the body that so many people with histories of trauma and neglect experience. I discovered that my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves. Sherry knew that picking her skin was a destructive thing to do and that it was related to her mother’s neglect, but understanding the source of the impulse made no difference in helping her control it.

  LOSING YOUR BODY

  Once I was alerted to this, I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. Sometimes I’d ask them to close their eyes and tell me what I had put into their outstretched hands. Whether it was a car key, a quarter, or a can opener, they often could not even guess what they were holding—their sensory perceptions simply weren’t working.

  I talked this over with my friend Alexander McFarlane in Australia, who had observed the same phenomenon. In his laboratory in Adelaide he had studied the question: How do we know without looking at it that we’re holding a car key? Recognizing an object in the palm of your hand requires sensing its shape, weight, temperature, texture, and position. Each of those distinct sensory experiences is transmitted to a different part of the brain, which then needs to integrate them into a single perception. McFarlane found that people with PTSD often have trouble putting the picture together.2

  When our senses become muffled, we no longer feel fully alive. In an article called “What Is an Emotion?” (1884),3 William James, the father of American psychology, reported a striking case of “sensory insensibility” in a woman he interviewed: “I have . . . no human sensations,” she told him. “[I am] surrounded by all that can render life happy and agreeable, still to me the faculty of enjoyment and of feeling is wanting. . . . Each of my senses, each part of my proper self, is as it were separated from me and can no longer afford me any feeling; this impossibility seems to depend upon a void which I feel in the front of my head, and to be due to the diminution of the sensibility over the whole surface of my body, for it seems to me that I never actually reach the objects which I touch. All this would be a small matter enough, but for its frightful result, which is that of the impossibility of any other kind of feeling and of any sort of enjoyment, although I experience a need and desire of them that render my life an incomprehensible torture.”

  This response to trauma raises an important question: How can traumatized people learn to integrate ordinary sensory experiences so that they can live with the natural flow of feeling and feel secure and complete in their bodies?

  HOW DO WE KNOW WE’RE ALIVE?

  Most early neuroimaging studies of traumatized people were like those we’ve seen in chapter 3; they focused on how subjects reacted to specific reminders of the trauma. Then, in 2004, my colleague Ruth Lanius, who scanned Stan and Ute Lawrence’s brains, posed a new question: What happens in the brains of trauma survivors when they are not thinking about the past? Her studies on the idling brain, the “default state network” (DSN), opened up a whole new chapter in understanding how trauma affects self-awareness, specifically sensory self-awareness.4

  Dr. Lanius recruited a group of sixteen “normal” Canadians to lie in a brain scanner while thinking about nothing in particular. This is not easy for anyone to do—as long as we are awake, our brains are churning—but she asked them to focus their attention on their breathing and try to empty their minds as much as possible. She then repeated the same experiment with eighteen people who had histories of severe, chronic childhood abuse.

  What is your brain doing when you have nothing in particular on your mind? It turns out that you pay attention to yourself: The default state activates the brain areas that work together to create your sense of “self.”

  When Ruth looked at the scans of her normal subjects, she found activation of DSN regions that previous researchers had described. I like to call this the Mohawk of self-awareness, the midline structures of the brain, starting out right above our eyes, running through the center of the brain all the way to the back. All these midline structures are involved in our sense of self. The largest bright region at the back of the brain is the posterior cingulate, which gives us a physical sense of where we are—our internal GPS. It is strongly connected to the medial prefrontal cortex (MPFC), the watchtower I discussed in chapter 4. (This connection doesn’t show up on the scan because the fMRI can’t measure it.) It is also connected with brain areas that register sensations coming from the rest of the body: the insula, which relays messages from the viscera to the emotional centers; the parietal lobes, which integrate sensory information; and the anterior cingulate, which coordinates emotions and thinking. All of these areas contribute to consciousness.

  Locating the self. The Mohawk of self-awareness. Starting from the front of the brain (at right), this consists of: the orbital prefrontal cortex, the medial prefrontal cortex, the anterior cingulate, the posterior cingulate, and the insula. In individuals with histories of chronic trauma the same regions show sharply decreased activity, making it difficult to register internal states and assessing the personal relevance of incoming information.

  The contrast with the scans of the eighteen chronic PTSD patients with severe early-life trauma was startling. There was almost no activation of any of the self-sensing areas of the brain: The MPFC, the anterior cingulate, the parietal cortex, and the insula did not light up at all; the only area that showed a slight activation was the posterior cingulate, which is responsible for basic orientation in space.

  There could be only one explanation for such results: In response to the trauma itself, and in coping with the dread that persisted long afterward, these patients had learned to shut down the brain areas that transmit the visceral feelings and emotions that accompany and define terror. Yet in everyday life, those same brain areas are responsible for registering the entire range of emotions and sensations that form the foundation of our self-awareness, our sense of who we are. What we witnessed here was a tragic adaptation: In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive.

  The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction. I used to be surprised by how often my patients asked me for advice about the most ordinary things, and then by how rarely they followed it. Now I understood that their relationship with their own inner reality was impaired. How could they make decisions, or put any plan into action, if they couldn’t define what they wanted or, to be more precise, what the sensations in their bodies, the basis of all emotions, were trying to tell them?

  The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror. Brain scans show that this is not the result of mere inattention: The structures in charge of self-recognition may be knocked out
along with the structures related to self-experience.

  When Ruth Lanius showed me her study, a phrase from my classical high school education came back to me. The mathematician Archimedes, teaching about the lever, is supposed to have said: “Give me a place to stand and I will move the world.” Or, as the great twentieth-century body therapist Moshe Feldenkrais put it: “You can’t do what you want till you know what you’re doing.” The implications are clear: to feel present you have to know where you are and be aware of what is going on with you. If the self-sensing system breaks down we need to find ways to reactivate it.

  THE SELF-SENSING SYSTEM

  It was fascinating to see how much Sherry benefited from her massage therapy. She felt more relaxed and adventurous in her day-to-day life and she was also more relaxed and open with me. She became truly involved in her therapy and was genuinely curious about her behavior, thoughts, and feelings. She stopped picking at her skin, and when summer came she started to spend evenings sitting outside on her stoop, chatting with her neighbors. She even joined a church choir, a wonderful experience of group synchrony.

  It was at about this time that I met Antonio Damasio at a small think tank that Dan Schacter, the chair of the psychology department at Harvard, had organized. In a series of brilliant scientific articles and books Damasio clarified the relationship among body states, emotions, and survival. A neurologist who has treated hundreds of people with various forms of brain damage, he became fascinated with consciousness and with identifying the areas of the brain necessary for knowing what you feel. He has devoted his career to mapping out what is responsible for our experience of “self.” The Feeling of What Happens is, for me, his most important book, and reading it was a revelation.5 Damasio starts by pointing out the deep divide between our sense of self and the sensory life of our bodies. As he poetically explains, “Sometimes we use our minds not to discover facts, but to hide them. . . . One of the things the screen hides most effectively is the body, our own body, by which I mean the ins of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day.”6

  He goes on to describe how this “screen” can work in our favor by enabling us to attend to pressing problems in the outside world. Yet it has a cost: “It tends to prevent us from sensing the possible origin and nature of what we call self.”7 Building on the century-old work of William James, Damasio argues that the core of our self-awareness rests on the physical sensations that convey the inner states of the body:

  [P]rimordial feelings provide a direct experience of one’s own living body, wordless, unadorned, and connected to nothing but sheer existence. These primordial feelings reflect the current state of the body along varied dimensions, . . . along the scale that ranges from pleasure to pain, and they originate at the level of the brain stem rather than the cerebral cortex. All feelings of emotion are complex musical variations on primordial feelings.8

  Our sensory world takes shape even before we are born. In the womb we feel amniotic fluid against our skin, we hear the faint sounds of rushing blood and a digestive tract at work, we pitch and roll with our mother’s movements. After birth, physical sensation defines our relationship to ourselves and to our surroundings. We start off being our wetness, hunger, satiation, and sleepiness. A cacophony of incomprehensible sounds and images presses in on our pristine nervous system. Even after we acquire consciousness and language, our bodily sensing system provides crucial feedback on our moment-to-moment condition. Its constant hum communicates changes in our viscera and in the muscles of our face, torso, and extremities that signal pain and comfort, as well as urges such as hunger and sexual arousal. What is taking place around us also affects our physical sensations. Seeing someone we recognize, hearing particular sounds—a piece of music, a siren—or sensing a shift in temperature all change our focus of attention and, without our being aware of it, prime our subsequent thoughts and actions.

  As we have seen, the job of the brain is to constantly monitor and evaluate what is going on within and around us. These evaluations are transmitted by chemical messages in the bloodstream and electrical messages in our nerves, causing subtle or dramatic changes throughout the body and brain. These shifts usually occur entirely without conscious input or awareness: The subcortical regions of the brain are astoundingly efficient in regulating our breathing, heartbeat, digestion, hormone secretion, and immune system. However, these systems can become overwhelmed if we are challenged by an ongoing threat, or even the perception of threat. This accounts for the wide array of physical problems researchers have documented in traumatized people.

  Yet our conscious self also plays a vital role in maintaining our inner equilibrium: We need to register and act on our physical sensations to keep our bodies safe. Realizing we’re cold compels us to put on a sweater; feeling hungry or spacey tells us our blood sugar is low and spurs us to get a snack; the pressure of a full bladder sends us to the bathroom. Damasio points out that all of the brain structures that register background feelings are located near areas that control basic housekeeping functions, such as breathing, appetite, elimination, and sleep/wake cycles: “This is because the consequences of having emotion and attention are entirely related to the fundamental business of managing life within the organism. It is not possible to manage life and maintain homeostatic balance without data on the current state of the organism’s body.”9 Damasio calls these housekeeping areas of the brain the “proto-self,” because they create the “wordless knowledge” that underlies our conscious sense of self.

  THE SELF UNDER THREAT

  In 2000 Damasio and his colleagues published an article in the world’s foremost scientific publication, Science, which reported that reliving a strong negative emotion causes significant changes in the brain areas that receive nerve signals from the muscles, gut, and skin—areas that are crucial for regulating basic bodily functions. The team’s brain scans showed that recalling an emotional event from the past causes us to actually reexperience the visceral sensations felt during the original event. Each type of emotion produced a characteristic pattern, distinct from the others. For example, a particular part of the brain stem was “active in sadness and anger, but not in happiness or fear.”10 All of these brain regions are below the limbic system, to which emotions are traditionally assigned, yet we acknowledge their involvement every time we use one of the common expressions that link strong emotions with the body: “You make me sick”; “It made my skin crawl”; “I was all choked up”; “My heart sank”; “He makes me bristle.”

  The elementary self system in the brain stem and limbic system is massively activated when people are faced with the threat of annihilation, which results in an overwhelming sense of fear and terror accompanied by intense physiological arousal. To people who are reliving a trauma, nothing makes sense; they are trapped in a life-or-death situation, a state of paralyzing fear or blind rage. Mind and body are constantly aroused, as if they are in imminent danger. They startle in response to the slightest noises and are frustrated by small irritations. Their sleep is chronically disturbed, and food often loses its sensual pleasures. This in turn can trigger desperate attempts to shut those feelings down by freezing and dissociation.11

  How do people regain control when their animal brains are stuck in a fight for survival? If what goes on deep inside our animal brains dictates how we feel, and if our body sensations are orchestrated by subcortical (subconscious) brain structures, how much control over them can we actually have?

  AGENCY: OWNING YOUR LIFE

  “Agency” is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances. The veterans who put their fists through drywall at the VA were trying to assert their agency—to
make something happen. But they ended up feeling even more out of control, and many of these once-confident men were trapped in a cycle between frantic activity and immobility.

  Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilize to manage them. But we can’t do this unless our watchtower, the MPFC, learns to observe what is going on inside us. This is why mindfulness practice, which strengthens the MPFC, is a cornerstone of recovery from trauma.12

  After I saw the wonderful movie March of the Penguins, I found myself thinking about some of my patients. The penguins are stoic and endearing, and it’s tragic to learn how, from time immemorial, they have trudged seventy miles inland from the sea, endured indescribable hardships to reach their breeding grounds, lost numerous viable eggs to exposure, and then, almost starving, dragged themselves back to the ocean. If penguins had our frontal lobes, they would have used their little flippers to build igloos, devised a better division of labor, and reorganized their food supplies. Many of my patients have survived trauma through tremendous courage and persistence, only to get into the same kinds of trouble over and over again. Trauma has shut down their inner compass and robbed them of the imagination they need to create something better.