📚 node [[the body keeps the score]]
📓 garden/houshuang/content/The-Body-Keeps-the-Score.md by @houshuang
  • #book #inProgress
    • Subtitle: Brain, Mind, and Body in the Treatment of Trauma
    • Bessel van der Kolk
    • Read from April 4th, 2020 to April 27th, 2020
  • new science giving us more insight
    • neuroscience, the study of how the brain supports mental processes;
    • [[developmental psychopathology]], the study of the impact of adverse experiences on the development of mind and brain; and
    • [[interpersonal neurobiology]], the study of how our behavior influences the emotions, biology, and mind-sets of those around us
  • trauma
    • unbearable and intolerable.
      • Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.
    • diagnosis
      • Rorschach test
        • Unlike tests that require answers to straightforward questions, responses to the Rorschach are almost impossible to fake. (p. 15)
    • Post-traumatic stress disorder PTSD
      • trauma produces actual physiological changes, including
        • a recalibration of the brain’s alarm system,
        • an increase in stress hormone activity, and
        • alterations in the system that filters relevant information from irrelevant.
        • compromises the brain area that communicates the physical, embodied feeling of being alive.
      • post-traumatic reactions
        • While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial.
          • Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones.
          • This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions.
          • These posttraumatic reactions feel incomprehensible and overwhelming. Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption.
        • numbness
          • Maybe the worst of Tom’s symptoms was that he felt emotionally numb. He desperately wanted to love his family, but he just couldn’t evoke any deep feelings for them. (p. 14)
        • disconnected from others
          • After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers. (p. 18)
    • therapy
      • For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present. (p. 21)
      • Not wanting to be cured
        • “I realized that if I take the pills and the nightmares go away,” he replied, “I will have abandoned my friends, and their deaths will have been in vain. I need to be a living memorial to my friends who died in Vietnam.” (p. 10)
        • Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past. (p. 18)
      • There are fundamentally three avenues:
          1. top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma;
          1. by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, and
          1. bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma
  • Clippings:
    • other
      • Our great teacher, Elvin Semrad, actively discouraged us from reading psychiatry textbooks during our first year. (This intellectual starvation diet may account for the fact that most of us later became voracious readers and prolific writers.) Semrad did not want our perceptions of reality to become obscured by the pseudocertainties of psychiatric diagnoses. E: Limiting external input when thinking
    • psychiatric system not taking trauma seriously enough
      • incest used to be bagatellized
        • the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women.8 Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital. Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology (p. 20)
        • The textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world.”9 In fact, as it turned out, incest had devastating effects on women’s well-being. (p. 20)
      • We now know that more than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their families (p. 24)
    • stress / cortisol
      • Steven Maier of the University of Colorado, who had collaborated with Martin Seligman of the University of Pennsylvania. His topic was learned helplessness in animals.
        • Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.”9 Being a dog lover, I realized that I could never have done such research myself, but I was curious about how this cruelty would affect the animals. (p. 29)
        • Maier and Seligman also found that traumatized dogs secreted much larger amounts of stress hormones than was normal. (p. 30)
      • traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount Sinai in New York confronted us with her seemingly paradoxical findings that the levels of the stress hormone cortisol are low in PTSD.
        • Her discoveries only started to make sense when her research clarified that **cortisol puts an end to the stress response by sending an all-safe signal, and that, in PTSD, the body’s stress hormones do, in fact, not return to baseline after the threat has passed. **
        • Ideally our stress hormone system should provide a lightning-fast response to threat, but then quickly return us to equilibrium.
          • the only way to teach the traumatized dogs to get off the electric grids when the doors were open was to repeatedly drag them out of their cages so they could physically experience how they could get away. I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control? (p. 30)
    • Scared animals return home, regardless of whether home is safe or frightening
      • when researchers played a loud, intrusive sound, mice that had been raised in a warm nest with plenty of food scurried home immediately. But another group, raised in a noisy nest with scarce food supplies, also ran for home, even after spending time in more pleasant surroundings.11 Scared animals return home, regardless of whether home is safe or frightening. (p. 31)
    • Freud had a term for such traumatic reenactments: “the compulsion to repeat.”
      • He and many of his followers believed that reenactments were an unconscious attempt to get control over a painful situation and that they eventually could lead to mastery and resolution. There is no evidence for that theory—repetition leads only to further pain and self-hatred. In fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation. (p. 32)
    • Richard Solomon of the University of Pennsylvania had shown that the body learns to adjust to all sorts of stimuli. (even fear, aversion)
      • We may get hooked on recreational drugs because they right away make us feel so good, but activities like sauna bathing, marathon running, or parachute jumping, which initially cause discomfort and even terror, can ultimately become very enjoyable. This gradual adjustment signals that a new chemical balance has been established within the body, so that marathon runners, say, get a sense of well-being and exhilaration from pushing their bodies to the limit. (p. 32)
      • At this point, just as with drug addiction, we start to crave the activity and experience withdrawal when it’s not available. In the long run people become more preoccupied with the pain of withdrawal than the activity itself. This theory could explain why some people hire someone to beat them, or burn themselves with cigarettes. or why they are only attracted to people who hurt them. Fear and aversion, in some perverse way, can be transformed into pleasure. (p. 32)
    • brain
      • the amygdala, (sensitivity depends on serotonin)
        • a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat.
        • Gray’s data showed that the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain.
          • Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.
    • “strong emotions can block pain” was the result of the release of morphinelike substances manufactured in the brain. This suggested that for many traumatized people, reexposure to stress might provide a similar relief from anxiety.
    • My patients were always blowing up in response to small provocations and felt devastated by the slightest rejection. I became fascinated by the possible role of serotonin in PTSD.
      • Other researchers had shown that dominant male monkeys had much higher levels of brain serotonin than lower-ranking animals but that their serotonin levels dropped when they were prevented from maintaining eye contact with the monkeys they had once lorded over.
      • In contrast, low-ranking monkeys who were given serotonin supplements emerged from the pack to assume leadership. The social environment interacts with brain chemistry. Manipulating a monkey into a lower position in the dominance hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the rank of former subordinates.
    • fluoxetine, which, under the brand name Prozac, became one of the most successful psychoactive drugs ever created.
    • The implications for traumatized people were obvious. Like Gray’s low-serotonin animals, they were hyperreactive, and their ability to cope socially was often compromised. If we could find ways to increase brain serotonin levels, perhaps we could address both problems simultaneously.
    • On Monday, February 8, 1988, Prozac was released by the drug company Eli Lilly.
      • Prozac worked significantly better than the placebo for the patients from the Trauma Clinic. They slept more soundly; they had more control over their emotions and were less preoccupied with the past than those who received a sugar pill.
      • Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged.
    • Prozac made a radical difference: It gave PTSD patients a sense of perspective and helped them to gain considerable control over their impulses.
    • Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems. Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs.
    • The brain-disease model overlooks four fundamental truths:
      • (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being;
      • (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning;
      • (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and
      • (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.
    • It was already well known that intense emotions activate the limbic system, in particular an area within it called the amygdala. We depend on the amygdala to warn us of impending danger and to activate the body’s stress response. Our study clearly showed that when traumatized people are presented with images, sounds, or thoughts related to their particular experience, the amygdala reacts with alarm—even, as in Marsha’s case, thirteen years after the event. Activation of this fear center triggers the cascade of stress hormones and nerve impulses that drive up blood pressure, heart rate, and oxygen intake—preparing the body for fight or flight. (p. 42)
    • Our most surprising finding was a white spot in the left frontal lobe of the cortex, in a region called Broca’s area. In this case the change in color meant that there was a significant decrease in that part of the brain. Broca’s area is one of the speech centers of the brain, which is often affected in stroke patients when the blood supply to that region is cut off. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. In other words, we had visual proof that the effects of trauma are not necessarily different from—and can overlap with—the effects of physical lesions like strokes. All (p. 43)
    • 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. (p. 43)
    • Body responds as if traumatic event is happening right now
      • Flashbacks
        • 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, 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 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.
      • 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.
    • brain hemisphere model
      • We now know that the two halves of the brain do speak different languages.
        • **the left is linguistic, sequential, and analytical. **
          • does all the talking
            • 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.
          • remembers facts, statistics, and the vocabulary of events.
            • We call on it to explain our experiences and put them in order.
          • Deactivation 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.
        • ** The right is intuitive, emotional, visual, spatial, and tactual, and **
          • 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 first to develop in the womb,
            • and it carries the nonverbal communication between mothers and infants.
          • 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.
    • After the emotional storm passes, they may look for something or somebody to blame for it. They behaved the way they did because you were ten minutes late, or because you burned the potatoes, or because you “never listen to me.” (p. 45)
    • 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. (p. 46)
    • 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. (p. 46)
    • 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. (p. 48)
    • 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 life. (p. 53)
    • 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. (p. 53)
    • 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.” (p. 54)
    • 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. (p. 55)
    • 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. (p. 54)
    • The most important job of the brain is to ensure our survival, even under the most miserable conditions. Everything else is secondary. In order to do that, brains need to: (1) generate internal signals that register what our bodies need, such as food, rest, protection, sex, and shelter; (2) create a map of the world to point us where to go to satisfy those needs; (3) generate the necessary energy and actions to get us there; (4) warn us of dangers and opportunities along the way; and (5) adjust our actions based on the requirements of the moment. (p. 55)
    • Our rational, cognitive brain is actually the youngest part of the brain and occupies only about 30 percent of the area inside our skull. The rational brain is primarily concerned with the world outside us: understanding how things and people work and figuring out how to accomplish our goals, manage our time, and sequence our actions. Beneath the rational brain lie two evolutionarily older, and to some degree separate, brains, which are in charge of everything else: the moment-by-moment registration and management of our body’s physiology and the identification of comfort, safety, threat, hunger, fatigue, desire, longing, excitement, pleasure, and pain. (p. 55)
    • The brain is built from the bottom up. It develops level by level within every child in the womb, just as it did in the course of evolution. The most primitive part, the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain. It is located in the brain stem, just above the place where our spinal cord enters the skull. The reptilian brain is responsible for all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating. The brain stem and the hypothalamus (which sits directly above it) together control the energy levels of the body. They coordinate the functioning of the heart and lungs and also the endocrine and immune systems, ensuring that these basic life-sustaining systems are maintained within the relatively stable internal balance known as homeostasis. (p. 55)
    • Right above the reptilian brain is the limbic system. It’s also known as the mammalian brain, because all animals that live in groups and nurture their young possess one. Development of this part of the brain truly takes off after a baby is born. It is the seat of the emotions, the monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is or is not important for survival purposes. It is also a central command post for coping with the challenges of living within our complex social networks. (p. 56)
    • Breathing, eating, sleeping, pooping, and peeing are so fundamental that their significance is easily neglected when we’re considering the complexities of mind and behavior. However, if your sleep is disturbed or your bowels don’t work, or if you always feel hungry, or if being touched makes you want to scream (as is often the case with traumatized children and adults), the entire organism is thrown into disequilibrium. It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal. (p. 56)
    • The limbic system is shaped in response to experience, in partnership with the infant’s own genetic makeup and inborn temperament. (p. 56)
    • If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment. (p. 56)
    • Taken together the reptilian brain and limbic system make up what I’ll call the “emotional brain” throughout this book.6 The emotional brain is at the heart of the central nervous system, and its key task is to look out for your welfare. If it detects danger or a special opportunity—such as a promising partner—it alerts you by releasing a squirt of hormones. The resulting visceral sensations (ranging from mild queasiness to the grip of panic in your chest) will interfere with whatever your mind is currently focused on and get you moving—physically and mentally—in a different direction. Even at their most subtle, these sensations have a huge influence on the small and large decisions we make throughout our lives: what we choose to eat, where we like to sleep and with whom, what music we prefer, whether we like to garden or sing in a choir, and whom we befriend and whom we detest. (p. 57)
    • The emotional brain’s cellular organization and biochemistry are simpler than those of the neocortex, our rational brain, and it assesses incoming information in a more global way. As a result, it jumps to conclusions based on rough similarities, in contrast with the rational brain, which is organized to sort through a complex set of options. (p. 57)
    • (The textbook example is leaping back in terror when you see a snake—only to realize that it’s just a coiled rope.) (p. 57)
    • Frontal lobes
      • plan and reflect,
      • to imagine and play out future scenarios.
      • mirror neurons the seat of empathy—our ability to “feel into” someone else, important for learning, also makes you vulnerable to other people's negativity.
        • discovery
          • One of the truly sensational discoveries of modern neuroscience took place in 1994, when in a lucky accident a group of Italian scientists identified specialized cells in the cortex that came to be known as mirror neurons.
            • The researchers had attached electrodes to individual neurons in a monkey’s premotor area, then set up a computer to monitor precisely which neurons fired when the monkey picked up a peanut or grasped a banana. At one point an experimenter was putting food pellets into a box when he looked up at the computer. The monkey’s brain cells were firing at the exact location where the motor command neurons were located. But the monkey wasn’t eating or moving. He was watching the researcher, and his brain was vicariously mirroring the researcher’s actions.
        • explained many previously unexplainable aspects of the mind, such as empathy, imitation, synchrony, and even the development of language.
        • also make us vulnerable to others’ negativity, so that we respond to their anger with fury or are dragged down by their depression.
      • can also (sometimes, but not always) stop us from doing things that will embarrass us or hurt others. The more intense the visceral, sensory input from the emotional brain, the less capacity the rational brain has to put a damper on
        • We don’t have to eat every time we’re hungry, kiss anybody who rouses our desires, or blow up every time we’re angry. But it is exactly on that edge between impulse and acceptable behavior where most of our troubles begin.
    • These sensations converge in the thalamus, an area inside the limbic system that acts as the “cook” within the brain.
      • stirs all the input from our perceptions into a fully blended autobiographical soup, an integrated, coherent experience of “this is what is happening to me.”
        • The sensations are then passed on in two directions—
          • down to the amygdala, (low road - extremely fast)
            • two small almond-shaped structures that lie deeper in the limbic, unconscious brain, "brain's smoke detector"
              • to identify whether incoming input is relevant for our survival.
                • It does so quickly and automatically, with the help of feedback from the hippocampus,
                  • a nearby structure that relates the new input to past experiences.
                • If it senses a threat—a potential collision with an oncoming vehicle, a person on the street who looks threatening—it sends an instant message down to the hypothalamus and the brain stem, recruiting the stress-hormone system and the autonomic nervous system (ANS) to orchestrate a whole-body response.
              • The amygdala’s danger signals trigger the release of powerful stress hormones, including cortisol and adrenaline, which increase heart rate, blood pressure, and rate of breathing, preparing us to fight back or run away.
          • and up to the frontal lobes, (high road, slower)
            • where they reach our conscious awareness (frontal cortex)
              • If the amygdala is the smoke detector in the brain, think of the frontal lobes—and specifically the medial prefrontal cortex located directly above our eyes—as the watchtower, offering a view of the scene from on high.
              • Ordinarily the executive capacities of the prefrontal cortex enable people to observe what is going on, predict what will happen if they take a certain action, and make a conscious choice. Being able to hover calmly and objectively over our thoughts, feelings, and emotions (an ability I’ll call mindfulness throughout this book) and then take our time to respond allows the executive brain to inhibit, organize, and modulate the hardwired automatic reactions preprogrammed into the emotional brain. This capacity is crucial for preserving our relationships with our fellow human beings.
              • (Our watchtower also tells us that other people’s anger and threats are a function of their emotional state.)
        • but can break down
          • However, processing by the thalamus can break down. Sights, sounds, smells, and touch are encoded as isolated, dissociated fragments, and normal memory processing disintegrates. Time freezes, so that the present danger feels like it will last forever.
    • There are two ways of changing the threat detection system:
      • from the top down, via modulating messages from the medial prefrontal cortex (not just prefrontal cortex), or
      • from the bottom up, via the reptilian brain, through breathing, movement, and touch.
        • Bottom-up regulation involves recalibrating the autonomic nervous system, (which, as we have seen, originates in the brain stem). We can access the ANS through breath, movement, or touch. breathing is one of the few body functions under both conscious and autonomic control.
    • emotions is not opposed to reason; our emotions assign value to experiences and thus are the foundation of reason.
      • Our self-experience is the product of the balance between our rational and our emotional brains. When these two systems are in balance, we “feel like ourselves.”
        • As long as the weather is calm and the path is smooth, the rider can feel in excellent control. But unexpected sounds or threats from other animals can make the horse bolt, forcing the rider to hold on for dear life. Likewise, when people feel that their survival is at stake or they are seized by rages, longings, fear, or sexual desires, they stop listening to the voice of reason, and it makes little sense to argue with them. Whenever the limbic system decides that something is a question of life or death, the pathways between the frontal lobes and the limbic system become extremely tenuous. (p. 64)
    • The context and meaning of an experience are determined by the system that includes the dorsolateral prefrontal cortex (DLPFC)
      • it tells us how our present experience relates to the past and how it may affect the future—you can think of it as the timekeeper of the brain.
    • and the hippocampus. The structures along the midline of the brain are devoted to your inner experience of yourself, those on the side are more concerned with your relationship with your surroundings.
      • When those areas are deactivated, people lose their sense of time and become trapped in the moment, without a sense of past, present, or future.
    • Knowing that whatever is happening is finite and will sooner or later come to an end makes most experiences tolerable. The opposite is also true—situations become intolerable if they feel interminable (p. 69)
    • Depersonalization is one symptom of the massive dissociation created by trauma. (p. 72)
    • But instead of struggling to escape, Ute had dissociated her fear and felt nothing. (p. 72)
    • Toward the end of his career, in 1872, Charles Darwin published [[The Expression of the emotions in Man and Animals]].
      • about the book
        • turns out to be an extraordinary exploration of the foundations of emotional life, filled with observations and anecdotes drawn from decades of inquiry, as well as close-to-home stories of Darwin’s children and household pets.
        • It’s still in print today, readily available in a recent edition with a terrific introduction and commentaries by Paul Ekman, a modern pioneer in the study of emotions.
      • mammalian emotions are fundamentally rooted in biology: They are the indispensable source of **motivation to initiate action. **
      • Emotions (from the Latin emovere—to move out) give shape and direction to whatever we do, and their primary expression is through the muscles of the face and body.
        • These facial and physical movements communicate our mental state and intention to others:
          • Angry expressions and threatening postures caution them to back off.
          • Sadness attracts care and attention.
          • Fear signals helplessness or alerts us to danger.
        • We instinctively read the dynamic between two people simply from their tension or relaxation, their postures and tone of voice, their changing facial expressions. Watch a movie in a language you don’t know, and you can still guess the quality of the relationship between the characters. We often can read other mammals (monkeys, dogs, horses) in the same way.
    • Darwin goes on to observe that the fundamental purpose of emotions is to initiate movement that will restore the organism to safety and physical equilibrium.
      • Here is his comment on the origin of what today we would call PTSD:
        • Behaviors to avoid or escape from danger have clearly evolved to render each organism competitive in terms of survival. But inappropriately prolonged escape or avoidance behavior would put the animal at a disadvantage in that successful species preservation demands reproduction which, in turn, depends upon feeding, shelter and mating activities all of which are reciprocals of avoidance and escape.
    • Darwin also wrote about body-brain connections that we are still exploring today. Intense emotions involve not only the mind but also the gut and the heart: “Heart, guts, and brain communicate intimately via the ‘pneumogastric’ nerve,
      • the critical nerve involved in the expression and management of emotions in both humans and animals. When the mind is strongly excited, it instantly affects the state of the viscera; so that under excitement there will be much mutual action and reaction between these, the two most important organs of the body.”
    • Of course we experience our most devastating emotions as gut-wrenching feelings and heartbreak. As long as we register emotions primarily in our heads, we can remain pretty much in control, but feeling as if our chest is caving in or we’ve been punched in the gut is unbearable. We’ll do anything to make these awful visceral sensations go away, whether it is clinging desperately to another human being, rendering ourselves insensible with drugs or alcohol, or taking a knife to the skin to replace overwhelming emotions with definable sensations. (p. 76)
    • Until recently, this bidirectional communication between body and mind was largely ignored by Western science, even as it had long been central to traditional healing practices in many other parts of the world, notably in India and China. (p. 76)
    • All of the little signs we instinctively register during a conversation—the muscle shifts and tensions in the other person’s face, eye movements and pupil dilation, pitch and speed of the voice—as well as the fluctuations in our own inner landscape—salivation, swallowing, breathing, and heart rate—are linked by a single regulatory system.5 All are a product of the synchrony between the two branches of the autonomic nervous system (ANS): the sympathetic, which acts as the body’s accelerator, and the parasympathetic, which serves as its brake.6 These are the “reciprocals” Darwin spoke of, and working together they play an important role in managing the body’s energy flow, one preparing for its expenditure, the other for its conservation (p. 76)
    • The sympathetic nervous system (SNS) is responsible for arousal, including the fight-or-flight response (Darwin’s “escape or avoidance behavior”). Almost two thousand years ago the Roman physician Galen gave it the name “sympathetic” because he observed that it functioned with the emotions (sym pathos). The SNS moves blood to the muscles for quick action, partly by triggering the adrenal glands to squirt out adrenaline, which speeds up the heart rate and increases blood pressure. The (p. 77)
    • The sympathetic nervous system (SNS) is responsible for arousal, including the fight-or-flight response (Darwin’s “escape or avoidance behavior”). Almost two thousand years ago the Roman physician Galen gave it the name “sympathetic” because he observed that it functioned with the emotions (sym pathos). The SNS moves blood to the muscles for quick action, partly by triggering the adrenal glands to squirt out adrenaline, which speeds up the heart rate and increases blood pressure. The second branch of the ANS is the parasympathetic (“against emotions”) nervous system (PNS), which promotes self-preservative functions like digestion and wound healing. It triggers the release of acetylcholine to put a brake on arousal, slowing the heart down, relaxing muscles, and returning breathing to normal. As Darwin pointed out, “feeding, shelter, and mating activities” depend on the PNS. (p. 77)
    • As we breathe, we continually speed up and slow down the heart, and because of that the interval between two successive heartbeats is never precisely the same. A measurement called heart rate variability (HRV) can be used to test the flexibility of this system, and good HRV—the more fluctuation, the better—is a sign that the brake and accelerator in your arousal system are both functioning properly and in balance. (p. 77)
    • Whenever you take a deep breath, you activate the SNS. The resulting burst of adrenaline speeds up your heart, which explains why many athletes take a few short, deep breaths before starting competition. Exhaling, in turn, activates the PNS, which slows down the heart. (p. 77)
    • Polyvagal Theory
      • Introduced by Stephen Porges in 1994, built on Charles Darwin’s observations and added another 140 years of scientific discoveries to those early insights.
      • (Polyvagal refers to the many branches of the vagus nerve—Darwin’s “pneumogastric nerve”—which connects numerous organs, including the brain, lungs, heart, stomach, and intestines.)
      • It provided us with a more sophisticated understanding of the biology of safety and danger,
        • one based on the subtle interplay between the visceral experiences of our own bodies and the voices and faces of the people around us.
        • It explained why a kind face or a soothing tone of voice can dramatically alter the way we feel.
        • It clarified why knowing that we are seen and heard by the important people in our lives can make us feel calm and safe,
          • and why being ignored or dismissed can precipitate rage reactions or mental collapse.
        • It helped us understand why focused attunement with another person can shift us out of disorganized and fearful states.
    • In short, Porges’s theory made us look beyond the effects of fight or flight and put social relationships front and center in our understanding of trauma.
    • Human beings are astoundingly attuned to subtle emotional shifts in the people (and animals) around them. Slight changes in the tension of the brow, wrinkles around the eyes, curvature of the lips, and angle of the neck quickly signal to us how comfortable, suspicious, relaxed, or frightened someone is.
    • When the message we receive from another person is “You’re safe with me,” we relax. If we’re lucky in our relationships, we also feel nourished, supported, and restored as we look into the face and eyes of the other.
    • Global oneness
      • Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe.
      • We are part of that tribe even when we are by ourselves, whether listening to music (that other people created), watching a basketball game on television (our own muscles tensing as the players run and jump), or preparing a spreadsheet for a sales meeting (anticipating the boss’s reactions). Most of our energy is devoted to connecting with others.
    • almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (as in the case of habitually becoming enraged, shut down, overexcited, or disorganized).
    • Porges coined the word “neuroception” to describe the capacity to evaluate relative danger and safety in one’s environment.
    • What accounts for this spectrum of responses: focused, collapsed, or frantic? Porges’s theory provides an explanation: The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time. Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse. (p. 80)
    • The social-engagement system depends on nerves that have their origin in the brain stem regulatory centers, primarily the vagus—also known as the tenth cranial nerve—together with adjoining nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx. When the “ventral vagal complex” (VVC) runs the show, we smile when others smile at us, we nod our heads when we agree, and we frown when friends tell us of their misfortunes. When the VVC is engaged, it also sends signals down to our heart and lungs, slowing down our heart rate and increasing the depth of breathing. As a result, we feel calm and relaxed, centered, or pleasurably aroused.
    • When something distressing happens, we automatically signal our upset in our facial expressions and tone of voice, changes meant to beckon others to come to our assistance. However, if no one responds to our call for help, the threat increases, and the older limbic brain jumps in. The sympathetic nervous system takes over, mobilizing muscles, heart, and lungs for fight or flight.12 Our voice becomes faster and more strident and our heart starts pumping faster. If a dog is in the room, she will stir and growl, because she can smell the activation of our sweat glands. Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart “drop”), we can’t breathe, and our gut stops working or empties (literally “scaring the shit out of” us). This is the point at which we disengage, collapse, and freeze.
    • You can see the difference between these two systems at any big pet store. Kittens, puppies, mice and gerbils constantly play around, and when they’re tired they huddle together, skin to skin, in a pile. In contrast, the snakes and lizards lie motionless in the corners of their cages, unresponsive to the environment.
    • Yet for many people panic and rage are preferable to the opposite: shutting down and becoming dead to the world. Activating flight/flight at least makes them feel energized. That is why so many abused and traumatized people feel fully alive in the face of actual danger, while they go numb in situations that are more complex but objectively safe, like birthday parties or family dinners.
    • Collapse and disengagement are controlled by the DVC, an evolutionarily ancient part of the parasympathetic nervous system that is associated with digestive symptoms like diarrhea and nausea. It also slows down the heart and induces shallow breathing. Once this system takes over, other people, and we ourselves, cease to matter. Awareness is shut down, and we may no longer even register physical pain.
    • In Porges’s grand theory the VVC evolved in mammals to support an increasingly complex social life. All mammals, including human beings, band together to mate, nurture their young, defend against common enemies, and coordinate hunting and food acquisition. The more efficiently the VVC synchronizes the activity of the sympathetic and parasympathetic nervous systems, the better the physiology of each individual will be attuned to that of other members of the tribe.
    • Being in tune with other members of our species via the VVC is enormously rewarding. What begins as the attuned play of mother and child continues with the rhythmicity of a good basketball game, the synchrony of tango dancing, and the harmony of choral singing or playing a piece of jazz or chamber music—all of which foster a deep sense of pleasure and connection.
    • Steve Porges helped me realize that the natural state of mammals is to be somewhat on guard. However, in order to feel emotionally close to another human being, our defensive system must temporarily shut down. In order to play, mate, and nurture our young, the brain needs to turn off its natural vigilance.
    • We were more open to the value of other age-old, nonpharmacological approaches to health that have long been practiced outside Western medicine, ranging from breath exercises (pranayama) and chanting to martial arts like qigong to drumming and group singing and dancing. All rely on interpersonal rhythms, visceral awareness, and vocal and facial communication, which help shift people out of fight/flight states, reorganize their perception of danger, and increase their capacity to manage relationships. (p. 86)
    • the most common response to distress is to seek out people we like and trust to help us and give us the courage to go on. We may also calm down by engaging in a physical activity like biking or going to the gym. We start learning these ways of regulating our feelings from the first moment someone feeds us when we’re hungry, covers us when we’re cold, or rocks us when we’re hurt or scared. 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. (p. 88)
    • I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. (p. 89)
    • 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. (p. 90)
    • 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.” (p. 90)
    • 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. (p. 90)
    • 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. (p. 91)
    • 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. (p. 92)
    • The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror. (p. 92)
    • 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.” (p. 93)
    • 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. (p. 93)
    • “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. (p. 95)
    • call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. (p. 95)
    • 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. (p. 95)
    • Traumatized children have fifty times the rate of asthma as their nontraumatized peers. (p. 98)
    • alexithymia—Greek for not having words for feelings (p. 98)
    • Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean. They may look furious but deny that they are angry; they may appear terrified but say that they are fine. Not being able to discern what is going on inside their bodies causes them to be out of touch with their needs, and they have trouble taking care of themselves, whether it involves eating the right amount at the right time or getting the sleep they need. (p. 98)
    • They tend to register emotions as physical problems rather than as signals that something deserves their attention. Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found. (p. 98)
    • How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them. (p. 101)
    • The most natural way for human beings to calm themselves when they are upset is by clinging to another person. This means that patients who have been physically or sexually violated face a dilemma: They desperately crave touch while simultaneously being terrified of body contact. (p. 101)
    • I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse. (p. 120)
    • This does not imply that child abuse is irrelevant41, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas.42 For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation. (p. 121)
    • As the poet W. H. Auden wrote: Truth, like love and sleep, resents Approaches that are too intense.1 I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know. (p. 125)
    • When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA-to-RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA-to-RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells. (p. 127)
    • “You know, Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor—I was trained to take care of the needs of grown-up, insecure men. But after two years I trust you enough to tell you that those comments make me feel terrible. Yes, it’s true; I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.” (p. 128)
    • Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; victims of domestic violence often cover up for their abusers. (p. 133)
    • ​No source. Saw something abtf stockholm syndrome being made up (p. 133)
    • Later research by Martin Teicher at McLean Hospital showed that different forms of abuse have different impacts on various brain areas at different stages of development (p. 140)
    • if you carry a memory of having felt safe with somebody long ago, the traces of that earlier affection can be reactivated in attuned relationships when you are an adult, whether these occur in daily life or in good therapy. However, if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop.9 If that is the case, how can people learn to calm themselves down and feel grounded in their bodies? (p. 141)
    • More than half of those with ACE scores of four or higher reported having learning or behavioral problems, compared with 3 percent of those with a score of zero. (p. 146)
    • As the ACE score rises, chronic depression in adulthood also rises dramatically. For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. (p. 146)
    • Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. (p. 146)
    • Recent research has swept away the simple idea that “having” a particular gene produces a particular result. It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation), making it more or less sensitive to messages from the body. While life events can change the behavior of the gene, they do not alter its fundamental structure. Methylation patterns, however, can be passed on to offspring—a phenomenon known as epigenetics. Once again, the body keeps the score, at the deepest levels of the organism. (p. 152)
    • The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group. (p. 163)
    • The sexually abused girls have an entirely different developmental pathway. They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress. Other kids usually don’t want anything to do with them—they simply are too weird. (p. 163)
    • Seventy percent of prisoners in California spent time in foster care while growing up. (p. 170)
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developmental **psychopathology**
interpersonal **neurobiology**
the expression of the **emotions** in man and animals

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