(This 20 page Summary, the curator’s take-aways prepared in January 2025, offers a non-professional perspective rather than a condensation of the text.  The reason for including this review among pain science informed stories is that van der Kolk offers neuroscience insights about brain functions that are related to neuroplastic pain and symptoms.  Professionals may find useful clinical insights in the omitted portions of the book.  The book captures a glimpse of both his perspectives and initiatives, along with historical timelines to help understand changes in: trauma effects, causes, and treatments; the diversity of perspectives and innovation in mental health; and the response of the health community to new approaches.)

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This is the story written by Bessel van der Kolk, an MD Psychiatrist, describing his life’s work on trauma disorders and evolution of the understanding of the related causes, effects and remedies for trauma.  The story spans from the 1960s to about 2014, the copyright date, and he continues his work in 2025.  He is considered to be a major influence in the US on treatment of trauma disorders that don’t fit well into either the current professional medical or mental health communities.  He promotes the ‘Consensus Proposed Criteria for Developmental Trauma Disorder’, which he fostered.  The book seems to be aimed at mental health professionals, but using a dictionary for unfamiliar terminology will be helpful for others.

The Prologue:  Facing trauma

Humans are resilient but traumatic experiences leave traces: dark secrets on our minds and emotions.   By definition trauma is unbearable and intolerable, creating unpleasant emotions.    We may push trauma memory out of our conscious mind as if nothing happened but may still feel damaged beyond redemption.  Would it be possible someday to understand how our brains, minds, and love work, as well as we understand, how other bodily systems work?

Three new branches of science birthed a vast increase in our knowledge about the effects of trauma, abuse and neglect:  1) neuroscience;  2) developmental psychopathology; and 3) interpersonal neurobiology.  The new understanding demonstrates that trauma causes actual changes in our brains, which helps explain why we may repeat the same problems, but the result is not necessarily a moral failing.

New possibilities to reverse that damage take three avenues:  1) top-down, by talking to others while processing memories;  2) medications and technologies that change the way the brain organizes information and;  3)  bottom-up, by allowing the body to have experiences that contradict the helpless resulting from trauma.

His life work is anchored at the Trauma Center he founded in 1984 to collaborate with others to discover the effects of traumatic stress and demonstrate the efficacy of various treatments.  Their goal was to understand how people can gain control over the residues of past trauma and return to being masters of their own ship.   Well-designed studies to obtain definitive insight of concepts and treatments are a common thread through his work.

Outline of Contents:

The first four parts of the book (12 chapters) describe:  1) the current revolution in understanding, informed by recent neuroscience insights of how the brain functions during a traumatic event;  2) the relationship between the brain and body during a trauma experience;  3) the unique influence of trauma on the brain construction of children in their developing years and;  4) how memories of trauma are rooted in the brain and produce unwanted emotional reactions afterward.

The last part of the book (8 chapters) briefly describes eight treatment methods that have been demonstrated to be effective in some cases, including:  owning yourself; finding language to communicate with your subconscious; Eye Movement Desensitization and Reprocessing; inhabiting your body via yoga; self-leadership; creating structures; brain/computer interface technology; and communal rhythms.

Prologue, chapters, and Epilogue = 359 pgs, plus 87 pgs Acknowledgements, Appendix, Resources, Further Reading, Notes, and Index.

Epilogue

We now understand: the effects of trauma on the brain; how it disrupts social engagement throughout life; that abuse and neglect in childhood causes are the single most preventable cause of mental illness, substance abuse, and shortened lifespan; that trauma, abuse and neglect are endemic with poverty; that trauma damage is treatable; and that the greatest hope for effected children is education in a safe school were they learn how their bodies and brains work and how to understand and instill the resilience to deal with emotions and trauma in life.

Feeling safe with other people defines mental health.  Trauma is our most urgent public health issue.  Our choice is to act on what we know to be effective.

Part One – The rediscovery of trauma

Chapter 1 – Lessons from Vietnam veterans.

His professional introduction to trauma was in 1978 at the Boston Veterans Administration Clinic.  Initially it involved listening to veterans telling their trauma stories from the war, their subsequent problems, and his search for medical references on the problems they described. He found only one, ‘The Traumatic  Neurosis of War’ (Kardiner), published in 1941, based on World War I veterans and released in anticipation of shell-shocked soldiers in WWII.

Kardiner described the same phenomena van der Kolk heard in his patient’s stories.  What Kardiner called traumatic neuroses, we now call PTSD.    He saw lives shattered by overwhelming experiences and his quest became to understand how to enable them to feel fully alive again.

The first study he did at the VA was to systematically learn what had happened to veterans in Vietnam.   A close associate of his was Sarah Haley, one of the first to write about the phenomenon, in ‘When the Patient Reports Atrocities’ (1974).  They report that they despise themselves for how terrified, dependent, excited, and enraged they felt.  Years later, van der Kolk encountered similar phenomenon in victims of child abuse.   The consequences of trauma include losing one’s sense of self, a part of you seems forever destroyed – the part that was good, honorable and trustworthy.   There may be confusion about whether you are a victim or a willing participant.

Numbing to emotions is another symptom, not able to really feel anything.  Never feeling fully alive and keeping busy or indulging addictions are ways to avoid confronting your demons.

Another study he conducted explored how trauma changed a person’s perceptions and imagination.   Humans are meaning-making creatures, and our brains try to assign meaning to things we see, hear and sense.  Traumatized people look at the world differently than other people.   Imagination is absolutely critical for quality of life, the essential launchpad for making hopes come true.  When people are stuck in the past without imagination there is no hope.  Traumatic events have a beginning, middle and end, so they are in the past but unwanted memories lack real time bounds and can replay past emotions when triggered.

Progress in diagnosing posttraumatic stress was slow, the turning point was 1980.  A group of Vietnam veterans and two New York doctors lobbied the American Psychiatric Association to create a new diagnosis for PTSD (posttraumatic stress disorder).  This led to an explosion of research and attempts at finding effective treatments.  He proposed a study on the biology of traumatic memories, did memories differ between those with PTSD and others?  That proposal was rejected by the VA because it had never been shown that PTSD was a relevant mission of the VA.  He left the unwilling VA organization to teach psychopharmacology at the Harvard Teaching hospital.  There he noted the similarity of the symptoms from molestation and family violence to symptoms his earlier veterans.  For many people war begins in the home, 3 million children a year in the US.  It is difficult for growing-children when their source of terror is their own caretakers.

The new understanding of trauma began in the early 1990s with brain imaging tools.   We have learned that overwhelming experiences affect our innermost sensations and our relationship to physical reality – the core of who we are.   Trauma is not just an event in the past but leaves an imprint on mind, brain, and body, resulting in reorganization of the way the mind and brain manage perceptions.  Finding words to describe their trauma is helpful, but not enough.   The body beyond our conscious brain needs to learn the damage is past for real change to take place.  Their search to understand trauma changed their thinking about the structure of the mind as well as the processes that help it heal.  (He seems to equate the mind with our conscious brain.)

Chapter 2 – Revolutions in Understanding Mind and Brain

In the late 1960s, his initial years in medical school, he was an attendant at a research ward and became an accidental witness to the profound transition in the medical approach to mental suffering.   His job was to keep the patients, college-age students from Boston universities with unpredictable behaviors, engaged in normal activities like eating pizza, sailing, camping, and Red Sox games.  On sleepless nights they told him their stories of trauma at the hands of parents, relatives classmates and neighbors.   He was permitted to observe morning rounds where the doctors rarely heard the stories he had heard patients tell.   The study from that research effort was published in 1968 showed that drug treatment for schizophrenic patients had a better outcome than talk therapy, a milestone on the road to changing from talk therapy to a brain-based model of discrete disorders.  The primary treatment for mental illness shifted in the 1950s and 60s from talk therapy to medical intervention.

A few years later as a doctor doing physical exams prior to electroshock treatment for depression, he observed the medical model in action where the stories he heard patients tell him would later be erased from their memories.  He wondered if the earlier stories he heard students tell in the nighttime were fragments of memories rather than hallucinations.

Later in his psychiatry training his mentor taught that the greatest source of our suffering is the lies we tell ourselves, and people can never get better without knowing what they know and feeling what they feel.  You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

The available technology has always determined the medical approach to treatment.  The new paradigm fixed ‘disorders due to chemical imbalances’.  He embraced the pharmacological revolution in 1973 when he became chief resident at a Boston health center.   Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals from 1955 to 1996.   The ability to measure hormones and neurotransmitters in patients led eventually to publication of the Diagnostic and Statistical Manual of Mental Disorders in 1980.

He attended a 1984 neuropsychopharmacology meeting looking for ideas about traumatic stress.   A presentation on learned helplessness in dogs and their stress hormone levels captured his attention about the underpinnings of traumatic stress.   Later research revealed that traumatized people continue to have high levels of stress hormones long after the actual danger is passed, and that cortisol ends stress response but is low in PTSD patients.

A presentation in the 1985 neuropsychopharmacology meeting showed that sensitivity of the amygdala to threat depended on its level of serotonin.  Prozac, which increases serotonin in the brain, was marketed first in 1988.  He prescribed it, and observed beneficial effects on his patients, but it had no effect for veterans with PTSD.

The pharmacology revolution gave doctors a tool beyond talk therapy, and did much good, but in the end may have done as much harm as good, because drugs deflect attention from the underlying issues.   The brain-disease model takes control over people’s fate out of their hands, transferring it to doctors and insurance companies.  After three decades of psychiatric medications more money is spent on them, and more people are taking them.  They make children more manageable, but they interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society.  Because drugs are so profitable studies of nondrug treatments are rarely funded.  The fact that we can change our own physiology and inner equilibrium by means other than drugs is rarely considered.

The brain-disease model overlooks four fundamental truths: 1) restoring relationships is central to restoring well-being; 2)  we have the power of language to change our situation; 3) we have the ability to regulate our own physiology; and 4) we can change social conditions to create safe environments  for children and adults to feel safe and thrive.  Considering the limitations of drugs, he wonders if we could find natural ways to help people deal with post-traumatic responses.

Beginning in the 60s, drugs were a major factor in releasing thousands of people from mental hospitals into mainstream society.

Chapter 3 – Looking into the Brain: The Neuroscience Revolution

In the early 1990s PET (positron emission tomography) and fMRI (functional magnetic resonance imaging) technology provided the ability to observe which parts of the brain were activated in certain tasks or remembering events of the past.   He was asked about a study to understand what happens in people’s brains who have flashbacks and proposed a study of 8 people’s brain activity using two scripted audio tapes as the test circumstance.  The first script re-enacted the images, sounds, and feelings of a past trauma and the second reenacted a scene where they felt safe and in control.   He identifies bright areas of one set of three scan images: the right limbic area (the emotional brain including the amygdala), the visual cortex (where images first enter the brain), and the speech center.    The amygdala warns of danger and activates stress response.

The most surprising finding was that the speech center was deactivated whenever a flashback was triggered so feelings are almost impossible to articulate.  They were also surprised to see the visual cortex activated (apparently with images from the trauma event), so long after the event.

The right side of the brain processes intuition, emotion, spatial, and tactual aspects while the left side processes rational, sequential and analytical aspects.   Images of past trauma activate the right side and deactivate the left side.  Usually, the two sides work together but in different ways.  During a trauma the left side may not work very well.  Without sequencing we can’t identify the cause and effect to grasp the long-term effects.  When something reminds traumatized people of the past, it’s as if it were happening now, but they may not be aware it is a past event.

Another possible response to threat is denial, (not a discernable response in scans), where the mind goes on as if nothing happened.  But the alarm signal from the emotional brain continues producing stress hormones, because the body continues to keep the score.  For hundreds of years textbooks have recommended talking about distressed feelings to resolve them, but trauma gets in the way of that effort.  The rational brain is impotent to talk to the emotional brain out of its own reality.  The scanned volunteers had not integrated their experience into the ongoing thread of their life, so were not able to be fully here in the present.

Three years later one of the eight volunteers was successfully treated with EDMR (Chapter 15).   Her body kept the score for 16 years.

Part Two – This is your brain on trauma

Chapter 4 – Running for your life: Anatomy of Survival

Two adaptive responses to threat are becoming an agent in your own rescue and creating alternatives to help others.  Traumatized people become stuck in their growth.  A group of his veterans gave him a WWII era watch, because their lives had stopped in one sense in 1944.  After trauma the world is experienced with a different nervous system, focused on suppressing the inner chaos.

The whole body is organized to respond to the threat, including all organs and muscles and trauma survivors are prone to continue to protect themselves.  Knowing how the system works is essential to understand how trauma affects each part and can serve as a guide to resolving traumatic stress.

The most important brain job is survival, managing 5 aspects: 1) internal signals to control organs; 2) create a map of where to go to satisfy needs;  3) generate the energy and actions to get there;  4) warn of dangers and opportunities and;  5) adjust actions to cope with current conditions.   Psychological problems occur when any aspect is inadequate.

He uses a three-part brain model here.   The cognitive, rational brain occupies the top part of the skull, about 30% of the volume.   Below are two subconscious brains that manage everything else.  The lowest brain develops first in newborn babies and controls organ functions that sustain life.   The next brain to develop above that is the limbic brain which manages living in complex social networks.  It develops in response to life experiences and has neuroplastic characteristics that permit the default patterns to change.    He calls the two lower brains the emotional brain.

The rational brain provides: planning, anticipation, sense of time, context, empathy and understanding.   The limbic brain provides: organization/surrounding map, emotional relevance, categorization, and perception.   The lowest brain provides: arousal, sleep/wake, hunger/satiation, breathing, and chemical balance.

The emotional brain response is rapid and automatic, based on incoming information similarities to past experiences.   The rational brain begins to develop in the second year of life enabling language, abstract thought, creativity, and empathy.   In 1994 a group of Italian scientists discovered mirror neurons that lead to understanding empathy, imitation, synchrony, and language.   Realizing other people think and feel differently from us is a developmental step for two- and three-year-olds.   Trauma involves not being mirrored to easily respond to others emotional state.

Information initially enters the limbic brain, which routes it rapidly to the lowest brain for an evaluation of threat to survival, then more slowly to the rational brain for a nuanced evaluation.  The lower brain functions like a preprogrammed fire detector and the rational brain like a watch tower.   Problematic rational decisions are fewer than problematic emotional decisions.

When the lower brain makes a high threat conclusion, whether warranted or not by the situation, it initiates release of stress hormones to the whole body to prepare for action.   But the rational brain has some ability to moderate the stress response.   Dealing with stress is a balance between the detector and the watchtower influence, which are described as ‘top-down and bottom-up influences.  Top-down efforts strengthen the capacity of the watchtower to monitor body sensations.  (Mindfulness meditation and yoga have been demonstrated to help this mode.)  Bottom-up attempts to recalibrate the autonomic nervous system in the emotional brain to increase the accuracy of the detector response.   (Breathing practice, physical movement, and touch have been demonstrated to help this mode.)

Emotions assign value to experiences as a foundational aspect of reason.  Our self-experience is a balance between our emotional and rational brains, perhaps like a more or less competent rider and his unruly horse.  But when the limbic system (emotional brain) decides something is a matter of life and death, communication between the rational and emotional brains becomes extremely tenuous so in a conflict moment the rational brain has less influence so emotions tend to prevail.

An example of Stan and Ute’s brains on Trauma ends Chapter 4.  In September 1999 Stan and Ute encountered dense fog traveling to a business meeting, which resulted in a multi-vehicle pile-up.  They were trapped in vehicle 13 of the 87-vehicle pileup and heard a girl pounding on their roof and screaming for rescue from flames.  They were unable to assist, and she died.  He eventually broke their windshield and climbed out while Ute was sitting, frozen in her seat.  They were taken to a hospital and their injuries were minor.

That night neither could sleep, feeling if they let go, they would die.  They were irritable jumpy and on edge, could not stop the images and the what-if questions from haunting them, drank wine to numb their fears, and after 3 months sought help from a Dr. Lanius a psychiatrist who had been van der Kolk’s student.  She used a fMRI to capture their brain images in response to a script of their trapped experiences.  The MRI showed the activation visual images, smells, and other sensations they had experienced trapped in their car 3 months earlier, were still trapped in their brains.

Stan immediately experienced a flashback from the trapped experience with sweating, heart racing and high blood pressure.  He relived what had happened 3 months earlier rather than remembering it an event of the past.   The detector in his brain was on overdrive and the timekeeper link between his rational and emotional brains had collapsed so he was unable to separate the actual and fMRI events as past and present events.  Talk therapy won’t work as long as people keep being pulled back into the past but they need to be physically grounded or anchored in the present during the therapy.

Ute had nearly the same trapped experience in the pileup, but her mind went blank and the fMRI showed no activity, a condition called dissociation or depersonalization.    After seeing her fMRI van der Kolk concluded talk conventional therapy also would be useless for her.  He later realized she responded differently because in surviving difficult events in her childhood she had learned to blank out her mind during horrible events.  She eventually recovered with a bottom-up therapy approach.  Numbing is the other side of the coin in PTSD.

The challenge of trauma treatment is enhancing the day-to-day experience while dealing with the past.

Chapter 5 – Body-Brain Connections

A person plans, plays, learns, and attends to the needs of others in the conscious part of their brain, while the subconscious brain communicates with the person only by sensations and feelings in their body.   Hunger pangs, sensations to urinate and move bowels, and sensations that prompt babies to cry for attention exist early.

Various emotions produce subconscious bodily effects like: smiling, blushing, lump-in-the-throat, and knot-in-the-stomach associated with different levels of pleasure or threat.   These emotions are also communicated to that person, and to others in the vicinity, by subconscious changes in: breathe and heart rate; facial muscles; posture; movement; voice tone and speech speed, etc.

Subconscious emotions and bodily changes are transmitted through the autonomic nervous system (ANS), which has two branches: the sympathetic nervous system (SNS) that acts as an accelerator, or through the parasympathetic nervous system (PNS) that acts as a brake.  The sympathetic label associates it with ‘emotional’ arousal like fight or flight, while the parasympathetic label is ‘against emotions’ like digestion and healing.

Inhaling a deep breath activates the sympathetic system, so short deep breaths result in a burst of adrenaline and an increased heart rate.  Exhaling slows down the heart rate through the parasympathetic system.   Heart rate variability (HRV) is a measure of the flexibility of the system and more fluctuation is better.   Instruments to measure HRV can be used to help treat PTSD.

In 1994 Polyvagal Theory (related to the significance of the vagal nerve which connects the brain to numerous organs) was introduced and put social relationships in the forefront of research rather than the effects of fight or flight.    It clarified why knowing we are seen and heard by the important people in our lives can make us feel calm and safe, while being ignored and dismissed can precipitate rage reactions or mental collapse.

Our mirror neurons register their inner experience, and our bodies make adjustments to whatever we notice.   Most of our energy is devoted to connecting with others.   The standard medical practice of discovering the right drug for a particular ‘disorder’ can distract from grappling with how the problems interfere with our functioning with other humans.  The critical issue is reciprocity, we need to feel safe, seen and heard by the people around us.   Social support is the most powerful protection against being overwhelmed by stress and trauma.  Discovering initial relationships with animals like dogs and horses is an entry path for some trauma patients.

Trauma changes the nervous system’s perception of risk and safety.  Losing consciousness but otherwise uninjured in an event can lead to mental collapse.  Some people panic during the trauma and stay frantic until effective treatment.   Some remain calm and resourceful in helping others during the trauma experience.  An explanation for these three levels of response by the autonomic system defines ‘social engagement’ as the first level, i.e. help from those around us.  If no help comes the second response is ‘fight or flight’, followed by ‘freeze or collapse’ to expend the least energy possible.   Stan responded in the social engagement mode but Ute in the collapse mode, perhaps because she felt more trapped.

The natural state of mammals is to be somewhat on guard.  On order to play, mate, or nurture young the brain needs to turn off its natural vigilance.  Past trauma can lead to either heightened vigilance because danger is everywhere or a loss of vigilance because defending seems futile.   Treatment programs centered on play and rhythmic body movements, like yoga, can create a small safe social engagement that has been helpful.

The body keeps the score.  So, if trauma is encoded in our organs by emotions, then understanding emotional regulation will be to remedy route rather than changing a person’s rational thinking.

Chapter 6 – Losing your body, losing yourself

He describes Sherry’s experiences, because she taught him that many people with trauma lose their sensory perception of whole areas of their body.  Living a normal life means integrating ordinary sensory experiences.   He referred her to a massage therapist.

A study by his colleague in 2004 on the difference in the ‘default state network’ (DSN) comparing normal adults to PTSD patients with early life trauma, revealed the person’s sense of ‘self’ by their thought activity when they have nothing in particular in mind.   There was almost no activation of any self-sensing brain area in the PTSD patients.  He now understands why they frequently asked him for advice about ordinary things.   How could they make decisions if the relationship with their own inner reality was impaired?   You can’t do what you want until you know what you are doing.

The core of our self-awareness rests on the physical sensations that convey the inner states of the body.    The consequences of having emotion and attention are entirely related to the fundamental business of managing life within the organism.  Recalling an emotional past event causes reexperience of the visceral sensation felt during the original event.

Agency, owning your life, means feeling in charge of it.  Trauma shuts down that inner compass, the watchtower mentioned earlier, robbing a person of the imagination to create something better.  Our gut feelings signal what is safe, life sustaining or threatening, even if we can’t explain why.  Traumatized people feel unsafe inside their bodies, the past is alive in the form of gnawing interior discomfort, unable to detect what is dangerous or harmful but also what is safe and nourishing.  Neuroplastic symptoms are ubiquitous for traumatized people.

People with emotional blindness, having no words for feelings, tend to describe action or problems as emotion rather than a feeling needing their attention.    They can be professionally successful but have bleak intimate relationships.   They can’t tell what is upsetting them.  Recognizing the relationship between their physical sensations and their emotions is the key to their improvement.

Trauma victims need to befriend the sensations of their body.  Being frightened is a body on guard, angry.   Physical self-awareness is the first step to releasing the tyranny of the past.   Clinging to another person is the most natural way to toward calmness.

Many traumatized people are unable to make eye contact with others.  Their mirror neurons were not activated which means their ability to make friends and get along is impaired.   They need to experience others as separate individuals in order to have genuine relationships.

Part Three – The Minds of Children

Chapter 7 – Attachment and attunement

Babies ‘attach’ their sense of being and what is real to whoever functions as their caregiver, by means of their physical and emotional interactions.   Attachment encodes a sense of safety in the baby’s brain.    They learn about the give and take of actions and feelings that are similar and different than their actions and feelings.    The need for attachment never lessens and most humans cannot tolerate being disengaged from others for any length of time.

Secure attachment develops when caregiving includes emotional attunement, the ability for a child to synchronize their emotions with those of another being.  Associating intense sensations of changing situations with safety, comfort, and mastery is the foundation of self-regulation.

Babies have a sense of agency when they understand their actions can change how they feel and how others respond to them.   When their body and mind become the place where they live, their sense of identity is real.    These concepts become the foundation of how babies become whatever the mother’s idea of what a baby is.

Abused children can be very sensitive and tend to interpret changes in the emotional situation as threats rather than as clues for how to stay in synch.   Children learn to live with the parents they have, by developing a coping style to get at least some of their needs met, either by being chronically upset or more passive and withdrawn.

With most ‘good enough’ caregivers children learn that broken connections can be repaired.   One study of middle-class children showed about 62 % secure, 15% avoidant, 9 % anxious, and 15% disorganized.  Traumatized parents need help to be attuned to their child’s needs.   A child’s reaction to painful events is related to how calm or stressed their parents are.

Disorganized attachment is characteristic of either pre-occupied mothers or helpless, fearful mothers, usually related to the mother’s childhood.

Infants in secure parent relationships can communicate both frustrations and distress, and also their interests, preferences, and goals.   Dissociation means simultaneously knowing and not knowing, feeling lost from the world.  What cannot be communicated to the mother cannot become part of the baby’s self.    When you cannot tolerate what you know or feel, the only option is denial and dissociation.

Early attachment patterns create inner relationship maps in the emotional brain that are not reversible by understanding how they were created.    Being in synch means resonating with people around you through the sounds and rhythms of daily activities.

Chapter 8 – Trapped in relationships: the cost of abuse and neglect

A child’s viewpoint of the world is unique, with them at the center.   They trust the viewpoint of those around them.    Whether they were told they were cute and worthy, or abused and worthless, they would believe it.    Later in life the ‘worthy’ person would protest inconsistent treatment, but the ‘unworthy’ person would fail to protest mistreatment and conclude they deserve it.

It’s possible to help an ‘unworthy’ person to reconstruct their inner map of the world. Reconstructing inner maps changes may spontaneously occur during adolescence or when becoming new parents.    The change occurs when a person learns to use their rational brain to override their emotional brain.    Learning to trust is a major challenge.

In order to have an identity we must know we are real.   That means being able to observe our surroundings, label them correctly, and trust our memories.   Losing awareness and cultivating denial might be essential for survival at times, but the price you pay is knowing who you are, what you are feeling, and of what and whom you can trust,

Trauma is not stored as a narrative with a beginning, middle, and end but jumbled in disconnected fragments of various types.   The will to live one’s own life counteracts trauma at the time and many consider survivors to be heroes, particularly their determination to recover.

Chapter 9 – What’s love got to do with it?

Psychiatry as a subspecialty of medicine that aspires to understand mental illness with the precision like understanding a specific cancer.    But the complexity of the mind, brain, and human attachment systems is beyond the current understanding.   A definitive diagnosis is a key characteristic of effective treatment in the medical community but mostly not achievable in the mental health community.

The first serious attempt in the mental community was in 1980 with the third edition of  the Diagnostic and Statistical Manual of Mental Disorders, (DSM-III).    Sale of that document earned the American Psychiatric Association $100 million since then.

Many psychiatric diagnoses can have serious consequences and are often mere tallies of symptoms, which don’t seem to be helpful.   Collaborating with others, van der Kolk has tried to change the way diagnoses are made.   The first attempt was the Trauma Antecedents Questionnaire (TAQ), which starts with who does what in your home, then explores childhood relationships.

In one study 81% of hospital patients who were diagnosed with Borderline Personality Disorder (BPD) reported severe histories of child abuse, the vast majority beginning before age 7.  Those children did not have a sense of safety but were making their way in the world unprotected and unseen.   When does a hypothesis become a scientifically established fact?  That study changed the Trauma Center’s direction from focus on singular events (PTSD), to looking at long term relationships.   He concluded that the brains of children who lack a deep memory of feeling loved and safe, fail to develop the capacity to respond to human kindness.

That prompted their study to determine if the symptoms of patients with different trauma type histories (childhood physical or sexual abuse; recent domestic violence; and natural disasters) were the same or different, and it showed a dramatic difference, particularly between abused children and those in natural disasters.   He presented the results to the DSM-IV work group, which voted overwhelmingly to establish a new diagnosis for victims of interpersonal trauma, which they labeled ‘Complex PTSD’.  But DSM-IV in May 1994 did not include it, nor did revisions -V and -VI.    (a ‘Consensus Proposed Criteria for Developmental Trauma Disorder’ is included in the book Appendix.)

A study, now referred to as the ACE study (Adverse Childhood Experiences), by the Kaiser Permanente Department of Preventive Medicine in San Diego, involved over 17,000 patients responding to 10 new questions about early childhood experiences in their existing comprehensive evaluation was published in 1998.    It revealed that a significant portion of the healthcare challenges for the whole population are related to mental challenges in childhood.   This book is a significant influence in focusing increased attention on preventing that gap in attention to continue by diagnosing and treating childhood trauma so that abuse and neglect do not burden the next generation of children.

The 1964 publication of the Surgeon General’s report on smoking unleashed a campaign that changed the lives and health prospects for millions.  Child abuse is America’s most costly health care issue, exceeding the cost of cancer or heart disease.   In the first twenty years after the ACE’s publication a similar effect has not occurred and the daily life of children in treatment centers remained virtually the same.
Chapter 10 – Developmental Trauma: The hidden epidemic

Child abuse isn’t something you get over but an evil of unchecked violence perpetuated within our culture.

No genes have been found that change DNA but experiments with mice and monkeys (called epigenetics) revealed that chemical modifications attached to DNA affect how they are turned on and off.

Congress established the National Child Traumatic Stress Network (NCTSN) in 2001 in response to a broad effort van der Kolk and others began in 1998.   By the book publication of ‘The Body Keeps the Score’ date in 2014 it had expanded to 150 centers.   An early survey of about 2000 children in the network showed they mirrored  the middle-aged, middle-class adults with high scores in the ACES study.

The adoption of the DSM-III PTSD diagnosis in 1980 led to greatly increased focus and funding toward PTSD so that it can now be effectively treated.    However, 82% of traumatized children do not meet the PTSD criteria, but are diagnosed with 3 to 8 different DSM disorders which together are not a useful diagnoses for treatment.

Over a 4 year period a group of clinician researchers specializing in childhood trauma analyzed 130 studies covering 100k children and drafted a proposal for an appropriate diagnosis which they called a ‘Developmental Trauma Disorder’ (DTD).    They discovered a consistent profile of: 1) a pervasive pattern of dysregulation;  2) problems with attention and concentration; and  3) difficulty  getting along with themselves and others.

DTD located the origin of abused children’s problems in a combination of trauma and compromised attachment.   They submitted the proposed diagnosis to the American Psychological Association (APA) for inclusion in revision DSM-5, but it was declined because of a committee consensus there was no new diagnosis needed to fill: ‘a missing diagnostic niche’.

A study of Risk and Adaption began in 1975 to address the issue of nature versus nurture as a cause of disorders.  One hundred-thirty children and their families were followed from 6 months before birth to the child’s age 30.    The fundamental questions were:  1) how do children learn to pay attention while regulating their arousal and,   2) what kinds of support do they need and when?   Two clear patterns developed:  children who received consistent care giving became well-regulated kids while erratic caregiving produced unpredictable children.

A study begun in 1986 with 84 girls with confirmed family incest, on the impact of sexual abuse on female development.    After 20 years the negative effects were unambiguous compared to other with other girls of the same age, race, and social circumstances; sexually abused girls suffer from a large range of negative effects.

DSM-5 published in May 2013 included 5 new disorders associated with early life trauma.  Even before it was published the APA released the results of validity tests on various new diagnoses indicating they lacked reliability in a scientific sense.  In April the National Institute of Mental Health (NIMH) rejected the symptom basis of the DSM in favor of Research Domain Criteria, which like the DSM conceptualized mental illness as a brain disorder and focused on exploring brain circuits.

After DSM -5 was published without the DTD, thousands of clinicians sent small donations to the Trauma Center for a large field trial of the DTD, which was published in 2013.  Van d

er Kolk sees the difference in DTD to be that it: follows the science of neuroplasticity; assumes parents do the best they can; and has the potential to make a difference in reducing the violence in our society while reducing its cost.

Part Four – The imprint of trauma

Chapter 11 – Uncovering secrets: The problem of traumatic memory

A study of 200 Harvard sophomores to understand Adult Development began in 1939 with later detailed interviews in 1945/6, and 1989/90, which included involvement in WWII.  Comparing war experience descriptions, the majority described different accounts in the two interviews, but for those who developed PTSD their descriptions were the same, their memories remained the same.

Day-to-day memories pass into oblivion, but insults and emotional injury remain, if only dislike for the person involved.    Studies have shown that the more adrenaline secreted during the incident, the more precise the memory will be.

Two examples cited are:  of the cigarette girl who escaped from the Coconut Grove fire in 1942 then annually reenacted her escape during the 1970s and1980s, and a Vietnam veteran who annually staged an armed robbery implying he had a gun in an unconscious attempt at ‘suicide by cop’.

When a traumatic event is reactivated in an fMRI study there is no integration of the rational brain story with the emotional brain feelings.   The rational brain shuts down and only the fragmented sensory and emotional memories are active.

The difference between narrative memory and traumatic memory was demonstrated in the 1880s.   Traumatized people have little memory of the story of the events but later tend to act the events out emotionally.     The problem with PTSD is dissociation of the rational story from the emotional events, but when the two versions are reassociated (reintegrated), the undesired emotional effects end.    How can doctors, police, and social workers recognize someone is suffering from traumatic stress if he reenacts rather than remembers it?

Chapter 12 – The unbearable heaviness of remembering

Soldiers were traumatized in both world wars, but the effects and treatment were different, and You Tube has videos of soldier’s symptoms from both wars.

It was called shell shock in the first war variously labelled neurasthenia, ‘not yet diagnosed, Nervous (NYDN), officially denied and explained as men undisciplined, unwilling , and unfit to be soldiers.

In 1924 Congress awarded each US soldier $1.25/day overseas but it was never paid.   A Veteran demonstration of 15,000 on the Washington Mall for Immediate payment was forcefully dispersed.   The 1929 book ‘All Quiet on the Western Front’ and the movie in 1930 became the primary public description of the situation.  Van der Kolk links denial of the consequences of trauma with debasement of human rights and the rise of Hitler.

At the outbreak of WWII two psychiatrists published accounts of their work related to trauma in WWI in 1941.

After the first war affected men would flail, display facial tics, and collapse with paralyzed bodies but after the second war affected soldiers talked, cringed, had stomachs upset, hearts race, and overwhelming panic.   Culture shapes the expression of traumatic stress.
Van der Kolk observed in his work at the VA the young were admitted for psychiatric treatment but the old for medical treatment.    ‘The Body Keeps the Score’.    The physical ailments of veterans were treated at the VA but the psychological scars were not.  The latest writing on combat trauma he could find was in 1947.   The Vietnam war prompted numerous studies and the inclusion of the PTSD diagnosis.

Memory loss, repressed memory, is reported in people related to natural disasters, accidents, war, kidnapping, torture, concentration camps, physical and sexual abuse and PTSD.    A study of 136 girls, ages 10-12 admitted to the hospital for sexual abuse were interviewed in the 1970s and again 17 years later.    Thirty-eight percent did not recall the abuse (younger girls), 12% stated they had never been abused, and 68% reported other sexual abuse.

Recent neuroscience research has revealed that memories are modified in the recall process, the act of telling changes the tale.   Watching horror movies does not cause PTSD.  The terror and helplessness associated with PTSD can only be studied in the brains of traumatized people.

A 1994 study van der Kolk collaborated in asked 76 volunteers to describe a non-traumatic event in their lives and a traumatic event.    Two main differences were how the stories were organized and the teller’s physical reactions.   Non-traumatic events had a beginning, middle and end, but traumatic events were disorganized.    Eventually during the interview 85% could tell a coherent trauma story.  The five who had been abused as children had the most fragmented stories.    Their study confirmed an earlier report that traumatic memories are different than ordinary stories.

Research has shown that Cognitive Behavior Therapy (CBT) to find words to describe what happened to you can be transformative but does not always abolish PTSB symptoms.

He concludes the chapter with a long description of the director of nursing at a hospital who consulted with him several times related to anesthesia awareness after a routine outpatient laparoscopic surgery, which was traumatic.     After surgery her disturbing dreams were related to memories of conversations in the operating room.   She functioned well at work after returning but otherwise her life was greatly impacted by the memories, she lived a dual existence.  She finally found some help in psychodynamic therapy and Pilates.

Part Five – Paths to recovery:

Chapter 13 – Healing trauma: Owning yourself

A review of the new focus on integrating the emotional brain with the rational brain, including limbic system therapy, befriending the emotional brain with hyperarousal, mindfulness, relationships, and communal rhythms and synchrony, integrating traumatic memories, CBT, desensitization.    Available drugs treat some symptoms but do not treat the cause.

Chapter 14 – Language: Miracle and tyranny

Expressing your feelings, self-discovery, telling your story, our dual awareness, the body is the bridge, writing to yourself, art, music, and dance, and becoming ‘Some Body’.

Chapter 15 – Letting go of the past: EMDR

Eye Movement Desensitization and Reprocessing is able to eliminate painful recreations of trauma.    It was discovered by happenchance in 1987 when a psychiatrist noticed painful memories were dramatically removed by rapid eye movements.    Van der Kolk studied EDMR and collaborated in a study EDMR was more effective than drugs and cured rather than masking the symptoms.

The procedure can be done by a patient watching a clinician’s finger oscillate and doesn’t involve the relationship between the two of them.    There seems to be a relationship between EDMR and rapid eye movements during sleep.   How it works is not understood.

Chapter 16 – Learning to inhabit your body: Yoga

Focuses on the need to become safe in your body before being able to go back to explore your experiences.   The connection between breathing and heart rate variations, (a bottom-up regulation approach), and PTSD was first published by van der Kolk and collaborators in 2014.

Chapter 17 – Putting the pieces together: Self-leadership

Addresses the reality that the person with DTD primarily needs to do the work to heal, rather than getting fixed by a professional.

Chapter 18 – Filling in the holes: Creating structures

The focus is on PBSP (Pesso Boyden System Psychomotor) therapy, a partially scripted small group theater where one person is the protagonist, who is the focus of the process, which is claimed to access the protagonist’s amygdala.   The ‘witness’ asks the protagonist to describe some portion of their past experience, which the witness reflects back to their description in a supportive manner.    The witness then asks specific members of the group to represent various people in the protagonist’s story and exploration of the story continues.

Van der Kolk became a Pesso student and later when he was the protagonist and furniture rather than people were the only participants other than Pesso.  It is a method of rescripting your life by revisiting your past.

Chapter 19 – Applied neuroscience: Rewiring the fear-driven mind with brain/computer interface

Brain waves research demonstrates that all parts of the brain normally synchronize to extract the meaning of new information received but the brain waves of people with PTSD are less coordinated.  Van der Kolk describes the use of a neurofeedback to help the brain focus and calm the fear center which decreases trauma-based problems and improves executive function.

Chapter 20 – Finding your voice: Communal rhythms and Theater

Our sense of agency, how much we feel in control, is defined as our relationship with our body and its rhythms.   Collective movement and music create a larger context for our lives, a meaning beyond our individual fate.    Traumatized people are terrified to feel deeply and afraid of conflict.

Theater programs for angry frightened people have demonstrated great possibilities to help them embody their experiences and become competent.    Van der Kolk describes several variations that have been effective.

Epilogue: Choices to be made

Poverty, unemployment, social isolation, inferior schools, availability of guns, and substandard housing are all breeding ground for trauma.   Child abuse and neglect is the single most preventable cause of mental illness and a significant contributor to major lifestyle diseases and death.   The greatest hope for traumatized, abused, and neglected children is to receive a good education in schools where they are seen and known, where they can learn to regulate themselves and develop a sense of agency.   Feeling safe with other people defines mental health.  Trauma is now our most urgent public health issue.