The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Van der Kolk defines agency as “the technical term for the feeling of being in charge of your life” (97). Agency means “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” (97). Loss of agency is a key factor in trauma. Both adults and children who have been traumatized experience a lack of agency, which leads to feeling like they don’t know themselves and have no control over their lives. 

Literally translated from Greek as “not having words for feelings” (100), alexithymia is the inability to describe feelings. Van der Kolk observes that “people who suffer from alexithymia tend to feel physically uncomfortable but cannot describe exactly what the problem is” (275). Alexithymia represents an extreme form of the disconnection between brain and body many traumatized people experience. This phenomenon can improve when patients learn to reconnect mind and language to physical sensation that. 

The amygdala, which van der Kolk also refers to as the “smoke detector,” is the part of the limbic system that identifies “whether incoming input is relevant for survival” (60). Like a smoke detector, the amygdala reacts when it senses potential danger, flooding the body with stress hormones that “prepare the body for fight or flight” (42). In traumatized people, the amygdala is often constantly on overdrive, reacting to everything as a threat, which causes a host of other mental and physical issues and makes connection with others difficult. 

Also called “ambivalent attachment,” anxious attachment is a less than ideal, but still functional, attachment strategy in John Bowlby’s attachment theory. This type of attachment, described as “feeling but not dealing” (118), causes infants to be overly emotional in response to their mother being gone, but not comforted by her being present. Like avoidant attachment, this strategy can negatively impact how a person relates to others as they get older. 

John Bowlby developed attachment theory in the 1940s. He was shunned for suggesting that “children’s disturbed behavior was a response to actual life experiences […] rather than the product of infantile sexual fantasies” (112). Attachment theory postulates that babies learn how to be in sync with their environments from their relationships with their mothers, and that these early interactions can determine how a person will interface with the world for the rest of their lives. Secure attachment is the goal, in which parent and child are attuned to each other. Avoidant attachment, anxious or ambivalent attachment, and disorganized attachment are less positive possibilities. 

The ANS regulates bodily functions, acting primarily without a person being consciously aware of its activity. It is comprised of two branches, the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS), which act as the accelerator and brake for the functions the ANS controls. The SNS “is responsible for arousal, including the fight-or-flight response” (79), while the PNS “promotes self-preservative functions like digestion and wound healing” (79). The SNS and PNS are directly connected to inhalation and exhalation, which makes activities that teach awareness and breath control helpful for helping calm a system in panic mode. By focusing on exhalations, a person can activate their PNS to flood their body with hormones for relaxation and potentially work through feelings of anxiety. 

One of the less than ideal, but still functional, attachment strategies in John Bowlby’s attachment theory, avoidant attachment is described as “dealing but not feeling” (118). In these cases, infants look outwardly seem unaffected by their mothers, but are actually affected on a deep inner level. This strategy can have long-lasting negative effects on a person’s ability to relate to others later in life. 

Bottom-up regulation is one of two options for managing emotions, and “involves recalibrating the autonomic nervous system” (63) through techniques involving breath, movement, or touch. Several of the therapy options van der Kolk recommends in Part 5 rely on bottom-up regulation—retraining the body in order to calm the brain’s responses. 

Broca’s area is a region in the left frontal lobe of the brain that is “one of the speech centers” (43). Van der Kolk observes, “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” (43). Scans showing Broca’s area going offline during PTSD flashbacks provide empirical scientific data to support the claim that flashbacks interfere with language. People with PTSD literally cannot explain in words what’s happening during a flashback because the area of their brain that controls language doesn’t work. 

A popular treatment method in psychiatry, CBT is a process “[I]n which people are repeatedly exposed to signals that remind them of past trauma until the interpretive system in their brains realizes that they are, in fact, safe” (77). While effective for treating phobias, CBT “has not done so well for traumatized individuals, particularly those with histories of childhood abuse” (223). CBT continues to be a widely-attempted treatment method for trauma even though it is clearly less effective than the therapies that van der Kolk recommends in Part 5—another example of the medical field lagging behind on trauma treatments.

DSN is the term for when a brain is idling—when people are not thinking. “Normal” brains at rest pay attention to what’s going on in the body. PTSD patients’ brains do not register any of the same activity when idle, since “their relationship with their own inner reality was impaired” (94). These findings about the DSN help provide biological explanation for why traumatized people have difficulty feeling a sense of self. 

A symptom of dissociation, depersonalization is a separation from the self after trauma, “the outward manifestation of the biological freeze reaction” (72). While “blanking out” is a survival strategy for trauma, it causes patients to be unable to “think, feel deeply, remember, or make sense of what is going on” (72). In depersonalization, the whole brain essentially goes dark from lack of activity—as with van der Kolk’s patient Ute, who was in a terrible car accident. 

The result of four years’ of work by 12 clinicians/researchers, DTD is what van der Kolk and his colleagues hoped would become a new DSM diagnosis for traumatized children. DTD means a child has “a pervasive pattern of dysregulation, problems with attention and concentration, and difficulties getting along with themselves and others” (160). Despite considerable time and effort, and support from mental health commissioners all over the country, the DSM rejected DTD because “no new diagnosis was required to fill a ‘missing diagnostic niche’” (161). Van der Kolk’s cites trying to get DTD classified as a diagnosis as a striking example of the medical field failing to adequately help traumatized individuals. 

The DSM is essentially the bible of psychiatry, an “official list of all mental disease recognized by the American Psychiatric Association” (139). The DSM wields considerable influence: “Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories” (139).

Without an accurate diagnostic category in the DSM, a clinician may not be able to help a patient. For van der Kolk, this happens with children and Developmental Trauma Disorder. Van der Kolk mentions repeatedly that the DSM is a failure, having become primarily a moneymaking endeavor that perpetuates treating all mental illnesses with medications. 

Intended as a diagnosis for “victims of interpersonal trauma” (145), DESNOS describes patients with trauma who do not fit the diagnosis of PTSD. Van der Kolk attempts unsuccessfully to have DESNOS added to the fourth edition of the DSM, even after his work group votes overwhelmingly to include it. Due to its exclusion, psychiatrists must continue to treat non-PTSD patients by categorizing them incorrectly and ignoring the underlying causes of their mental and behavioral issues. 

Disorganized attachment is the worst-case scenario in Bowlby’s attachment theory, which van der Kolk calls “fright without solution” (119). Most of the children and many of the adults in psychiatric clinics have this form of attachment, which arises when “caretakers themselves were a source of distress or terror” (119). An unstable environment where the caretaker is a source of stress leaves children without a way to navigate the world, which in turn has lasting repercussions. Children subjected to this kind of upbringing do not develop the skills or instincts to connect meaningfully with others. 

In van der Kolk’s words, “dissociation is the essence of trauma” (66). Dissociation is the separation from normal mental processes that causes the fragmentation of thoughts and feelings characteristic of most trauma. Traumatized people feel disconnected from themselves and the world around them, which reinforces their feelings of fear or isolation. An essential aspect of treating traumatized individuals is bringing them back to conscious awareness of themselves and others. 

An EEG measures brain waves using electrodes attached to a person’s head. Different types of brain waves correspond to different types of mental activities, and “[e]ach line on an EEG charts the activity in a different part of the brain: a mixture of different rhythms, ranged on a scale from slow to fast” (322). The EEGs of traumatized people show that “brain waves of traumatized subjects were more loosely coordinated and failed to come together into a coherent pattern” (313). Understanding brain waves gave rise to neurofeedback therapy, where therapists track what’s happening in a patient’s brain as they provide electrical signals to change the patterns. 

Composed of the reptilian brain that controls basic functioning and the limbic system, the emotional brain “is at the heart of the central nervous system, and its key task is to look out for your welfare” (57). The emotional brain processes information and generates automatic physiological reactions. Traumatic reactions largely happen in the emotional brain, and trauma in general involves the balance between emotional and rational brains shifting too far in the emotional brain’s direction, resulting in adrenaline-driven responses to stimuli rather than rational responses. 

Covered in Part 5, EMDR involves a therapist moving fingers in front of a patient’s eyes while asking them to notice what’s happening internally as they follow the fingers. While the underlying scientific mechanisms are still unexplained, researchers believe EMDR helps mimic REM sleep, essentially putting a patient into a dreamlike state where they can process information safely. EMDR is especially interesting as a treatment method because it “enables [people] to observe their experiences in a new way, without verbal give-and-take with another person” (255), indicating that EMDR could help even those who never feel comfortable opening up. 

Part of the rational brain, the frontal lobes “are responsible for the qualities that make us unique within the animal kingdom” (58)—in other words, they are the source of higher thinking. Van der Kolk calls the frontal lobes the “watchtower,” the part of the brain making informed judgments about the sensory information we receive. In an ideal brain, the frontal lobes and amygdala are balanced. In a traumatized brain, the amygdala tends to overwork, leaving the frontal lobes underperforming. Part of trauma treatment is getting the frontal lobes to do their share assessing sensory information. 

HRV measures the balance of “accelerator” and “brake”—the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS). Van der Kolk points out that “people with PTSD have unusually low HRV” (269), which is why traumatized people tend to overreact to stressors. Effective trauma treatment involves getting the SNS and PNS back in sync, improving HRV as well. 

Hysteria is one of the first scientific terms for what eventually became PTSD. In the late 19th century, psychiatrists Jean-Martin Charcot, Pierre Janet, and Sigmund Freud examined hysteria as “a mental disorder characterized by emotional outbursts, susceptibility to suggestion, and contractions and paralyses of the muscles that could not be explained by simple anatomy” (179). 

Inescapable shock is a key component of trauma. It is “a physical condition in which the organism cannot do anything to affect to inevitable” (78). Inescapable shock creates learned helplessness—a trait common to many trauma sufferers, which contributes to a pattern of being retraumatized. 

IFS flows out of the idea that everyone’s personality is split into subpersonality parts that perform different functions. Exiles are the traumatized parts, managers the critics, and firefighters the panic system. These parts are essential to normal function, but when a single part dominates, it interferes with a person’s ability to interface with themselves and others. IFS involves recognizing parts for the jobs they do, thanking them, and allowing the vulnerable parts to heal. 

The left brain is “linguistic, sequential, and analytical” (44), and controls most of how a person communicates with the outside world. The left brain also “remembers facts, statistics, and the vocabulary of events” (44-45). In trauma, the left brain mostly shuts down, cutting off a person’s ability to make sense of the sensations they feel or to give words to their feelings. 

The limbic system is part of the emotional brain. It sits above the reptilian brain and 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” (56). Together with the reptilian brain, the limbic system controls how we respond to sensory input; it becomes overactive in traumatized individuals.  

In van der Kolk’s definition, mindfulness is “[b]eing able to hover calmly and objectively over our thoughts, feelings, and emotions” (62). It promotes awareness of the self and “has been shown to have a positive effect on numerous psychiatric, psychosomatic, and stress-related symptoms” (211). Many of the therapies that van der Kolk uses in his treatments and recommends to others involves some component of mindfulness, as reconnecting with oneself can combat dissociation. 

Mirror neurons in the brain mimic the actions and emotions of those around us. These neurons form the basis of “empathy, imitation, synchrony, and even the development of language” (58). Synchrony is critical for feeling in tune with others and ourselves. In trauma, synchrony dampens, causing disconnected feelings. 

Established by Congress in 2001, the NCTSN is a “comprehensive organization dedicated to the research and treatment of traumatized children” (157). Van der Kolk was part of a group of researchers that founded the NCTSN to improve treatment for traumatized children and establish diagnoses and therapies that will treat their actual problems rather than surface issues. 

Neurofeedback is one of the therapies van der Kolk describes in Part 5. It “nudges the brain to make more of some frequencies and less of others, creating new patterns that enhance its natural complexity and its bias toward self-regulation” (315). Van der Kolk adds, “Neurofeedback changes brain connectivity patterns; the mind follows by creating new patterns of engagement” (322). Changing brain waves benefits traumatized patients, improves performance in sports and art, might counter learning disabilities, and could treat addictions. 

Neurotransmitters are “chemical messengers that carry information from neuron to neuron” (29), making them an essential part of the nervous system. Most psychotropic medications work by affecting a particular neurotransmitter. Modern psychiatry focuses more on using medications that change neurotransmitter levels than any other form of treatment. 

In 1980, the DSM defined a patient with PTSD as:

A person is exposed to a horrendous event ‘that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,’ causing ‘intense fear, helplessness, or horror,’ which results in a variety of manifestations: intrusive re-experiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability) (159).

This definition allowed therapists to name the experiences of many combat veterans and rape and domestic abuse survivors, leading to new and better treatments. However, PTSD does not adequately cover all trauma, which has led to other traumatized people being misdiagnosed and mistreated. 

Psychomotor therapy is one of the treatments van der Kolk recommends in Part 5. It involves building three-dimensional “structures” that represent the unconscious feelings of a “protagonist,” who is supported by a “witness” who validates their feelings and “contact persons” who represent people in their lives. These structures allow traumatized individuals to externalize their experience and create new, safer memories alongside their existing traumatic ones, offering a new way for their brain to consider their trauma. 

Also known as the neocortex, and consisting primarily of the frontal lobes, the rational brain “is primarily concerned with the world outside us” (55). In trauma, the rational brain tends to shut down, while the emotional brain goes into overdrive. 

Repressed memories are traumatic memories that a person literally cannot remember. They may surface years after being formed in response to specific triggers, and “[t]otal memory loss is most common in childhood sexual abuse” (192). Van der Kolk has personally testified in court as to the validity of repressed memory, but many people still deny its existence, even in the face of numerous scientific publications that document it.  

The oldest part of the brain, 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” (56). The reptilian brain is part of the emotional brain that becomes overactive in response to trauma. 

Different parts of the brain control different aspects of our mental processing. The right brain is “intuitive, emotional, visual, spatial, and tactual” (44). Van der Kolk adds, “The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants” (44). In traumatized people, the right brain overreacts as though the event were happening in the present, which in turn affects how the person interprets what’s going on around them. 

In attachment theory, secure attachment is ideal: Mother and baby are attuned to each other, feel comfortable with each other, and can recover quickly in each other’s presence from moments of distress. Van der Kolk notes: “Safe and protective early relationships are critical to protect children from long-term problems” (156). 

Like hysteria, shell shock is a diagnosis of trauma before the term PTSD existed. Seen primarily around World War I, shell shock negatively impacted soldiers on both sides of the war, to the point where army leaders denied it existed and claimed that shell shock was merely a sign of “undisciplined and unwilling soldiers” (187). Such public reactions to shell shock are an example of how resistance to trauma as a diagnosis has persisted through history. 

The thalamus is an area inside the limbic system of the brain that van der Kolk nicknames the “cook,” as it “stirs all the input from our perceptions into a fully blended autobiographical soup” (60). Once sensations are processed, the thalamus sends information to the amygdala and neocortex for further processing, making it essential to how people perceive the world. 

Top-down regulation is a strategy for overcoming trauma that “involves strengthening the capacity of the watchtower to monitor your body’s sensations” (63). Top-down regulation treatments focus on improving the rational mind’s ability to regain control when the emotional brain goes into overdrive.