Dr. van der Kolk, who has worked with trauma patients for his entire career, shares his knowledge about trauma's influence on the body and the brain, and the interconnection between both. In the "nature vs. nurture" argument, he (indirectly) seems to take a firm stance that nurture is possibly a lot more important than nature. van der Kolk argues that childhood abuse is perhaps one of America's biggest public health crises right now, and something that is not getting as much support and attention as it should.

Through the book, he shares first-hand stories of the trauma patients he has worked with, the different treatments he has tried, and his learnings from all of these experiences. He starts with his initial work with Vietnam War veterans, and the difference between those who experience trauma as adults (i.e. war, car accidents, loss of family members) and those who experience trauma in childhood (this affects the development of your brain in very negative ways)

---

Overall: I learned a lot about trauma. This book has convinced me in the "nature vs nurture" debate that perhaps nurture has more of an influence than we think. It almost seemed like Kolk's (indirect) message was that nurture is possibly a lot more important than nature. Kolk's argument is that childhood abuse is perhaps one of America's biggest public crises right now, and something that is not getting as much support as it should. A lot of psychiatrists or doctors resort to prescribing pills but that is not always the best solution for things like this.

Notes

There is a lot we do not know about trauma

• "We had only one real textbook... our patients. We should trust only what we could learn from them - and from our own experience... The greatest sources of our suffering are the lies we tell ourselves" (11) (Elvin Semrad)
• The imprecision of psychiatric labels
  • 82 percent of traumatized children do not meet PTSD diagnostic criteria
    • traumatized children often shut down, suspicious, aggressive, and so get diagnoses like "oppositional defiant disorder" (159)
    • "impressive but meaningless labels"
  • We need new vocabulary other than "victim or perpetrator"

Public Health Problem

• Child abuse is our nation's largest public health problem (150)
  • unchecked cycle of violence
  • "Bad genes?"
    • "We have failed to find consistent genetic patterns for schizophrenia - or for any other psychiatric illness, for that matter" (154)
    • "It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed..." (154)
    • Epigenetics - genes alone are not deterministic!!!
    • "Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world" (154) (Moshe Szyf)
• "I wish i could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. In today's world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life" (350)
• 70% of prisoners in California spent time in foster care growing up

"Trauma breeds further trauma; hurt people hurt other people" (350)

• "I like to believe that once our society truly focuses on the needs of children, all forms of social support for families - a policy that remains so controversial in this country - will gradually come to seem not only desirable but also doable" (352)
• "Trauma is now our most urgent public health issue, and we have the knowledge necessary to respond effectively. The choice is ours to act on what we know" (358)

Symptoms of Trauma, stemming from observation

• Many lose the capacity to let their minds play (ex: Looking at Rorschach tests, losing their imagination, only seeing the same things)
• "Trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe" (61)
• In PTSD critical balance between amygdala (smoke detector) and MPFC (watchtower) shifts ... harder to control emotions and impulses
• "The threat-perception system of the brain has changed, and people's physical reactions are dictated by the imprint of the past" (67)
• Brain-body disconnect
  • i.e. when you are young and you never learn to regulate your feelings (when hungry, cold, scared, etc) because you don't have parental figures to offer that emotional support. then you need to discover other ways to take care of yourself - drugs, alcohol, binge eating, cutting - anything to offer relief (90)
• Lack of self-awareness common in victims of chronic childhood trauma
  • Often cannot recognize themselves in the mirror... Brain scans show that structures in charge of self-recognition may be knocked out along with structures related to self-experience (94)
  • Brain and body are tightly knit ecoystem!
• Alexithymia: No words for feelings (100)
  • Many traumatized people cannot describe what they are feeling because they cannot identify what their physical sensations mean
• Being frightened, always on guard
  • "Angry people live in angry bodies" (102)
  • Bodies of child-abuse victims are tense and defensive until they find a way to relax and feel safe
  • DRUGS - drugs often blunt sensations, rather than teaching people the skills to deal with distressing physical reactions (103)
• Pervasive biological and emotional dysregulation, failed or disrupted attachment, problems staying focused and on track, and a hugely deficient sense of coherent personal identity and competence (168)
• Trauma is not just an issue of being stuck in the past, it is as much a problem of not being fully alive in the present (223)
• "Many behaviors that are classified as psychiatric problems, including some obsessions, compulsions, and panic attacks, as well as most self-destructive behaviors, started out as strategies for self-protection" (280)
  • "Viewing these symptoms as permanent disabilities narrows the focus of treatment to finding the proper drug regimen, which can lead to lifelong dependence — as though trauma survivors were like kidney patients on dialysis" (280)
  • Trauma is NOT a permanent disability!
  • "It is more productive to see aggression or depression, arrogance or passivity as learned behaviors" (280)

Treatment

• "People can never get better without knowing what they know and feeling what they feel" (27) (Elvin Semrad)
• The triumph of pharmacology (and the limitations of drugs in solving PTSD)
  • "In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues" (36)
    • reminds me of geriatrics
    • "The brain-disease model takes control over people's fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems" (37)
  • Too much money spent on antidepressants and antipsychotics
    • 1 in ten Americans take antidepressants (37)
    • Medicaid spends more on antipsychotics than on any other class of drugs (37)
    • In 2008, 19045 children age five and under were prescribed antipsychotics through Medicaid (37)
• Therapists:
  • Can help assist people mindfully observe emotions and sensations, help them get in touch with context from which they emerge
• Humans are social creatures. We need social support (81)
  • Reciprocity: being truly heard and seen
  • "No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities" (81)
• Recovery
  • Reestablish ownership of your body and your mind - of your self (205)
    • feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, collapsed
  • Mindfulness as lens for scattered energies of your mind and focusing them into coherent source of energy (211)
  • Treating Holocaust survivors with LSD (225)
• Too much money spent on drugs
  • Departments of Defense and Veterans Affairs combined spent over 4.5 billion on antidepressants, antipsychotics, and antianxiety drugs over past decade
  • But drugs cannot "cure" trauma
  • they only dampen the expressions of a disturbed psychology
  • they do not teach the lasting lessons of self-regulation (226)
  • children from low-income families are 4 times as likely as the privately insured to receive antipsychotic medicines (228)
  • Texas Medicaid spent 96 million on antipsychotic drugs for teenagers and children in one year - including 3 infants
• EDMR - Eye Movement Desensitization and Reprocessing - surprisingly works very well
  • One study showed that a "focused, trauma-specific therapy like EDMR could be much more effective than medication" (256)
  • works better for stuck traumatic memories vs. effects of betrayal or abandonment from chronic child abuse
  • EDMR integrates (rather than desensitizes) people to traumatic material
  • "Focusing not only on regulating the intense memories activated by trauma but also on restoring a sense of agency, engagement, and commitment through ownership of body and mind" (258)
  • Reminded me, actually, of the methods for getting rid of Boggarts (esp. p 261 - "everybody's making fun of him")
    • "activate a series of unsought and seemingly unrelated sensations, emotions, images, and thoughts in conjunction with the original memory... Reassembling old information into new packages" (261)
  • Related to REM sleep?
  • We don't know how EDMR works but "the same is true of Prozac" (264). We also don't know really how Prozac works. Just because it is a pill doesn't mean it is a cure-all. It is just packaged, that is all.
• Yoga
• IFS - internal family systems therapy. Dissociation occurs on a continuum. When we are abused the parts that are hurt the most become frozen.
  • Role of therapist = "to collaborate rather than to teach, confront, or fill holes in your psyche" (284)
  • Mindful self-leadership
• Filling in the holes - Creating structures
  • revising the past, rescripting your life
• EEG to look at brain
  • Trauma brain - "Their brains are not organized to pay careful attention to what is going on in the present moment" (313)
  • Neurofeedback
• Using theater
  • i.e. in Greek drama, Athens was at war a LOT of the time.
  • treating trauma through theater
  • "Being able to perform becomes the critical issue: Competence is the best defense against the helplessness of trauma" (343)
• A lot of psychiatrists just prescribe drugs
  • "Such shortcuts in treatment make it impossible to develop self-care and leadership" (351)
  • "Rampant prescription of painkillers, which now kill more people each year in the United States than guns or car accidents" (351)
  • "Our increasing use of drugs to treat these conditions doesn't answer the real issues: What are these patients trying to cope with? What are their internal or external resources?" (351)

Child Abuse

• For every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes" (21)
• Often, underlying trauma is obscured by a blizzard of diagnoses (i.e. conduct disorder, bipolar disorder, ADHD, etc) (111)
• Childhood
  • "Our most intimate sense of self is created in our minute-to-minute exchanges with our caregivers" (111)
  • Bowlby (British psychoanalyst from 1940s) - "children's disturbed behavior was a response to actual life experiences — to neglect, brutality, and separation — rather than the product of infantile sexual fantasies" (112)
    • "Attachment theory"
    • Vs. Freud's theory
  • Need parents to teach us self-regulation, how to manage arousal
  • Emotional withdrawal from parents is worse than hostile or intrusive behavior (122)
• "Children are programmed to be fundamentally loyal to their caretakers, even if they are abused by them" (135)
• "Different forms of abuse have different impacts on various brain areas at different stages of development" (142)
• Childhood trauma different from veteran trauma
  • "Childhood trauma has prevented them from developing some of the mental capacities that adult soldiers possessed before their traumas occurred" (144)
• Childhood trauma is far more common than expected
  • ACE study (Adverse Childhood Experiences)
    • Higher prevalence in women (66 percent) than men (35 percent) for chronic depression
    • Abused or neglected girls are more likely to be raped later in life (148)
• Child abuse is our nation's largest public health problem (150)
  • unchecked cycle of violence
  • "Bad genes?"
    • "We have failed to find consistent genetic patterns for schizophrenia - or for any other psychiatric illness, for that matter" (154)
    • "It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed..." (154)
    • Epigenetics - genes alone are not deterministic!!!
    • "Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world" (154) (Moshe Szyf)
  • "I wish i could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. In today's world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life" (350)
• Young monkeys taken away from mothers at birth and brought up solely with their peers → desperately cling to one another and do not engage in healthy exploration and play (156)
  • they grow up uptight - scared in new situations and lacking in curiosity
  • "Regardless of their genetic predisposition, peer-raised monkeys overreact to minor stresses" — more cortisol in response to loud noises
  • "Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem" (156)
  • Important — "Safe and protective early relationships are critical to protect children from long-term problems"
  • Thus trauma is generational
• "To fully understand how we become the persons we are — the complex, step-by-step evolution of our orientations, capacities, and behavior over time — requires more than a list of ingredients, however important any one of them might be. It requires an understanding of the process of development, how all of these factors work together in an ongoing way over time" (186)
• In the US we NEED more social support for children (170)
  • 70% of prisoners in California spent time in foster care growing up
  • What is wrong with the US
  • US spends 84 billion per year to incarcerate people, at about 44K per prisoner... northern European countries spend a fraction of that amount and instead invest in helping parents raise their children in safe and predictable surroundings

• "Chronic childhood abuse causes very different mental and biological adaptations than discrete traumatic events in adulthood" (257)

Mindfulness

• Being able to hover calmly and objectively over our feelings, thoughts, emotions
• Two distinct forms of self-awareness: "one that keeps track of the self across time and one that registers the self in the present moment" (238)

Brains

• Right brain - intuitive, emotional, visual, spatial, tactual. Remembers more memories of sound, touch, smell, and the emotions they evoke
• Left brain - linguistic, sequential, analytical. Remembers more facts, statistics, vocabulary of events
• Trauma - often, deactivation of the left hemisphere (esp Broca's area) ... makes it hard to order events into logical sequences... "experiencing the los of executive functioning" (45)
  • "Because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past" (45)
  • Stuck in fight or flight... "Drugs and medication can temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score" (46)
• Brains are built to help us function as members of a tribe
  • "Most of our energy is devoted to connecting with others" (80)
• "The brain is a cultural organ - experience shapes the brain" (86) (Ed Tronick)
• Michael Gazzaniga - mind as a kind of society
  • Mind as composed of semiautonomous functioning modules, each of which has a special role (282)
  • Marvin Minsky - "The legend of the single Self can only divert us from the target of that inquiry... It can make sense to think there exists, inside your brain, a society of different minds" (283)

The Imprint of Trauma

• Autobiographical memories are not precise reflections of reality - "they are stories we tell to convey our personal take on our experience" (177)
• Grant Study of Adult Development - followed Harvard men from 1940s to present. Interviewed about detail about their war experiences in 40s and then again in 90s. 4.5 decades later, majority gave very different accounts between time periods... events often bleached of intense horror
• "Narrative memory" vs. "Traumatic memory" (181)
  • Dissociation
  • Normal memory - integrates elements of each experience into continuous flow of self-experience
  • Normal memory - has a beginning, middle, end (195)
  • Traumatic memory - disorganized
• Freud: "He reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering" (183)
• Body keeps the score: World War 1 soldiers: facial tics, collapse with paralyzed bodies... vietnam soldiers: cringes, stomachs upset, hearts race, overwhelmed by panic
• Repressed memories
  • Memory of trauma can be repressed and resurface years or decades later (192)