Survivors of trauma are underserved by current diagnoses.

Van der Kolk argues that individuals who have experienced trauma are often misdiagnosed with a host of comorbid labels (such as bipolar disorder, depression, and attention-deficit/hyperactivity disorder, or ADHD) that attempt to treat merely the symptoms but not the source of their problems. A correct diagnosis is vital to ensuring that a patient receives the proper care, because improper treatment may have devastating consequences, as discussed in Chapter 9. In order for a new diagnosis to be recognized, it must be accepted widely by both the psychiatric community and a reputable organization, such as by inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Van der Kolk successfully campaigned for PTSD to be included in the DSM-III in 1980. He has also supported proposals for the inclusion of C-PTSD and developmental trauma disorder, or DTD, in newer editions of the DSM, but so far, these diagnoses have been rejected and argued to be unnecessary. The process of submitting DTD for inclusion in the DSM is detailed in Chapter 10.

The goal of trauma therapy is integration.

Van der Kolk proposes that the key issue that trauma survivors face is an inability to distinguish the past from the present. Cases such as that of Stan and Ute Lawrence in Chapter 4 demonstrate that during flashbacks or other instances of reliving trauma, the same emotions (such as panic, grief, and fear) and physiological effects (such as elevated heart rate, rapid breathing, or dissociation) that occur during a traumatic incident are experienced once again in the moment of reliving.  In the case of flashbacks, which can occur at any time, either randomly or because of a trigger, the effects can be devastating because of their unpredictability, frequency, and intensity, as seen with Vietnam veterans Bill and Tom in Chapter 1.

The key component to understanding why reliving past trauma can result in the same physiological changes is in the brain. As explained in Chapter 4, certain key brain systems are shown to be offline or going haywire in individuals with PTSD or other trauma related conditions. Hyperactivation often occurs in the amygdala (the emotional center of the brain that creates stress responses). Deactivation occurs in the dorsolateral prefrontal cortex (which controls the brain’s sense of time) and the thalamus (which is responsible for the parts of memory related to our sense). With the combination of activation and deactivation in these different parts of the brain, survivors of trauma have increased stress responses, an inability to distinguish between past and present events on a biological level, and a jumbled mess of sensations related to the trauma, not a complete narrative of events. In order to help cope with these traumatic memories, then, traumatic memories must be processed when these different areas of the brain are functioning properly and the patient is properly grounded in the present. Only then can the patient integrate the traumatic memory as part of their past and not their present.

Trauma has lasting physiological effects on survivors.

Trauma leaves its mark not only the mind of a survivor, but upon their body as well. Lasting physiological changes often begin in the brain, with the innate alarm systems meant to keep each person safe going into overdrive, resulting in hypervigilance and paranoia. Activity in the medial prefrontal cortex, the “watchtower” of the brain and logic center which is responsible for calling off unnecessary stress responses, is disrupted by an overactive amygdala, the “smoke detector” and emotional center of the brain responsible for identifying threats and activating the stress response, as explained in Chapter 4. In traumatized individuals, the amygdala may identify threats when none are actually present, creating a stress response regardless, with the medial prefrontal cortex often unable to override the amygdala’s judgment. These changes in the brain’s function can lead to a whole host of other problematic symptoms, such as flashbacks, irritability, explosive outburst, emotional numbing, issues with attention and concentration, nightmares, dissociation, depersonalization, alexithymia, and the possibility of other comorbid conditions, such as borderline personality disorder.

The rest of the body does not escape trauma unscathed, either. Essential functions of life, such as sleep, may be disrupted by continuous stress responses, and over time, different systems within the body may begin to weaken as a result. In Chapter 8, one such consequence was studied by van der Kolk and his colleagues Scott Wilson and Richard Kradin. A study of incest survivors showed that their immune systems were overly defensive, due to a misbalanced ratio of memory cells, and may falsely sense a threat when there is none and attack the body itself. The body may also be injured by the individual themselves via destructive coping mechanisms used to deal with the mental distress of trauma, including self-harm, substance abuse, risk-taking, and suicidal tendencies.

A holistic approach should be taken to trauma therapy.

Van der Kolk argues that medication is often prescribed inappropriately and ineffectively, being used as a front line or sole source of treatment in situations where it may be ineffective or even harmful. In Chapter 13, van der Kolk discusses how medications may often only be effective at dampening symptoms, but will never fully treat trauma. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have mixed, but generally positive results with patients. Medications that calm the autonomic nervous system may be helpful as well, but are not more or less effective than other forms of therapy. Tranquilizing medications may lead to addiction, and antipsychotic medications, while providing the desired calming effect, can also dull the patient’s senses and emotions, and, especially in children, may reduce social skills and important learning processes. Furthermore, as discussed in Chapter 2, the same medication may not be helpful for all: combat veterans were found to rarely benefit from Prozac, an SSRI, while civilians did benefit.

Instead, van der Kolk suggests alternative forms of therapy that target the source of the patient’s discomfort, their trauma, and not just the symptoms. Processing and integration of traumatic memories is the main goal of trauma therapy, and may be achieved in several ways. Eye movement desensitization and reprocessing, or EMDR, use rapid eye movements and vocal cues to allow a patient to process traumatic memories completely internally via loose association between images. Yoga seeks to improve mindfulness and restore the mind and body connection, allowing patients to be aware of the physicality of their trauma and the areas in which it and its effects are stored. Internal family systems therapy has that patient recognize the different parts of their mind that serve as protectors or are exiled from their core Self, and to understand how these parts work in relation to each other. Psychomotor therapy treats patients via creating 3D structures, or representations, of their traumatic past using other people or objects, and to be able to visualize and interact with their past in this manner. Neurofeedback measures electrical activity within the brain and modifies it, encouraging new brainwave patterns that may help patients better self-regulate. Participation in theater and other communal rhythms has a multitude of benefits, from increased socialization to an increased sense of agency.

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