The Body Keeps Score

Book Summary, and the Role of Trauma in Eating Disorders

The Body Keeps the Score is a New York Times bestselling book by Dr. Bessel Van Der Kolk, a Boston-based psychiatrist who has been researching the effects of trauma for decades. Since I refer to this book often in my clinical practice (and everyday life), I thought it would be useful to provide a summary that could be used by patients and providers alike.

We’ll cover four main areas:

  1. What is Trauma?
  2. How trauma affects the body, brain, and personality.
  3. Moving beyond trauma — healing and regaining stability. What can you do?
  4. The role of Trauma in Eating Disorders.

What is Trauma?

Dr. Van Der Kolk defines trauma as:

”an overwhelming experience that deeply disturb us inwardly and continues to negatively affect how we view and relate to ourselves, and to everything else in our world.”

Traumatic experiences often involve visible physical wounds that heal over time. They can also produce deep and debilitating psychological damage that can affect survivors for a lifetime, if not addressed and healed. Unhealed trauma can interfere with daily functioning in numerous ways by affecting our brains, emotions and our bodies. The symptoms are varied and numerous but often include emotional numbness, hyper vigilance, and fear. Limited functioning, and greatly diminished capacity for joy and connectedness with themselves and others is also typical. Physically, traumatic stress manifests in the body by weakening and compromising the immune system, causing fatigue and creating stress related illness and disease.

The Domino Effect of Trauma

Trauma not only affects the victims, it also has the capacity to seep out and spill over into the lives of others.

Unhealed traumatized people can and do traumatize others around them. This can occur intentionally or unwittingly, but can have the same wounding impact in either situation. For some of you who are married to men who have been traumatized in their childhood, their unhealed trauma impacts you and your children. In this way, the effects and impact of traumatizing events compound and adversely affect scores of others lives not directly involved in the precipitating, triggering experience.

A Modern Look at an Age Old Problem

According to Dr. Van Der Kolk, Trauma has been traditionally viewed in the following overly simplified ways:

  • As an inability to forget and let go of bad memories.
  • Changes in brain chemistry that deplete “feel good” hormones.
  • Alterations in the fear circuitry in our brain, producing over sensitized fight or flight responses.

Significant advances in medications were thought to be the solution to these and many related issues. Modern technology however, continued to allow much closer inspection of brain activity in real time. This has enabled us to see and learn how the brain and the body operate separately, as well as how they affect and respond to one another. Technology has also revealed that previously held views about trauma were in fact overly simplistic, and insufficiently understood to provide effective solutions. These outdated views were also inadequate to account for the reality that many traumatized people are unable to return and function in their lives in any semblance of normal or healthy ways. As recently as 1980, the medical community officially identified what we know today as PTSD — Post Traumatic Stress Disorder. This diagnosis refers to a cluster of symptoms, first identified in war veterans and evident among them in varying degrees. Today, PTSD is also used to identify trauma victims, with similar symptoms, among increasing numbers of non-war related segments of the general population, especially victims of chronic abuse.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5), May 2013, American Psychiatric Association

How Trauma Affects the Brain, Body and Personality

Two Pathways

Most people are aware that under stressful situations our bodies activate a defense mechanism called the Fight or Flight response. Denial is an alternative defensive response that likewise helps us cope with overwhelming situations and experiences where we refuse to integrate the reality around us. These two responses operate very differently, but with the same end in mind; to enable us to manage and survive events that threaten and endanger us physically, emotionally or mentally.

We are hard wired to survive.

Pathway #1: Fight or Flight

Prepares us to either engage the threat or to escape from it. Is located on the right side of our brains and when activated, hormones are released including large doses of adrenaline and other chemical. This fuel provides the focus, energy and strength needed to respond by fighting against or fleeing from (real or perceived) danger. When we are prevented from fight or flight (either by being captured or held down), or can’t escape because we freeze, this becomes more traumatic to our sense of self and shame and a overwhelming sense of powerlessness and shame linger.

Pathway #2: Denial

This response allows us to consciously deny that anything dangerous or traumatic is actually happening to us. Denial however, does not stop our bodies from reacting to the threat subconsciously. The flight and fight mechanism is still activated (along with the corresponding release of chemicals needed to respond.) However the conscious mind minimizes or ignores the threat altogether, as well as the bodily sensations triggered by the “silent” alarm.

Denial is useful in certain settings, allowing us to postpone processing something until we feel more prepared to do so (as in grief that is not immediately felt). However, when denial as a protective mechanism continues too long, it carries its own kind of trouble.

Flashbacks

Trauma survivors are often trapped by in a painful feedback loop, frequently experiencing frightening, intrusive fragments of their trauma, called flashbacks. They have no control over where or when flashbacks may occur, or how long they may last, creates intense fear and loss of control. These mental “snapshots” cause the same intense mental and physical reactions in us as the original experience. The episodes trigger our threat detection system (located in the brain) when our brains perceives that sensory input (from our present daily lives) is “the same as” or similar enough to the original event where the “mental photographs” were initially taken.

During the initial trauma and subsequent triggering events, the body is flooded with chemicals to equip us to either fight or flee. When we do neither, (because there is no actual threat in a flashback) but rather the “unused” chemicals remain trapped in the body and become toxic and harmful, rather than life saving. Dr. Van Der Kolk says,

“The physical effects on the organs go on unabated until they demand attention in the form of illness or disease. Medications, drug and alcohol use and abuse are often used to dull or obliterate unbearable sensations and emotions. However, the body continues to keep the score.”

Denial is more difficult to detect and treat in trauma survivors because it remains hidden and acknowledged by the victim only at the subconscious level.

Dr. Elvin Semrad, a deeply influential professor to the author of this book, says:

“So much human suffering is related to love and loss. The greatest sources of our suffering are the lies we tell ourselves.”

Denial is a lie that we initially tell to prevent ourselves from being overwhelmed by traumatic experiences. In time however, denial becomes a destructive lie that cuts us off from any awareness that we need help. We must learn to be honest about every facet of our experience. This validates the importance of committing to the truth, and no longer pretending. Dr. Semrad continues:

“People can never get better without knowing what they know and feeling what they felt. The job of the helping professions is to help people acknowledge, experience, and bear the reality of life, with all its pleasures and heartbreaks.”

Trauma Affects Both Sides of our Brain: Rational & Emotional

The left side of our brain is the rational, calculating side that enables us to speak, think, analyze and sequentially organize our experiences in a way that makes sense to us. The left side does more of the thinking and talking, the right side does more of the feeling and experiencing.

The different sides of our brain also process information differently. The left side remembers facts, statistics and gives us the words we need to use when we’re trying to explain something that happened in a sequential order. During traumatic situations, activity in the Rational Brain (left side) decreases dramatically or goes off-line altogether. This includes the area responsible for speech (Broca’s area) and explains why rational speech is difficult or non- existent for trauma survivors. Dr. Van Der Kolk says:

“All trauma is preverbal. Our bodies re-experience terror, rage, helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate. Trauma by natures drives us to the edge of our comprehension.”

Consequently, the trauma becomes “trapped” inside us with no means of expressing it and thereby expelling it. This point is very important for those of us who find ourselves “tongue tied” when frightened, or when we can’t put things into words or can’t even remember the factual details of what happened when questioned by police, family members, or treatment providers.

In the moment, your body shakes, your heart pounds, your right brain is registering “trauma” but your left brain (speech, rational thought) is temporarily unable to help you. You’re not thinking clearly (rationally) and are “reacting emotionally.” This is often why many of us feel stuck in the reactive mode when triggered.

Even years later traumatized people may still have enormous difficulty telling what happened to them. Even if they become able to speak of the experience, it is often just the “cover story, “the “safe” version, (the left brain version) initially told to explain symptoms and behaviors, to others (and even to themselves.) Inside the pages of the cover story however, there is a deeper more detailed version (right brain) that often involves deeply felt emotions, horror, revulsion, overwhelming helplessness, shame (why couldn’t I stop it, what’s wrong with me, I’m bad) etc. These aspects of the trauma — the most difficult to reach and articulate — are most essential to healing and moving toward full recovery. They are however stored in the emotional/right side of the brain.

Both sides of the brain must be engaged for full healing/recovery to occur.

The left brain develops later than the right side starting around age two and continues to develop throughout adolescence, while the right side begins operating in the womb even experiencing non-verbal communication between mother and child. The right brain is responsible for storing the memories of experience — sight, sound, touch, smell and all the subsequence emotions that the experience evokes. In normal situations both sides of the brain work together but when one side shuts down (left side) during trauma or a memory of trauma (flashback), then their left brain isn’t able to help the traumatized person figure out what’s happening and they get “stuck” in their experience.

The Emotional Brain (the right side) begins as the reptilian brain — the primitive brain which regulates heartbeat, breathing, combined with the processes of the Limbic System which handle a multitude of vital responsibilities. It is the Emotional Brain that processes all non-verbal communication, generates creativity, imagination, sensitivity, etc. It is the seat of our emotions, monitor of danger, the umpire of what scares us or feels pleasurable and the arbiter of what we need to operate and to survive.

The emotional brain also enables us in varying degrees, to detect nuances and “vibes” felt at the gut level, even if we are unable to explain how we “know” what we know.

The emotional brain develops and begins functioning first, while still in the womb. This early functionality is what enables newborns to do all the things they are capable of doing — hearing, swallowing, crying, etc.

During traumatic experiences and flashbacks, the emotional brain reacts differently and independently of the rational brain, becoming hyper active and intensely engaged. Meanwhile, activity in the left side significantly slows or stops altogether. When the left side goes off-line in this way, all rational, logical thoughts are deactivated. This leaves the right side, which at this point is fully charged and revved up, with no braking system, no moderator, no tempering.

Without the left side of the brain to help you process or “think” about your experience, the right brain often reacts to current events and misperceives them as if they are more dangerous or traumatic than they actually are, setting up a repetitive cycle of overreacting to situations that are misinterpreted. Two sides are better than one.

Both sides of our brains have separate but essential tasks to perform, to keep us functioning well. The rational side of our brain helps us to know why we feel and respond this way or that, in various situations. It cannot however, change painful and/or frightening feelings — this is the exclusive function of the emotional brain. The rational brain cannot abolish emotions, sensations or even thoughts.

Full recovery from trauma involves both sides of the brain working optimally and in harmony and balance with the other side.

How Trauma Affects the Body

Not only is the brain affected by original traumatic experiences and ongoing flashbacks, but the body is significantly involved and affected also. This occurs because the brain and major organs of the body engage in two way
“speak” and respond to each other. The Vagus nerve functions like a two way street, transporting signals and messages from the brain downward, but also from the body upward into the brain.

Trauma alters the way our autonomic nervous system (ANS) operates. The ANS includes dual systems called the sympathetic nervous system (SNS and parasympathetic nervous system (PNS). The first system (SNS) triggers the flight or fight response prompting defensive actions by fueling the body with the right balance of necessary chemical reactions. The second system (PNS) works to reverse and balance the first. When functioning properly it allows us to return to a calm state after the threat has passed.

This desired state is called homeostasis and occurs when the autonomic nervous system (ANS) puts the brakes on the sympathetic nervous system (SNS), which then causes our breathing and heart rate to slow down and our tense muscles to relax.

Trauma was traditionally viewed as originating in the brain, and primarily affecting only the brain. Bodily sensations and symptoms described by patients have all too often been dismissed, and considered to be “all in the mind.” Today we’re learning that the body has very useful information to share, and that trauma-related issues, including bodily symptoms, are not “just” in the mind of the sufferer.

Unhealed trauma “shrinks” our world so that our main focus becomes suppressing inner chaos, and trying to control unbearable physiological reactions. This perpetual battle against our own minds is both exhausting, and capable of producing a whole range of physical syndromes such as fibromyalgia, chronic fatigue and immune disorders. Engaging in physical activity helps to pull this internally trapped energy into our muscles and limbs where it can be expended in ways that promote rather than deplete our health. This partially explains why it is critical for trauma treatment and recovery to engage the whole person; both sides of the brain (rational and the emotional) as well as the body.

I Feel Therefore I Am

As humans, we each have within us the basic needs of comfort, touch, feeling safe, feeling loved. Dr. Semrad said:

“Failure to accept and attend to these fundamental needs produces a stunted experience, resulting in a stunted version of ourselves. When we lose an essential connection to our own bodies, the vitality in our life is greatly diminished.”

Think of a hose connected to a freely flowing faucet, with a sprayer on the other end. Both the source and the means to direct the water is available and operational. However, a kink in the delivery system (the hose) limits the flow or even cuts it off completely. When our body is “amputated” in this way, and we lose touch of our physical sensations and awareness, we lose a vital part of our overall selves.

“No amount of lofty (even spiritual) thoughts, nor a portfolio of laudable accomplishments, can adequately compensate or substitute for this loss.”

Dr. Van Der Kolk stresses the importance of “befriending” our bodies and integrating them into the recovery process by saying, “You cannot be fully in charge of your life until you can acknowledge the reality of your body.” All of our life experiences are received and perceived first through our bodily senses, before they are processed by our brains. Therefore the body and the brain must be connected and working in harmony for us to experience a fulfilling and meaningful existence.

Moving Beyond Trauma

Traditionally it was believed that the inner working of our two sided brains was primarily based on unchangeable factors, like the genes we inherited and our unique inborn temperaments. From this perspective, we appeared to be limited by what we received from nature or nurture (for better, or for worse). According to this understanding, once the internal programming was set, it was difficult, if not impossible, to alter or improve to any significant degree.

Science now shows us that it is possible to transform our individual architecture in ways that will enable us to respond differently, rather than repeating and returning to the same pre-programmed reactions. Amazingly, this potential to alter some aspects of our neural landscape is possible even if our brains have had deeply engrained, well-worn neural trails (or ruts) in place for many years.

We do not have to remain victimized by traumatic experiences, or live out our lives repeating outdated, harmful, self-defeating behaviors.

Accessing these abilities can be facilitated using pathways of the Vagus Nerve, a system of nerves runs from the stem of the brain (at the base of the skull) all the way down into the body. From there it branches off into many of the vital organs in our bodies, including the heart, lungs, stomach and intestines. In this way, the interconnectedness of our brains and bodies (a previously troublesome connection for trauma survivors) can be utilized as “rescuing organs” — helping us to absorb traumatic experiences into the bigger life picture, “diluting them”, so they are only one ingredient in the overall mix, rather than the main ingredient.

How is it done? Top Down vs. Bottom Up

Beginning with the brain’s abilities to affect positive change in bodily reactions and behavior is called the Top Down approach. A number of therapeutic practices are effectively helping traumatized people live more normal and healthy lives, including the following:

  • EMDR (Eye Movement Desensitization and Reprocessing)
  • Neurofeedback — enhances focused attention and concentration. The brain is trained to produce new/different patterns of electrical activity. The benefits of neurofeedback are well documented.
  • Limbic System Therapy, a term coined by Dr. Van Der Kolk basically means using body-based therapies to focus on calming reactive hyper- and hypo-aroused emotional brain centers. The goal is to repair the brain’s faulty alarm systems (which have been on overdrive, or “high alert”) and establish a new set point. When this happens, the alarm system can return to functioning as intended — to operate quietly and unobtrusively in the backdrop of our lives.
One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies. We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to recognize, trust, and act on these sensations in order to navigate safely through life.

Beginning with the body, we use it to access and improve brain functioning. This is what the author means by the Bottom Up approach. This can be done by engaging any and all of our senses and by paying attention and learning from this sensory information. Physical self-awareness is the first step of healing from trauma. And then from there, neuroscience shows us that the best way we can change the way we feel is by becoming aware of what we’re experiencing in our minds and our bodies, and then by being compassionate with what is going on inside. We need to allow ourselves to befriend even the hyperaroused self. Practicing mindfulness, meditation, yoga or martial arts are way to using breathing, movement, and gentle awareness in order to achieve a more calm state, even when revved up inside.
Physical, creative activities become vehicles that facilitate positive healthy communication between our bodies and brains. Vital self-awareness is a critical part of recovery and can be cultivated in numerous and various ways, including:

  • Practicing mindfulness — paying attention to bodily sensations and inner emotions without judgment — just observing them, learning to label them and be compassionate towards them instead of being afraid or them, shaming them or suppressing them. Learning to observe and tolerate unpleasant physical sensations noticing that they constantly shift and change.
  • Talking through your thoughts and experiences with others who are caring and viewed as safe by the traumatized individual.
  • Journaling/writing therapy — learning to put words (left brain) to your sensations and feelings (right brain)
  • Practicing yoga and other martial arts, feeling your body, feeling yourself in your body, feeling your breathe. Learning to be okay within your body and feeling a greater sense of control.
  • Singing, Dance, Theatre
  • Engaging in meaningful work

In short, any physical, individual or group activity that fosters self-awareness (knowing what we feel and why both physically and emotionally), cooperation, community, individual and relational confidence, self-respect, etc. helps the brain rewire itself and build new pathways. The author warns:

“The more people try to push away and ignore internal warning signs, the more likely they are to take over and leave them bewildered, confused, and ashamed. People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic- they develop a fear of fear itself.”

Instead of befriending the feeling he or she pushes it away, the stronger it gets, the more frozen or panicky they feel.

The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, what is safe and nourishing. Self-regulation depends on having a friendly relationship with your body.

Living in the Here and Now

A traumatized person often perceives things differently. Any number of normal daily experiences can trigger some recall of the original trauma, and cause them to react accordingly. Although they are physically present and may appear to be watching the same “environmental screen” as others around them, they are actually “viewing” and perceiving a different movie being played out. This is an isolating experience that prevents them from experiencing the here and now and separates them from those around them. This disconnectedness will continue until they are able to integrate their experience into the ongoing ebb and flow of daily life. Only by doing so, can they learn how to be “here,” fully engaged and enjoying the present reality, rather than “there”, re-experiencing over and over the pain of their past.

The fundamental issue therefore, in resolving traumatic stress, is to restore proper balance between the rational and emotional brain (to feel in charge again over how you respond and how you conduct your life). As long as people are either hyper aroused or shut down, they cannot learn from daily experience. Even if they manage to stay “in control”, they become inflexible, stubborn and stuck. Recovery on the other hand, produces a healthy sense of self-control and management of one’s life. Recovery also involves regaining self-confidence, respect, and a restored capacity for playfulness, creativity and imagination.

The Role of Trauma in Eating Disorders

An Eating Disorder is a serious mental disorder, not a lifestyle choice.

What might start out as a preoccupation with food and weight is often an attempt to control overwhelming feelings of low self-esteem, lack of control, loneliness, depression and/or anxiety. Interestingly, these are the same underlying symptoms of trauma and abuse. Over 10% of women will develop PTSD in their lifetime, and many more experience trauma and distressing psychological consequences that may not be diagnosed as full-blown PTSD.

Disordered eating behaviors may be a person’s way of coping with the distressing emotions related to trauma. For example, an individual may begin restricting food intake as a way of feeling in control, or may binge eat as a way to self-sooth through food.

Trauma of a sexual nature, especially at a young age, is thought to be a significant risk factor for the development of an eating disorder. It is estimated that over 30% of individuals with an eating disorder have a history of being sexually abused. While more research is needed to clarify the relationship trauma and eating disorders, it is felt that body shame might be triggering habits geared towards “punishing” the body of which the abuse victim feels so ashamed. Eating disorder behaviors at thought to be a coping mechanism for dealing with distressing emotions, similar to those who engage in other types of self-harm.

Treating Co-occurring Trauma & Eating Disorders

Trauma survivors often want to know “Why did this happen to me?” The unfortunate reality is that these questions can rarely be answered. However, what can be done is helping the individual move from “why” to “how” in order to shift focus to questions such as:

  • How do I regulate my stress response?
  • How do I cope with distressing thoughts and emotions?

I often use the analogy with my patients that we’re all like pressure cookers, with stress and tension building up inside of us. No one experiences life completely unscathed, or painlessly, and this pressure build-up is bound to come out somehow. Rather than unhealthy coping strategies, such as disordered eating or self-harm, we need to find ways to relieve stress in a healthy way.

Interestingly, when animals in the wild are faced with imminent danger, their bodies are charged with energy as they enter “fight or flight”, so they can rise to the occasion. Once the threat is gone, animals release this pent-up energy, and then return to normal functioning. Humans produce a similar energy during traumatic experiences, however, many of them never rid themselves of this tension, unlike their animal counterparts in the wild.

Trauma is not just a psychological condition, it is very physiological as well; therefore, the mind and the body must be included in treatment and healing.

Movement therapies discussed above, such as yoga and dance, can lead to self discovery, and help people learn to love their bodies and no longer desire to harm them. Art therapy lets an individual express emotions without words, and animal therapy gives the opportunity to bond with creature they feel is safe.

An individual often enters treatment because an eating disorder has taken over his/her life, but if the trauma is not addressed, the treatment is simply incomplete. The challenge of recovery is to reestablish ownership of yourself, including body and mind.