Bessel A. van der Kolk

The Body Keeps the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress

&NA; Ever since peoples responses to overwhelming experiences have been systematically explored, researchers have noted that a trauma is stored in somatic memory and expressed as changes in the biological stress response. Intense emotions at the time of the trauma initiate the long‐term conditional responses to reminders of the event, which are associated both with chronic alterations in the physiological stress response and with the amnesias and hypermnesias characteristic of posttraumatic stress disorder (PTSD). Continued physiological hyperarousal and altered stress hormone secretion affect the ongoing evaluation of sensory stimuli as well. Although memory is ordinarily an active and constructive process, in PTSD failure of declarative memory may lead to organization of the trauma on a somatosensory level (as visual images or physical sensations) that is relatively impervious to change. The inability of people with PTSD to integrate traumatic experiences and their tendency, instead, to continuously relive the past are mirrored physiologically and hormonally in the misinterpretation of innocuous stimuli as potential threats. Animal research suggests that intense emotional memories are processed outside of the hippo‐campally mediated memory system and are difficult to extinguish. Cortical activity can inhibit the expression of these subcortically based emotional memories. The effectiveness of this inhibition depends, in part, on physiological arousal and neurohormonal activity. These formulations have implications for both the psychotherapy and the pharmacotherapy of PTSD.Ever since peoples responses to overwhelming experiences have been systematically explored, researchers have noted that a trauma is stored in somatic memory and expressed as changes in the biological stress response. Intense emotions at the time of the trauma initiate the long-term conditional responses to reminders of the event, which are associated both with chronic alterations in the physiological stress response and with the amnesias and hypermnesias characteristic of posttraumatic stress disorder (PTSD). Continued physiological hyperarousal and altered stress hormone secretion affect the ongoing evaluation of sensory stimuli as well. Although memory is ordinarily an active and constructive process, in PTSD failure of declarative memory may lead to organization of the trauma on a somatosensory level (as visual images or physical sensations) that is relatively impervious to change. The inability of people with PTSD to integrate traumatic experiences and their tendency, instead, to continuously relive ...

Complex Trauma in Children and Adolescents

The present paper highlights seven primary domains of impairment observed in children exposed to complex trauma. These phenomenologically based domains have been identified based on the extant child clinical and research literatures, the adult research on Disorders of Extreme Stress Not Otherwise Specified (Pelcovitz et al, 1997; van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman, 1996; van der Kolk, Roth, et al., in press), and the combined expertise of the NCTSN Complex Trauma Taskforce.

Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder

Two hundred thirty four participants in the DSM-IV Posttraumatic Stress Disorder (PTSD) Field Trial who reported sexual and/or physical abuse were evaluated. Participants were categorized according to type of abuse (physical, sexual, both), duration of abuse (acute versus chronic), and onset of abuse (early versus late). Separate logistic regression analyses examined the relationship between age of onset, duration, abuse type, and the complex PTSD (CP) lifetime diagnosis for women and men. Sexually abused women, especially those who also experienced physical abuse, had a higher risk of developing CP, although CP symptoms occurred at a high base rate among physically abused women. The theoretical implications and incremental clinical usefulness of targeting CP symptoms with abused populations are discussed.

Trauma and memory

The study of traumatic memories challenges several basic notions about the nature of memory: (i) that memory always is a constructive process; (ii) that memory is primarily declarative (i.e. that people can articulate what they know in words and symbol) (iii) that memory is present in consciousness in a continuous and uninterrupted fashion; and (iv) that memory always disintegrates in accuracy over time. A century of study of traumatic memories shows that (i) semantic representations may coexist with sensory imprints; (ii) unlike trauma narratives, these sensory experiences often remain stable over time, unaltered by other life experiences; (iii) they may return, triggered by reminders, with a vividness as if the experience were happening all over again; and (iv) these flashbacks may occur in a mental state in which victims are unable to precisely articulate what they are feeling and thinking. The present paper reviews the literature on traumatic memories and discusses the recent neuroimaging studies which seem to clarify the neurobiological underpinnings of the differences between ordinary and traumatic memories.

Development of a criteria set and a structured interview for disorders of extreme stress (SIDES)

Data regarding the development of a structured interview measuring alterations that may accompany extreme stress are presented. A list of 27 criteria often seen in response to extreme trauma and not addressed by DSM-IV criteria for posttraumatic stress disorder (PTSD) were generated based on a systematic review of the literature and a survey of 50 experts. A structured interview for disorders of extreme stress (SIDES) measuring the presence of these criteria was administered to 520 subjects as part of the DSM-IV PTSD field trials. Inter-rater reliability as measured by Kappa coefficients for lifetime Disorders of Extreme Stress was .81. Internal consistency using coefficient alpha ranged from .53 to .96. Results indicate that the SIDES is a useful tool for investigation of response to extremes stress.

Clinical Implications of Neuroscience Research in PTSD

Abstract:  The research showing how exposure to extreme stress affects brain function is making important contributions to understanding the nature of traumatic stress. This includes the notion that traumatized individuals are vulnerable to react to sensory information with subcortically initiated responses that are irrelevant, and often harmful, in the present. Reminders of traumatic experiences activate brain regions that support intense emotions, and decrease activation in the central nervous system (CNS) regions involved in (a) the integration of sensory input with motor output, (b) the modulation of physiological arousal, and (c) the capacity to communicate experience in words. Failures of attention and memory in posttraumatic stress disorder (PTSD) interfere with the capacity to engage in the present: traumatized individuals “lose their way in the world.” This article discusses the implications of this research by suggesting that effective treatment needs to involve (a) learning to tolerate feelings and sensations by increasing the capacity for interoception, (b) learning to modulate arousal, and (c) learning that after confrontation with physical helplessness it is essential to engage in taking effective action.

The neurobiology of childhood trauma and abuse

During the past decade there has been rapid progress in the understanding of the effects of exposure to traumatic life experiences on subsequent psychopathology in children. Trauma exposure affects what children anticipate and focus on and how they organize the way they appraise and process information. Trauma-induced alterations in threat perception are expressed in how they think, feel, behave, and regulate their biologic systems. The task of therapy is to help these children develop a sense of physical mastery and awareness of who they are and what has happened to them to learn to observe what is happening in present time and physically respond to current demands instead of recreating the traumatic past behaviorally, emotionally, and biologically.

Down will come baby, cradle and all: diagnostic and therapeutic implications of chronic trauma on child development

Objective: This review examines the clinical outcomes associated with exposure to chronic intrafamilial trauma and explores the treatment of the psychological, biological and cognitive sequelae. Method: The existing research literature on the subject was collected, using Index Medicus/MEDLINE, Psychological Abstracts and the PILOTS database. The research findings were supplemented with clinical observations by the authors and other clinical writings on this topic. Results: Children with histories of exposure to multiple traumatic experiences within their families or in medical settings usually meet criteria for numerous clinical diagnoses, none of which capture the complexity of their biological, emotional and cognitive problems. These are expressed in a multitude of psychological, cognitive, somatic and behavioural problems, ranging from learning disabilities to aggression against self and others. Conclusions: Exposure to intrafamilial violence and other chronic trauma results in pervasive psychological and biological deficits. Treatment needs to address issues of safety, stabilise impulsive aggression against self and others, promote mastery experiences, compensate for specific developmental deficits, and judiciously process both the traumatic memories and trauma-related expectations.

What psychological testing and neuroimaging tell us about the treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing.

To better understand the pathophysiology and treatment of Posttraumatic Stress Disorder (PTSD), standard psychological testing, Rorschach Ink Blot testing, and neuroimaging using Single Photon Emission Computed Tomography (SPECT) were administered to subjects with PTSD prior to and following three sessions of Eye Movement Desensitization and Reprocessing (EMDR). Using this within-subject design, data from one of six subjects in our series is presented as a case report. Following EMDR, the subject experienced improvement in his level of distress, which correlated with decrements in PTSD and depressive symptomatology on psychological testing. Analysis of the Rorschach data corroborated these changes. Among other findings, the Hypervigilance Index went from positive to negative, indicating that the subject was spending less time scanning the environment for threats, and available ego resources also increased, as measured by the Experience Actual variable. Upon recall of the traumatic memory during SPECT scanning, two areas of the brain were hyperactive post-EMDR treatment relative to pretreatment: the anterior cingulate gyrus and the left frontal lobe. These changes were consistent with summed data from four out of six subjects in the ongoing study. An important implication of these findings is that successful treatment of PTSD does not reduce arousal at the limbic level, but instead, enhances the ability to differentiate real from imagined threat. The psychology and neurophysiology of PTSD are discussed in greater detail.

The trauma spectrum: The interaction of biological and social events in the genesis of the trauma response

When Kardiner first described the full syndrome of what is now called PTSD in 1941, he called the trauma response a “physioneurosis,” that is, a mental disorder which affects both the soma and the psyche. Now, more than 40 years later much knowledge has been gained about the biological effects of traumatization. Based on the studies of disruptions of attachment bonds in non-human primates, the animal model of inescapable shock, and numerous studies of traumatized children and adults, we are beginning to understand the nature of the biological changes which underlie the psychological response to trauma. This paper will explore (1) the nature of the biological alterations in response to traumatization, (2) how these biological shifts depend on the maturation of the central nervous system (CNS), cognitive processes, and the social matrix in which they occur, (3) and how these alterations can influence psychopathological and interpersonal processes.