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

NOTES

PROLOGUE

1. V. Felitti, et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study.” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58.

CHAPTER 1: LESSONS FROM VIETNAM VETERANS

1. A. Kardiner, The Traumatic Neuroses of War (New York: P. Hoeber, 1941). Later I discovered that numerous textbooks on war trauma were published around both the First and Second World Wars, but as Abram Kardiner wrote in 1947: “The subject of neurotic disturbances consequent upon war has, in the past 25 years, been submitted to a good deal of capriciousness in public interest and psychiatric whims. The public does not sustain its interest, which was very great after World War I, and neither does psychiatry. Hence these conditions are not subject to continuous study.”

2. Op cit, p. 7.

3. B. A. van der Kolk, “Adolescent Vulnerability to Post Traumatic Stress Disorder,” Psychiatry 48 (1985): 365–70.

4. S. A. Haley, “When the Patient Reports Atrocities: Specific Treatment Considerations of the Vietnam Veteran,” Archives of General Psychiatry 30 (1974): 191–96.

5. E. Hartmann, B. A. van der Kolk, and M. Olfield, “A Preliminary Study of the Personality of the Nightmare Sufferer,” American Journal of Psychiatry 138 (1981): 794–97; B. A. van der Kolk, et al., “Nightmares and Trauma: Life-long and Traumatic Nightmares in Veterans,” American Journal of Psychiatry141 (1984): 187–90.

6. B. A. van der Kolk and C. Ducey, “The Psychological Processing of Traumatic Experience: Rorschach Patterns in PTSD,” Journal of Traumatic Stress 2 (1989): 259–74.

7. Unlike normal memories, traumatic memories are more like fragments of sensations, emotions, reactions, and images, that keep getting reexperienced in the present. The studies of Holocaust memories at Yale by Dori Laub and Nanette C. Auerhahn, as well as Lawrence L. Langer’s book Holocaust Testimonies: The Ruins of Memory, and, most of all, Pierre Janet’s 1889, 1893, and 1905 descriptions of the nature of traumatic memories helped us organize what we saw. That work will be discussed in the memory chapter.

8. D. J. Henderson, “Incest,” in Comprehensive Textbook of Psychiatry, eds. A. M. Freedman and H. I. Kaplan, 2nd ed. (Baltimore: Williams & Wilkins, 1974), 1536.

9. Ibid.

10. K. H. Seal, et al., “Bringing the War Back Home: Mental Health Disorders Among 103,788 U.S. Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities,” Archives of Internal Medicine 167, no. 5 (2007): 476–82; C. W. Hoge, J. L. Auchterlonie, and C. S. Milliken, “Mental Health Problems, Use of Mental Health Services, and Attrition from Military Service After Returning from Deployment to Iraq or Afghanistan,” Journal of the American Medical Association 295, no. 9 (2006): 1023–32.

11. D. G. Kilpatrick and B. E. Saunders, Prevalence and Consequences of Child Victimization: Results from the National Survey of Adolescents: Final Report (Charleston, SC: National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina 1997).

12. U.S. Department of Health and Human Services, Administration on Children, Youth and Families, Child Maltreatment 2007, 2009. See also U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, Child Maltreatment 2010, 2011.

CHAPTER 2: REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN

1. G. Ross Baker, et al., “The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada,” Canadian Medical Association Journal 170, no. 11 (2004): 1678–86; A. C. McFarlane, et al., “Posttraumatic Stress Disorder in a General Psychiatric Inpatient Population,” Journal of Traumatic Stress 14, no. 4 (2001): 633–45; Kim T. Mueser, et al., “Trauma and Posttraumatic Stress Disorder in Severe Mental Illness,” Journal of Consulting and Clinical Psychology 66, no. 3 (1998): 493; National Trauma Consortium, www.nationaltraumaconsortium.org.

2. E. Bleuler, Dementia Praecox or the Group of Schizophrenias, trans. J. Zinkin (Washington, DC: International Universities Press, 1950), p. 227.

3. L. Grinspoon, J. Ewalt, and R. I. Shader, “Psychotherapy and Pharmacotherapy in Chronic Schizophrenia,” American Journal of Psychiatry 124, no. 12 (1968): 1645–52. See also L. Grinspoon, J. Ewalt, and R. I. Shader, Schizophrenia: Psychotherapy and Pharmacotherapy (Baltimore: Williams and Wilkins, 1972).

4. T. R. Insel, “Neuroscience: Shining Light on Depression,” Science 317, no. 5839 (2007): 757–58. See also C. M. France, P. H. Lysaker, and R. P. Robinson, “The ‘Chemical Imbalance’ Explanation for Depression: Origins, Lay Endorsement, and Clinical Implications,” Professional Psychology: Research and Practice 38 (2007): 411–20.

5. B. J. Deacon, and J. J. Lickel, “On the Brain Disease Model of Mental Disorders,” Behavior Therapist 32, no. 6 (2009).

6. J. O. Cole, et al., “Drug Trials in Persistent Dyskinesia (Clozapine),” in Tardive Dyskinesia, Research and Treatment, ed. R. C. Smith, J. M. Davis, and W. E. Fahn (New York: Plenum, 1979).

7. E. F. Torrey, Out of the Shadows: Confronting America’s Mental Illness Crisis (New York: John Wiley & Sons, 1997). However, other factors were equally important, such as President Kennedy’s 1963 Community Mental Health Act, in which the federal government took over paying for mental health care and which rewarded states for treating mentally ill people in the community.

8. American Psychiatric Association, Committee on Nomenclature. Work Group to Revise DSM-III. Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Publishing, 1980).

9. S. F. Maier and M. E. Seligman, “Learned Helplessness: Theory and Evidence,” Journal of Experimental Psychology: General 105, no. 1 (1976): 3. See also M. E. Seligman, S. F. Maier, and J. H. Geer, “Alleviation of Learned Helplessness in the Dog,” Journal of Abnormal Psychology 73no. 3 (1968): 256; and R. L. Jackson, J. H. Alexander, and S. F. Maier, “Learned Helplessness, Inactivity, and Associative Deficits: Effects of Inescapable Shock on Response Choice Escape Learning,” Journal of Experimental Psychology: Animal Behavior Processes 6no. 1 (1980): 1.

10. G. A. Bradshaw and A. N. Schore, “How Elephants Are Opening Doors: Developmental Neuroethology, Attachment and Social Context,” Ethology 113 (2007): 426–36.

11. D. Mitchell, S. Koleszar, and R. A. Scopatz, “Arousal and T-Maze Choice Behavior in Mice: A Convergent Paradigm for Neophobia Constructs and Optimal Arousal Theory,” Learning and Motivation 15 (1984): 287–301. See also D. Mitchell, E. W. Osborne, and M. W. O’Boyle, “Habituation Under Stress: Shocked Mice Show Nonassociative Learning in a T-maze,” Behavioral and Neural Biology 43 (1985): 212–17.

12. B. A. van der Kolk, et al., “Inescapable Shock, Neurotransmitters and Addiction to Trauma: Towards a Psychobiology of Post Traumatic Stress,” Biological Psychiatry 20 (1985): 414–25.

13. C. Hedges, War Is a Force That Gives Us Meaning (New York: Random House Digital, 2003).

14. B. A. van der Kolk, “The Compulsion to Repeat Trauma: Revictimization, Attachment and Masochism,” Psychiatric Clinics of North America 12 (1989): 389–411.

15. R. L. Solomon, “The Opponent-Process Theory of Acquired Motivation: The Costs of Pleasure and the Benefits of Pain,” American Psychologist 35 (1980): 691–712.

16. H. K. Beecher, “Pain in Men Wounded in Battle,” Annals of Surgery 123, no. 1 (January 1946): 96–105.

17. B. A. van der Kolk, et al., “Pain Perception and Endogenous Opioids in Post Traumatic Stress Disorder,” Psychopharmacology Bulletin 25 (1989): 117–21. See also R. K. Pitman, et al., “Naloxone Reversible Stress Induced Analgesia in Post Traumatic Stress Disorder,” Archives of General Psychiatry47 (1990): 541–47; and Solomon, “Opponent-Process Theory of Acquired Motivation.”

18. J. A. Gray and N. McNaughton, “The Neuropsychology of Anxiety: Reprise,” in Nebraska Symposium on Motivation (University of Nebraska Press, 1996), 43, 61–134. See also C. G. DeYoung and J. R. Gray, “Personality Neuroscience: Explaining Individual Differences in Affect, Behavior, and Cognition, in The Cambridge Handbook of Personality Psychology (2009), 323–46.

19. M. J. Raleigh, et al., “Social and Environmental Influences on Blood Serotonin Concentrations in Monkeys,” Archives of General Psychiatry 41 (1984): 505–10.

20. B. A. van der Kolk, et al., “Fluoxetine in Post Traumatic Stress,” Journal of Clinical Psychiatry (1994): 517–22.

21. For the Rorschach aficionados among you, it reversed the C + CF/FC ratio.

22. Grace E. Jackson, Rethinking Psychiatric Drugs: A Guide for Informed Consent (AuthorHouse, 2005); Robert Whitaker, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America (New York: Random House, 2011).

23. We will return to this issue in chapter 15, where we discuss our study comparing Prozac with EMDR, in which EMDR had better long-term results than Prozac in treating depression, at least in adult onset trauma.

24. J. M. Zito, et al., “Psychotropic Practice Patterns for Youth: A 10-Year Perspective,” Archives of Pediatrics and Adolescent Medicine 157 (January 2003): 17–25.

25. http://en.wikipedia.org/wiki/List_of_largest_selling_pharmaceutical_products.

26. Lucette Lagnado, “U.S. Probes Use of Antipsychotic Drugs on Children,” Wall Street Journal, August 11, 2013.

27. Katie Thomas, “J.&J. to Pay $2.2 Billion in Risperdal Settlement,” New York Times, November 4, 2013.

28. M. Olfson, et al., “Trends in Antipsychotic Drug Use by Very Young, Privately Insured Children,” Journal of the American Academy of Child & Adolescent Psychiatry 49, no.1 (2010): 13–23.

29. M. Olfson, et al., “National Trends in the Outpatient Treatment of Children and Adolescents with Antipsychotic Drugs,” Archives of General Psychiatry 63, no. 6 (2006): 679.

30. A. J. Hall, et al., “Patterns of Abuse Among Unintentional Pharmaceutical Overdose Fatalities,” Journal of the American Medical Association 300, no. 22 (2008): 2613–20.

31. During the past decade two editors in chief of the most prestigious professional medical journal in the United States, the New England Journal of Medicine, Dr. Marcia Angell and Dr. Arnold Relman, have resigned from their positions because of the excessive power of the pharmaceutical industry over medical research, hospitals, and doctors. In a letter to the New York Times on December 28, 2004, Angell and Relman pointed out that the previous year one drug company had spent 28 percent of its revenues (more than $6 billion) on marketing and administrative expenses, while spending only half that on research and development; keeping 30 percent in net income was typical for the pharmaceutical industry. They concluded: “The medical profession should break its dependence on the pharmaceutical industry and educate its own.” Unfortunately, this is about as likely as politicians breaking free from the donors that finance their election campaigns.

CHAPTER 3: LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION

1. B. Roozendaal, B. S. McEwen, and S. Chattarji, “Stress, Memory and the Amygdala,” Nature Reviews Neuroscience 10, no. 6 (2009): 423–33.

2. R. Joseph, The Right Brain and the Unconscious (New York: Plenum Press, 1995).

3. The movie The Assault (based on the novel of the same name by Harry Mulisch), which won the Oscar for Best Foreign Language Film in 1986, is a good illustration of the power of deep early emotional impressions in determining powerful passions in adults.

4. This is the essence of cognitive behavioral therapy. See Foa, Friedman, and Keane, 2000 Treatment Guidelines for PTSD.

CHAPTER 4: RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL

1. R. Sperry, “Changing Priorities,” Annual Review of Neuroscience 4 (1981): 1–15.

2. A. A. Lima, et al., “The Impact of Tonic Immobility Reaction on the Prognosis of Posttraumatic Stress Disorder,” Journal of Psychiatric Research 44, no. 4 (March 2010): 224–28.

3. P. Janet, L’automatisme psychologique (Paris: Félix Alcan, 1889).

4. R. R. Llinás, I of the Vortex: From Neurons to Self (Cambridge, MA: MIT Press, 2002). See also R. Carter and C. D. Frith, Mapping the Mind (Berkeley: University of California Press, 1998); R. Carter, The Human Brain Book (Penguin, 2009); and J. J. Ratey, A User’s Guide to the Brain (New York: Pantheon Books, 2001), 179.

5. B. D. Perry, et al., “Childhood Trauma, the Neurobiology of Adaptation, and Use Dependent Development of the Brain: How States Become Traits,” Infant Mental Health Journal 16, no. 4 (1995): 271–91.

6. I am indebted to my late friend David Servan-Schreiber, who first made this distinction in his book The Instinct to Heal.

7. E. Goldberg, The Executive Brain: Frontal Lobes and the Civilized Mind (London, Oxford University Press, 2001).

8. G. Rizzolatti and L. Craighero “The Mirror-Neuron System,” Annual Review of Neuroscience 27 (2004): 169–92. See also M. Iacoboni, et al., “Cortical Mechanisms of Human Imitation,” Science 286, no. 5449 (1999): 2526–28; C. Keysers and V. Gazzola, “Social Neuroscience: Mirror Neurons Recorded in Humans,” Current Biology 20, no. 8 (2010): R353–54; J. Decety and P. L. Jackson, “The Functional Architecture of Human Empathy,” Behavioral and Cognitive Neuroscience Reviews 3 (2004): 71–100; M. B. Schippers, et al., “Mapping the Information Flow from One Brain to Another During Gestural Communication,” Proceedings of the National Academy of Sciences of the United States of America 107, no. 20 (2010): 9388–93; and A. N. Meltzoff and J. Decety, “What Imitation Tells Us About Social Cognition: A Rapprochement Between Developmental Psychology and Cognitive Neuroscience,” Philosophical Transactions of the Royal Society, London 358 (2003): 491–500.

9. D. Goleman, Emotional Intelligence (New York: Random House, 2006). See also V. S. Ramachandran, “Mirror Neurons and Imitation Learning as the Driving Force Behind ‘the Great Leap Forward’ in Human Evolution,” Edge (May 31, 2000), http://edge.org/conversation/mirror-neurons-and-imitation-learning-as-the-driving-force-behind-the-great-leap-forward-in-human-evolution (retrieved April 13, 2013).

10. G. M. Edelman, and J. A. Gally, “Reentry: A Key Mechanism for Integration of Brain Function,” Frontiers in Integrative Neuroscience 7 (2013).

11. J. LeDoux, “Rethinking the Emotional Brain,” Neuron 73, no. 4 (2012): 653–76. See also J. S. Feinstein, et al., “The Human Amygdala and the Induction and Experience of Fear,” Current Biology 21, no. 1 (2011): 34–38.

12. The medial prefrontal cortex is the middle part of the brain (neuroscientists call them “the midline structures”). This area of the brain comprises a conglomerate of related structures: the orbito-prefrontal cortex, the inferior and dorsal medial prefrontal cortex, and a large structure called the anterior cingulate, all of which are involved in monitoring the internal state of the organism and selecting the appropriate response. See, e.g., D. Diorio, V. Viau, and M. J. Meaney, “The Role of the Medial Prefrontal Cortex (Cingulate Gyrus) in the Regulation of Hypothalamic-Pituitary-Adrenal Responses to Stress,” Journal of Neuroscience 13, no. 9 (September 1993): 3839–47; J. P. Mitchell, M. R. Banaji, and C. N. Macrae, “The Link Between Social Cognition and Self-Referential Thought in the Medial Prefrontal Cortex,” Journal of Cognitive Neuroscience 17, no. 8. (2005): 1306–15; A. D’Argembeau, et al., “Valuing One’s Self: Medial Prefrontal Involvement in Epistemic and Emotive Investments in Self-Views,” Cerebral Cortex 22 (March 2012): 659–67; M. A. Morgan, L. M. Romanski, J. E. LeDoux, “Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163 (1993):109–13; L. M. Shin, S. L. Rauch, and R. K. Pitman, “Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD,” Annals of the New York Academy of Sciences 1071, no. 1 (2006): 67–79; L. M. Williams, et al., “Trauma Modulates Amygdala and Medial Prefrontal Responses to Consciously Attended Fear,” Neuroimage, 29, no. 2 (2006): 347–57; M. Koenig and J. Grafman, “Posttraumatic Stress Disorder: The Role of Medial Prefrontal Cortex and Amygdala,” Neuroscientist 15, no. 5 (2009): 540–48; and M. R. Milad, I. Vidal-Gonzalez, and G. J. Quirk, “Electrical Stimulation of Medial Prefrontal Cortex Reduces Conditioned Fear in a Temporally Specific Manner,” Behavioral Neuroscience 118, no. 2 (2004): 389.

13. B. A. van der Kolk, “Clinical Implications of Neuroscience Research in PTSD,” Annals of the New York Academy of Sciences 1071 (2006): 277–93.

14. P. D. MacLean, The Triune Brain in Evolution: Role in Paleocerebral Functions (New York, Springer, 1990).

15. Ute Lawrence, The Power of Trauma: Conquering Post Traumatic Stress Disorder, iUniverse, 2009.

16. Rita Carter and Christopher D. Frith, Mapping the Mind (Berkeley: University of California Press, 1998). See also A. Bechara, et al., “Insensitivity to Future Consequences Following Damage to Human Prefrontal Cortex,” Cognition 50no. 1 (1994): 7–15; A. Pascual-Leone, et al., “The Role of the Dorsolateral Prefrontal Cortex in Implicit Procedural Learning,” Experimental Brain Research 107, no. 3 (1996): 479–85; and S. C. Rao, G. Rainer, and E. K. Miller, “Integration of What and Where in the Primate Prefrontal Cortex,” Science 276, no. 5313 (1997): 821–24.

17. H. S. Duggal, “New-Onset PTSD After Thalamic Infarct,” American Journal of Psychiatry 159, no. 12 (2002): 2113-a. See also R. A. Lanius, et al., “Neural Correlates of Traumatic Memories in Posttraumatic Stress Disorder: A Functional MRI Investigation,” American Journal of Psychiatry 158, no. 11 (2001): 1920–22; and I. Liberzon, et al., “Alteration of Corticothalamic Perfusion Ratios During a PTSD Flashback,” Depression and Anxiety 4, no. 3 (1996): 146–50.

18. R. Noyes Jr. and R. Kletti, “Depersonalization in Response to Life-Threatening Danger,” Comprehensive Psychiatry 18, no. 4 (1977): 375–84. See also M. Sierra, and G. E. Berrios, “Depersonalization: Neurobiological Perspectives,” Biological Psychiatry 44, no. 9 (1998): 898–908.

19. D. Church, et al., “Single-Session Reduction of the Intensity of Traumatic Memories in Abused Adolescents After EFT: A Randomized Controlled Pilot Study,” Traumatology 18, no. 3 (2012): 73–79; and D. Feinstein and D. Church, “Modulating Gene Expression Through Psychotherapy: The Contribution of Noninvasive Somatic Interventions,” Review of General Psychology 14, no. 4 (2010): 283–95. See also www.vetcases.com.

CHAPTER 5: BODY-BRAIN CONNECTIONS

1. C. Darwin, The Expression of the Emotions in Man and Animals (London: Oxford University Press, 1998).

2. Ibid., 71.

3. Ibid.

4. Ibid., 71–72.

5. P. Ekman, Facial Action Coding System: A Technique for the Measurement of Facial Movement (Palo Alto, CA: Consulting Psychologists Press, 1978). See also C. E. Izard, The Maximally Discriminative Facial Movement Coding System (MAX) (Newark, DE: University of Delaware Instructional Resource Center, 1979).

6. S. W. Porges, The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, Norton Series on Interpersonal Neurobiology (New York: WW Norton & Company, 2011).

7. This is Stephen Porges’s and Sue Carter’s name for the ventral vagal system. http://www.pesi.com/bookstore/A_Neural_Love_Code__The_Body_s_Need_to_Engage_and_Bond-details.aspx

8. S. S. Tomkins, Affect, Imagery, Consciousness (vol. 1, The Positive Affects) (New York: Springer, 1962); S. S. Tomkin, Affect, Imagery, Consciousness (vol. 2, The Negative Affects) (New York: Springer, 1963).

9. P. Ekman, Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life (New York: Macmillan, 2007); P. Ekman, The Face of Man: Expressions of Universal Emotions in a New Guinea Village (New York: Garland STPM Press, 1980).

10. See, e.g., B. M. Levinson, “Human/Companion Animal Therapy,” Journal of Contemporary Psychotherapy 14, no. 2 (1984): 131–44; D. A. Willis, “Animal Therapy,” Rehabilitation Nursing 22, no. 2 (1997): 78–81; and A. H. Fine, ed., Handbook on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice (Academic Press, 2010).

11. P. Ekman, R. W. Levenson, and W. V. Friesen, “Autonomic Nervous System Activity Distinguishes Between Emotions,” Science 221 (1983): 1208–10.

12. J. H. Jackson, “Evolution and Dissolution of the Nervous System,” in Selected Writings of John Hughlings Jackson, ed. J. Taylor (London: Stapes Press, 1958), 45–118.

13. Porges pointed out this pet store analogy to me.

14. S. W. Porges, J. A. Doussard-Roosevelt, and A. K. Maiti, “Vagal Tone and the Physiological Regulation of Emotion,” in The Development of Emotion Regulation: Biological and Behavioral Considerations, ed. N. A. Fox, Monographs of the Society for Research in Child Development, vol. 59 (2–3, serial no. 240) (1994), 167–86. http://www.amazon.com/The-Development-Emotion-Regulation-Considerations/dp/0226259404).

15. V. Felitti, et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58.

16. S. W. Porges, “Orienting in a Defensive World: Mammalian Modifications of Our Evolutionary Heritage: A Polyvagal Theory,” Psychophysiology 32 (1995): 301–18.

17. B. A. Van der Kolk, “The Body Keeps the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress,” Harvard Review of Psychiatry 1, no. 5 (1994): 253–65.

CHAPTER 6: LOSING YOUR BODY, LOSING YOUR SELF

1. K. L. Walsh, et al., “Resiliency Factors in the Relation Between Childhood Sexual Abuse and Adulthood Sexual Assault in College-Age Women,” Journal of Child Sexual Abuse 16, no. 1 (2007): 1–17.

2. A. C. McFarlane, “The Long‐Term Costs of Traumatic Stress: Intertwined Physical and Psychological Consequences,” World Psychiatry 9, no. 1 (2010): 3–10.

3. W. James, “What Is an Emotion?” Mind 9: 188–205.

4. R. L. Bluhm, et al., “Alterations in Default Network Connectivity in Posttraumatic Stress Disorder Related to Early-Life Trauma,” Journal of Psychiatry & Neuroscience 34, no. 3 (2009): 187. See also J. K. Daniels, et al., “Switching Between Executive and Default Mode Networks in Posttraumatic Stress Disorder: Alterations in Functional Connectivity,” Journal of Psychiatry & Neuroscience 35, no. 4 (2010): 258.

5. A. Damasio, The Feeling of What Happens: Body and Emotion in the Making of Consciousness (New York: Hartcourt Brace, 1999). Damasio actually says, “Consciousness was invented so that we could know life”, p. 31.

6. Damasio, Feeling of What Happens, p. 28.

7. Ibid., p. 29.

8. A. Damasio, Self Comes to Mind: Constructing the Conscious Brain (New York, Random House Digital, 2012), 17.

9. Damasio, Feeling of What Happens, p. 256.

10. Antonio R. Damasio, et al., “Subcortical and Cortical Brain Activity During the Feeling of Self-Generated Emotions.” Nature Neuroscience 3, vol. 10 (2000): 1049–56.

11. A. A. T. S. Reinders, et al., “One Brain, Two Selves,” NeuroImage 20 (2003): 2119–25. See also E. R. S. Nijenhuis, O. Van der Hart, and K. Steele, “The Emerging Psychobiology of Trauma-Related Dissociation and Dissociative Disorders,” in Biological Psychiatry, vol. 2., eds. H. A. H. D’Haenen, J. A. den Boer, and P. Willner (West Sussex, UK: Wiley 2002), 1079–198; J. Parvizi and A. R. Damasio, “Consciousness and the Brain Stem,” Cognition 79 (2001): 135–59; F. W. Putnam, “Dissociation and Disturbances of Self,” in Dysfunctions of the Self, vol. 5, eds. D. Cicchetti and S. L. Toth (New York: University of Rochester Press, 1994), 251–65; and F. W. Putnam, Dissociation in Children and Adolescents: A Developmental Perspective (New York: Guilford, 1997).

12. A. D’Argembeau, et al., “Distinct Regions of the Medial Prefrontal Cortex Are Associated with Self-Referential Processing and Perspective Taking,” Journal of Cognitive Neuroscience 19, no. 6 (2007): 935–44. See also N. A. Farb, et al., “Attending to the Present: Mindfulness Meditation Reveals Distinct Neural Modes of Self-Reference,” Social Cognitive and Affective Neuroscience 2, no. 4 (2007): 313–22; and B. K. Hölzel, et al., “Investigation of Mindfulness Meditation Practitioners with Voxel-Based Morphometry,” Social Cognitive and Affective Neuroscience 3, no. 1 (2008): 55–61.

13. P. A. Levine, Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body (Berkeley: North Atlantic Books, 2008); and P. A. Levine, In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness (Berkeley: North Atlantic Books, 2010).

14. P. Ogden and K. Minton, “Sensorimotor Psychotherapy: One Method for Processing Traumatic Memory,” Traumatology 6, no. 3 (2000): 149–73; and P. Ogden, K. Minton, and C. Pain, Trauma and the Body: A Sensorimotor Approach to Psychotherapy, Norton Series on Interpersonal Neurobiology (New York: WW Norton & Company, 2006).

15. D. A. Bakal, Minding the Body: Clinical Uses of Somatic Awareness (New York: Guilford Press, 2001).

16. There are innumerable studies on the subject. A small sample for further study: J. Wolfe, et al., “Posttraumatic Stress Disorder and War-Zone Exposure as Correlates of Perceived Health in Female Vietnam War Veterans,” Journal of Consulting and Clinical Psychology 62, no. 6 (1994): 1235–40; L. A. Zoellner, M. L. Goodwin, and E. B. Foa, “PTSD Severity and Health Perceptions in Female Victims of Sexual Assault,” Journal of Traumatic Stress 13, no. 4 (2000): 635–49; E. M. Sledjeski, B. Speisman, and L. C. Dierker, “Does Number of Lifetime Traumas Explain the Relationship Between PTSD and Chronic Medical Conditions? Answers from the National Comorbidity Survey-Replication (NCS-R),” Journal of Behavioral Medicine 31 (2008): 341–49; J. A. Boscarino, “Posttraumatic Stress Disorder and Physical Illness: Results from Clinical and Epidemiologic Studies,” Annals of the New York Academy of Sciences 1032 (2004): 141–53; M. Cloitre, et al., “Posttraumatic Stress Disorder and Extent of Trauma Exposure as Correlates of Medical Problems and Perceived Health Among Women with Childhood Abuse,” Women & Health 34, no. 3 (2001): 1–17; D. Lauterbach, R. Vora, and M. Rakow, “The Relationship Between Posttraumatic Stress Disorder and Self-Reported Health Problems,” Psychosomatic Medicine 67, no. 6 (2005): 939–47; B. S. McEwen, “Protective and Damaging Effects of Stress Mediators,” New England Journal of Medicine 338, no. 3 (1998): 171–79; P. P. Schnurr and B. L. Green, Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress (Washington, DC: American Psychological Association, 2004).

17. P. K. Trickett, J. G. Noll, and F. W. Putnam, “The Impact of Sexual Abuse on Female Development: Lessons from a Multigenerational, Longitudinal Research Study,” Development and Psychopathology 23, no. 2 (2011): 453.

18. K. Kosten and F. Giller Jr., ”Alexithymia as a Predictor of Treatment Response in Post-Traumatic Stress Disorder,” Journal of Traumatic Stress 5, no. 4 (October 1992): 563–73.

19. G. J. Taylor and R. M. Bagby, “New Trends in Alexithymia Research,” Psychotherapy and Psychosomatics 73, no. 2 (2004): 68–77.

20. R. D. Lane, et al., “Impaired Verbal and Nonverbal Emotion Recognition in Alexithymia,” Psychosomatic Medicine 58, no. 3 (1996): 203–10.

21. H. Krystal and J. H. Krystal, Integration and Self-Healing: Affect, Trauma, Alexithymia (New York: Analytic Press, 1988).

22. P. Frewen, et al., “Clinical and Neural Correlates of Alexithymia in Posttraumatic Stress Disorder,” Journal of Abnormal Psychology 117, no. 1 (2008): 171–81.

23. D. Finkelhor, R. K. Ormrod, and H. A. Turner, (2007). “Re-Victimization Patterns in a National Longitudinal Sample of Children and Youth,” Child Abuse & Neglect 31, no. 5 (2007): 479-502; J. A. Schumm, S. E. Hobfoll, and N. J. Keogh, “Revictimization and Interpersonal Resource Loss Predicts PTSD Among Women in Substance-Use Treatment, Journal of Traumatic Stress, 17, no. 2 (2004): 173–81; J. D. Ford, J. D. Elhai, D. F. Connor, and B. C. Frueh, “Poly-Victimization and Risk of Posttraumatic, Depressive, and Substance Use Disorders and Involvement in Delinquency in a National Sample of Adolescents,” Journal of Adolescent Health, 46, no. 6 (2010): 545–52.

24. P. Schilder, “Depersonalization,” in Introduction to a Psychoanalytic Psychiatry, no. 50 (New York: International Universities Press, 196), p. 120.

25. S. Arzy, et al., “Neural Mechanisms of Embodiment: Asomatognosia Due to Premotor Cortex Damage,” Archives of Neurology 63, no. 7 (2006): 1022–25. See also S. Arzy et al., “Induction of an Illusory Shadow Person,” Nature 443, no. 7109 (2006): 287; S. Arzy et al., “Neural Basis of Embodiment: Distinct Contributions of Temporoparietal Junction and Extrastriate Body Area,” Journal of Neuroscience 26, no. 31 (2006): 8074–81; O. Blanke et al., “Out-of-Body Experience and Autoscopy of Neurological Origin,” Brain 127, part 2 (2004): 243–58; and M. Sierra, et al., “Unpacking the Depersonalization Syndrome: An Exploratory Factor Analysis on the Cambridge Depersonalization Scale,” Psychological Medicine 35 (2005): 1523–32.

26. A. A. T. Reinders, et al., “Psychobiological Characteristics of Dissociative Identity Disorder: A Symptom Provocation Study,” Biological Psychiatry 60, no. 7 (2006): 730–40.

27. In his book Focusing, Eugene Gendlin coined the term “felt sense”: “A felt sense is not a mental experience but a physical one. A bodily awareness of a situation or person or event; Focusing (New York, Random House Digital, 1982).

28. C. Steuwe, et al., “Effect of Direct Eye Contact in PTSD Related to Interpersonal Trauma: An fMRI Study of Activation of an Innate Alarm System,” Social Cognitive and Affective Neuroscience 9, no. 1 (January 2012): 88–97.

CHAPTER 7: GETTING ON THE SAME WAVELENGTH, ATTACHMENT AND ATTUNEMENT

1. N. Murray, E. Koby, and B. van der Kolk, “The Effects of Abuse on Children’s Thoughts,” chapter 4 in Psychological Trauma (Washington, DC: American Psychiatric Press, 1987).

2. The attachment researcher Mary Main told six-year-olds a story about a child whose mother had gone away and asked them to make up a story of what happened next. Most six-year-olds who, as infants, had been found to have secure relationships with their mothers made up some imaginative tale with a good ending, while the kids who five years earlier had been classified as having a disorganized attachment relationship had a tendency toward catastrophic fantasies and often gave frightened responses like “The parents will die” or “The child will kill herself.” In Mary Main, Nancy Kaplan, and Jude Cassidy. “Security in Infancy, Childhood, and Adulthood: A Move to the Level of Representation,” Monographs of the Society for Research in Child Development (1985).

3. J. Bowlby, Attachment and Loss, vol. 1, Attachment (New York Random House, 1969); J. Bowlby, Attachment and Loss, vol. 2, Separation: Anxiety and Anger (New York: Penguin, 1975); J. Bowlby, Attachment and Loss, vol. 3, Loss: Sadness and Depression (New York: Basic, 1980); J. Bowlby, “The Nature of the Child’s Tie to His Mother 1,” International Journal of Psycho-Analysis, 1958, 39, 350–73.

4. C. Trevarthen, “Musicality and the Intrinsic Motive Pulse: Evidence from Human Psychobiology and Rhythms, Musical Narrative, and the Origins of Human Communication,” Muisae Scientiae, special issue, 1999, 157–213.

5. A. Gopnik and A. N. Meltzoff, Words, Thoughts, and Theories (Cambridge: MIT Press, 1997); A. N. Meltzoff and M. K. Moore, “Newborn Infants Imitate Adult Facial Gestures,” Child Development 54, no. 3 (June 1983): 702–9; A. Gopnik, A. N. Meltzoff, and P. K. Kuhl, The Scientist in the Crib: Minds, Brains, and How Children Learn (New York: HarperCollins, 2009).

6. E. Z. Tronick, “Emotions and Emotional Communication in Infants,” American Psychologist 44, no. 2 (1989): 112. See also E. Tronick, The Neurobehavioral and Social-Emotional Development of Infants and Children (New York, WW Norton & Company, 2007); E. Tronick and M. Beeghly, “Infants’ Meaning-Making and the Development of Mental Health Problems,” American Psychologist 66, no. 2 (2011): 107; and A. V. Sravish, et al., “Dyadic Flexibility During the Face-to-Face Still-Face Paradigm: A Dynamic Systems Analysis of Its Temporal Organization,” Infant Behavior and Development 36, no. 3 (2013): 432–37.

7. M. Main, “Overview of the Field of Attachment,” Journal of Consulting and Clinical Psychology 64, no. 2 (1996): 237–43.

8. D. W. Winnicott, Playing and Reality (New York: Psychology Press, 1971). See also D. W. Winnicott, “The Maturational Processes and the Facilitating Environment,” (1965); and D. W. Winnicott, Through Paediatrics to Psycho-analysis: Collected Papers (New York: Brunner/Mazel, 1975).

9. As we saw in chapter 6, and as Damasio has demonstrated, this sense of inner reality is, at least in part, rooted in the insula, the brain structure that plays a central role in body-mind communication, a structure that is often impaired in people with histories of chronic trauma.

10. D. W. Winnicott, Primary Maternal Preoccupation (London: Tavistock, 1956), 300–305.

11. S. D. Pollak, et al., “Recognizing Emotion in Faces: Developmental Effects of Child Abuse and Neglect,” Developmental Psychology 36, no. 5 (2000): 679.

12. P. M. Crittenden, “IV Peering into the Black Box: An Exploratory Treatise on the Development of Self in Young Children,” Disorders and Dysfunctions of the Self 5 (1994): 79; P. M. Crittenden, and A. Landini, Assessing Adult Attachment: A Dynamic-Maturational Approach to Discourse Analysis(New York: WW Norton & Company, 2011).

13. Patricia M. Crittenden, “Children’s Strategies for Coping with Adverse Home Environments: An Interpretation Using Attachment Theory,” Child Abuse & Neglect 16, no. 3 (1992): 329–43.

14. Main, 1990, op cit.

15. Main, 1990, op cit.

16. Ibid.

17. E. Hesse, and M. Main, “Frightened, Threatening, and Dissociative Parental Behavior in Low-Risk Samples: Description, Discussion, and Interpretations,” Development and Psychopathology 18, no. 2 (2006): 309–343. See also E. Hesse and M. Main, “Disorganized Infant, Child, and Adult Attachment: Collapse in Behavioral and Attentional Strategies,” Journal of the American Psychoanalytic Association 48, no. 4 (2000): 1097–127.

18. Main, “Overview of the Field of Attachment,” op cit.

19. Hesse and Main, 1995, op cit, p. 310.

20. We looked at this from a biological point of view when we discussed “immobilization without fear” in chapter 5. S. W. Porges, “Orienting in a Defensive World: Mammalian Modifications of Our Evolutionary Heritage: A Polyvagal Theory,” Psychophysiology 32 (1995): 301–318.

21. M. H. van Ijzendoorn, C. Schuengel, and M. Bakermans-Kranenburg, “Disorganized Attachment in Early Childhood: Meta-analysis of Precursors, Concomitants, and Sequelae,” Development and Psychopathology 11 (1999): 225–49.

22. Ijzendoorn, op cit.

23. N. W. Boris, M. Fueyo, and C. H. Zeanah, “The Clinical Assessment of Attachment in Children Under Five,” Journal of the American Academy of Child & Adolescent Psychiatry, 36, no. 2 (1997): 291–93; K. Lyons-Ruth, “Attachment Relationships Among Children with Aggressive Behavior Problems: The Role of Disorganized Early Attachment Patterns,” Journal of Consulting and Clinical Psychology, 64, no. 1 (1996), 64.

24. Stephen W. Porges, et al., “Infant Regulation of the Vagal ‘Brake’ Predicts Child Behavior Problems: A Psychobiological Model of Social Behavior,” Developmental Psychobiology 29, no. 8 (1996): 697–712.

25. Louise Hertsgaard, et al., “Adrenocortical Responses to the Strange Situation in Infants with Disorganized/Disoriented Attachment Relationships,” Child Development 66, no. 4 (1995): 1100–6; Gottfried Spangler, and Klaus E. Grossmann, “Biobehavioral Organization in Securely and Insecurely Attached Infants,” Child Development 64, no. 5 (1993): 1439–50.

26. Main and Hesse, 1990, op cit.

27. M. H. van Ijzendoorn, et al., “Disorganized Attachment in Early Childhood,” op cit.

28. B. Beebe, and F. M. Lachmann, Infant Research and Adult Treatment: Co-constructing Interactions (New York: Routledge, 2013); B. Beebe, F. Lachmann, and J. Jaffe (1997). Mother-Infant Interaction Structures and Presymbolic Self‐ and Object Representations. Psychoanalytic Dialogues, 7, no. 2 (1997): 133–82.

29. R. Yehuda, et al., “Vulnerability to Posttraumatic Stress Disorder in Adult Offspring of Holocaust Survivors,” American Journal of Psychiatry 155, no. 9 (1998): 1163–71. See also R. Yehuda, et al., “Relationship Between Posttraumatic Stress Disorder Characteristics of Holocaust Survivors and Their Adult Offspring,” American Journal of Psychiatry 155, no. 6 (1998): 841–43; R. Yehuda, et al., “Parental Posttraumatic Stress Disorder as a Vulnerability Factor for Low Cortisol Trait in Offspring of Holocaust Survivors,” Archives of General Psychiatry 64, no. 9 (2007): 1040 and R. Yehuda, et al., “Maternal, Not Paternal, PTSD Is Related to Increased Risk for PTSD in Offspring of Holocaust Survivors,” Journal of Psychiatric Research 42, no. 13 (2008): 1104–11.

30. R. Yehuda, et al., “Transgenerational Effects of PTSD in Babies of Mothers Exposed to the WTC Attacks During Pregnancy,” Journal of Clinical Endocrinology and Metabolism 90 (2005): 4115–18.

31. G. Saxe, et al., “Relationship Between Acute Morphine and the Course of PTSD in Children with Burns,” Journal of the American Academy of Child & Adolescent Psychiatry 40, no. 8 (2001): 915–21. See also G. N. Saxe, et al., “Pathways to PTSD, Part I: Children with Burns,” American Journal of Psychiatry 162, no. 7 (2005): 1299–304.

32. C. M. Chemtob, Y. Nomura, and R. A. Abramovitz, “Impact of Conjoined Exposure to the World Trade Center Attacks and to Other Traumatic Events on the Behavioral Problems of Preschool Children,” Archives of Pediatrics and Adolescent Medicine 162, no. 2 (2008): 126. See also P. J. Landrigan, et al., “Impact of September 11 World Trade Center Disaster on Children and Pregnant Women,” Mount Sinai Journal of Medicine 75, no. 2 (2008): 129–34.

33. D. Finkelhor, R. K. Ormrod, and H. A. Turner, “Polyvictimization and Trauma in a National Longitudinal Cohort,” Development and Psychopathology 19, no. 1 (2007): 149–66; J. D. Ford, et al., “Poly-victimization and Risk of Posttraumatic, Depressive, and Substance Use Disorders and Involvement in Delinquency in a National Sample of Adolescents,” Journal of Adolescent Health 46, no. 6 (2010): 545–52; J. D. Ford, et al., “Clinical Significance of a Proposed Development Trauma Disorder Diagnosis: Results of an International Survey of Clinicians,” Journal of Clinical Psychiatry 74, no. 8 (2013): 841–49.

34. Family Pathways Project, http://www.challiance.org/academics/familypathwaysproject.aspx.

35. K. Lyons‐Ruth and D. Block, “The Disturbed Caregiving System: Relations Among Childhood Trauma, Maternal Caregiving, and Infant Affect and Attachment,” Infant Mental Health Journal 17, no. 3 (1996): 257–75.

36. K. Lyons-Ruth, “The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental States, and Hostile/Helpless Relational Processes,” Journal of Infant, Child, and Adolescent Psychotherapy 2 (2003): 105.

37. G. Whitmer, “On the Nature of Dissociation,” Psychoanalytic Quarterly 70, no. 4 (2001): 807–37. See also K. Lyons-Ruth, “The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental States, and Hostile/Helpless Relational Processes,” Journal of Infant, Child, and Adolescent Psychotherapy 2, no. 4 (2002): 107–19.

38. Mary S. Ainsworth and John Bowlby, “An Ethological Approach to Personality Development,” American Psychologist 46, no. 4 (April 1991): 333–41.

39. K. Lyons-Ruth and D. Jacobvitz, 1999; Main, 1993; K. Lyons-Ruth, “Dissociation and the Parent-Infant Dialogue: A Longitudinal Perspective from Attachment Research,” Journal of the American Psychoanalytic Association 51, no. 3 (2003): 883–911.

40. L. Dutra, et al., “Quality of Early Care and Childhood Trauma: A Prospective Study of Developmental Pathways to Dissociation,” Journal of Nervous and Mental Disease 197, no. 6 (2009): 383. See also K. Lyons-Ruth, et al., “Borderline Symptoms and Suicidality/Self-Injury in Late Adolescence: Prospectively Observed Relationship Correlates in Infancy and Childhood,” Psychiatry Research 206, nos. 2–3 (April 30, 2013): 273–81.

41. For meta-analysis of the relative contributions of disorganized attachment and child maltreatment, see C. Schuengel, et al., “Frightening Maternal Behavior Linking Unresolved Loss and Disorganized Infant Attachment,” Journal of Consulting and Clinical Psychology 67, no. 1 (1999): 54.

42. K. Lyons-Ruth and D. Jacobvitz, “Attachment Disorganization: Genetic Factors, Parenting Contexts, and Developmental Transformation from Infancy to Adulthood,” in Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd ed., ed. J. Cassidy and R. Shaver (New York: Guilford Press, 2008), 666–97. See also E. O’connor, et al., “Risks and Outcomes Associated with Disorganized/Controlling Patterns of Attachment at Age Three Years in the National Institute of Child Health & Human Development Study of Early Child Care and Youth Development,” Infant Mental Health Journal 32, no. 4 (2011): 450–72; and K. Lyons-Ruth, et al., “Borderline Symptoms and Suicidality/Self-Injury.

43. At this point we have little information about what factors affect the evolution of these early regulatory abnormalities, but intervening life events, the quality of other relationships, and perhaps even genetic factors are likely to modify them over time. It is obviously critical to study to what degree consistent and concentrated parenting of children with early histories of abuse and neglect can rearrange biological systems.

44. E. Warner, et al., “Can the Body Change the Score? Application of Sensory Modulation Principles in the Treatment of Traumatized Adolescents in Residential Settings,” Journal of Family Violence 28, no. 7 (2003): 729–38.

CHAPTER 8: TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT

1. W. H. Auden, The Double Man (New York: Random House, 1941),

2. S. N. Wilson, et al., “Phenotype of Blood Lymphocytes in PTSD Suggests Chronic Immune Activation,” Psychosomatics 40, no. 3 (1999): 222–25. See also M. Uddin, et al., “Epigenetic and Immune Function Profiles Associated with Posttraumatic Stress Disorder,” Proceedings of the National Academy of Sciences of the United States of America 107, no. 20 (2010): 9470–75; M. Altemus, M. Cloitre, and F. S. Dhabhar, “Enhanced Cellular Immune Response in Women with PTSD Related to Childhood Abuse,” American Journal of Psychiatry 160, no. 9 (2003): 1705–7; and N. Kawamura, Y. Kim, and N. Asukai, “Suppression of Cellular Immunity in Men with a Past History of Posttraumatic Stress Disorder,” American Journal of Psychiatry 158, no. 3 (2001): 484–86.

3. R. Summit, “The Child Sexual Abuse Accommodation Syndrome,” Child Abuse & Neglect 7 (1983): 177–93.

4. A study using fMRI at the University of Lausanne in Switzerland showed that when people have these out-of-body experiences, staring at themselves as if looking down from the ceiling, they are activating the superior temporal cortex in the brain. O. Blanke, et al., “Linking Out-of-Body Experience and Self Processing to Mental Own-Body Imagery at the Temporoparietal Junction,” Journal of Neuroscience 25, no. 3 (2005): 550–57. See also O. Blanke and T. Metzinger, “Full-Body Illusions and Minimal Phenomenal Selfhood,” Trends in Cognitive Sciences 13, no. 1 (2009): 7–13.

5. When an adult uses a child for sexual gratification, the child invariably is caught in a confusing situation and a conflict of loyalties: By disclosing the abuse, she betrays and hurts the perpetrator (who may be an adult on whom the child depends for safety and protection), but by hiding the abuse, she compounds her shame and vulnerability. This dilemma was first articulated by Sándor Ferenczi in 1933 in “The Confusion of Tongues Between the Adult and the Child: The Language of Tenderness and the Language of Passion,” International Journal of Psychoanalysis, 30 no. 4 (1949): 225–30, and has been explored by numerous subsequent authors.

CHAPTER 9: WHAT’S LOVE GOT TO DO WITH IT?

1. Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Penguin, 2013).

2. http://www.thefreedictionary.com/diagnosis.

3. The TAQ can be accessed at the Trauma Center Web site: www.traumacenter.org/products/instruments.php.

4. J. L. Herman, J. C. Perry, and B. A. van der Kolk, “Childhood Trauma in Borderline Personality Disorder,” American Journal of Psychiatry 146, no. 4 (April 1989): 490–95.

5Teicher found significant changes in the orbitofrontal cortex (OFC), a region of the brain that is involved in decision making and the regulation of behavior involved in sensitivity to social demands. M. H. Teicher, et al., “The Neurobiological Consequences of Early Stress and Childhood Maltreatment,” Neuroscience & Biobehavioral Reviews 27, no. 1 (2003): 33–44. See also M. H. Teicher, “Scars That Won’t Heal: The Neurobiology of Child Abuse,” Scientific American 286, no. 3 (2002): 54–61; M. Teicher, et al., “Sticks, Stones, and Hurtful Words: Relative Effects of Various Forms of Childhood Maltreatment,” American Journal of Psychiatry 163, no. 6 (2006): 993–1000; A. Bechara, et al., “Insensitivity to Future Consequences Following Damage to Human Prefrontal Cortex,” Cognition 50 (1994): 7–15. Impairment in this area of the brain results in excessive swearing, poor social interactions, compulsive gambling, excessive alcohol / drug use and poor empathic ability. M. L. Kringelbach and E. T. Rolls, “The Functional Neuroanatomy of the Human Orbitofrontal Cortex: Evidence from Neuroimaging and Neuropsychology,” Progress in Neurobiology 72 (2004): 341–72The other problematic area Teicher identified was the precuneus, a brain area involved in understanding oneself and being able to take perspective on how your perceptions may be different from someone else’sA. E. Cavanna and M. R. Trimble “The Precuneus: A Review of Its Functional Anatomy and Behavioural Correlates,” Brain 129 (2006): 564–83.

6. S. Roth, et al., “Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder,” Journal of Traumatic Stress 10 (1997): 539–55; B. A. van der Kolk et al., “Dissociation, Somatization, and Affect Dysregulation: The Complexity of Adaptation to Trauma,” American Journal of Psychiatry 153 (1996): 83–93; D. Pelcovitz, et al., “Development of a Criteria Set and a Structured Interview for Disorders of Extreme Stress (SIDES),” Journal of Traumatic Stress 10 (1997): 3–16; S. N. Ogata, et al., “Childhood Sexual and Physical Abuse in Adult Patients with Borderline Personality Disorder,” American Journal of Psychiatry 147 (1990): 1008–1013; M. C. Zanarini, et al., “Axis I Comorbidity of Borderline Personality Disorder,” American Journal of Psychiatry 155, no. 12. (December 1998): 1733–39; S. L. Shearer, et al., “Frequency and Correlates of Childhood Sexual and Physical Abuse Histories in Adult Female Borderline Inpatients,” American Journal of Psychiatry 147 (1990): 214–16; D. Westen, et al., “Physical and Sexual Abuse in Adolescent Girls with Borderline Personality Disorder,” American Journal of Orthopsychiatry 60 (1990): 55–66; M. C. Zanarini, et al., “Reported Pathological Childhood Experiences Associated with the Development of Borderline Personality Disorder,” American Journal of Psychiatry 154 (1997): 1101–1106.

7. J. Bowlby, A Secure Base: Parent-Child Attachment and Healthy Human Development (New York: Basic Books, 2008), 103.

8. B. A. van der Kolk, J. C. Perry, and J. L. Herman, “Childhood Origins of Self- Destructive Behavior,” American Journal of Psychiatry 148 (1991): 1665–71.

9. This notion found further support in the work of the neuroscientist Jaak Panksepp, who found that young rats that were not licked by their moms during the first week of their lives did not develop opioid receptors in the anterior cingulate cortex, a part of the brain associated with affiliation and a sense of safety. See E. E. Nelson and J. Panksepp, “Brain Substrates of Infant-Mother Attachment: Contributions of Opioids, Oxytocin, and Norepinephrine,” Neuroscience & Biobehavioral Reviews 22, no. 3 (1998): 437–52. See also J. Panksepp, et al., “Endogenous Opioids and Social Behavior,” Neuroscience & Biobehavioral Reviews 4, no. 4 (1981): 473–87; and J. Panksepp, E. Nelson, and S. Siviy, “Brain Opioids and Mother-Infant Social Motivation,” Acta paediatrica 83, no. 397 (1994): 40–46.

10. The delegation to Robert Spitzer also included Judy Herman, Jim Chu, and David Pelcovitz.

11. B. A. van der Kolk, et al., “Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma,” Journal of Traumatic Stress 18, no. 5 (2005): 389–99. See also J. L. Herman, “Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma,” Journal of Traumatic Stress 5, no. 3 (1992): 377–91; C. Zlotnick, et al., “The Long-Term Sequelae of Sexual Abuse: Support for a Complex Posttraumatic Stress Disorder,” Journal of Traumatic Stress 9, no. 2 (1996): 195–205; S. Roth, et al., “Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM‐IV Field Trial for Posttraumatic Stress Disorder,” Journal of Traumatic Stress 10, no. 4 (1997): 539–55; and D. Pelcovitz, et al., “Development and Validation of the Structured Interview for Measurement of Disorders of Extreme Stress,” Journal of Traumatic Stress 10 (1997): 3–16.

12. B. C. Stolbach, et al., “Complex Trauma Exposure and Symptoms in Urban Traumatized Children: A Preliminary Test of Proposed Criteria for Developmental Trauma Disorder,” Journal of Traumatic Stress 26, no. 4 (August 2013): 483–91.

13. B. A. van der Kolk, et al., “Dissociation, Somatization and Affect Dysregulation: The Complexity of Adaptation to Trauma,” American Journal of Psychiatry 153, suppl (1996): 83–93. See also D. G. Kilpatrick, et al., “Posttraumatic Stress Disorder Field Trial: Evaluation of the PTSD Construct—Criteria A Through E,” in: DSM-IV Sourcebook, vol. 4 (Washington: American Psychiatric Press, 1998), 803-844; T. Luxenberg, J. Spinazzola, and B. A. van der Kolk, “Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment,” Directions in Psychiatry 21, no. 25 (2001): 373–92; and B. A. van der Kolk, et al., “Disorders of Extreme Stress: The Empirical Foundation of a Compex Adaptation to Trauma,” Journal of Traumatic Stress 18, no. 5 (2005): 389–99.

14. These questions are available on the ACE Web site: http://acestudy.org/.

15. http://www.cdc.gov/ace/findings.htm; http://acestudy.org/download; V. Felitti, et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58. See also R. Reading, “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology,” Child: Care, Health and Development 32, no. 2 (2006): 253–56; V. J. Edwards, et al., “Experiencing Multiple Forms of Childhood Maltreatment and Adult Mental Health: Results from the Adverse Childhood Experiences (ACE) Study,” American Journal of Psychiatry 160, no. 8 (2003): 1453–60; S. R. Dube, et al., “Adverse Childhood Experiences and Personal Alcohol Abuse as an Adult,” Addictive Behaviors27, no. 5 (2002): 713–25; S. R. and S. R. Dube, et al., “Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study,” Pediatrics 111, no. 3 (2003): 564–72.

16. S. A. Strassels, “Economic Burden of Prescription Opioid Misuse and Abuse,” Journal of Managed Care Pharmacy 15, no. 7 (2009): 556–62.

17. C. B. Nemeroff, et al., “Differential Responses to Psychotherapy Versus Pharmacotherapy in Patients with Chronic Forms of Major Depression and Childhood Trauma,” Proceedings of the National Academy of Sciences of the United States of America 100, no. 24 (2003): 14293–96. See also C. Heim, P. M. Plotsky, and C. B. Nemeroff, “Importance of Studying the Contributions of Early Adverse Experience to Neurobiological Findings in Depression,” Neuropsychopharmacology 29, no. 4 (2004): 641–48.

18. B. E. Carlson, “Adolescent Observers of Marital Violence,” Journal of Family Violence 5, no. 4 (1990): 285–99. See also B. E. Carlson, “Children’s Observations of Interparental Violence,” in Battered Women and Their Families, ed. A. R. Roberts (New York: Springer, 1984), 147–67; J. L. Edleson, “Children’s Witnessing of Adult Domestic Violence,” Journal of Interpersonal Violence 14, no. 8 (1999): 839–70; K. Henning, et al., “Long-Term Psychological and Social Impact of Witnessing Physical Conflict Between Parents,” Journal of Interpersonal Violence 11, no. 1 (1996): 35–51; E. N. Jouriles, C. M. Murphy, and D. O’Leary, “Interpersonal Aggression, Marital Discord, and Child Problems,” Journal of Consulting and Clinical Psychology 57, no. 3 (1989): 453–55; J. R. Kolko, E. H. Blakely, and D. Engelman, “Children Who Witness Domestic Violence: A Review of Empirical Literature,” Journal of Interpersonal Violence 11, no. 2 (1996): 281–93; and J. Wolak and D. Finkelhor, “Children Exposed to Partner Violence,” in Partner Violence: A Comprehensive Review of 20 Years of Research, ed. J. L. Jasinski and L. Williams (Thousand Oaks, CA: Sage, 1998).

19. Most of these statements are based on conversations with Vincent Felitti, amplified by J. E. Stevens, “The Adverse Childhood Experiences Study—the Largest Public Health Study You Never Heard Of,” Huffington Post, October 8, 2012, http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp _1_b_1943647.html.

20. Population attributable risk: the proportion of a problem in the overall population whose problems can be attributed to specific risk factors.

21. National Cancer Institute, “Nearly 800,000 Deaths Prevented Due to Declines in Smoking” (press release), March 14, 2012, available at http://www.cancer.gov/newscenter/newsfromnci/2012/TobaccoControlCISNET.

CHAPTER 10: DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

1. These cases were part of the DTD field trial, conducted jointly by Julian Ford, Joseph Spinazzola, and me.

2. H. J. Williams, M. J. Owen, and M. C. O’Donovan, “Schizophrenia Genetics: New Insights from New Approaches,” British Medical Bulletin 91 (2009): 61–74. See also P. V. Gejman, A. R. Sanders, and K. S. Kendler, “Genetics of Schizophrenia: New Findings and Challenges,” Annual Review of Genomics and Human Genetics 12 (2011): 121–44; and A. Sanders, et al., “No Significant Association of 14 Candidate Genes with Schizophrenia in a Large European Ancestry Sample: Implications for Psychiatric Genetics,” American Journal of Psychiatry 165, no. 4 (April 2008): 497–506.

3. R. Yehuda, et al., “Putative Biological Mechanisms for the Association Between Early Life Adversity and the Subsequent Development of PTSD,” Psychopharmacology 212, no. 3 (October 2010): 405–417; K. C. Koenen, “Genetics of Posttraumatic Stress Disorder: Review and Recommendations for Future Studies,” Journal of Traumatic Stress 20, no. 5 (October 2007): 737–50; M. W. Gilbertson, et al., “Smaller Hippocampal Volume Predicts Pathologic Vulnerability to Psychological Trauma,” Nature Neuroscience 5 (2002): 1242–47.

4. Koenen, “Genetics of Posttraumatic Stress Disorder.” See also R. F. P. Broekman, M. Olff, and F. Boer, “The Genetic Background to PTSD,” Neuroscience & Biobehavioral Reviews 31, no. 3 (2007): 348–62.

5. M. J. Meaney and A. C. Ferguson-Smith, “Epigenetic Regulation of the Neural Transcriptome: The Meaning of the Marks,” Nature Neuroscience 13, no. 11 (2010): 1313–18. See also M. J. Meaney, “Epigenetics and the Biological Definition of Gene × Environment Interactions,” Child Development 81,no. 1 (2010): 41–79; and B. M. Lester, et al., “Behavioral Epigenetics,” Annals of the New York Academy of Sciences 1226, no. 1 (2011): 14–33.

6. M. Szyf, “The Early Life Social Environment and DNA Methylation: DNA Methylation Mediating the Long-Term Impact of Social Environments Early in Life,” Epigenetics 6, no. 8 (2011): 971–78.

7. Moshe Szyf, Patrick McGowan, and Michael J. Meaney, “The Social Environment and the Epigenome,” Environmental and Molecular Mutagenesis 49, no. 1 (2008): 46–60.

8. There now is voluminous evidence that life experiences of all sorts changes gene expression. Some examples are: D. Mehta et al., “Childhood Maltreatment Is Associated with Distinct Genomic and Epigenetic Profiles in Posttraumatic Stress Disorder,” Proceedings of the National Academy of Sciences of the United States of America 110, no. 20 (2013): 8302–7; P. O. McGowan, et al., “Epigenetic Regulation of the Glucocorticoid Receptor in Human Brain Associates with Childhood Abuse,” Nature Neuroscience 12, no. 3 (2009): 342–48; M. N. Davies, et al., “Functional Annotation of the Human Brain Methylome Identifies Tissue-Specific Epigenetic Variation Across Brain and Blood,” Genome Biology 13, no. 6 (2012): R43; M. Gunnar and K. Quevedo, “The Neurobiology of Stress and Development,” Annual Review of Psychology 58 (2007): 145–73; A. Sommershof, et al., “Substantial Reduction of Naïve and Regulatory T Cells Following Traumatic Stress,” Brain, Behavior, and Immunity 23, no. 8 (2009): 1117–24; N. Provençal, et al., “The Signature of Maternal Rearing in the Methylome in Rhesus Macaque Prefrontal Cortex and T Cells,” Journal of Neuroscience 32, no. 44 (2012): 15626–42; B. Labonté, et al., “Genome-wide Epigenetic Regulation by Early-Life Trauma,” Archives of General Psychiatry 69, no. 7 (2012): 722–31; A. K. Smith, et al., “Differential Immune System DNA Methylation and Cytokine Regulation in Post-traumatic Stress Disorder,” American Journal of Medical Genetics Part B: Neuropsychiatric Genetics 156B, no. 6 (2011): 700–708; M. Uddin, et al., “Epigenetic and Immune Function Profiles Associated with Posttraumatic Stress Disorder,” Proceedings of the National Academy of Sciences of the United States of America 107, no. 20 (2010): 9470–75.

9. C. S. Barr, et al., “The Utility of the Non‐human Primate Model for Studying Gene by Environment Interactions in Behavioral Research,” Genes, Brain and Behavior 2, no. 6 (2003): 336–40.

10. A. J. Bennett, et al., “Early Experience and Serotonin Transporter Gene Variation Interact to Influence Primate CNS Function,” Molecular Psychiatry 7, no. 1 (2002): 118–22. See also C. S. Barr, et al., “Interaction Between Serotonin Transporter Gene Variation and Rearing Condition in Alcohol Preference and Consumption in Female Primates,” Archives of General Psychiatry 61no. 11 (2004): 1146; and C. S. Barr, et al., “Serotonin Transporter Gene Variation Is Associated with Alcohol Sensitivity in Rhesus Macaques Exposed to Early‐Life Stress,” Alcoholism: Clinical and Experimental Research 27, no. 5 (2003): 812–17.

11. A. Roy, et al., “Interaction of FKBP5, a Stress-Related Gene, with Childhood Trauma Increases the Risk for Attempting Suicide,” Neuropsychopharmacology 35, no. 8 (2010): 1674–83. See also M. A. Enoch, et al., “The Influence of GABRA2, Childhood Trauma, and Their Interaction on Alcohol, Heroin, and Cocaine Dependence,” Biological Psychiatry 67 no. 1 (2010): 20–27; and A. Roy, et al., “Two HPA Axis Genes, CRHBP and FKBP5, Interact with Childhood Trauma to Increase the Risk for Suicidal Behavior,” Journal of Psychiatric Research 46, no. 1 (2012): 72–79.

12. A. S. Masten and D. Cicchetti, “Developmental Cascades,” Development and Psychopathology 22, no. 3 (2010): 491–95; S. L. Toth, et al., “Illogical Thinking and Thought Disorder in Maltreated Children,” Journal of the American Academy of Child & Adolescent Psychiatry 50, no. 7 (2011): 659–68; J. Willis, “Building a Bridge from Neuroscience to the Classroom,” Phi Delta Kappan 89, no. 6 (2008): 424; I. M. Eigsti and D. Cicchetti, “The Impact of Child Maltreatment on Expressive Syntax at 60 Months,” Developmental Science 7, no. 1 (2004): 88–102.

13. J. Spinazzola, et al., “Survey Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and Adolescents,” Psychiatric Annals 35, no. 5 (2005): 433–39.

14. R. C. Kessler, C. B. Nelson, and K. A. McGonagle, “The Epidemiology of Co-occuring Addictive and Mental Disorders,” American Journal of Orthopsychiatry 66, no. 1 (1996): 17–31. See also Institute of Medicine of the National Academies, Treatment of Posttraumatic Stress Disorder (Washington: National Academies Press, 2008); and C. S. North, et al., “Toward Validation of the Diagnosis of Posttraumatic Stress Disorder,” American Journal of Psychiatry 166, no. 1 (2009): 34–40.

15. Joseph Spinazzola, et al., “Survey Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and Adolescents,” Psychiatric Annals (2005).

16. Our work group consisted of Drs. Bob Pynoos, Frank Putnam, Glenn Saxe, Julian Ford, Joseph Spinazzola, Marylene Cloitre, Bradley Stolbach, Alexander McFarlane, Alicia Lieberman, Wendy D’Andrea, Martin Teicher, and Dante Cicchetti.

17. The proposed criteria for Developmental Trauma Disorder can be found in the Appendix.

18. http://www.traumacenter.org/products/instruments.php.

19. Read more about Sroufe at www.cehd.umn.edu/icd/people/faculty/cpsy/sroufe.html and more about the Minnesota Longitudinal Study of Risk and Adaptation and its publications at http://www.cehd.umn.edu/icd/research/parent-child/ and http://www.cehd.umn.edu/icd/research/parent-child/publications/. See also L. A. Sroufe and W. A. Collins, The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2009); and L. A. Sroufe, “Attachment and Development: A Prospective, Longitudinal Study from Birth to Adulthood,” Attachment & Human Development 7, no. 4 (2005): 349–67.

20. L. A. Sroufe, The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2005). Harvard researcher Karlen Lyons-Ruth had similar findings in a sample of children she followed for about eighteen years: Disorganized attachment, role reversal, and lack of maternal communication at age three were the greatest predictors of children being part of the mental health or social service system at age eighteen.

21. D. Jacobvitz and L. A. Sroufe, “The Early Caregiver-Child Relationship and Attention-Deficit Disorder with Hyperactivity in Kindergarten: A Prospective Study,” Child Development 58, no. 6 (December 1987): 1496–504.

22. G. H. Elder Jr., T. Van Nguyen, and A. Caspi, “Linking Family Hardship to Children’s Lives,” Child Development 56, no. 2 (April 1985): 361–75.

23. For children who were physically abused, the chance of being diagnosed with conduct disorder or oppositional defiant disorder went up by a factor of three. Neglect or sexual abuse doubled the chance of developing an anxiety disorder. Parental psychological unavailability or sexual abuse doubled the chance of later developing PTSD. The chance of receiving multiple diagnoses was 54 percent for children who suffered neglect, 60 percent for physical abuse, and 73 percent for both sexual abuse.

24. This was a quote based on the work of Emmy Werner, who has studied 698 children born on the island of Kauai for forty years, starting in 1955. The study showed that most children who grew up in unstable households grew up to experience problems with delinquency, mental and physical health, and family stability. One-third of all high-risk children displayed resilience and developed into caring, competent, and confident adults. Protective factors were 1. being an appealing child, 2. a strong bond with a nonparent caretaker (such as an aunt, a babysitter, or a teacher) and strong involvement in church or community groups. E. E. Werner and R. S. Smith, Overcoming the Odds: High Risk Children from Birth to Adulthood (Ithaca and London: Cornell University Press, 1992).

25. P. K. Trickett, J. G. Noll, and F. W. Putnam, “The Impact of Sexual Abuse on Female Development: Lessons from a Multigenerational, Longitudinal Research Study,” Development and Psychopathology 23 (2011): 453–76. See also J. G. Noll, P. K. Trickett, and F. W. Putnam, “A Prospective Investigation of the Impact of Childhood Sexual Abuse on the Development of Sexuality,” Journal of Consulting and Clinical Psychology 71 (2003): 575–86; P. K. Trickett, C. McBride-Chang, and F. W. Putnam, “The Classroom Performance and Behavior of Sexually Abused Females,” Development and Psychopathology 6 (1994): 183–94; P. K. Trickett and F. W. Putnam, Sexual Abuse of Females: Effects in Childhood (Washington: National Institute of Mental Health, 1990–1993); F. W. Putnam and P. K. Trickett, The Psychobiological Effects of Child Sexual Abuse (New York: W. T. Grant Foundation, 1987).

26. In the sixty-three studies on disruptive mood regulation disorder, nobody asked anything about attachment, PTSD, trauma, child abuse, or neglect. The word “maltreatment” is used in passing in just one of the sixty-three articles. There is nothing about parenting, family dynamics, or about family therapy.

27. In the appendix at the back of the DSM, you can find the so-called V-codes, diagnostic labels without official standing that are not eligible for insurance reimbursement. There you will see listings for childhood abuse, childhood neglect, childhood physical abuse, and childhood sexual abuse.

28. Ibid., p 121.

29. At the time of this writing, the DSM-5 is number seven on Amazon’s best-seller list. The APA earned $100 million on the previous edition of the DSM. The publication of the DSM constitutes, with contributions from the pharmaceutical industry and membership dues, the APA’s major source of income.

30. Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Penguin, 2013), 239.

31. In an open letter to the APA David Elkins, the chairman of one of the divisions of the American Psychological Association, complained that DSM-V was based on shaky evidence, carelessness with the public health, and the conceptualizations of mental disorder as primarily medical phenomena.” His letter attracted nearly five thousand signatures. The president of the American Counseling Association sent a letter on behalf of its 115,000 DSM-buying members to the president of the APA, also objecting to the quality of the science behind DSM-5—and “urge(d) the APA to make public the work of the scientific review committee it had appointed to review the proposed changes, as well as to allow an evaluation of “all evidence and data by external, independent groups of experts.”

32. Thomas Insel had formerly done research on the attachment hormone oxytocin in non-human primates.

33. National Institute of Mental Health, “NIMH Research Domain Criteria (RDoC),” http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml.

34. The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford Press, 2005).

35. B. A. van der Kolk, “Developmental Trauma Disorder: Toward a Rational Diagnosis for Children with Complex Trauma Histories,” Psychiatric Annals 35, no. 5 (2005): 401–8; W. D’Andrea, et al., “Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis,” American Journal of Orthopsychiatry 82 (2012): 187–200. J. D. Ford, et al., “Clinical Significance of a Proposed Developmental Trauma Disorder Diagnosis: Results of an International Survey of Clinicians,” Journal of Clinical Psychiatry 74, no. 8 (2013): 841–849. Up-to-date results from the Developmental Trauma Disorder field trial study are available on our Web site: www.traumacenter.org.

36. J. J. Heckman, “Skill Formation and the Economics of Investing in Disadvantaged Children,” Science 312, no. 5782 (2006): 1900–2.

37. D. Olds, et al., “Long-Term Effects of Nurse Home Visitation on Children’s Criminal and Antisocial Behavior: 15-Year Follow-up of a Randomized Controlled Trial,” JAMA 280, no. 14 (1998): 1238–44. See also J. Eckenrode, et al., “Preventing Child Abuse and Neglect with a Program of Nurse Home Visitation: The Limiting Effects of Domestic Violence,” JAMA 284, no. 11 (2000): 1385–91; D. I. Lowell, et al., “A Randomized Controlled Trial of Child FIRST: A Comprehensive Home-Based Intervention Translating Research into Early Childhood Practice,” Child Development 82, no. 1 (January/February 2011): 193–208; S. T. Harvey and J. E. Taylor, “A Meta-Analysis of the Effects of Psychotherapy with Sexually Abused Children and Adolescents, Clinical Psychology Review 30, no. 5 (July 2010): 517–35; J. E. Taylor and S. T. Harvey, “A Meta-Analysis of the Effects of Psychotherapy with Adults Sexually Abused in Childhood,” Clinical Psychology Review 30, no. 6 (August 2010): 749–67; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; B. C. Stolbach, et al., “Complex Trauma Exposure and Symptoms in Urban Traumatized Children: A Preliminary Test of Proposed Criteria for Developmental Trauma Disorder,” Journal of Traumatic Stress 26, no. 4 (August 2013): 483–91.

CHAPTER 11: UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY

1. Unlike clinical consultations, in which doctor-patient confidentiality applies, forensic evaluations are public documents to be shared with lawyers, courts, and juries. Before doing a forensic evaluation I inform clients of that and warn them that nothing they tell me can be kept confidential.

2. K. A. Lee, et al., “A 50-Year Prospective Study of the Psychological Sequelae of World War II Combat,” American Journal of Psychiatry 152, no. 4 (April 1995): 516–22.

3. J. L. McGaugh and M. L. Hertz, Memory Consolidation (San Fransisco: Albion Press, 1972); L. Cahill and J. L. McGaugh, “Mechanisms of Emotional Arousal and Lasting Declarative Memory,” Trends in Neurosciences 21, no. 7 (1998): 294–99.

4. A. F. Arnsten, et al., “α-1 Noradrenergic Receptor Stimulation Impairs Prefrontal Cortical Cognitive Function,” Biological Psychiatry 45, no. 1 (1999): 26–31. See also A. F. Arnsten, “Enhanced: The Biology of Being Frazzled,” Science 280, no. 5370 (1998): 1711–12; S. Birnbaum, et al., “A Role for Norepinephrine in Stress-Induced Cognitive Deficits: α-1-adrenoceptor Mediation in the Prefrontal Cortex,” Biological Psychiatry 46, no. 9 (1999): 1266–74.

5. Y. D. Van Der Werf, et al. “Special Issue: Contributions of Thalamic Nuclei to Declarative Memory Functioning,” Cortex 39 (2003): 1047–62. See also B. M. Elzinga and J. D. Bremner, “Are the Neural Substrates of Memory the Final Common Pathway in Posttraumatic Stress Disorder (PTSD)?” Journal of Affective Disorders 70 (2002): 1–17; L. M. Shin et al., “A Functional Magnetic Resonance Imaging Study of Amygdala and Medial Prefrontal Cortex Responses to Overtly Presented Fearful Faces in Posttraumatic Stress Disorder,” Archives of General Psychiatry 62 (2005): 273–81; L. M. Williams et al., “Trauma Modulates Amygdala and Medial Prefrontal Responses to Consciously Attended Fear,” Neuroimage 29 (2006): 347–57; R. A. Lanius et al., “Brain Activation During Script-Driven Imagery Induced Dissociative Responses in PTSD: A Functional Magnetic Resonance Imaging Investigation,” Biological Psychiatry 52 (2002): 305–311; H. D Critchley, C. J. Mathias, and R. J. Dolan, “Fear Conditioning in Humans: The Influence of Awareness and Autonomic Arousal on Functional Neuroanatomy,” Neuron 33 (2002): 653–63; M. Beauregard, J. Levesque, and P. Bourgouin, “Neural Correlates of Conscious Self-Regulation of Emotion,” Journal of Neuroscience 21 (2001): RC165; K. N. Ochsner et al., “For Better or for Worse: Neural Systems Supporting the Cognitive Down- and Up-Regulation of Negative Emotion,” NeuroImage 23 (2004): 483–99; M. A. Morgan, L. M. Romanski, and J. E. LeDoux, et al., “Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163 (1993): 109–13; M. R. Milad and G. J. Quirk, “Neurons in Medial Prefrontal Cortex Signal Memory for Fear Extinction,” Nature 420 (2002): 70–74; and J. Amat, et al., “Medial Prefrontal Cortex Determines How Stressor Controllability Affects Behavior and Dorsal Raphe Nucleus,” Nature Neuroscience 8 (2005): 365–71.

6. B. A. Van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8, no. 4 (1995): 505–25.

7. Hysteria as defined by Free Dictionary, http://www.thefreedictionary.com/hysteria.

8. A. Young, The Harmony of Illusions: Inventing Post-traumatic Stress Disorder (Princeton University Press, 1997). See also H. F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (Basic Books, 2008).

9. T. Ribot, Diseases of Memory (Appleton, 1887), 108–9; Ellenberger, Discovery of the Unconscious.

10. J. Breuer and S. Freud, “The Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud (London: Hogarth Press, 1893).

11. A. Young, Harmony of Illusions.

12. J. L. Herman, Trauma and Recovery (New York: Basic Books, 1997), 15.

13. A. Young, Harmony of Illusions. See also J. M. Charcot, Clinical Lectures on Certain Diseases of the Nervous System, vol. 3 (London: New Sydenham Society, 1888).

14. http://en.wikipedia.org/wiki/File:Jean-Martin_Charcot_chronophotography.jpg

15. P. Janet, L’Automatisme psychologique (Paris: Félix Alcan, 1889).

16. Onno van der Hart introduced me to the work of Janet and probably is the greatest living scholar of his work. I had the good fortune of closely collaborating with Onno on summarizing Janet’s fundamental ideas. B. A. van der Kolk and O. van der Hart, “Pierre Janet and the Breakdown of Adaptation in Psychological Trauma,” American Journal of Psychiatry 146 (1989): 1530–40; B. A. van der Kolk and O. van der Hart, “The Intrusive Past: The Flexibility of Memory and the Engraving of Trauma,” Imago 48 (1991): 425–54.

17. P. Janet, “L’amnésie et la dissociation des souvenirs par l’emotion” [Amnesia and the dissociation of memories by emotions], Journal de Psychologie 1 (1904): 417–53.

18. P. Janet, Psychological Healing (New York: Macmillan, 1925); p 660.

19. P. Janet, L’Etat mental des hystériques, 2nd ed. (Paris: Félix Alcan, 1911; repr. Marseille, France: Lafitte Reprints, 1983). P. Janet, The Major Symptoms of Hysteria (London and New York: Macmillan, 1907; repr. New York: Hafner, 1965); P. Janet, L’evolution de la memoire et de la notion du temps(Paris: A. Chahine, 1928).

20. J. L. Titchener, “Post-traumatic Decline: A Consequence of Unresolved Destructive Drives,” Trauma and Its Wake 2 (1986): 5–19.

21. J. Breuer, and S. Freud, “The Physical Mechanisms of Hysterical Phenomena.”

22. S. Freud and J. Breuer, “The Etiology of Hysteria,” in the Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 3, ed. J. Strachy (London: Hogarth Press, 1962): 189–221.

23. S. Freud, “Three Essays on the Theory of Sexuality,” in the Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 7 (London: Hogarth Press, 1962): 190: The reappearance of sexual activity is determined by internal causes and external contingencies . . . I shall have to speak presently of the internal causes; great and lasting importance attaches at this period to the accidental external [Freud’s emphasis] contingencies. In the foreground we find the effects of seduction, which treats a child as a sexual object prematurely and teaches him, in highly emotional circumstances, how to obtain satisfaction from his genital zones, a satisfaction which he is then usually obliged to repeat again and again by masturbation. An influence of this kind may originate either from adults or from other children. I cannot admit that in my paper on ‘The Aetiology of Hysteria’ (1896c) I exaggerated the frequency or importance of that influence, though I did not then know that persons who remain normal may have had the same experiences in their childhood, and though I consequently overrated the importance of seduction in comparison with the factors of sexual constitution and development. Obviously seduction is not required in order to arouse a child’s sexual life; that can also come about spontaneously from internal causes. S. Freud “Introductory Lectures in Psycho-analysis in Stand ard Edition (1916), 370: Phantasies of being seduced are of particular interest, because so often they are not phantasies but real memories.

24. S. Freud, Inhibitions Symptoms and Anxiety (1914), 150. See also Strachey, Standard Edition of the Complete Psychological Works.

25. B. A. van der Kolk, Psychological Trauma (Washington, D: American Psychiatric Press, 1986).

26. B. A. Van der Kolk, “The Compulsion to Repeat the Trauma,” Psychiatric Clinics of North America 12, no. 2 (1989): 389–411.

CHAPTER 12: THE UNBEARABLE HEAVINESS OF REMEMBERING

1. A. Young, The Harmony of Illusions: Inventing Post-traumatic Stress Disorder (Princeton, NJ: Princeton University Press, 1997), 84.

2. F. W. Mott, “Special Discussion on Shell Shock Without Visible Signs of Injury,” Proceedings of the Royal Society of Medicine 9 (1916): i–xliv. See also C. S. Myers, “A Contribution to the Study of Shell Shock,” Lancet 1 (1915): 316–20; T. W. Salmon, “The Care and Treatment of Mental Diseases and War Neuroses (“Shell Shock”) in the British Army,” Mental Hygiene 1 (1917): 509–47; and E. Jones and S. Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf (Hove, UK: Psychology Press, 2005).

3. J. Keegan, The First World War (New York: Random House, 2011).

4. A. D. Macleod, “Shell Shock, Gordon Holmes and the Great War.” Journal of the Royal Society of Medicine 97, no. 2 (2004): 86–89; M. Eckstein, Rites of Spring: The Great War and the Birth of the Modern Age (Boston: Houghton Mifflin, 1989).

5. Lord Southborough, Report of the War Office Committee of Enquiry into “Shell-Shock” (London: His Majesty’s Stationery Office, 1922).

6. Booker Prize winner Pat Barker has written a moving trilogy about the work of army psychiatrist W. H. R. Rivers: P. Barker, Regeneration (London: Penguin UK, 2008); P. Barker, The Eye in the Door (New York: Penguin, 1995); P. Barker, The Ghost Road (London: Penguin UK, 2008). Further discussions of the aftermath of World War I can be found in A. Young, Harmony of Illusions; and B. Shephard, A War of Nerves, Soldiers and Psychiatrists 1914–1994 (London: Jonathan Cape, 2000).

7. J. H. Bartlett, The Bonus March and the New Deal (1937); R. Daniels, The Bonus March: An Episode of the Great Depression (1971).

8. E. M. Remarque, All Quiet on the Western Front, trans. A. W. Wheen (London: GP Putnam’s Sons, 1929).

9. Ibid., pp. 192–93.

10. For an account, see http://motlc.wiesenthal.com/site/pp.asp?c=gvKVLcMVIuG&b=395007.

11. C. S. Myers, Shell Shock in France 1914–1918 (Cambridge UK, Cambridge University Press, 1940).

12. A. Kardiner, The Traumatic Neuroses of War (New York: Hoeber, 1941).

13. http://en.wikipedia.org/wiki/Let_There_Be_Light_(film).

14. G. Greer and J. Oxenbould, Daddy, We Hardly Knew You (London: Penguin, 1990).

15. A. Kardiner and H. Spiegel, War Stress and Neurotic Illness (Oxford, England: Hoeber, 1947).

16. D. J. Henderson, “Incest,” in Comprehensive Textbook of Psychiatry, 2nd ed., eds. A. M. Freedman and H. I. Kaplan (Baltimore: Williams & Wilkins, 1974), p. 1536.

17. W. Sargent and E. Slater, “Acute War Neuroses,” The Lancet 236, no. 6097 (1940): 1–2. See also G. Debenham, et al., “Treatment of War Neurosis,” The Lancet 237, no. 6126 (1941): 107–9; and W. Sargent and E. Slater, “Amnesic Syndromes in War,” Proceedings of the Royal Society of Medicine (Section of Psychiatry) 34, no. 12 (October 1941): 757–64.

18. Every single scientific study of memory of childhood sexual abuse, whether prospective or retrospective, whether studying clinical samples or general population samples, finds that a certain percentage of sexually abused individuals forget, and later remember, their abuse. See, e.g., B. A. van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8 (1995): 505–25; J. W. Hopper and B. A. van der Kolk, “Retrieving, Assessing, and Classifying Traumatic Memories: A Preliminary Report on Three Case Studies of a New Standardized Method,” Journal of Aggression, Maltreatment & Trauma 4 (2001): 33–71; J. J. Freyd and A. P. DePrince, eds., Trauma and Cognitive Science (Binghamton, NY: Haworth Press, 2001), 33–71; A. P. DePrince and J. J. Freyd, “The Meeting of Trauma and Cognitive Science: Facing Challenges and Creating Opportunities at the Crossroads,” Journal of Aggression, Maltreatment & Trauma 4, no. 2 (2001): 1–8; D. Brown, A. W. Scheflin, and D. Corydon Hammond, Memory, Trauma Treatment and the Law (New York: Norton, 1997); K. Pope and L. Brown, Recovered Memories of Abuse: Assessment, Therapy, Forensics (Washington: American Psychological Association, 1996); and L. Terr, Unchained Memories: True Stories of Traumatic Memories, Lost and Found (New York: Basic Books, 1994).

19. E. F. Loftus, S. Polonsky, and M. T. Fullilove, “Memories of Childhood Sexual Abuse: Remembering and Repressing,” Psychology of Women Quarterly 18, no. 1 (1994): 67–84. L. M. Williams, “Recall of Childhood Trauma: A Prospective Study of Women’s Memories of Child Sexual Abuse,” Journal of Consulting and Clinical Psychology 62, no. 6 (1994): 1167–76.

20. L. M. Williams, “Recall of Childhood Trauma.”

21. L. M. Williams, “Recovered Memories of Abuse in Women with Documented Child Sexual Victimization Histories,” Journal of Traumatic Stress 8, no. 4 (1995): 649–73.

22. The prominent neuroscientist Jaak Panksepp states in his most recent book: “Abundant preclinical work with animal models has now shown that memories that are retrieved tend to return to their memory banks with modifications.” J. Panksepp and L. Biven, The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2012).

23. E. F. Loftus, “The Reality of Repressed Memories,” American Psychologist 48, no. 5 (1993): 518–37. See also E. F. Loftus and K. Ketcham, The Myth of Repressed Memory: False Memories and Allegations of Sexual Abuse (New York: Macmillan, 1996).

24. J. F. Kihlstrom, “The Cognitive Unconscious,” Science 237, no. 4821 (1987): 1445–52.

25. E. F. Loftus, “Planting Misinformation in the Human Mind: A 30-Year Investigation of the Malleability of Memory,” Learning & Memory 12, no. 4 (2005): 361–66.

26. B. A. Van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic Stress 8, no. 4 (1995): 505–25.

27. We will explore this further in chapter 14.

28. L. L. Langer, Holocaust Testimonies: The Ruins of Memory (New Haven: Yale University Press, 1991).

29. Ibid., p.5.

30. L. L. Langer, op cit., p. 21.

31. L. L. Langer, op cit., p. 34.

32. J. Osterman and B. A. van der Kolk, “Awareness during Anaesthesia and Posttraumatic Stress Disorder,” General Hospital Psychiatry 20 (1998): 274-81. See also K. Kiviniemi, “Conscious Awareness and Memory During General Anesthesia,” Journal of the American Association of Nurse Anesthetists62 (1994): 441–49; A. D. Macleod and E. Maycock, “Awareness During Anaesthesia and Post Traumatic Stress Disorder,” Anaesthesia and Intensive Care 20, no. 3 (1992) 378–82; F. Guerra, “Awareness and Recall: Neurological and Psychological Complications of Surgery and Anesthesia,” in International Anesthesiology Clinicsvol. 24. ed. B. T Hindman (Boston: Little Brown, 1986), 75–99; J. Eldor and D. Z. N. Frankel, “Intra-anesthetic Awareness,” Resuscitation 21 (1991): 113–19; J. L. Breckenridge and A. R. Aitkenhead, “Awareness During Anaesthesia: A Review,” Annals of the Royal College of Surgeons of England 65, no. 2 (1983), 93.

CHAPTER 13: HEALING FROM TRAUMA: OWNING YOUR SELF

1. “Self-leadership” is the term used by Dick Schwartz in internal family system therapy, the topic of chapter 17.

2. The exceptions are Pesso’s and Schwartz’s work, detailed in chapters 17 and 18, which I practice, and from which I have personally benefited, but which I have not studied scientifically—at least not yet.

3. A. F. Arnsten, “Enhanced: The Biology of Being Frazzled,” Science 280, no. 5370 (1998): 1711–12; A. Arnsten, “Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function,” Nature Reviews Neuroscience 10, no. 6 (2009): 410–22.

4. D. J. Siegel, The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration (New York: WW Norton, 2010).

5. J. E. LeDoux, “Emotion Circuits in the Brain,” Annual Review of Neuroscience 23, no. 1 (2000): 155–84. See also M. A. Morgan, L. M. Romanski, and J. E. LeDoux, “Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163, no. 1 (1993): 109–113; and J. M. Moscarello and J. E. LeDoux, “Active Avoidance Learning Requires Prefrontal Suppression of Amygdala-Mediated Defensive Reactions,” Journal of Neuroscience 33, no. 9 (2013): 3815–23.

6. S. W. Porges, “Stress and Parasympathetic Control,” Stress Science: Neuroendocrinology 306 (2010). See also S. W. Porges, “Reciprocal Influences Between Body and Brain in the Perception and Expression of Affect,” in The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2009), 27.

7. B. A. van der Kolk, et al., “Yoga As an Adjunctive Treatment for PTSD.” Journal of Clinical Psychiatry 75, no. 6 (June 2014): 559–65.

8. Sebern F. Fisher, Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain. (New York: WW Norton & Company, 2014).

9. R. P. Brown and P. L. Gerbarg, “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression—Part II: Clinical Applications and Guidelines,” Journal of Alternative & Complementary Medicine 11, no. 4 (2005): 711–17. See also C. L. Mandle, et al., “The Efficacy of Relaxation Response Interventions with Adult Patients: A Review of the Literature,” Journal of Cardiovascular Nursing 10 (1996): 4–26; and M. Nakao, et al., “Anxiety Is a Good Indicator for Somatic Symptom Reduction Through Behavioral Medicine Intervention in a Mind/Body Medicine Clinic,” Psychotherapy and Psychosomatics 70 (2001): 50–57.

10. C. Hannaford, Smart Moves: Why Learning Is Not All in Your Head (Arlington, VA: Great Ocean Publishers, 1995), 22207–3746.

11. J. Kabat-Zinn, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, 2013). See also D. Fosha, D. J. Siegel, and M. Solomon, eds., The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice, Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2011); and B. A. van der Kolk, “Posttraumatic Therapy in the Age of Neuroscience,” Psychoanalytic Dialogues 12, no. 3 (2002): 381–92.

12. As we have seen in chapter 5, brain scans of people suffering from PTSD show altered activation in areas associated with the default network, which is involved with autobiographical memory and a continuous sense of self.

13. P. A. Levine, In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness (Berkeley: North Atlantic, 2010).

14. P. Ogden, Trauma and the Body (New York: Norton, 2009). See also A. Y. Shalev, “Measuring Outcome in Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 61, supp. 5 (2000): 33–42.

15. I. Kabat-Zinn, Full Catastrophe Living. p. xx

16. S. G. Hofmann, et al., “The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review,” Journal of Consulting and Clinical Psychology 78, no.2 (2010): 169–83; J. D. Teasdale, et al., “Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy,” Journal of Consulting and Clinical Psychology 68 (2000): 615–23. See also Britta K. Hölzel, et al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural Perspective.” Perspectives on Psychological Science 6, no. 6 (2011): 537–59; and P. Grossman, et al., “Mindfulness-Based Stress Reduction and Health Benefits: A Meta-Analysis,” Journal of Psychosomatic Research 57, no. 1 (2004): 35–43.

17. The brain circuits involved in mindfulness meditation have been well established, and improve attention regulation and has a positive effect on the interference of emotional reactions with attentional performance tasks. See L. E. Carlson, et al., “One Year Pre-Post Intervention Follow-up of Psychological, Immune, Endocrine and Blood Pressure Outcomes of Mindfulness-Based Stress Reduction (MBSR) in Breast and Prostate Cancer Outpatients,” Brain, Behavior, and Immunity 21, no. 8 (2007): 1038–49; and R. J. Davidson, et al., “Alterations in Brain and Immune Function Produced by Mindfulness Meditation,” Psychosomatic Medicine 65, no. 4 (2003): 564–70.

18. Britta Hölzel and her colleagues have done extensive research on meditation and brain function and have shown that it involves the dorsomedial PFC, ventrolateral PFC, and rostral anterior congulate (ACC). See B. K. Hölzel, et al., “Stress Reduction Correlates with Structural Changes in the Amygdala,” Social Cognitive and Affective Neuroscience 5 (2010): 11–17; B. K. Hölzel, et al., “Mindfulness Practice Leads to Increases in Regional Brain Gray Matter Density,” Psychiatry Research 191, no. 1 (2011): 36–43; B. K. Hölzel, et al., “Investigation of Mindfulness Meditation Practitioners with Voxel-Based Morphometry,” Social Cognitive and Affective Neuroscience 3, no. 1 (2008): 55–61; and B. K. Hölzel, et al., “Differential Engagement of Anterior Cingulate and Adjacent Medial Frontal Cortex in Adept Meditators and Non-meditators,” Neuroscience Letters 421, no. 1 (2007): 16–21.

19. The main brain structure involved in body awareness is the anterior insula. See A. D. Craig, “Interoception: The Sense of the Physiological Condition of the Body,” Current Opinion on Neurobiology 13 (2003): 500–505; Critchley, Wiens, Rotshtein, Ohman, and Dolan, 2004; N. A. S Farb, Z. V. Segal, H. Mayberg, J. Bean, D. McKeon, Z. Fatima, et al., “Attending to the Present: Mindfulness Meditation Reveals Distinct Neural Modes of Self-Reference,” Social Cognitive and Affective Neuroscience 2 (2007): 313–22.; J. A. Grant, J. Courtemanche, E. G. Duerden, G. H. Duncan, and P. Rainville, (2010). “Cortical Thickness and Pain Sensitivity in Zen Meditators,” Emotion 10, no. 1 (2010): 43–53.

20. S. J. Banks, et al., “Amygdala-Frontal Connectivity During Emotion-Regulation,” Social Cognitive and Affective Neuroscience 2, no. 4 (2007): 303–12. See also M. R. Milad, et al., “Thickness of Ventromedial Prefrontal Cortex in Humans Is Correlated with Extinction Memory,” Proceedings of the National Academy of Sciences of the United States of America 102, no. 30 (2005): 10706–11; and S. L. Rauch, L. M. Shin, and E. A. Phelps, “Neurocircuitry Models of Posttraumatic Stress Disorder and Extinction: Human Neuroimaging Research—Past, Present, and Future,” Biological Psychiatry 60, no. 4 (2006): 376–82.

21. A. Freud and D. T. Burlingham. War and Children (New York University Press, 1943).

22. There are three different ways in which people deal with overwhelming experiences: dissociation (spacing out, shutting down), depersonalization (feeling like it’s not you it’s happening to), and derealization (feeling like whatever is happening is not real).

23. My colleagues at the Justice Resource Institute created a residential treatment program for adolescents, The van der Kolk Center at Glenhaven Academy, that implements many of the trauma-informed treatments discussed in this book, including yoga, sensory integration, neurofeedback and theater. http://www.jri.org/vanderkolk/about. The overarching treatment model, attachment, self-regulation, and competency (ARC), was developed by my colleagues Margaret Blaustein and Kristine Kinneburgh. Margaret E. Blaustein, and Kristine M. Kinniburgh, Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience Through Attachment, Self-Regulation, and Competency (New York: Guilford Press, 2012).

24. C. K. Chandler, Animal Assisted Therapy in Counseling (New York: Routledge, 2011). See also A. J. Cleveland, “Therapy Dogs and the Dissociative Patient: Preliminary Observations,” Dissociation 8, no. 4 (1995): 247–52; and A. Fine, Handbook on Animal Assisted Therapy: Theoretical Foundations and Guidelines for Practice (San Diego: Academic Press, 2010).

25. E. Warner, et al., “Can the Body Change the Score? Application of Sensory Modulation Principles in the Treatment of Traumatized Adolescents in Residential Settings,” Journal of Family Violence 28, no. 7 (2013): 729–38. See also A. J. Ayres, Sensory Integration and Learning Disorders (Los Angeles: Western Psychological Services, 1972); H. Hodgdon, et al., “Development and Implementation of Trauma-Informed Programming in Residential Schools Using the ARC Framework,” Journal of Family Violence 27, no. 8 (2013); J. LeBel, et al., “Integrating Sensory and Trauma-Informed Interventions: A Massachusetts State Initiative, Part 1,” Mental Health Special Interest Section Quarterly 33, no. 1 (2010): 1–4;

26. They appeared to have activated the vestibule-cerebellar system in the brain, which seems to be involved in self-regulation and can be damaged by early neglect.

27. Aaron R. Lyon and Karen S. Budd, “A Community Mental Health Implementation of Parent–Child Interaction Therapy (PCIT).” Journal of Child and Family Studies 19, no. 5 (2010): 654–68. See also Anthony J. Urquiza and Cheryl Bodiford McNeil, “Parent-Child Interaction Therapy: An Intensive Dyadic Intervention for Physically Abusive Families.” Child Maltreatment 1, no 2 (1996): 134–44; J. Borrego Jr., et al. “Research Publications.” Child and Family Behavior Therapy 20: 27-54.

28. B. A. van der Kolk, et al., “Fluoxetine in Post Traumatic Stress,” Journal of Clinical Psychiatry (1994): 517–22.

29. P. Ogden, K. Minton, and C. Pain, Trauma and the Body (New York, Norton, 2010)P. Ogden and J. Fisher, Sensorimotor Psychotherapy: Interventions for Trauma and Attachment (New York: Norton, 2014).

30. P. Levine, In an Unspoken Voice (Berkeley: North Atlantic Books); P. Levine, Waking the Tiger (Berkeley: North Atlantic Books).

31. For more on impact model mugging, see http://modelmugging.org/.

32. S. Freud, Remembering, Repeating, and Working Through (Further Recommendations on the Technique of Psychoanalysis II), standard ed. (London: Hogarth Press, 1914), p. 371

33. E. Santini, R. U. Muller, and G. J. Quirk, “Consolidation of Extinction Learning Involves Transfer from NMDA-Independent to NMDA-Dependent Memory,” Journal of Neuroscience 21 (2001): 9009–17.

34. E. B. Foa and M. J. Kozak, “Emotional Processing of Fear: Exposure to Corrective Information,” Psychological Bulletin 99, no. 1 (1986): 20–35.

35. C. R. Brewin, “Implications for Psychological Intervention,” in Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives, ed. J. J. Vasterling and C. R. Brewin (New York: Guilford, 2005), 272.

36. T. M. Keane, “The Role of Exposure Therapy in the Psychological Treatment of PTSD,” National Center for PTSD Clinical Quarterly 5, no. 4 (1995): 1–6.

37. E. B. Foa and R. J. McNally, “Mechanisms of Change in Exposure Therapy,” in Current Controversies in the Anxiety Disorders, ed. R. M. Rapee (New York: Guilford, 1996), 329–43.

38. J. D. Ford and P. Kidd, “Early Childhood Trauma and Disorders of Extreme Stress as Predictors of Treatment Outcome with Chronic PTSD,” Journal of Traumatic Stress 18 (1998): 743–61. See also A. McDonagh-Coyle, et al., “Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse,” Journal of Consulting and Clinical Psychology 73, no. 3 (2005): 515–24; Institute of Medicine of the National Academies, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (Washington: National Academies Press, 2008); and R. Bradley, et al., “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” American Journal of Psychiatry 162, no. 2 (2005): 214–27.

39. J. Bisson, et al., “Psychological Treatments for Chronic Posttraumatic Stress Disorder: Systematic Review and Meta-Analysis,” British Journal of Psychiatry 190 (2007): 97–104. See also L. H. Jaycox, E. B. Foa, and A. R. Morrall, “Influence of Emotional Engagement and Habituation on Exposure Therapy for PTSD,” Journal of Consulting and Clinical Psychology 66 (1998): 185–92.

40. “Dropouts: in prolonged exposure (n = 53 [38%]); in present-centered therapy (n = 30 [21%]) (P = .002). The control group also had a high rate of casualties: 2 nonsuicidal deaths, 9 psychiatric hospitalizations, and 3 suicide attempts.” P. P. Schnurr, et al., “Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women,” JAMA 297, no. 8 (2007): 820–30.

41. R. Bradley, et al., “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” American Journal of Psychiatry 162, no. 2 (2005): 214–27.

42. J. H. Jaycox and E. B. Foa, “Obstacles in Implementing Exposure Therapy for PTSD: Case Discussions and Practical Solutions,” Clinical Psychology and Psychotherapy 3, no. 3 (1996): 176–84. See also E. B. Foa, D. Hearst-Ikeda, and K. J. Perry, “Evaluation of a Brief Cognitive-Behavioral Program for the Prevention of Chronic PTSD in Recent Assault Victims,” Journal of Consulting and Clinical Psychology 63 (1995): 948–55.

43. Alexander McFarlane personal communication.

44. R. K. Pitman, et al., “Psychiatric Complications During Flooding Therapy for Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 52, no. 1 (January 1991): 17–20.

45. Jean Decety, Kalina J. Michalska, and Katherine D. Kinzler, “The Contribution of Emotion and Cognition to Moral Sensitivity: A Neurodevelopmental Study,” Cerebral Cortex 22 no. 1 (2012): 209–20; Jean Decety, C. Daniel Batson, “Neuroscience Approaches to Interpersonal Sensitivity,” 2, nos. 3-4 (2007).

46. K. H. Seal, et al., “VA Mental Health Services Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses,” Journal of Traumatic Stress 23 (2010): 5–16.

47. L. Jerome, “(+/-)-3,4-Methylenedioxymethamphetamine (MDMA, “Ecstasy”) Investigator’s Brochure,” December 2007, available at www.maps.org/research/mdma/protocol/ib_mdma_new08.pdf (accessed August 16, 2012).

48. John H. Krystal, et al. “Chronic 3, 4-methylenedioxymethamphetamine (MDMA) use: effects on mood and neuropsychological function?.” The American Journal of Drug and Alcohol Abuse 18.3 (1992): 331-341.

49. Mithoefer, Michael C., et al., “The safety and efficacy of±3, 4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study.” Journal of Psychopharmacology 25.4 (2011): 439-452; M. C. Mithoefer, et al., “Durability of Improvement in Post-traumatic Stress Disorder Symptoms and Absence of Harmful Effects or Drug Dependency after 3, 4-Methylenedioxymethamphetamine-Assisted Psychotherapy: A Prospective Long-Term Follow-up Study,” Journal of Psychopharmacology 27, no. 1 (2013): 28–39.

50. J. D. Bremner, “Neurobiology of Post-traumatic Stress Disorder,” in Posttraumatic Stress Disorder: A Critical Review, ed. R. S. Rynoos (Lutherville, MD: Sidran Press, 1994), 43–64.

51. http://cdn.nextgov.com/nextgov/interstitial.html?v=2.1.1&rf=http%3A%2F%2Fwww.nextgov.com%2Fhealth%2F2011%2F01%2Fmilitarys-drug-policy-threatens-troops-health-doctors-say%2F48321%2F.

52. J. R. T. Davidson, “Drug Therapy of Post-traumatic Stress Disorder,” British Journal of Psychiatry 160 (1992): 309–314. See also R. Famularo, R. Kinscherff, and T. Fenton, “Propranolol Treatment for Childhood Posttraumatic Stress Disorder Acute Type,” American Journal of Disorders of Childhood142 (1988): 1244–47; F. A. Fesler, “Valproate in Combat-Related Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 52 (1991): 361–64; B. H. Herman, et al., “Naltrexone Decreases Self-Injurious Behavior,” Annals of Neurology 22 (1987): 530–34; and B. A. van der Kolk, et al., “Fluoxetine in Posttraumatic Stress Disorder.”

53. B. Van der Kolk, et al., “A Randomized Clinical Trial of EMDR, Fluoxetine and Pill Placebo in the Treatment of PTSD: Treatment Effects and Long-Term Maintenance,” Journal of Clinical Psychiatry 68 (2007): 37–46.

54. R. A. Bryant, et al., “Treating Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive Counseling Techniques,” American Journal of Psychiatry 156, no. 11 (November 1999): 1780–86; N. P. Roberts et al., “Early Psychological Interventions to Treat Acute Traumatic Stress Symptoms,” Cochran Database of Systematic Reviews 3 (March 2010).

55. This includes the alpha1 receptor antagonist prazosin, the alpha2 receptor antagonist clonidine, and the beta receptor antagonist propranolol. See M. J. Friedman and J. R. Davidson, “Pharmacotherapy for PTSD,” in Handbook of PTSD: Science and Practice, ed. M. J. Friedman, T. M. Keane, and P. A. Resick (New York: Guilford Press, (2007), 376.

56. M. A. Raskind, et al., “A Parallel Group Placebo Controlled Study of Prazosin for Trauma Nightmares and Sleep Disturbance in Combat Veterans with Post-traumatic Stress Disorder,” Biological Psychiatry 61, no. 8 (2007): 928–34. F. B. Taylor, et al., “Prazosin Effects on Objective Sleep Measures and Clinical Symptoms in Civilian Trauma Posttraumatic Stress Disorder: A Placebo-Controlled Study,” Biological Psychiatry 63, no. 6 (2008): 629–32.

57. Lithium, lamotrigin, carbamazepine, divalproex, gabapentin, and topiramate may help to control trauma-related aggression and irritability. Valproate has been shown to be effective in several case reports with PTSD, including with military veteran patients with chronic PTSD. Friedman and Davidson, “Pharmacotherapy for PTSD”; F. A. Fesler, “Valproate in Combat-Related Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 52, no. 9 (1991): 361–64. The following study showed a 37.4 percent reduction in PTSD S. Akuchekian and S. Amanat, “The Comparison of Topiramate and Placebo in the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind Study,” Journal of Research in Medical Sciences 9, no. 5 (2004): 240–44.

58. G. Bartzokis, et al., “Adjunctive Risperidone in the Treatment of Chronic Combat-Related Posttraumatic Stress Disorder,” Biological Psychiatry 57, no. 5 (2005): 474–79. See also D. B. Reich, et al., “A Preliminary Study of Risperidone in the Treatment of Posttraumatic Stress Disorder Related to Childhood Abuse in Women,” Journal of Clinical Psychiatry 65, no. 12 (2004): 1601–1606.

59. The other methods include interventions that usually help traumatized individuals sleep, like the antidepressant trazodone, binaural beat apps, light/sound machines like Proteus (www.brainmachines.com), HRV monitors like hearthmath (http://www.heartmath.com/), and iRest, an effective yoga-based intervention. (http://www.irest.us/)

60. D. Wilson, “Child’s Ordeal Shows Risks of Psychosis Drugs for Young,” New York Times, September 1, 2010, available at http://www.nytimes.com/2010/09/02/business/02kids.html?pagewanted=all&_r=0.

61. M. Olfson, et al., “National Trends in the Office-Based Treatment of Children, Adolescents, and Adults with Antipsychotics,” Archives of General Psychiatry 69, no. 12 (2012): 1247–56.

62. E. Harris, et al., “Perspectives on Systems of Care: Concurrent Mental Health Therapy Among Medicaid-Enrolled Youths Starting Antipsychotic Medications,” FOCUS 10, no. 3 (2012): 401–407.

63. B. A. Van der Kolk, “The Body Keeps the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress,” Harvard Review of Psychiatry 1, no. 5 (1994): 253–65.

64. B. Brewin, “Mental Illness is the Leading Cause of Hospitalization for Active-Duty Troops,” Nextgov.com, May 17, 2012, http://www.nextgov.com/health/2012/05/mental-illness-leading-cause-hospitalization-active-duty-troops/55797/.

65. Mental health drug expenditures, Department of Veterans affairs. http://www.veterans.senate.gov/imo/media/doc/For%20the%20Record%20-%20CCHR%204.30.14.pdf.

CHAPTER 14: LANGUAGE: MIRACLE AND TYRANNY

1. Dr. Spencer Eth to Bessel A. van der Kolk, March 2002.

2. J. Breuer and S. Freud, “The Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud (London: Hogarth Press, 1893). J. Breuer and S. Freud, Studies on Hysteria (New York: Basic Books, 2009).

3. T. E. Lawrence, Seven Pillars of Wisdom (New York: Doubleday, 1935).

4. E. B. Foa, et al., “The Posttraumatic Cognitions Inventory (PTCI): Development and Validation,” Psychological Assessment 11, no. 3 (1999): 303–314.

5. K. Marlantes, What It Is Like to Go to War (New York: Grove Press, 2011).

6. Ibid., 114.

7. Ibid., 129.

8. H. Keller, The World I Live In (1908), ed. R. Shattuck (New York: NYRB Classics, 2004). See also R. Shattuck, “A World of Words,” New York Review of Books, February 26, 2004.

9. H. Keller, The Story of My Life, ed. R. Shattuck and D. Herrmann (New York: Norton, 2003).

10. W. M. Kelley, et al., “Finding the Self? An Event-Related fMRI Study,” Journal of Cognitive Neuroscience 14, no. 5 (2002): 785–94. See also N. A. Farb, et al., “Attending to the Present: Mindfulness Meditation Reveals Distinct Neural Modes of Self-Reference,” Social Cognitive and Affective Neuroscience 2, no. 4 (2007): 313–22. P. M. Niedenthal, “Embodying Emotion,” Science 316, no. 5827 (2007): 1002–1005; and J. M. Allman, “The Anterior Cingulate Cortex,” Annals of the New York Academy of Sciences 935, no. 1 (2001): 107–117.

11. J. Kagan, dialogue with the Dalai Lama, Massachusetts Institute of Technology, 2006. http://www.mindandlife.org/about/history/.

12. A. Goldman and F. de Vignemont, “Is Social Cognition Embodied?” Trends in Cognitive Sciences 13, no. 4 (2009): 154–59. See also A. D. Craig, “How Do You Feel—Now? The Anterior Insula and Human Awareness,” Nature Reviews Neuroscience 10 (2009): 59–70; H. D. Critchley, “Neural Mechanisms of Autonomic, Affective, and Cognitive Integration,” Journal of Comparative Neurology 493, no. 1 (2005): 154–66; T. D. Wager, et al., “Prefrontal-Subcortical Pathways Mediating Successful Emotion Regulation,” Neuron 59, no. 6 (2008): 1037–50; K. N. Ochsner, et al., “Rethinking Feelings: An fMRI Study of the Cognitive Regulation of Emotion,” Journal of Cognitive Neuroscience 14, no. 8 (2002): 1215–29; A. D’Argembeau, et al., “Self-Reflection Across Time: Cortical Midline Structures Differentiate Between Present and Past Selves,” Social Cognitive and Affective Neuroscience 3, no. 3 (2008): 244–52; Y. Ma, et al., “Sociocultural Patterning of Neural Activity During Self-Reflection,” Social Cognitive and Affective Neuroscience 9, no. 1 (2014): 73–80; R. N. Spreng, R. A. Mar, and A. S. Kim, “The Common Neural Basis of Autobiographical Memory, Prospection, Navigation, Theory of Mind, and the Default Mode: A Quantitative Meta-Analysis,” Journal of Cognitive Neuroscience 21, no. 3 (2009): 489–510; H. D. Critchley, “The Human Cortex Responds to an Interoceptive Challenge,” Proceedings of the National Academy of Sciences of the United States of America 101, no. 17 (2004): 6333–34; and C. Lamm, C. D. Batson, and J. Decety, “The Neural Substrate of Human Empathy: Effects of Perspective-Taking and Cognitive Appraisal,” Journal of Cognitive Neuroscience 19, no. 1 (2007): 42–58.

13. J. W. Pennebaker, Opening Up: The Healing Power of Expressing Emotions (New York: Guilford Press, 2012), 12.

14. Ibid., p. 19.

15. Ibid., p.35.

16. Ibid., p. 50.

17. J. W. Pennebaker, J. K. Kiecolt-Glaser, and R. Glaser, “Disclosure of Traumas and Immune Function: Health Implications for Psychotherapy,” Journal of Consulting and Clinical Psychology 56, no. 2 (1988): 239–45.

18. D. A. Harris, “Dance/Movement Therapy Approaches to Fostering Resilience and Recovery Among African Adolescent Torture Survivors,” Torture 17, no. 2 (2007): 134–55; M. Bensimon, D. Amir, and Y. Wolf, “Drumming Through Trauma: Music Therapy with Post-traumatic Soldiers,” Arts in Psychotherapy 35, no. 1 (2008): 34–48; M. Weltman, “Movement Therapy with Children Who Have Been Sexually Abused,” American Journal of Dance Therapy 9, no. 1 (1986): 47–66; H. Englund, “Death, Trauma and Ritual: Mozambican Refugees in Malawi,” Social Science & Medicine 46, no. 9 (1998): 1165–74; H. Tefferi, Building on Traditional Strengths: The Unaccompanied Refugee Children from South Sudan (1996); D. Tolfree, Restoring Playfulness: Different Approaches to Assisting Children Who Are Psychologically Affected by War or Displacement (Stockholm: Rädda Barnen, 1996), 158–73; N. Boothby, “Mobilizing Communities to Meet the Psychosocial Needs of Children in War and Refugee Crises,” in Minefields in Their Hearts: The Mental Health of Children in War and Communal Violence, ed. R. Apfel and B. Simon (New Haven, Yale Universit Press, 1996), 149–64; S. Sandel, S. Chaiklin, and A. Lohn, Foundations of Dance/Movement Therapy: The Life and Work of Marian Chace (Columbia, MD: American Dance Therapy Association, 1993); K. Callaghan, “Movement Psychotherapy with Adult Survivors of Political Torture and Organized Violence,” Arts in Psychotherapy 20, no. 5 (1993): 411–21; A. E. L. Gray, “The Body Remembers: Dance Movement Therapy with an Adult Survivor of Torture,” American Journal of Dance Therapy 23, no. 1 (2001): 29–43.

19. A. M. Krantz, and J. W. Pennebaker, “Expressive Dance, Writing, Trauma, and Health: When Words Have a Body.” Whole Person Healthcare 3 (2007): 201–29.

20. P. Fussell, The Great War and Modern Memory (London: Oxford University Press, 1975).

21. Theses findings have been replicated in the following studies: J. D. Bremner, “Does Stress Damage the Brain?” Biological Psychiatry 45, no. 7 (1999): 797–805; I. Liberzon, et al., “Brain Activation in PTSD in Response to Trauma-Related Stimuli,” Biological Psychiatry 45, no. 7 (1999): 817–26; L. M. Shin, et al., “Visual Imagery and Perception in Posttraumatic Stress Disorder: A Positron Emission Tomographic Investigation,” Archives of General Psychiatry 54, no. 3 (1997): 233–41; L. M. Shin, et al., “Regional Cerebral Blood Flow During Script-Driven Imagery in Childhood Sexual Abuse–Related PTSD: A PET Investigation,” American Journal of Psychiatry 156, no. 4 (1999): 575–84.

22. I am not sure if this term originated with me or with Peter Levine. I own a video where he credits me, but most of what I have learned about pendulation I’ve learned from him.

23. A small body of evidence offers support for claims that exposure/acupoints stimulation yields stronger outcomes and exposures strategies that incorporate conventional relaxation techniques. (www.vetcases.com). D. Church, et al., “Single-Session Reduction of the Intensity of Traumatic Memories in Abused Adolescents After EFT: A Randomized Controlled Pilot Study,” Traumatology 18, no. 3 (2012): 73–79; and D. Feinstein and D. Church, “Modulating Gene Expression Through Psychotherapy: The Contribution of Noninvasive Somatic Interventions,” Review of General Psychology 14, no. 4 (2010): 283–95.

24. T. Gil, et al., “Cognitive Functioning in Post‐traumatic Stress Disorder,” Journal of Traumatic Stress 3, no. 1 (1990): 29–45; J. J. Vasterling, et al., “Attention, Learning, and Memory Performances and Intellectual Resources in Vietnam Veterans: PTSD and No Disorder Comparisons,” Neuropsychology 16,no. 1 (2002): 5.

25. In a neuroimaging study the PTSD subjects deactivated the speech area of their brain, Broca’s area, in response to neutral words. In other words: the decreased Broca’s area functioning that we had found in PTSD patients (see chapter 3) did not only occur in response to traumatic memories; it also happened when they were asked to pay attention to neutral words. This means that, as a group, traumatized patients have a harder time to articulate what they feel and think about ordinary events. The PTSD group also had decreased activation of the medial prefrontal cortex (mPFC), the frontal lobe area that, as we have seen, conveys awareness of one’s self, and dampens activation of the amygdala, the smoke detector. This made it harder for them to suppress the brain’s fear response in response to a simple language task and again, made it harder to pay attention and go on with their lives. See: Moores, K. A., Clark, C. R., McFarlane, A. C., Brown, G. C., Puce, A., & Taylor, D. J. (2008). Abnormal recruitment of working memory updating networks during maintenance of trauma-neutral information in post-traumatic stress disorder. Psychiatry Research: Neuroimaging, 163(2), 156–170.

26. J. Breuer and S. Freud, “The Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud (London: Hogarth Press, 1893).

27. D. L. Schacter, Searching for Memory (New York: Basic Books, 1996).

CHAPTER 15: LETTING GO OF THE PAST: EMDR

1. F. Shapiro, EMDR: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress, and Trauma (New York: Basic Books, 2004).

2. B. A. van der Kolk, et al., “A Randomized Clinical Trial of Eye Movement Desensitization and Reprocessing (EMDR), Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder: Treatment Effects and Long-Term Maintenance,” Journal of Clinical Psychiatry 68, no. 1 (2007): 37–46.

3. J. G. Carlson, et al., “Eye Movement Desensitization and Reprocessing (EDMR) Treatment for Combat-Related Posttraumatic Stress Disorder,” Journal of Traumatic Stress 11, no. 1 (1998): 3–24.

4. J. D. Payne, et al., “Sleep Increases False Recall of Semantically Related Words in the Deese-Roediger-McDermott Memory Task,” Sleep 29 (2006): A373.

5. B. A. van der Kolk and C. P. Ducey, “The Psychological Processing of Traumatic Experience: Rorschach Patterns in PTSD,” Journal of Traumatic Stress 2, no. 3 (1989): 259–74.

6. M. Jouvet, The Paradox of Sleep: The Story of Dreaming, trans. Laurence Garey (Cambridge, MA: MIT Press, 1999).

7. R. Greenwald, “Eye Movement Desensitization and Reprocessing (EMDR): A New Kind of Dreamwork?” Dreaming 5, no. 1 (1995): 51–55.

8. R. Cartwright, et al., “REM Sleep Reduction, Mood Regulation and Remission in Untreated Depression,” Psychiatry Research 121, no. 2 (2003): 159–67. See also R. Cartwright, et al., “Role of REM Sleep and Dream Affect in Overnight Mood Regulation: A Study of Normal Volunteers,” Psychiatry Research81, no. 1 (1998): 1–8.

9. R. Greenberg, C. A. Pearlman, and D. Gampel, “War Neuroses and the Adaptive Function of REM Sleep,” British Journal of Medical Psychology 45, no. 1 1972): 27–33. Ramon Greenberg and Chester Pearlman, as well as our lab, found that traumatized veterans wake themselves up as soon as they enter a REM period. While many traumatized individuals use alcohol to help them sleep, they thereby keep themselves from the full benefits of dreaming (the integration and transformation of memory) and thereby may contribute to preventing the resolution of their PTSD.

10. B. van der Kolk, et al., “Nightmares and Trauma: A Comparison of Nightmares After Combat with Lifelong Nightmares in Veterans,” American Journal of Psychiatry 141, no. 2 (1984): 187–90.

11. N. Breslau, et al., “Sleep Disturbance and Psychiatric Disorders: A Longitudinal Epidemiological Study of Young Adults,” Biological Psychiatry 39, no. 6 (1996): 411–18.

12. R. Stickgold, et al., “Sleep-Induced Changes in Associative Memory,” Journal of Cognitive Neuroscience 11, no. 2 (1999): 182–93. See also R. Stickgold, “Of Sleep, Memories and Trauma,” Nature Neuroscience 10, no. 5 (2007): 540–42; and B. Rasch, et al., “Odor Cues During Slow-Wave Sleep Prompt Declarative Memory Consolidation,” Science 315, no. 5817 (2007): 1426–29.

13. E. J. Wamsley, et al., “Dreaming of a Learning Task Is Associated with Enhanced Sleep-Dependent Memory Consolidation,” Current Biology 20, no. 9, (May 11, 2010): 850–55.

14. R. Stickgold, “Sleep-Dependent Memory Consolidation,” Nature 437 (2005): 1272–78.

15. R. Stickgold, et al., “Sleep-Induced Changes in Associative Memory,” Journal of Cognitive Neuroscience 11, no. 2 (1999): 182–93.

16. J. Williams, et al., “Bizarreness in Dreams and Fantasies: Implications for the Activation-Synthesis Hypothesis,” Consciousness and Cognition 1, no. 2 (1992): 172–85. See also Stickgold, et al., “Sleep-Induced Changes in Associative Memory.”

17. M. P. Walker, et al., “Cognitive Flexibility Across the Sleep-Wake Cycle: REM-Sleep Enhancement of Anagram Problem Solving,” Cognitive Brain Research 14 (2002): 317–24.

18. R. Stickgold, “EMDR: A Putative Neurobiological Mechanism of Action,” Journal of Clinical Psychology 58 (2002): 61–75.

19. There are several studies on how eye movements help to process and transform traumatic memories. M. Sack, et al., “Alterations in Autonomic Tone During Trauma Exposure Using Eye Movement Desensitization and Reprocessing (EMDR)—Results of a Preliminary Investigation,” Journal of Anxiety Disorders 22, no. 7 (2008): 1264–71; B. Letizia, F. Andrea, and C. Paolo, Neuroanatomical Changes After Eye Movement Desensitization and Reprocessing (EMDR) Treatment in Posttraumatic Stress Disorder, The Journal of Neuropsychiatry and Clinical Neurosciences, 19no. 4 (2007): 475–76; P. Levin, S. Lazrove, and B. van der Kolk, (1999). What Psychological Testing and Neuroimaging Tell Us About the Treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing, Journal of Anxiety Disorders, 13, nos. 1–2, 159–72; M. L. Harper, T. Rasolkhani Kalhorn, J. F. Drozd, “On the Neural Basis of EMDR Therapy: Insights from Qeeg Studies, Traumatology, 15, no. 2 (2009): 81–95; K. Lansing, D. G. Amen, C. Hanks, L. Rudy, “High-Resolution Brain SPECT Imaging and Eye Movement Desensitization and Reprocessing in Police Officers with PTSD,” The Journal of Neuropsychiatry and Clinical Neurosciences 17, no. 4 (2005): 526–32; T. Ohtani, K. Matsuo, K. Kasai, T. Kato, and N. Kato, “Hemodynamic Responses of Eye Movement Desensitization and Reprocessing in Posttraumatic Stress Disorder. Neuroscience Research, 65, no. 4 (2009): 375–83; M. Pagani, G. Högberg, D. Salmaso, D. Nardo, Ö. Sundin, C. Jonsson, and T. Hällström, “Effects of EMDR Psychotherapy on 99mtc-HMPAO Distribution in Occupation-Related Post-Traumatic Stress Disorder,” Nuclear Medicine Communications 28 (2007): 757–65; H. P. Söndergaard and U. Elofsson, “Psychophysiological Studies of EMDR,” Journal of EMDR Practice and Research 2, no. 4 (2008): 282–88.

CHAPTER 16: LEARNING TO INHABIT YOUR BODY: YOGA

1. Acupuncture and acupressure are widely practiced among trauma-oriented clinicians and is beginning to be systematically studied as a treatment for clinical PTSD. M. Hollifield, et al., “Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial,” Journal of Nervous and Mental Disease 195, no. 6 (2007): 504–513. Studies that use fMRI to measure the effects of acupuncture on the areas of the brain associated with fear report acupuncture to produce rapid regulation of these brain regions. K. K. Hui, et al., “The Integrated Response of the Human Cerebro-Cerebellar and Limbic Systems to Acupuncture Stimulation at ST 36 as Evidenced by fMRI,” NeuroImage 27 (2005): 479–96; J. Fang, et al., “The Salient Characteristics of the Central Effects of Acupuncture Needling: Limbic-Paralimbic-Neocortical Network Modulation,” Human Brain Mapping 30 (2009): 1196–206. D. Feinstein, “Rapid Treatment of PTSD: Why Psychological Exposure with Acupoint Tapping May Be Effective,” Psychotherapy: Theory, Research, Practice, Training 47, no. 3 (2010): 385–402; D. Church, et al., “Psychological Trauma Symptom Improvement in Veterans Using EFT (Emotional Freedom Technique): A Randomized Controlled Trial,” Journal of Nervous and Mental Disease 201 (2013): 153–60; D. Church, G. Yount, and A. J. Brooks, “The Effect of Emotional Freedom Techniques (EFT) on Stress Biochemistry: A Randomized Controlled Trial,” Journal of Nervous and Mental Disease200 (2012): 891–96; R. P. Dhond, N. Kettner, and V. Napadow, “Neuroimaging Acupuncture Effects in the Human Brain,” Journal of Alternative and Complementary Medicine 13 (2007): 603–616; K. K. Hui, et al., “Acupuncture Modulates the Limbic System and Subcortical Gray Structures of the Human Brain: Evidence from fMRI Studies in Normal Subjects,” Human Brain Mapping 9 (2000): 13–25.

2. M. Sack, J. W. Hopper, and F. Lamprecht, “Low Respiratory Sinus Arrhythmia and Prolonged Psychophysiological Arousal in Posttraumatic Stress Disorder: Heart Rate Dynamics and Individual Differences in Arousal Regulation,” Biological Psychiatry 55, no. 3 (2004): 284–90. See also H. Cohen, et al., “Analysis of Heart Rate Variability in Posttraumatic Stress Disorder Patients in Response to a Trauma-Related Reminder,” Biological Psychiatry 44, no. 10 (1998): 1054–59; H. Cohen, et al., “Long-Lasting Behavioral Effects of Juvenile Trauma in an Animal Model of PTSD Associated with a Failure of the Autonomic Nervous System to Recover,” European Neuropsychopharmacology 17, no. 6 (2007): 464–77; and H. Wahbeh and B. S. Oken, “Peak High-Frequency HRV and Peak Alpha Frequency Higher in PTSD,” Applied Psychophysiology and Biofeedback 38, no. 1 (2013): 57–69.

3. J. W. Hopper, et al., “Preliminary Evidence of Parasympathetic Influence on Basal Heart Rate in Posttraumatic Stress Disorder,” Journal of Psychosomatic Research 60, no. 1 (2006): 83–90.

4. Arieh Shalev at Hadassah Medical School in Jerusalem and Roger Pitman’s experiments at Harvard also pointed in this direction: A. Y. Shalev, et al., “Auditory Startle Response in Trauma Survivors with Posttraumatic Stress Disorder: A Prospective Study,” American Journal of Psychiatry 157, no. 2 (2000): 255–61; R. K. Pitman, et al., “Psychophysiologic Assessment of Posttraumatic Stress Disorder Imagery in Vietnam Combat Veterans,” Archives of General Psychiatry 44, no. 11 (1987): 970–75; A. Y. Shalev, et al., “A Prospective Study of Heart Rate Response Following Trauma and the Subsequent Development of Posttraumatic Stress Disorder,” Archives of General Psychiatry 55, no. 6 (1998): 553–59.

5. P. Lehrer, Y. Sasaki, and Y. Saito, “Zazen and Cardiac Variability,” Psychosomatic Medicine 61, no. 6 (1999): 812–21. See also R. Sovik, “The Science of Breathing: The Yogic View,” Progress in Brain Research 122 (1999): 491–505; P. Philippot, G. Chapelle, and S. Blairy, “Respiratory Feedback in the Generation of Emotion,” Cognition & Emotion 16, no. 5 (2002): 605–627; A. Michalsen, et al., “Rapid Stress Reduction and Anxiolysis Among Distressed Women as a Consequence of a Three-Month Intensive Yoga Program,” Medcal Science Monitor 11, no. 12 (2005): 555–61; G. Kirkwood et al., “Yoga for Anxiety: A Systematic Review of the Research Evidence,” British Journal of Sports Medicine 39 (2005): 884–91; K. Pilkington, et al., “Yoga for Depression: The Research Evidence,” Journal of Affective Disorders 89 (2005): 13–24; and P. Gerbarg and R. Brown, “Yoga: A Breath of Relief for Hurricane Katrina Refugees,” Current Psychiatry 4 (2005): 55–67.

6. B. Cuthbert et al., “Strategies of Arousal Control: Biofeedback, Meditation, and Motivation,” Journal of Experimental Psychology 110 (1981): 518–46. See also S. B. S. Khalsa, “Yoga as a Therapeutic Intervention: A Bibliometric Analysis of Published Research Studies,” Indian Journal of Physiology and Pharmacology 48 (2004): 269–85; M. M. Delmonte, “Meditation as a Clinical Intervention Strategy: A Brief Review,” International Journal of Psychosomatics 33 (1986): 9–12; I. Becker, “Uses of Yoga in Psychiatry and Medicine,” in Complementary and Alternative Medicine and Psychiatry, vol. 19, ed. P. R. Muskin PR (Washington: American Psychiatric Press, 2008); L. Bernardi, et al., “Slow Breathing Reduces Chemoreflex Response to Hypoxia and Hypercapnia, and Increases Baroreflex Sensitivity,” Journal of Hypertension 19, no. 12 (2001): 2221–29; R. P. Brown and P. L. Gerbarg, “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression: Part I: Neurophysiologic Model,” Journal of Alternative and Complementary Medicine 11 (2005): 189–201; R. P. Brown and P. L. Gerbarg, “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression: Part II: Clinical Applications and Guidelines,” Journal of Alternative and Complementary Medicine 11 (2005): 711–17; C. C. Streeter, et al., “Yoga Asana Sessions Increase Brain GABA Levels: A Pilot Study,” Journal of Alternative and Complementary Medicine 13 (2007): 419–26; and C. C. Streeter, et al., “Effects of Yoga Versus Walking on Mood, Anxiety, and Brain GABA Levels: A Randomized Controlled MRS Study,” Journal of Alternative and Complementary Medicine 16 (2010): 1145–52.

7. There are dozens of scientific articles showing the positive effect of yoga for various medical conditions. The following is a small sample: S. B. Khalsa, “Yoga as a Therapeutic Intervention”; P. Grossman, et al., “Mindfulness-Based Stress Reduction and Health Benefits: A Meta-Analysis,” Journal of Psychosomatic Research 57 (2004): 35–43; K. Sherman, et al., “Comparing Yoga, Exercise, and a Self-Care Book for Chronic Low Back Pain: A Randomized, Controlled Trial,” Annals of Internal Medicine 143 (2005): 849–56; K. A. Williams, et al., “Effect of Iyengar Yoga Therapy for Chronic Low Back Pain,” Pain 115 (2005): 107–117; R. B. Saper, et al., “Yoga for Chronic Low Back Pain in a Predominantly Minority Population: A Pilot Randomized Controlled Trial,” Alternative Therapies in Health and Medicine 15 (2009): 18–27; J. W. Carson, et al., “Yoga for Women with Metastatic Breast Cancer: Results from a Pilot Study,” Journal of Pain and Symptom Management 33 (2007): 331–41.

8. B. A. van der Kolk, et al., “Yoga as an Adjunctive Therapy for PTSD,” Journal of Clinical Psychiatry 75, no. 6 (June 2014): 559–65.

9. A California company, HeartMath, has developed nifty devices and computer games that are both fun and effective in helping people to achieve better HRV. To date nobody has studied whether simple devices such as those developed by HeartMath can reduce PTSD symptoms, but this very likely the case. (see in www.heartmath.org.)

10. As of this writing there are twenty-four apps available on iTunes that claim to be able to help increase HRV, such as emWave, HeartMath, and GPS4Soul.

11. B. A. van der Kolk, “Clinical Implications of Neuroscience Research in PTSD,” Annals of the New York Academy of Sciences 1071, no. 1 (2006): 277–93.

12. S. Telles, et al., “Alterations of Auditory Middle Latency Evoked Potentials During Yogic Consciously Regulated Breathing and Attentive State of Mind,” International Journal of Psychophysiology 14, no. 3 (1993): 189–98. See also P. L. Gerbarg, “Yoga and Neuro-Psychoanalysis,” in Bodies in Treatment: The Unspoken Dimension, ed. Frances Sommer Anderson (New York, Analytic Press, 2008), 127–50.

13. D. Emerson and E. Hopper, Overcoming Trauma Through Yoga: Reclaiming Your Body (Berkeley, North Atlantic Books, 2011).

14. A. Damasio, The Feeling of What Happens: Body and Emotion in the Making of Consciousness (New York, Hartcourt, 1999).

15. “Interoception” is the scientific name for this basic self-sensing ability. Brain-imaging studies of traumatized people have repeatedly shown problems in the areas of the brain related to physical self-awareness, particularly an area called the insula. J. W. Hopper, et al., “Neural Correlates of Reexperiencing, Avoidance, and Dissociation in PTSD: Symptom Dimensions and Emotion Dysregulation in Responses to Script‐Driven Trauma Imagery,” Journal of Traumatic Stress 20, no. 5 (2007): 713–25. See also I. A. Strigo, et al., “Neural Correlates of Altered Pain Response in Women with Posttraumatic Stress Disorder from Intimate Partner Violence,” Biological Psychiatry 68, no. 5 (2010): 442–50; G. A. Fonzo, et al., “Exaggerated and Disconnected Insular-Amygdalar Blood Oxygenation Level-Dependent Response to Threat-Related Emotional Faces in Women with Intimate-Partner Violence Posttraumatic Stress Disorder,” Biological Psychiatry 68, no. 5 (2010): 433–41; P. A. Frewen, et al., “Social Emotions and Emotional Valence During Imagery in Women with PTSD: Affective and Neural Correlates,” Psychological Trauma: Theory, Research, Practice, and Policy 2, no. 2 (2010): 145–57; K. Felmingham, et al., “Dissociative Responses to Conscious and Non-conscious Fear Impact Underlying Brain Function in Post-traumatic Stress Disorder,” Psychological Medicine 38, no. 12 (2008): 1771–80; A. N. Simmons, et al., “Functional Activation and Neural Networks in Women with Posttraumatic Stress Disorder Related to Intimate Partner Violence,” Biological Psychiatry 64, no. 8 (2008): 681–90; R. J. L. Lindauer, et al., “Effects of Psychotherapy on Regional Cerebral Blood Flow During Trauma Imagery in Patients with Post-traumatic Stress Disorder: A Randomized Clinical Trial,” Psychological Medicine 38, no. 4 (2008): 543–54 and A. Etkin and T. D. Wager, “Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia,” American Journal of Psychiatry 164, no. 10 (2007): 1476–88.

16. J. C. Nemiah and P. E. Sifneos, “Psychosomatic Illness: A Problem in Communication,” Psychotherapy and Psychosomatics 18, no. 1–6 (1970): 154–60. See also G. J. Taylor, R. M. Bagby, and J. D. A. Parker, Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness (Cambridge: Cambridge University Press, 1997).

17. A. R. Damásio, The Feeling of What Happens: Body and Emotion and the Making of Consciousness (Random House, 2000), 28.

18. B. A. van der Kolk, “Clinical Implications of Neuroscience Research in PTSD,” Annals of the New York Academy of Sciences 1071, no. 1 (2006): 277–93. See also B. K. Hölzel, et al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural Perspective,” Perspectives on Psychological Science 6, no. 6 (2011): 537–59.

19. B. K. Hölzel, et al., “Mindfulness Practice Leads to Increases in Regional Brain Gray Matter Density,” Psychiatry Research: Neuroimaging 191, no. 1 (2011): 36–43. See also B. K. Hölzel, et al., “Stress Reduction Correlates with Structural Changes in the Amygdala,” Social Cognitive and Affective Neuroscience 5, no. 1 (2010): 11–17; and S. W. Lazar, et al., “Meditation Experience Is Associated with Increased Cortical Thickness,” NeuroReport 16 (2005): 1893–97.

CHAPTER 17: PUTTING THE PIECES TOGETHER: SELF-LEADERSHIP

1. R. A. Goulding and R. C. Schwartz, The Mosaic Mind: Empowering the Tormented Selves of Child Abuse Survivors (New York: Norton, 1995), 4.

2. J. G. Watkins and H. H. Watkins, Ego States (New York: Norton, 1997). Jung calls personality parts archetypes and complexes; cognitive psychology schemes and the DID literature refers to them as alters. See also J. G. Watkins and H. H. Watkins, “Theory and Practice of Ego State Therapy: A Short-Term Therapeutic Approach,” Short-Term Approaches to Psychotherapy 3 (1979): 176–220; J. G. Watkins and H. H. Watkins, “Ego States and Hidden Observers,” Journal of Altered States of Consciousness 5, no. 1 (1979): 3–18; and C. G. Jung, Lectures: Psychology and Religion (New Haven CT: Yale University Press, 1960).

3. W. James, The Principles of Psychology (New York: Holt, 1890), 206.

4. C. Jung, Collected Works, vol. 9, The Archetypes and the Collective Unconscious (Princeton, NJ: Princeton University Press, 1955/1968), 330.

5. C. Jung, Collected Works, vol. 10, Civilization in Transition (Princeton, NJ: Princeton University Press, 1957/1964), 540.

6. Ibid., 133.

7. M. S. Gazzaniga, The Social Brain: Discovering the Networks of the Mind (New York: Basic Books, 1985), 90.

8. Ibid., 356.

9. M, Minsky, The Society of Mind (New York: Simon & Schuster, 1988), 51.

10. Goulding and Schwartz, Mosaic Mind, p. 290.

11. O. van der Hart, E. R. Nijenhuis, and K. Steele, The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization (New York: WW Norton, 2006); R. P. Kluft, Shelter from the Storm (self-published, 2013).

12. R. Schwartz, Internal Family Systems Therapy (New York: Guilford Press, 1995).

13. Ibid., p. 34.

14. Ibid., p. 19.

15. Goulding and Schwartz, Mosaic Mind, 63.

16. J. G. Watkins, 1997, illustrates this as an example of personifying depression: “We need to know what the imaginal sense of the depression is and who, which character, suffers it.”

17. Richard Schwartz, personal communication.

18. Goulding and Schwartz, Mosaic Mind, 33.

19. A. W. Evers, et al., “Tailored Cognitive-Behavioral Therapy in Early Rheumatoid Arthritis for Patients at Risk: A Randomized Controlled Trial,” Pain 100, no. 1–2 (2002): 141–53; E. K. Pradhan, et al., “Effect of Mindfulness-Based Stress Reduction in Rheumatoid Arthritis Patients,” Arthritis & Rheumatology 57, no. 7 (2007): p. 1134–42; J. M. Smyth, et al., “Effects of Writing About Stressful Experiences on Symptom Reduction in Patients with Asthma or Rheumatoid Arthritis: A Randomized Trial,” JAMA 281, no. 14 (1999): 1304–9; L. Sharpe, et al., “Long-Term Efficacy of a Cognitive Behavioural Treatment from a Randomized Controlled Trial for Patients Recently Diagnosed with Rheumatoid Arthritis,” Rheumatology (Oxford) 42, no. 3 (2003): 435–41; H. A. Zangi, et al., “A Mindfulness-Based Group Intervention to Reduce Psychological Distress and Fatigue in Patients with Inflammatory Rheumatic Joint Diseases: A Randomised Controlled Trial,” Annals of the Rheumatic Diseases 71, no. 6 (2012): 911–17.

CHAPTER 18: FILLING IN THE HOLES: CREATING STRUCTURES

1. Pesso Boyden System Psychomotor. See http://pbsp.com/.

2. D. Goleman, Social Intelligence: The New Science of Human Relationships (Random House Digital, 2006).

3. A. Pesso, “PBSP: Pesso Boyden System Psychomotor,” in Getting in Touch: A Guide to Body-Centered Therapies, ed. S. Caldwell (Wheaton, IL: Theosophical Publishing House, 1997); A. Pesso, Movement in Psychotherapy: Psychomotor Techniques and Training (New York: New York University Press, 1969); A. Pesso, Experience in Action: A Psychomotor Psychology (New York: New York University Press, 1973); A. Pesso and J. Crandell, eds., Moving Psychotherapy: Theory and Application of Pesso System/Psychomotor (Cambridge, MA: Brookline Books, 1991); M. Scarf, Secrets, Lies, and Betrayals (New York: Ballantine Books, 2005); M. van Attekum, Aan Den Lijve (Netherlands: Pearson Assessment, 2009); and A. Pesso, “The Externalized Realization of the Unconscious and the Corrective Experience,” in Handbook of Body-Psychotherapy / Handbuch der Körperpsychotherapie, ed. H. Weiss and G. Marlock (Stuttgart,Germany: Schattauer, 2006).

4. Luiz Pessoa, and Ralph Adolphs, “Emotion Processing and the Amygdala: from a ‘Low Road’ to ‘Many Roads’ of Evaluating Biological Significance.” Nature Reviews Neuroscience 11, no. 11 (2010): 773–83.

CHAPTER 19: REWIRING THE BRAIN: NEUROFEEDBACK

1. H. H. Jasper, P. Solomon, and C. Bradley, “Electroencephalographic Analyses of Behavior Problem Children,” American Journal of Psychiatry 95 (1938): 641–58; P. Solomon, H. H. Jasper, and C. Braley, “Studies in Behavior Problem Children,” American Neurology and Psychiatry 38 (1937): 1350–51.

2. Martin Teicher at Harvard Medical School, has done extensive research that documents temporal lobe abnormalities in adults who were abused as children: M. H. Teicher et al., “The Neurobiological Consequences of Early Stress and Childhood Maltreatment,” Neuroscience & Biobehavioral Reviews 27, no. 1–2) (2003): 33–44; M. H. Teicher et al., “Early Childhood Abuse and Limbic System Ratings in Adult Psychiatric Outpatients,” Journal of Neuropsychiatry & Clinical Neurosciences 5, no. 3 (1993): 301–6; M. H. Teicher, et al., “Sticks, Stones and Hurtful Words: Combined Effects of Childhood Maltreatment Matter Most,” American Journal of Psychiatry (2012).

3. Sebern F. Fisher, Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain. (New York: Norton, 2014).

4. J. N. Demos, Getting Started with Neurofeedback (New York: WW Norton, 2005). See also R. J. Davidson, “Affective Style and Affective Disorders: Prospectives from Affective Neuroscience,” Cognition and Emotion 12, no. 3 (1998): 307–30; and R. J. Davidson, et al., “Regional Brain Function, Emotion and Disorders of Emotion,” Current Opinion in Neurobiology 9 (1999): 228–34.

5. J. Kamiya, “Conscious Control of Brain Waves,” Psychology Today, April 1968, 56–60. See also D. P. Nowlis, and J. Kamiya, “The Control of Electroencephalographic Alpha Rhythms Through Auditory Feedback and the Associated Mental Activity,” Psychophysiology 6, no. 4 (1970): 476–84 and D. Lantz and M. B. Sterman, “Neuropsychological Assessment of Subjects with Uncontrolled Epilepsy: Effects of EEG Feedback Training,” Epilepsia 29, no. 2 (1988): 163–71.

6. M. B. Sterman, L. R. Macdonald, and R. K. Stone, “Biofeedback Training of the Sensorimotor Electroencephalogram Rhythm in Man: Effects on Epilepsy,” Epilepsia 15, no. 3 (1974): 395–416. A recent meta-analysis of eighty-seven studies showed that neurofeedback led to a significant reduction in seizure frequency in approximately 80 percent of epileptics who received the training. Gabriel Tan, et al., “Meta-Analysis of EEG Biofeedback in Treating Epilepsy,” Clinical EEG and Neuroscience 40, no. 3 (2009): 173–79.

7. This is part of the same circuit of self-awareness that I described in chapter 5. Alvaro Pascual-Leone has shown how, when one temporarily knocks out the area above the medial prefrontal cortex with transcranial magnetic stimulation (TMS), people can temporarily not identify whom they are looking at when they stare into the mirror. J. Pascual-Leone, “Mental Attention, Consciousness, and the Progressive Emergence of Wisdom,” Journal of Adult Development 7, no. 4 (2000): 241–54.

8. http://www.eegspectrum.com/intro-to-neurofeedback/.

9. S. Rauch, et al., “Symptom Provocation Study Using Positron Emission Tomography and Script Driven Imagery,” Archives of General Psychiatry 53 (1996): 380–87. Three other studies using a new way of imaging the brain, magnetoencephalography (MEG), showed that people with PTSD suffer from increased activation of the right temporal cortex: C. Catani, et al., “Pattern of Cortical Activation During Processing of Aversive Stimuli in Traumatized Survivors of War and Torture,” European Archives of Psychiatry and Clinical Neuroscience 259, no. 6 (2009): 340–51; B. E. Engdahl, et al., “Post-traumatic Stress Disorder: A Right Temporal Lobe Syndrome?” Journal of Neural Engineering 7, no. 6 (2010): 066005; A. P. Georgopoulos, et al., “The Synchronous Neural Interactions Test as a Functional Neuromarker for Post-traumatic Stress Disorder (PTSD): A Robust Classification Method Based on the Bootstrap,” Journal of Neural Engineering 7. no. 1 (2010): 016011.

10. As measured on the Clinician Administered PTSD Scale (CAPS).

11. As measured by John Briere’s Inventory of Altered Self-Capacities (IASC).

12. Posterior and central alpha rhythms are generated by thalamocortical networks; beta rhythms appear to be generated by local cortical networks; and the frontal midline theta rhythm (the only healthy theta rhythm in the human brain) is hypothetically generated by the septohippocampal neuronal network. For a recent review see J. Kropotov, Quantitative EEG, ERP’s And Neurotherapy (Amsterdam: Elsevier, 2009).

13. H. Benson, “The Relaxation Response: Its Subjective and Objective Historical Precedents and Physiology,” Trends in Neurosciences 6 (1983): 281–84.

14. Tobias Egner and John H. Gruzelier, “Ecological Validity of Neurofeedback: Modulation of Slow Wave EEG Enhances Musical Performance,” Neuroreport 14 no. 9 (2003): 1221–4; David J. Vernon, “Can Neurofeedback Training Enhance Performance? An Evaluation of the Evidence with Implications for Future Research,” Applied Psychophysiology and Biofeedback 30, no. 4 (2005): 347–64.

15. “Vancouver Canucks Race to the Stanley Cup—Is It All in Their Minds?” Bio-Medical.com, June 2, 2011, http://bio-medical.com/news/2011/06/vancouver-canucks-race-to-the-stanley-cup-is-it-all-in-their-minds/.

16. M. Beauregard, Brain Wars (New York: Harper Collins, 2013), p. 33.

17. J. Gruzelier, T. Egner, and D. Vernon, “Validating the Efficacy of Neurofeedback for Optimising Performance,” Progress in Brain Research 159 (2006): 421–31. See also D. Vernon and J. Gruzelier, “Electroencephalographic Biofeedback as a Mechanism to Alter Mood, Creativity and Artistic Performance,” in Mind-Body and Relaxation Research Focus, ed. B. N. De Luca (New York: Nova Science, 2008), 149–64.

18. See, e.g., M. Arns, et al., “Efficacy of Neurofeedback Treatment in ADHD: The Effects on Inattention, Impulsivity and Hyperactivity: A Meta-Analysis,” Clinical EEG and Neuroscience 40, no. 3 (2009): 180–89; T. Rossiter, “The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part I: Review of Methodological Issues,” Applied Psychophysiology and Biofeedback 29, no. 2 (June 2004): 95–112; T. Rossiter, “The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part II: Replication,” Applied Psychophysiology and Biofeedback 29, no. 4 (2004): 233–43; and L. M. Hirshberg, S. Chiu, and J. A. Frazier, “Emerging Brain-Based Interventions for Children and Adolescents: Overview and Clinical Perspective,” Child and Adolescent Psychiatric Clinics of North America 14, no. 1 (2005): 1–19.

19. For more on qEEG, see http://thebrainlabs.com/qeeg.shtml.

20. N. N. Boutros, M. Torello, and T. H. McGlashan, “Electrophysiological Aberrations in Borderline Personality Disorder: State of the Evidence,” Journal of Neuropsychiatry and Clinical Neurosciences 15 (2003): 145–54.

21. In chapter 17, we saw how essential it is to cultivate a state of steady, calm self-observation, which IFS calls a state of “being in self.” Dick Schwartz claims that with persistence anybody can achieve such a state, and indeed, I have seen him help very traumatized people do precisely that. I am not that skilled, and many of my most severely traumatized patients become frantic or spaced out when we approach upsetting subjects. Others feel so chronically out of control that it is difficult to find any abiding sense of “self.” In most psychiatric settings people with these problems are given medications to stabilize them. Sometimes that works, but many patients lose their motivation and drive. In our randomized controlled study of neurofeedback, chronically traumatized patients had an approximately 30 percent reduction in PTSD symptoms and a significant improvement in measures of executive function and emotional control (van der Kolk et al., submitted 2014).

22. Traumatized kids with sensory-integration deficits need programs specifically developed for their needs. At present, the leaders of this effort are my Trauma Center colleague Elizabeth Warner and Adele Diamond at the University of British Columbia.

23. R. J. Castillo, “Culture, Trance, and the Mind-Brain,” Anthropology of Consciousness 6, no. 1 (March 1995): 17–34. See also B. Inglis, Trance: A Natural History of Altered States of Mind (London: Paladin, 1990); N. F. Graffin, W. J. Ray, and R. Lundy, “EEG Concomitants of Hypnosis and Hypnotic Susceptibility,” Journal of Abnormal Psychology 104, no. 1 (1995): 123–31; D. L. Schacter, “EEG Theta Waves and Psychological Phenomena: A Review and Analysis,” Biological Psychology 5, no. 1 (1977): 47–82; and M. E. Sabourin, et al., “EEG Correlates of Hypnotic Susceptibility and Hypnotic Trance: Spectral Analysis and Coherence,” International Journal of Psychophysiology 10, no. 2 (1990): 125–42.

24. E. G. Peniston and P. J. Kulkosky, “Alpha-Theta Brainwave Neuro-Feedback Therapy for Vietnam Veterans with Combat-Related Post-traumatic Stress Disorder,” Medical Psychotherapy 4 (1991): 47–60.

25. T. M. Sokhadze, R. L. Cannon, and D. L. Trudeau, “EEG Biofeedback as a Treatment for Substance Use Disorders: Review, Rating of Efficacy and Recommendations for Further Research,” Journal of Neurotherapy 12, no. 1 (2008): 5–43.

26. R. C. Kessler, “Posttraumatic Stress Disorder: The Burden to the Individual and to Society,” Journal of Clinical Psychiatry 61, suppl. 5 (2000): 4–14. See also R. Acierno, et al., “Risk Factors for Rape, Physical Assault, and Posttraumatic Stress Disorder in Women: Examination of Differential Multivariate Relationships,” Journal of Anxiety Disorders 13, no. 6 (1999): 541–63; and H. D. Chilcoat and N. Breslau, “Investigations of Causal Pathways Between PTSD and Drug Use Disorders,” Addictive Behaviors 23, no. 6 (1998): 827–40.

27. S. L. Fahrion et al., “Alterations in EEG Amplitude, Personality Factors, and Brain Electrical Mapping After Alpha-Theta Brainwave Training: A Controlled Case Study of an Alcoholic in Recovery,” Alcoholism: Clinical and Experimental Research 16, no. 3 (June 1992): 547–52; R. J. Goldberg, J. C. Greenwood, and Z. Taintor, “Alpha Conditioning as an Adjunct Treatment for Drug Dependence: Part 1,” International Journal of Addiction 11, no. 6 (1976): 1085–89; R. F. Kaplan, et al., “Power and Coherence Analysis of the EEG in Hospitalized Alcoholics and Nonalcoholic Controls,” Journal of Studies on Alcohol 46 (1985): 122–27; Y. Lamontagne et al., “Alpha and EMG Feedback Training in the Prevention of Drug Abuse: A Controlled Study,” Canadian Psychiatric Association Journal 22, no. 6 (October 1977): 301–10; Saxby and E. G. Peniston, “Alpha-Theta Brainwave Neurofeedback Training: An Effective Treatment for Male and Female Alcoholics with Depressive Symptoms,” Journal of Clinical Psychology 51, no. 5 (1995): 685–93; W. C. Scott, et al., “Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population,” American Journal Drug and Alcohol Abuse31, no. 3 (2005): 455–69; and D. L. Trudeau, “Applicability of Brain Wave Biofeedback to Substance Use Disorder in Adolescents,” Child & Adolescent Psychiatric Clinics of North America 14, no. 1 (January 2005): 125–36.

28. E. G. Peniston, “EMG Biofeedback-Assisted Desensitization Treatment for Vietnam Combat Veterans Post-traumatic Stress Disorder,” Clinical Biofeedback and Health 9 (1986): 35–41.

29. Eugene G. Peniston, and Paul J. Kulkosky. “Alpha-Theta Brainwave Neurofeedback for Vietnam Veterans with Combat-Related Post-Traumatic Stress Disorder.” Medical Psychotherapy 4, no. 1 (1991): 47-60.

30. Similar results were reported by another group seven years later: W. C. Scott, et al., “Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population,” American Journal of Drug and Alcohol Abuse 31, no. 3 (2005): 455–69.

31. D. L. Trudeau, T. M. Sokhadze, and R. L. Cannon, “Neurofeedback in Alcohol and Drug Dependency,” in Introduction to Quantitative EEG and Neurofeedback: Advanced Theory and Applications, ed. T. Budzynski, et al. Amsterdam, Elsevier, (1999) pp. 241–68; F. D. Arani, R. Rostami, and M. Nostratabadi, “Effectiveness of Neurofeedback Training as a Treatment for Opioid-Dependent Patients,” Clinical EEG and Neuroscience 41, no. 3 (2010): 170–77; F. Dehghani-Arani, R. Rostami, and H. Nadali, “Neurofeedback Training for Opiate Addiction: Improvement of Mental Health and Craving,” Applied Psychophysiology and Biofeedback, 38, no. 2 (2013): 133–41; J. Luigjes, et al., “Neuromodulation as an Intervention for Addiction: Overview and Future Prospects,” Tijdschrift voor psychiatrie 55, no. 11 (2012): 841–52.

32. S. Othmer, “Remediating PTSD with Neurofeedback,” October 11, 2011, http://hannokirk.com/files/Remediating-PTSD_10-01-11.pdf.

33. F. H. Duffy, “The State of EEG Biofeedback Therapy (EEG Operant Conditioning) in 2000: An Editor’s Opinion,” an editorial in Clinical Electroencephalography 31, no. 1 (2000): v–viii.

34. Thomas R. Insel, “Faulty Circuits,” Scientific American 302, no. 4 (2010): 44-51.

35. T. Insel, “Transforming Diagnosis,” National Insitute of Mental Health, Director’s Blog, April 29, 2013, http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.

36. Joshua W. Buckholtz and Andreas Meyer-Lindenberg, “Psychopathology and the Human Connectome: Toward a Transdiagnostic Model of Risk For Mental Illness,” Neuron 74, no. 4 (2012): 990–1004.

37. F. Collins, “The Symphony Inside Your Brain,” NIH Director’s Blog, November 5, 2012, http://directorsblog.nih.gov/2012/11/05/the-symphony-inside-your-brain/.

CHAPTER 20: FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER

1. F. Butterfield, “David Mamet Lends a Hand to Homeless Vietnam Veterans,” New York Times, October 10, 1998. For more on the new shelter, see http://www.nechv.org/historyatnechv.html.

2. P. Healy, “The Anguish of War for Today’s Soldiers, Explored by Sophocles,” New York Times, November 11, 2009. For more on Doerries’s project, see http://www.outsidethewirellc.com/projects/theater-of-war/overview.

3. Sara Krulwich, “The Theater of War,” New York Times, November 11, 2009.

4. W. H. McNeill, Keeping Together in Time: Dance and Drill in Human History (Cambridge, MA: Harvard University Press, 1997).

5. Plutarch, Lives, vol. 1 (Digireads.com, 2009), 58.

6. M. Z. Seitz, “The Singing Revolution,” New York Times, December 14, 2007.

7. For more on Urban Improv, see http://www.urbanimprov.org/.

8. The Trauma Center Web site, offers a full-scale downloadable curriculum for a fourth-grade Urban Improv program that can be run by teachers nationwide. http://www.traumacenter.org/initiatives/psychosocial.php.

9. For more on the Possibility Project, see http://the-possibility-project.org/.

10. For more on Shakespeare in the Courts, see http://www.shakespeare.org/education/for-youth/shakespeare-courts/.

11. C. Kisiel, et al., “Evaluation of a Theater-Based Youth Violence Prevention Program for Elementary School Children,” Journal of School Violence 5, no. 2 (2006): 19–36.

12. The Urban Improv and Trauma Center leaders were Amie Alley, PhD, Margaret Blaustein, PhD, Toby Dewey, MA, Ron Jones, Merle Perkins, Kevin Smith, Faith Soloway, Joseph Spinazzola, PhD.

13. H. Epstein and T. Packer, The Shakespeare & Company Actor Training Experience (Lenox MA, Plunkett Lake Press, 2007); H. Epstein, Tina Packer Builds a Theater (Lenox, MA: Plunkett Lake Press, 2010).


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