on the Brain by MikeJenny


									                                                                           The fnrpact of Tnarrma
                                                                                                                                on the Brain
         L O U I SJ                     c0z0LlN0

                                                A d a p t a t i o n o t r a u m a , e s p e c i a t t y a r t y i n l i f e , b e c o m e sa s t a t e o f m i n d a r o u n dw h i c h a L L
                                                                  t                                    e
                                                s u b s e q u e n e x p e r i e n c e s r g a n i s e .P T S D b o r d e r l i n ep e r s o n a L i t d i s o r d e ra n d s e [ f - h a r n r
                                                                                      o                        ,                                      y
                                                c a n a t I r e f t e c tc o m p t e xa d a p t a t i o n o e a r l y t r a u m a .U n r e s o L v ea n d u n i n t e g r a t e dr a u m a
                                                                                                         t                                          d                           t
                                                m a y r e s u l t i n p o s t t r a u m a t i cs t r e s s d i s o r d e r ,a n d c u m u t a t i v eL i f e t i m e r a u m a i n c r e a s e s
                                                t h e t i k e l . i h o oo f d e v e L o p i n P T S D T h e i m p a c to f a w i d e v a r i e t y o f t r a u m a t i ce x p e r i e n c e s
                                                                                               g       .
                                                i s w o v e ni n t o t h e s t r u c t u r e o f p e r s o n a l i t yo ft e n m a k i n gi t d i f f i c u t tt o t r e a t . I n t h i s e x t r a c t
                                                f r o m ' T h eN e u r o s c i e n co f P s y c h o t h e r a p y :u i l . d i na n d R e b u i t d i n t h e H u m a nB r a i n ' , o u i s
                                                                                    e                           B               g                       g                          L
                                                C o z o l i n od r a w s o n c u r r e n t r e s e a r c h t o e x p t o r e t h e i r n p a c to f t r a u m a o n t h e h u m a n ' b r a i n .
                                                H e p r e s e n t se v i d e n c et o a r g u e t h a t t r a u m a i s n o t L i m i t e dt o s u r v i v i n gL i f e - t h r e a t e n i n g
                                                e x p e r i e n c e s ,b u t c a n o . . u l - u . r o l r s ' t h e t i f e s p a na s a p l . o d u c to f , t h e i n t e n s e s t r e s s e s t h a t
                                                c a n b e c h a r a c t e r i s t i c f t h e c o m p t e 4 i t i e s f h u m a n r e t a t i o n ! n i p si n d e x p e r i e n c g b o z o l . i n o
                                                                                    o                                    o                                                                 ,
                                                u s e s c a s e s t u d i e s f r o m h i s o w n' c t i n i c a tp r a c t i c e ' t od e m o n s t rt. l; e h o w p s y c h o t h e r a p y
                                                                                                         ''                             : '::
                                                c a n p r o v i d et h e p s y c h o L o g i c a In d n e u r o b i o L o g i c an t e g r a t i o nr e q u i r e dt o a l t e r n e u r a l
                                                                                                  a                                i t
                                                                                                      ' : .
                                                n e t w o r k i t h a t a r e o r g a n i s e di n a m a n n e r n o t c o n d u c i v e o ' m e n t a lh e a L t h ,.
                                                                                                                                          t                                  ]

 For each of us there is a point at which anxiety and fear crossthe line into trauma. Trauma can causeseyeredisturbances
 in the integration of cognitive anil emotional processing.The neurobiological reactions to theseexperiencesappear to lie
 on a continuum of intensity. The earlier, more severe,and more prolonged the trauma, the more negativeand
                                                                                                           far reaching
 the effects(De BeIIis, Baum, Birnmaher, Keshavan,Eccard, Boring, et aI., 1999;De BeIIis,Keshavan, Clark, Casey,Giedd,
 Boring, et aI., 1999).

   Unresolved and unintegrated                                        that interfere with all realms of personal                          trauma are widespread, devastating,
trauma may resuit in a disorder known                                 and interpersonal functioning (Perry,                               and difficult to treat. Becauseofthe
as posttraumatic stress disorder                                      Pollard,Blakley,Baker & Vigilante,                                  importance of a context of safety and
(PTSD). PTSD is comprised of a set of                                 1995).Support for the negative impact                               bonding in the early construction of the
symptoms that reflect the physiological                               of trauma comes from researchthat has                               brain, childhood trauma compromises
dysregulationand lack ofintegration of                                shown that cumulative lifetime trauma                               core neural networks. It stands to
multiple networks of implicit and explicit                            increasesthe likelihood of developing                               reasonthat the most devastating                   types
memory (Siegel,1999).                                                 PTSD(Yehuda r al, 1995)A history
                                                                                           e                .                             of trauma are those that occur at the
    We have all heard the sayings 'I4lhar                             ofprevious assaults         also increases        the               hands ofcaretakers.Physicaland sexual
doesn'tkill you makesyou stronger' and                                chancesof developing PTSD following                                 abuse by parents not only traumatizes
            healsall wounds'.Thesebits of                             rape (Resnick, Yehuda, Pitman, &                                    children, but also deprives them of
c o m m o n w i s d o m c o n j u r eu p p i c t u r e s              Foy, 1995).Likewise, childhood abuse                                healing interaclions. The wide range
o f d i f f i c u l t a n d t r a u m a t i ce x p e r i e n c e s    increases chancesof developing
                                                                                   the                                                    ofeffects involved in the adaptation to
that, once overcome) result in greater                                PTSD after aduit combat exposure                                    early unresolved trauma results in the
ievels of physical and emotional well-                                (Bremner, Southwick, johnson, Yehuda,                               phenomena of complex posttraumatic
being. Although trials and tribulations                               & Charney, 1993).It has also been                                   stressdisorder.
c a n c e r t a i n l yb u i l d c h a r a c t e rt,h e y             shown that severestressreactions during                                 Trauma is biochemicallyencoded
can also createpermanent biological,                                             .
                                                                      c o m b a tm a k e s u b s e q u e nn e g a t i v e
                                                                                                          t                               in the brain in a variety of ways,
neurolo gical, and psychological                                      reactionsto mild and moderatestress                                 including changes the availability
compromise. Trauma produces a wide                                    more likely (Solomon, 1990).                                        and effects of neurotransmitters and
variety of homeostatic dysregulations                                     The effects ofearly and severe                                  n e u r o m o d u l a t o r s . e ur o a n a t o m i c

22              PSYCHOTHERAPY lN AUSTRALIA r                              VOL ll      NO     3 MAY 2005
                                                               unborn child may become stressed             infant's first year of life demonstrate
encoding occurs through changes in
                                                               as a result of the shared biological         biochemical, physiologicai, and
structures like the hippocampus, and
                                                               environment with its mother. Studies         behaviourai dysregulation. These
i n t h e c o o r d i n a t i o na n d i n t e g r a t i o n
                                                               suggestthat maternal stressis associated     children show more neurophysiolo gical
of neural network functioning. These
                                                               with their children's iower birthweight,     and behavioural signs of stressand
changes in neurobiological mechanisms
are reflected in the victim's physioiogical,                   irritabilit% hyperactiviry and learning      depression,including greateractivation
                                                                                                            i n t h c i r r i g h t l r o n t a I l o b c s ,h i g h c r l c v e l s
      T r a u m as n o t L i m i t etd s u r v i vn g L i e - t h r e a t e n i n g
                  i                   o            i                                                        of norepinephrine, lower vagal tone,
                                                                                                            and higher heart rates and cortisoi levels

      e x p e r i e n c e s, F o r a y o u n g h i t d ,t r a u m am a yb e
                         ..                   c                                                             (Field, 1997;Field et al., 19BB).These
                                                                                                            infanrs tend to develop behaviours

       e x p e r i e n c en t h ef o r mo f s e p a r a t i o no mp a r e n t s '
                         id                                  fr                                             and biological processes   that mirror
                                                                                                            their depressedmothers. Just like their

       t o o k i n gn t ot h ee y e s fa d e p r e s s em o t h e ro r b e i n g
                   i                o                   d          ,                                        depressedmothers, such infants engage
                                                                                                            less irr interactive behaviours (e.g.,

       i n a h o u s e h o wdt ha h i g h[ e v e [ f m a r i t a tl e n s i o n .
                           Li                    o                                                          orienting toward and gazing at others)
                                                                                                            that are so vitally important for healthy
                                                                                                            development. Infants of depressed
 psychological, and interpersonal                               disabilities (Zuckerman, Bauchner,           mothers behave this way even with
 erperiences (eg., Carroll, Rueger, Foy, &                      Parker, & Cabral, 1990). Rats born to        other adults, making it more difficult
  Donahoe, 1985). Deficits in psychological                     stressedmothers show more clinging           for them to successfully interact with
  and interpersonal functioning then                            to the mother, lesslocomotion, and           nondepressed others (Field et aL, 1988).
  create additional stress which further                        decreasedenvironmental expioration               In another study, it was found that
  compromises neurobiological structures'                       (Schneider, 1992). Prenatal stressmay        depressedmothers were angry at their
  In this way, adaptation to trauma,                            also result in permartent alterations        infants more of the time and were more
  especially early in life, becomes a'state of                  in dopamine activity and cerebral            likely to poke at them, disengage from
  mind, brain, and body' around which all                       lateralization, making offspring more        them, and spend lesstime in'matched
  subsequentexperience   organizes.                             susceptible to both anriety and limiting     states' (Field, Healy, Goldstein, &
                                                                their functioning into adulthood (Field      Guthertz, 1990). These results suggest
   Expanding Definition
              the                                               et a1.,1988), Children of Holocaust          that infants are modelling on their
   of Trauma                                                    survivors have.an i-ncreasedprevalence        mother's behavior, exhibiting resonance
      Trauma not limitedto surviving
            is                                                  of PTSD despite similar rates of erposure     with their depressedstates,and reacting
   Iife-threatening experiences (as the                         to traumatic events when compared to          to the negative behaviours directed
   standard diagnostic manual appears                           children of non-Holocaust survivors.          toward them. Based on biologicai,
   to suggest;American Psychiatric                              This suggests tiat they experienced           physiological, and behavioural data,
   Association, 2000). For a young child,                       a transferred vulnerability through           having a depressed mother is a stressful
   trauma may be erperienced in the form                        interactions with their traumatized           and potentially traumatic experience
   of separation from parents, looking                          parents (Yehuda, 1999).                       for an infant. Fortunately, it has been
   into the eyesof a depressedmother, or                            Maternal depressionmay actuallY           shown that interventions with depressed
   being in a household with a high level                        serve as a highly stressful or traumatic     mothers and their infants have had
   of marital tension. For an adolescent,                        experience for infants and children.         positive results. For example, remission
   chronic stressand trauma may come                             Tiffany Field and her colleagues found           of maternal depressionand teaching
    from the incessant teasing ofpeers or                        that infants whose mothers                                             mothers to massage
    taking care of the needs of an alcohoiic                     were depressed                                                                      their infants on a
    parent. For an adult, chronic ioneliness,                    during the                                                                                      regularbasis
    the loss ofa pet, or a constant senseof
    shame or failure may have the same
    impact. Although it is impossible to
    understand the nature ofprenatal and
     infant experience, can assumethat
    the infant is stressedwell before the brain
    developsthe capacityfor consciousness.
    While we can't ask if it is stressed,we
    can assess whether an infant's body
    is experiencing biochemical changes
    indicative ofa stressresPonse(Gunnar,
     i992, 1998).
        There is a distinct possibiliry that
     stressis possible even before birth; an

                                                                                 PSYCHOTHERAPY lN AUSTRALIA              o   VOL       ll   NO     3 MAY 2005                          23
resulted in improvement of the infants'                      psychologicalprocesses. increased      An                                                      'I'raumatized
                                                                                                                                    and the immune system.
symptoms (Field, 1997).                                      i e v e lo f d o p a m i n e( a c t i v a t i n gh e f r o n t a l
                                                                                                             t                      individuals thus havehigher rates
      We would not considerthese infants                                                    w
                                                             c o r t e x )c o r r e l a t e s i t h h y p e r v i g i J a n c e ,   of physical iilness,which enhances
traumatized in the usual sense,and                           paranoia, and perceptual distortions                                   their experienceofbeing fragile and
o f t e n t h i n k o f i n f a n t sa s e x t r e m e l y   when under stress.Symptoms of social                                   vulnerable individuals.
resilient. On a biological level,however,                    withdrawal and the avoidanceof new                                         These biochemical and
the experience fhaving a depressed
                         o                                   and potentialiy dangerousstimuli                                                                  l
                                                                                                                                    n e u r o a n a t o m i c lc h a n g e r r e p r r a l l e l c d
mother may result in the same changes                        (neophobia) are shapedby the anxiety of                                by such symptomatology as emotional
as would occur in an adult exposedto                         thesebiochemical changes.                                              dyscontrol, socialwithdrawal, and
a life-threatening situation-After all,                         Lower levelsofserotonin have been                                   l o w e r l e v e l so f a d a p t i v e u n c t i o n i n g .
infants' lives - and the building of their                   found in traumatized humans and                                        Together, these and other negativeeffects
brains - depend on positiveinteractions                      in animals after being subjectedto                                     of trauma result in a personwhose
with their parents.The loss of maternal                      inescapabie shock (Anisman, l97B; Usdin,                               functioning is compromisedin some or
presence,engagement,     and vitaiity may                    Kvetnansky, & Kopin, 1976).Chronically                                 all areas of life. The impact of trauma
all be experienced(at a biological levei)                    lowlevels ofserotonin are correlated with                              depends on a complexinteraction of
as life threatening to an infant-                            higher levelsof irritabiliry, depression,                              the physical and psychological
                                                             aggression,arousalr and violence                                       development during which it occurs, the
N e u r o t r a n s m i t t ea n dH o r m o n a I            (Coccaro, Siever,Klar, & Maurea l9B9).                                 length and degreeofthe trauma, and
Changes                                                      Prisoners convicted of violent crimes have                             the presenceofvulnerabilities or past
    As we saw in chapter il, states                          lower serotonin levelswhen compared to                                 traumas. The impact of a wide variety of
 of acute stressresult in predictable                        criminals convicted of non-violent crimes.                             traumatic experiencesis woven into the
patterns of biochemical changes.                                 Endogenous opioids, which relieve                                  structure of personality, often making it
There are increasesin the levels of                          p a i n i n f i g h t - o r - f l i g h ts i t u a r i o n s c a n
                                                                                                                          ,         difficult to identify and treat.
norepinephrine, dopamine, endogenous                         have a profound effect on reality testing
opioids, and glucocorticoids, and a                          and memory processing when released                                    T h eS y m p t o m s f P o s t t r a u m a t i c
 decreasein serotonin. When stress is                        in responseto a variety of emotional                                   StressDisorder
 prolonged or chronic, changesoccur                          situations unrelated to danger. Higher                                    Trauma results in a variety of
 in the baseiine production, availability,                   opioid levels result not only in analgesia,                            psychological and physiological processes
 and homeostatic regulation of these                         b u t a l s oi n e m o t i o n a lb l u n t i n g a n d                reflecting the reaction of the mind and
 neurochemicals. These changesresult in                      difficulties with reality testing. Most                                body to threat. The pattern of reaction
 long-term behavioural and psychological                     likely, they are also involved with                                    to trauma is predictable and connected
 alterations. Each of these substances                       dissociative reactions and the experience                              to a variety ofwell-understood biological
 serves a different purpose in the stress                    of depersonalisation and derealization,                                processes.Reaction to trauma tends to
 response and contributes in different                       both ofwhich provide an experience                                     gradually diminish within a conrexr
 ways to the long-term impact of PTSD.                       of distance from the traumatized body                                  of resolving the traumatic situation,
    As we have seen,increasedlevels of                       (Shilony & Grossman, 1993).Opioids are                                 gathering support from others, and
 norepinephrine (NE), prepare us for                         also related to self-harm in adults abused                             having the ability to talk through the
 fight-or-fl ight readinessand reinforce                     as children (van der Kolk, 1994), a topic                              experience; these allow for regaining
 the biological encoding of traumatic                        we will soon address.                                                  a senseofpsychological control and
 memory. Higher levels of NE correlate                          As we have seen, high levels of                                     biological homeostasis.An awareness
 with an increasein the experience                           glucocorticoids have a catabolic effect on                             of the importance of rhesehealing
 of anxiety, arousal,and irritability.                       the nervous system and are thought to                                  processeshas led to the development and
 Heightened long-term activation                             be responsible for decreasedvolume of                                  testing of interventions made at different
 of NE results in an increasein the                          the hippocampus (Wantanabe, Gould,                                     intervals following traumatic situations
 level of tension and a heightened or                        & McEwen, 7992) and related memory                                     (Mitchell & Everly, 1993).
 unmodulated startle response(Butler                         deficits (Bremner, Scott, Delaney,                                         T a l k i n g t h r o u g ht h e r r a u m a r i c
 et al., 1990; Ornitz & Pynoos, l9B9).                       Southwick,Mason, )ohnson, et al., 1993;                                experience in the context ofsupportive
 Besides being stronger, the startle                         Nelson & Carver, I99B). Patienrs with                                  others createsthe neurobiological
 responseis also more resistantto                            PTSD related to childhood physical and                                 conditions for the reestablishmentof
 habituation in responseto subsequent                        sexuai abusehave been shown to have                                    neural coherence.            The co-construction
 milder and novel stressors(Nisenbaum,                       hippocampi that are 127osmaller than                                   of narratives drives the integration
 Zigmond, Sved,& Abercrombie, l99I;                          those of comparison subjects (Bremner                                  of cognition, affect, sensation,and
 Petty, Chae, Kramer, Jordan, & Wilson,                      et a\., 1997).Another study showed that                                behaviours. These are the very channels
 1994;van der Kolk, 1994).Consistent                         right hippocampi were B7osmaller in                                    that can stay dissociatedwhen early
 startle experiences  also enhancethe                        patients with combat-related PTSD.                                     trauma, such as child sexual abuse,
 victim's impression of the world as                         Glucocorticoidssacrificelong-term                                      is never discussed processed.or                 The
 a dangerousand unsettling place.                            conservation and homeostasis for short-                                suffering of Holocaust survivors and
 This is a good example of a feedback                        term survival. Chronically high levels                                 combat veterans is often exacerbatedby
 loop between physiological and                              have negative effects on brain structures                              the psychological           and political dynamics

 2I+            PSYCHOTHERAPY              IN AUSTRALIA       O voL        il No 3 t4AY 2005
that encouragedthem to remain silent                              A v o i d a n c ei s t h e a t L e m p t o d e f e n d              increasethe individual's vulnerability to
2hont I Ireir hnrrilwins              py ncrierrrc( Cn         against dangersby limiting contactwith                                 more trauma. This can manifest through
constructed narrativesin an emotionally                        the world, withdrawing from others, and                                engagement abusiverelationships,
supportive environment can provide the                         n a r r o w i n g t h e r a n g eo i t h o u g h t s a n d             p o o r j u d g m e n t ,o r a l a c k o f a d e q u a t e e l f -
necessary matrix for the psychological                         feelings.Avoidancecan take the form                                    protection. Long-term PTSD has been
and neurobiological integration required                       of denial and repression,
                                                                                       and, in more                                   shown to correlatewith the presence
t o a v o i d d i s s o c i a t i v ee a c t i o n s .
                                    r                          extreme instances,dissociationand                                      of rvhat are called'neurological soft
    When the trauma is severe,prolonged,                       amnesia.The power of avoidancewas                                      s i g n s 'p o i n t i n g t o s u b t l en e u r o l o g i c a l
or happens to a vulnerable individual,                         highlighted by the researchof Wiiiiams                                 impairments (Gurvits et al., 2000).
PTSD can develop.PTSD is caused                                (1994),who found that 38olo adult
                                                                                              of                                      These neurological signs could suggest
by the loss ofthe regulation ofthe                             women who had suffereddocumented                                       a vulnerabiiity to the development
neurobiological processes                dedicatedto           sexual abuse when they were children                                   ofPTSD, or they could reflect the
the appraisal and response threat.         to                  had no memory of the event. Compulsive                                 impact of the long-term physiological
There are three main symptom clusters                          activities can also aid in avoiding                                    dysregulation caused by PTSD (Green,
i n P T S D ; h y p e r a r o u s a li,n t r u s i o n ,       negative affect, as can alcohol and drug                               19Bi).
a n d a v o i d a n c e T h e s et h r e e g r o u p so f      abuse,both so common in victims of                                          When confronted with threat under
symptoms reflect the dysregulation of                          trauma. Avoidance servesshort-term                                     normal circumstances,the processes
the central nervous systemin response                          a n x i e t y r e d u c t i o nb u t p e r p e t u a t e t h e
                                                                                                                        s             related to arousal and the fight-or-flight
to unintegrated stress-Put another way,                        lack of neural network integration- The                                responsebecome activated.The threat
these symptoms demonstrate the loss                            passage time doesnot cure trauma,
                                                                      of                                                              is dealt with and soon passes.
of integration among neural networks
controlling cognition, sensation, affect,
and behavior.
   Hyperarousal reflects a stressinduced
dysregulation of the amygdala and
autonomic nervous system, resuiting in
an exaggeratedstartle reflex, agitation,
anxiery and irritability. That jumpy
feeling we get when we drink too
much caffeine gives us a taste for this                        nor does it diminish the intensity of                                  are not well equipped to cope with
experience.'Chronic hyperarousal Ieads                         IlasnDacKs.                                                            threat in this way. Fighting and fleeing
one to experience the world as a more                             When experienced in combination,                                    may actually decreasetheir chancesfor
dangerous and hostile place. Constant                          these symptoms result in a cycle of                                    survival becausetheir survival depends
or uncontrollable agitation makes us less                      activation and numbing reflecting the                                  on dependency.When a child first cries
desirable as companions and thus, less                         body's memory of the trauma (van                                       for help but no help arrives, or when
able to benefit from the companionship                         der Kolk, 1994).Instead ofserving to                                   trauma is being inflicted by a caretaker,
of others.                                                     mobilize the body to deal with new                                     he or she may shift from hyperarousal
  Intrusions occur when traumatic                              external threats, traumatic memories                                   to dissociation(Perry et al., 1995).
experiencesbreak into consciousness                            b e c o m et h e s t i m u l i f o r c o n t i n u i n g               Traumatized children who are agitated
and are experiencedas happening                                emotional responses.Someone suffering                                  may be misdiagnosed as suffering from
in the present. These may manifest                             from PTSD is, in essence, a continual
                                                                                         in                                           attention deficit disorder, while the
in flashbacks resulting in a veteran                           loop of unconscious self-traumatization,                               numbing responsein infants can be
hitting the ground in responseto a                             coping, and exhaustion. When these                                     misinterpreted as a lack of sensitivity to
car backfiring, or a rape victim having                        symptoms are experienced on a chronic                                  pain. This may also be true for women
a panic attack while making love to                            basis, they can devastateevery aspectof                                who are often unable to outrun or
her husband. These are activations of                          the victim's life, from physical well-being                            outfight male attackers.
subcortical systemscued by stimuli                             to the quality of relationshipsro the                                      Until recently, surgery was performed
reminiscent of the initial trauma. You                         victim's experience of the world.                                      on infants without anaesthesiabecause
may remember from the chapterson                                                                                                      their gradual lack of protesr was
memory and fear that the amygdala                              C o m p t e x o s t t r a u m a t iS t r e s s
                                                                           P                      c                                   mistakenly interpreted as insensitivity
both controls this activation and tends                        Disorder                                                               t o p a i n a s o p p o s e dt o a r r a u m a t i c
to generalize from the initial stimuli to                          Complex PTSD occurs in the context                                 reaction to it (Zeltzer, Anderson
a wide variety of cues.There is no sense                       of prolonged inescapablestressand                                      & Schecter,1990). Recent survey
o [ d i s t a n c ef r o m t h e t r a u m a i n t i m e o r   trauma. It is complex becauseof its                                    researchsuggeststhat iess lhan25o/o of
place,becausethe cortico-hippocampal                           extensive physiological effects and its                                p b y s i c i a n s e r f o r m i n g c i r c um c i s i o n
networks have not been able to                                 impact on all areasof deveiopmentand                                   o n n e w b o r n su s ea n y f o r m o f a n a l g e s i a
contextualize the somatic,sensory,                      and    functioning (Herman, i992). Enduring                                   (Wellington & Rieder, 1993),despite
emotional memories within networks of                          p e r s o n a l i t y r a i t s a n d c o p i n gs t r a t e g i e s
                                                                                   t                                                  physiologicalindications that neonates
autobiographical memory.                                       evolving from traumatic statestend to                                  are,experiencingstressand pain during

                                                                                        P S Y C H O T H E R A P YN A U S T R A L T Ao V O L I I N O i M A y 2 O o 5
                                                                                                                l                                                                                   25
and after the procedure (Hoyle et al-,                               defences      resulting in an aberrant                          resistanceand fear ofbeing seenas
l q B 3 ) .T h e s ep r a c t i c e s p p e a r o b e : r
                                    a         t                      o r g a n i z a t i o n f n e t w o r k so f m e m o r y ,
                                                                                            o                                                She reluctantly sharedabout her
holdover ofbeliefs that newborns either                              fear,and the social brain contribute to                         troubled childhood. lessefelt she had
don't experienceor don't remember                                    deficits of affect regulation, attachment                       o b v i o u s l yg o t t e no v e r h e r t r a u m a t i cp a < t
pain (Marshall, Stratton, Moore, &                                   and executive functioning (van der Kolk                         based on her latest successat work and
Boxerman, 1980). It makessensethat an                                et al., 1996).The malformation of these                         in her marriage. As she told me of her
appreciation for the possibility ofPTSD                              i n t e r d e p e n d e ns y s t e m s e s u l t si n m a n y
                                                                                              t            r                         mother's physical abuseat the hands of
reactionsin neonatesand young children                               disordersthat spring fronr extr eme eally                                        ,
                                                                                                                                     h c r f a L h e rs h c r u r n a i t r e t l o n f i t . l e r [ l[r a t
                                                                                                                                                                              c                     r
has laggedbehind other areas.                                        stress.Compulsive disordersrelated to                           there was no connection between her
   Researchwith rats has demonstrated                                e a t i n go r g a m b l i n g ,a n d s o m a t i z a t i o n   present physical pain and the emotional
that exposure to inescapable                   shock                 d i s o r d e r s n w h i c h e m o t i o n sa r e
                                                                                     i                                               pain of heryouth. Unfortunately, a
servesto sensitizetheir hippocampi to                                converted into physical symptoms, can                           common occurrencein her chiidhood
subsequentreleases norepinephrine
                               of                                    ail be understood in this way. PTSD,                            w a s t o b e l o c k e di n h e r r o o m b y h e r
under stress(Petty et al., 1994).This                                borderline personaliry disorder, and self-                      f a r h e rb e f o r eh e w o u l d b e g i n t o b e a t
suggests      that after proionged,inescapable                       harm can all reflect complex adaptation                         her mother. She would lie in bed feeiing
s h o c k ,r a t s ( a n d m o s t l i k e l yh u m a n s )          to early trauma (Saxeet al., 1994;van der                       horrified by their screams,her mother's
 r e a c tm o r e s t r o n g l yt o s u b s e q u e n t             Kolk et al., 1996)-                                             c r i e st o J e s s eo h e l p h e r ,a n d r h e l o n g
 stressthat is milder in nature. This                                                                                                ominous silencesthat always followed.
 neurobiological shift results in small                               I A m N o tC r a z y !                                            lesseremembered that shewould
 stressorsbeing experienced as more                                     ]essewas referred to me by her                               pound on the door and yeii to get her
 extreme.Petty and his colleaguessuggest                              neurologist after months of extensive                          father's attention. As she grew older,
 that this may help io explain the coping                             medical and neurodiagnostictesting.Her                         however, she gave up her outward
 difficulties seen in victims of PTSD when                            team ofdoctors could find no physical                          protests and instead lay in bed crying and
 confronted with mild to moderate stress                                        f
                                                                      c a u s e so r t h e d e b i l i t a t i n gp a i n s h e      clutching her head. Jesse said that she
 (Petty et al., 1994).                                                experienced in her head and throughout                         found herself driving her nails into her
    Dissociation aliows the traumatized                               her upper body. Alternative forms of                           head and shoulders, drawing blood, and
 indjvidual to escapethe trauma via a                                 treatment,such as chiropractic and                             eventually scarring herself. Sheshowed
 number of biological and psychological                               acupuncture, were also tried without                           me some of the scarsshe still carried. In
          Increased Ieveisof endogenous
 processes.                                                           symptomatic relief. Jesse  came to seeme                       listening to theseterrible reminiscences,
 opioids create a senseofwell-being                                   on the insistence ofher husband, and                           i felt that her pain symptoms might well
 and a decreasein explicit processing                                 she was not the least bit happy about                          be implicit somatic memories of these
 of overwhelming traumatic situations.                                it. Sitting opposite me with her arms                          experiences.   The stresses her present
 Psychological processessuch as                                       crossed and her jaw set, she glared at me                      life, including the fact that her own
 derealization and depersonalisation                                  and said, am not crazyl'                                       daughter was reaching the ageshe had
 allow the victim to either avoid the                                    Life had been going well for Jesse.                         been when she first became aware of the
 reality of his or her situation or watch                             She had a solid marriage and a happy                           beatings, could all serve as triggers for
 it as an observer. These processes                                   a nd healthy four-year-old daughter.                           these memories. From a psychological
 provide the experience ofleaving the                                 She found her work as an executivein                           perspective, her pain could be seen as
 bodS travelling to other worlds, or                                  a small computer firm interesting, and                         a form ofloyalty or connection to her
 immersing oneself into other objects                                 she liked her colleagueswho told her                           mother through suffering.
  in the environment. Hyperarousal and                                that they appreciatedher contributions                              I decided not to share these
  dissociation in childhood establish an                              to the business.Approximately a year                            interpretations becauseof |esset
  inner biopsychologicalenvironment                                   earlier, she had started to develop pain                        resistanceto the possiblepsychological
  primed to establishboundaries between                               in her head,hands, arms, and back, and                          origins ofher pain. Instead, I continued
  different emotional statesand experiences                           began a fruitless search for a medical                          to encourage       her to talk about her
  f o r a l i f e t i m e .l f i t i s t o o p a i n f u l t o        expianation.The pain becamethe center                           childhood in as much detail as she could
  experience the worid from inside one's                              ofher attention as her interest and abiiity                     tolerate. She also told me of her mother's
  body, seif-identity can become organized                            in being an executive, friend, wife,                            prolonged battle with cancer when ]esse
  outside the physicai self.                                          and mother gradually diminished. By                             was a teenager,and how she nursed her
       Early traumatic experiences                                    the time she came for therapy, she had                          through the final months. In my work
  determine biochemical levelsand                                     been spending most of her days taking                           with Jesse, avoided any talk ofher
  neuroanatomical networking, thus                                                        ,              a
                                                                      m e d i c a t i o n s n e a k i n g w a yf o r n a p s ,        physical pain and continued to refocus
  impacting experience and adaptation                                 and withdrawing to her room whenever                            her on sharing childhood experiences
  throughout development. The tendency                                she could find an excuse.There was no                           with me.
  to dissociate nd disconnecvarious
                         a                            t               ionger any fun or relaxation in her life,                           In the processofrepeatedlysharing
  tracks ofprocessing creates bias toward           a                 and her husband had become seriously                            stories from her childhood, her
  r rn i n t e g r a t e d n f o r m a t i o n p r o c e s s i n g
                           i                                          concerned-                                                      memories becameincreasingly                      more
  acrossconsciousawareness,                         sensation,           We were slow in developing a                                 detailedand her emotions more available
  affect, and behavior. General dissociative                          therapeutic relationship, given her                             a n d b e t t e rm a t c h e dt o t h e s i t u a t i o n s

  26             PSYCHOTHERAPY                 lN AUSTRALIA            o   VOL ll      NO 3 MAY 2005
 shedescribedJcsse xpressed er rage
                                 h                              retention whereashigh dosesimpair                         trauma overwl-relningthe defenses,  we
 at her father for his violent behavior                         retention (Introini-Collison & McGaugh,                   can also think in terms of an intense
 and she was ableto realizethat she was                         1987); this supportsYerkesand Dodson's                    activation of subcortical networks
 also angry at her mother for not leaving                       theory that moderate levels of arousal                    serving to inhibit the parriciparion of the
 him when Jessewas young. As she went                           enhance memory whereashigh levels                         hippocampus and cortex in the memory
 through thesememoriesand put them                              impair memory. In a study by Cahill
 into the perspective ofher current life,                       and his colleagues(Cahill, prins, Weber,                       Traumatic experiencecan clisruptthe
 Jesse was gradually able to feel that she                      & McGaugh, 1994),subjectswere read                        storage(encoding) of information and
                                                                                                                          t h e i n t e g r a t i o no f t h e v a r i o u ss y s t e m s
      S o m e o ns u f f e r i n gr o r np T S Di s , i n e s s e n c en a
                 e               f                                    i,                                                  of attention and memory (Vasterling,
                                                                                                                          Brailey,Constans,& Sutker, 1998;
      c o n t i n u a o o po f u n c o n s c i o u s l f - t r a u m a t i z a t i o n ,
                                                 se                                                                       Yehuda et ai., 1995;Zeitlin & McNally,
                                                                                                                          199I). Memory encoding for conscious
      c o p i n g ,n de x h a u s t i o n .
                 a                                                                                                        explicit memory can be disruptedwhen
                                                                                                                          the hippocampus is blocked or damaged
                                                                                                                          by glucocorticoids or is inhibited by
could connect with her mother through                           emotionally evocative and neutral                         heightened amygdala functioning. This
happinessinsreadofjoining her in                                stories and shown relatedslides.Half                      c o u l d l e a dt o a l a c k o f c o n s c i o u s e m o r y
suffering.                                                      ofthe subjects were given propranolol                     for traumatic and highly emotional
   We both came to notice that the                              (a drug that decreasesthe effects ofthe                   events(Adamec, 199]; Schacter,
intensity of her pain and the time                              NE) and the others were not. Results                      l986; Squire & Zola-Morgan, l99l).
she spent focusing on it gradually                              demonstrated that subjectswho received                    Memory integration can be impaired by
diminished. Toward the end of our last                          propranoloi had significantly impaired                    disruption of the cortico-hippocampal
session,she thanked me for helping                             memory for the emotion-arousing stories                    tracks dedicated to the integration of
her and said that although she didn,t                          but not lor the neutral stories.                           new memoriesinto existing memory
understand how or why, her physical                               Activation of the amygdala (and the                     networks. Remember that these systems
and emotional pain did seem to be                              related physiological and biological                       also provide contextualization in time
connected. Our unspoken agreement                              changes) is at the heart of the modulation                 and space,and integration ofsensory,
was that I wasn't allowed to be the one to                     o f e m o t i o n a l a n d t r a u m a t i cm e m o r y   affective, and behavioural memory with
suggest this possibility. Iessewinked at                       (Cahill & McGaugh, t99B). The release
                                                                                                                          conscious awareness.
me and said,'You are a tricky                                  of norepinephrine
                                                               during the stress
Traumatic emory
        M                                                      resPonseserves
   It has long been recognizedthat                             to heighten the
moderate amounts of stressenhance                              activation ofthe
Iearning and memory by increasing                              amygdala, thus
vigilance and heightening attention,                           reinforcing and
whereas high levelsimpair learning                             intensifying
and memory (Yerkes& Dodson, l90g).                             memories for
Trauma is a state of high arousal that                         traumatic events
impairs integration acrossmany domains                         (McGaugh, 1990).
of learning and memory. The neural                              Individuals with
networks in the limbic system and cortex                        PTSD have had their
involved in memory are influenced by                            amygdaloid memory
several systemsofascending fibres that                         systems imprinted
modulate arousal(Squire, l9B7). In this                        with trauma at such
way, stressful, threatening, and traumatic                     an extreme level
memories are emphasizedbased on                                that their memories
instinctual and learned appraisal of their                     are resistant to
dangerousness.           Eachof thesesystems                   cortical integration
has its own neurotransmitters, which                           (van der Kolk et
have different effectson the encoding                          al., i996). Extreme
and storage of memory. We have already                         trauma resultsin the
discussedNE, serotonin,dopamine,                               inhibition of neural
glucocorticoids,and endogenousopioids,
a l l o f w h i c h i m p a c tm e m o r y p r o c e s s eis
                                                               networks (cortico-
                                                               hippocampal) that
different ways.                                                could contextualize                                                                    rfl
     When NE is administered to rats after                     and attenuatethem-
an aversiveevent, low dosesenhance                             When we think of

                                                                                  PSYCHOTHERApy            tN AUSTRALTA o         VOL ||       NO    i     MAy 2005               27
   Thus, altl-roughwe may have verY                                        Bremner, Southwick, & Charney, 1998).                             These findings suggestactiveinhibition
accurate physiologicaland emotional                                        The lack of cortical-hippocampai                                              c      d
                                                                                                                                             of language enters uring trauma.
memories for a traumatic event,the                                         involvement resultsin an absenceof                                Basedon these results,speechless   terror
factual information may be quite                                           the localization f thc memory in time,
                                                                                             o                                               - often reported by victims of trauma
inaccurate given the inhibition of                                         so when it is triggeredt is experienced
                                                                                                  i                                          - may have neurobiological correlates
cortico-hippocampal involvement                                            as occurring in the present (Siegel,                              consistent with what we know about
during the trauma. Add to this the                                                        are also repetitive and
                                                                           1995).Flashbacks                                                  brain architecture and brain-behavior
tendency of the left-hemisphere                                            stereotypic,often seeming to proceed at                           relationships.This inhibitory effecton
i n t e r p r e t e rt o c o n f a b u a t ea s t o r y i n t h e
                                     l                                     the pacein which the eventsoriginally                             Broca'sareawill impair the encoding
absenceof accurateinformation, and we                                      occurred. This suggests              that although                of conscious memory for traumatic
may have when represents underlying         the                            the cortex may condenseand abbreviate                             eventsat the time they occur. it will then
mechanisms of the malleability of                                          m e m o r i e si n n a r r a l i v ea n d s y m b o l i c         naturally interfere with the deveiopment
memory-                                                                    form, these subcortical networks may                              ofnarratives that serve to processthe
                                                                           store memories in more concrete,                                  experienceand lead to neural network
                 F               s
T r a u m a t i c t a s h b a c ka n d                                     stimulus-response chains of sensations,                           integration and psychological healing,
5peech[ess error  T                                                        behaviours,and emotions.                                          Activating Broca's area and left cortical
    Flashbacks are commonly reported                                         ln flashbacks,the amygdala-                                     networks of explicit episodic memory
b y i n d i v i d u a l sw h o h a v ee x p e r i e n c e d                mediated fear networks (primarily in                              may be essential in psychotherapywith
trauma. They are described full-body      as                               the right hemisphere)are activated.The                            patients suffering from PTSD and other
 experiencesof aspects the traumatic
                       of                                                  amygdala'sdense connectivity with the                             anxiety-basedd isorders.
 event, including physioiogical
                              arousal                                      v i s u a l s y s t e mm o s t l i k e l y a c c o u n t sf o r
 and sensory stimulation. In a sense,the                                   the presence visual hallucinations
                                                                                       of                                                    ActivatingBroca's
                                                                                                                                                             Area Duringa
 victim ofa flashbackis transported back                                   d u r i n g f l a s h b a c k s .h i s i s c o m p a r e d
                                                                                                         T                                   Fl.ashback
 i n t i m e t o t h e t r a u m a t i ce x p e r i e n c e .              with the hallucinations in schizophrenia                            jan, seeingme for a one-time
                   a                     t
 F l a s h b a c k s r es o i n t e n s e h a t t h e y                    that involve the temporal lobes and are                           consultation, reported that she had
 overwhelm the reaiity constraints of                                      usually auditory in nature. Bereaved                              suffered from severephysical and sexual
 the contemporary situation and send                                       individuals often report seeing their                             abuse from early childhood into her late
 the victim into an all-too-familiar and                                   loved ones sitting in their favourite chair                       teens. She told me over the phone that
 recurrent nightmare.                                                      or walking acrossthe room in some                                 she was having flashbacks of increasing
    The power of traumatic flashbacks                                      familiar way. Those who have been                                 frequency in recent years; it had gotten
 was driven home for me one day in                                          attacked will sometimes think they see                           to the point where she was having three
 a therapy sessionwith a professional                                       their attacker out ofthe corner oftheir                          or four a day. Although her therapist had
 football player who stood nearly twice                                     eye. These emotionally charged visual                            encouraged her to expressthem as much
 my size. When recailing his early abuse,                                   hallucinations and illusions most likely                         as possible, Jan felt like she was getting
 he began to cry softly ashe spoke of one                                   reside in these amygdala-mediated                                worse instead ofbetter. Expressingher
 particularly painful experiencefrom                                        sysrems.                                                         feelings only triggered more frequent
 childhood. He describedin agonizing                                           Rauch and colleagues(i996) expiored                           and intense flashbacks.She reported
 detail his small body growing limp after                                   the neurobiology of intense fear using                           becoming less and lessfunctional,
 repeated blows from his father's fists.                                    patients with PTSD. They took eight                              which made her decide that she needed a
 This explicit memory cued an implicit                                      patients suffering from PTSD and                                 different approach to therapy.
 memory, a flashback;suddenly,he was                                        exposed them to two audiotapes: One                                   Jan arrived at my office with a stack
  standing over me and breathing heavily.                                   was emotionally neutral and the other                             of diaries and The Wall Street journal
  Despite my alarm, I managed to sit                                        was a script of a traumatic experience.                           under her arm. It was hard to beiieve that
  quietly, eventually asking him what he                                    While they were listening to these tapes,                         this was the same person I had spoken to
  w a s f e e l i n g . h i l e l o o k i n gi n t o m y e y e s            measuresof patients' heart rates and                              over the phone. My first thought was that
  he asked me in a child's voice to please                                  regional cerebral blood flow (RCBF)                               dissociation is an amazing defense.                  Jan
  not hurt him anymore. His fear of me in                                   were measured via PET scans. RCBF                                 was a well-dressed woman in her mid-
  contrast to our relative sizeswas a stark                                 was greater during traumatic audiotapes                           40s who was obviously bright and had a
  d e m o n s t r a t i o no f p r i m i t i v em e m o r y                 in right-sidedstructures including the                            good deal ofself-insight. The childhood
  systems overriding normal conscious                                       amygdala, orbitofrontal cortex, insular,                          experiencesshe recounted in my office
  processing.                                                               anterior and medial temporal lobe, and                            were horrendous, and I marvelled at her
       T r a u m a t i c f l a s h b a c ka r em e m o r i e s              the anterior cingulate cortex. These are                          very survival. Her intelligence and sheer
  ofa quite different nature than are those                                 the areasthought to be involved with                              will to live were remarkable. It seemed
  of nontraumatic events.To begin with,                                     intenseemotion.                                                   obvious,however,that her repeated                     re-
  t h e y a r e s t o r e di n m o r e p r i m i t i v e c i r c u i t s       An extremelyinterestingand                                     e x p e r i e n c i n g I t h e s em e m o r i e s a s n o t
                                                                                                                                                                    o                           w
  with less cortical and left-hemisphere                                    potentially important clinical fi nding                           helping. The nature of these memories
  involvement. Becauseof this, they are                                     was a decrease RCBF in Broca's
                                                                                             in                                               was not changing over time, nor were
  strongly somatic, sensory,                  and emotional,                area (ieft inferior frontal and middle                            the emotions evoked by her memories
  as well as inherently nonverbal (Krystal,                                 temporal cortex;Rauch et al., 1996).                              diminishing. In this case,they seemed

  2B               PSYCHOTHERAPY lN AUSTRALIA                                r   VOL ll      NO 3 MAY 2005
to retraumatize her eachtime she                                         At the end ofthe session    she thanked                         words, this processresuitsin a memory
experiencedthem.                                                       me and left; I didn't hear from her a                             c o n f i g u r a t i o nh a t i s n o l o n g e r ' i m p l i c i r
    Shebegan by talking about her work,                                number of months. When she called                                 only' but insteadbecomesintegrated
and then described the psychotherapy                                   one afternoon, she reported that since                            with the contextualizing properties of
and other forms of treatment in which                                  her visit with me, the nature of these                            explicit systemsof memory (Siegel,  1995).
s h e h a d e n g a g e d A p p r o x i m a t e l y1 0                 flashbackshad changed.She said she                                  The speechiess   terror, which has been
minutes into the session, she was
                        as                                             had wanted to wait before she cal]ed me                           recognizedas part of post-traumatic
discussingthe family memberswho had                                    becauseshe didn't expectthat the change                           reactionssince ancient times, now has a
abusedher, she began to have one ofthe                                 she experiencedafter our sessionwould                             neural correlate consistent with what is
flashbacksshe had describedover the                                    l a s t . G i v e n h e r d o z e n - p l u s e a r si n a
                                                                                                                   y                     known about brain functions. Why does
p h o n e . J a n r e p o r t e d p a i n i n v a r i o u sp a r t s   v a r i e t yo I u n h e l p f u lt r e a t m e n t s , t w a s
                                                                                                                             i           Broca'sareabecome inhibited during
of her body and contorted as if what she                               easy to be sympathetic to her negative                            trauma? Why would evolution select
w a s d e s c r i b i n g a s h a p p e n i n gt o h e r a t           expectations.Jan describedthat since our                          silencein times of crisis?Perhaps   when
this very moment. After 20 seconds,                        she         session,       the flashbacks         had changed in a            one is threatenedit is better to either
began to gag as a part of the memory of                                number of ways. She began by saying that                          run or fight or simply keep quiet and
the sexual abuse she experienced                       decades         they were lessphysicallyintense, thar the                         hope to stay undetected-In other words,
e a r l i e r . h ew a s r e - e x p e r i e n c i n t h e s e
              S                                      g                 b o d i l y s e n s a t i o n w e r en o t a s s t r o n g a s
                                                                                                     s                                   evolution has taught the brain to 'Shut up
p a i n f u l e p i s o d e s o t o n l y a sp i c t u r e s
                            n                                          before. Along with this, they were also less                      a n d d o s o m e t h i n g l 'w h e n i n d a n g e r T h e
 i n h e r m i n d , b u t a s s o m a t i cm e m o r i e s            frequent; on a few occasionsshe had even                          freezingreaction of animajs (being still
throughout her body.                                                   b e e n a b l et o s t o p o n e t h a t w a s c o m i n g o n    and quiet when they sensea predator)
     As she curled into the foetal position                            by thinking of her version of my words                            allows them to be lessvisible (becausea
 on the couch and gaspedfor breath,                                                        'This
                                                                       during the session:       is just a memory,                       still and silent rarget is more difficult to
 my mind raced trying to think of some                                 you are safenow, no one can hurt you'.                            spot). Spokenlanguageis fundamentally
 way to help. Remembering the research                                    Perhaps most interesting was the fact                          'sound'
                                                                                                                                                  t h a t p r i m i t i v e f e a rc i r c u i t r y
 done by Rauch and his coileagues,I                                    that during these flashbacksshe was                               has selectedto silence. Perhapsthose
 thought that I should somehow try and                                 now able to remember that she was not                             eariy prehumans who hung around
 activate Broca's area. I began to speak                               a child, that she was not to blame, and                           for conversation and negotiation with
 to Jan in a firm but gentle voice, loud                               it was those who were hurting her who                             predators didn't fare well enough to pass
 enough to reach her in the midst of                                   were bad. These thoughts were the sorts                           down as many genesas did those who
 her traumatic re-enactment but not so                                 of things her other therapists had told                           either kept quiet, fought, or ran away.
 Ioud as to frighten her and add to her                                her in the past, but only recently could
 trauma. I wondered if it mattered which                               she process them during her flashbacks.                           TheAddiction StressandSetf-
 ear I spoke into, wondering which ear                                 I told her that I felt thesewere signs that                       Harm
 has a more direct connection to the left                              the experienceswere beginning to be                                  Another phenomenon with a possibie
 hemisphere language centers.I moved                                   connected to her conscious adult self,                            biochemical mechanism is an addiction
 closer to her (careful not to get too close)                          and that now she was able to fight and                            to stressexperienced some patients
 and repeated over and over,'This is a                                 care for herselfeven in the face ofher                            with PTSD. They report that they feel
 memory, it isn't happening now. You are                               past. I encouragedher to keep talking                             calm and competent in life-threatening
 rem embering som ething that happened                                 throughout the fl ashbackexperiences                              situations but find it difficult to cope
 to you many years ago. It was a terrible                              and bring with her as much assertiveness,                         with normal day-to-day life. A large
 experiencebut it is oyer.It is a memory, it                           anger, and power as she could muster.                             portion of the initial work with these
 is not happening now'.                                                After a few minutes, we ended our                                 patients is designed to help them both
    As I repeated these and similar                                    conversation and I sat back thinking that                         decrease  the creation ofstress and,
 statements,I was concerned that Jan                                   neuroscience could actually be applied to                         paradoxically, tolerate the anxiety related
 would be unable to breathe or that my                                 psychotherapy.                                                    to the absenceofstress. They need to
 presencemight cause her more fear. The                                     It is impossible for me to know with                         learn how to function in a nontraumatic
 words of one of my supervisors flashed                                any certainty whether what I had done                             state.This can usually be accomplished
 through my mind               you do,                                 w i t h J a n d u r i n g o u r o n e m e e t i n gh a d          through some combination of stress-
 don't panic'. I was also encouragedby                                 a n y t h i n g t o d o w i t h t h e c h a n g e sn i            reduction techniques, medication, and
 the fact that she had survived this many                              h e r f l a s h b a c k s f i t d i d , p e r h a p sr h e
                                                                                               l.                                        psychotherapy.
 times. After 10 minutes (which seemed                                 active ingredient was the simultaneous                               These phenomena point to the
 to me like 10 hours), she appeared  to                                activation of the left-hemisphere verbal                          possibility that extreme and prolonged
 calm down and return to the present. Jan                              areasalong with the emotional centers                                   -
                                                                                                                                         stress significantenough to result in a
 reported that she heard me speakingas if                              of the right hemisphere and limbic                                chronic PTSD reaction- may motivate
 I were far awan but focused on my voice                               structures that stored the flashbacks.                            the creation of new trauma. The new
 and words as best she could. It was as if I                           Being simultaneously aware of inner                               trauma would, in turn, stimulate the
 were there in the past with her, calling to                           a n d o u t e r w o r l d sm a y s u p p o r ta h i g h e r       production of endogenous  opioids that
 her from a safe future where she would                                level ofcortical functioning, resulting in                        would lead to an increasedsense of
 be away from these people who hurt her.                               increased network integration. In other                           well-being.A so-called'normal' life

 3o              PSYCHOTHERAPY                 IN AUSTRALIA             o   V O L I I N O 3 M A Y 2 O O 5
 leavestraumatized persons a blank                                self-harm decreasewhen peoplewho                               their transference  and other projective
 screen onto which their dysregulated                             engagein this behavior are given a drug                        processesfrom reality. 'fhese are ail
 psychescan project fearful experiences,                          to block the effects of these endogenous                       reflectionsoflow ego strength. Despite
 leaving patientssuch as these in a state                         opioids (Pitman et al., 1990;van der                           Freud's best efforts to filter out these
 ofconstant vigilance,arousal, and fear                           Koik, i98B). Abstracting from the animal                       people,everyso often he got a surprise!
 (Fish-Murry, Koby, & van der Kolk,                               model, this would suggest rhat rhe srate                       People who appeared to be average
 1987).Trauma and stressas coping                                 ofdistress activatedby the experience of                       neurotics seemedto becomepsychotic
 strategies provide them with a shift                             abandonment is reversed the release
                                                                                           via                                   i n t h e c o n t e x to f t h e t h e r a p e u r i c
 from being anxious and wary to being                            of endorphins causedby the injury. The                          relationship. Freud came to refer to these
 calm and competent.Becausethese                                 anaigesic effects of these morphine-like                        p e o p l ea s h a v i n gp s y c h i cs t r u c t ur e so n
 individuals are so physicaliy worn down                         substancesmay account for the reports                           the borderline between neurotic and
 by this lifestyle, they often present with                      ofreduced anxiety. People who engage                            psychotic.
 depression, exhaustion, and a variety                           in self-harm report a sense ofcalm                                 Over the years,the conception ofa
 of medical conditions.It is as if they                          and reliefafter cutting, burning, or                            borderline psychic structure evolved.
 have a drug addiction, except that it is                        hurting themselves.These self-injurious                         into what is now called a borderline
 completely unconscious and they are                             behaviours maybe a form of impiicit                             personaiitydisorder (BpD). As we have
 their own pharmacy.                                             memory that is reinforced, in part, by the                      already seen,BPD may represent one
    At a biochemical level, endogenous                           endogenous opioid system.                                       variant of complex pTSD. The strongest
 opioids (eg.,the endorphins discussed                              Repeated suicide attempts are often                          evidence for this concept is the frequent
 in the neurochemistryof bonding and                             reinforced by the rapid attention of                           occurrenceofearly abuse,trauma, and
 trauma) also appearto be involved in                            health care professionals,family, and                          the use of dissociativesymptoms in these
 severecases ofself-harm and suicide                             friends. When woven into the personality                       individuals. Patients who carry this
 (van der Kolk, l98B). This same chemical                        as a means of affect regulation, this                          diagnosis are characterized by:
system mediates the distress calls of baby                       attention-getting behavior results in                            1. HypersensitivitF to real or imagined
primates and mothers' response to these                          a kind of characterological suicidality                        abandonment.
calls. Infants become distressed when                            (Schwartz, 1979). This behavior parallels
                                                                                                                                     2. Disturbances of self_identity.
their mothers are absent, and are soothed                        the distress calls of primates whose                                3. Intense and unstable relationships.
and calmed upon their mother's return.                           endorphin levels drop in the absence                              4. Alternating idealization and
The return of the mother is correlated                           of the mother. The ieappearance                                devaluation of themselvesand others
with the releaseof endorphins creating                           of the mother results in a raising of                          (black-and-white thinking).
the senseof well-being. Endorphins                               these endorphin levels and the infant                              5. Compulsive, risky, and sometimes
are also releasedafter injury to provide                         discontinues its cry. Characterological                        self-damaging behaviours.
analgesia pain, allowing us to
           for                                                   suicidality can serve a similar bio-                              Although rhere are a number of
continue fighting or escaping (pitman et                         chemical regulatory purpose if this                            theories concerning its cause,many
al., 1990).This sysrem,originally used                           system was inadequately formed during                          feel that the etiology of BpD stems
to cope with pain, was adapted by later-                         childhood. Although there are many                             from problems in early life related
evolving networks of attachment and                             sound psychological explanations for                            to bonding, attachment, and a sense
bonding.                                                        the relationship of childhood abusewith                         ofsafety. Researchalso suggeststhat
   The addiction to stresshas a related                         self-harm and suicidality in adulthood,                         affective disorders in these patients and
but more severevariant: self-mutilation                         the process may have a biochemical                              their parents occurs above chance levels.
and other forms of self-harm. Adults                            mechanism that could benefit from                              Overall, both their reported history
who engagein repeatedself-harm                                  pharmacological interventions designed                         and their symptoms suggestthat early
almost always describe childhoods that                          to block the impact of endogenous                              attachment was experienced as highly
included abuse,neglect, or a deep sense                         endorphins.                                                    traumatic, emotionally dysregulating,
of shame.This correlationhas led many
                                                                                                                               and possiblylife threatening.
theorists to explore the psychodynamic                          The Brain and Bordertine                                          In my work with thesepatients, I have
significance ofself-harm as a continued                         Personatity isorder
                                                                          D                                                    always felt that they may provide us with
involvementwith destruclive parents.                                 According to Freud, participation in                      a window to the intense and chaotic
Suicide has been described as the final                         analysis requires sufficient ego strength                      experience ofinfancy. As we have seen
act of compliance ith the parents'
                              w                                 to withstand the stressof therapy while                        (and this is where our neuroscientific
unconscious wish for the death of the                           s i m u l t a n e o u s l y a i n t ai n i n g c o n t a c t
                                                                                          m                                    knowledge comes in handy), the
c h i l d ( G r e e n ,l 9 7 B ) .T h e a s s o c i a t i o n   with reality. Based on this assumption,                        amygdala is highly functional at birth.
between self-harm and disorders of                              Freud did his best ro make sure that his                       Rememberthat the amygdalais at the
attachment has been noted and primarily                         prospective clients were not psychotic.                        center ofneural networks involving both
explained through psychological models.                         Psychotic individuals are characterized                        fear and attachment.The hippocampal
    Self-injurious behaviours in humans                         by severedistortions ofreality,                                a n d c o r t i c a ln e r w o r k s h a t e v e n t u a l l y
are often responses real or imagined
                               to                               disordersin their thinking processes,                          organizeand inhibit the amygdala grow
abandonment and ioss.Researchhas                                and decompensationunder stress-                                graduallyrhrough childhood. Because
d e m o n s t r a t e dh a t t h e f r e n u e n c vn f
                        t                                       They are also unable to differentiate                          of this developmental              timetable and the

                                                                                      PSYCHOTHERAPY IN AI]STRALIA                     O VOL I I NO          3 MAY 2OO5                    31
 prolonged dependenceon others for                                        . The networks ofthe social
                                                                                                      brain are                      an external neural circuit to aid in the
 survival, relationships must sometimes                                 unable to internaliseimages from early                       integration of networks left unintegrated
 be as overwhelmingly frightening to                                    interactionswith caretakersto provide                        during development.
 infants as they are to patientswith BpD.                               self-soothingand affect regulation.
       The symptoms thal emergen                    i                     . Rapid fluctuationsbetween
                                                                                                                                     N e u r a IN e t w o r kI n t e g r a t i o n
 t h i s d i s o r d e r c a u s ep a t i e n t s o c r e a t e
                                                 t                      sympathetic and parasympathetic                                  Unresolved trauma results in
 problematic and chaotic relationships                                  sratesresult in baselineirritability anrl                    information-proccssit)gdcficits that
 that can lead them through a lifetime of                               sympathetic survival responsesto real or                     disrupt integratedneural processing.
 s e r i a l a b an d o n m e n t s .J t i s e v e nc o r n m o n       rmagined abandonment.                                        In fact, the experienceofdissociative
 for therapists to abandon thesepatients                                  . Chronic high levels of
                                                                                                   stress                            symptoms immediately after a trauma
 becauseoftheir intensecriticism and                                    hormones compromise hippocampal                              is predictive of the later developmentof
 hostility. I find rhat rememberingthat                                 functioning, decreasing  the brain's                         PTSD (Koopman et al., 1994;McFarlane
 such patients are essentially                frightened                ability to control amygdala functioning                      & Y e h u d a ,1 9 9 6 ) .C o n s c i o u s w a r e n e si s
 c h i l d r e n h e l p s m e t o m a i n t a i na                     and exacerbating emotional dyscontrol.                       split from emotional, and physiological
 therapeutic posture. Their primitive                                     . Amygdaloid dyscontroi
                                                                                                     heightens                       processing. Iack ofintegration of
 fear, rage, and shame are a form of                                    the impact of early memory on adult                          right- and left-hemisphere functions
 impiicit posttraumatic memory from a                                   functioning, increasing the contemporary                     subsequentto stressmay also disrupt
 very early stage of development that are                               impact of early bonding failures-                            processes interpersonal bonding
 activated by real or imagined criticism                                  . Hippocampal compromise
                                                                                                         decreases                  and bodily regulation (Flenry, Satz,&
 or abandonment. When thesememory                                       reality testing and memory functioning,                     Sasloq 1934).Children victimized by
 networks become activated in treatment,                                contributing to the inability to maintain                   psychoiogical, physical, and sexual abuse
 they are so primitive and powerful that                                positive or soothing memories during                        have been shown to have a significantly
 the patient is unable to maintain contact                              statesofhigh arousal.                                       greater probability of demonstrating
 with reality. We also seethat the patient                                . Early bonding failures
                                                                                                   lead to lower                    brainwave abnormalities in the left
 is unable to maintain contactwith realiry.                             levels ofserotonin, resulting in greater                    frontal and temporal regions (Ito et al.,
 We also see the same phenomenain                                       risk of depression,irritability, and                        1993). Brainr,vavedyscoherencemay
 PTSD flashbacks, most likeiy stored in                                 decreasedpositive reinforcement from                        put individuals at higher risk for the
 the same implicit memory systems.This                                  interpersonal interactions.                                 development of ali forms of psychiatric
 confused Freud, becausehe believedthat                                   . Self-harm during dysregulated
                                                                                                            states                  disorders (Teicher et al., 1997).
 everyone was either neurotic or psychotic.                             results in endorphin releaseand a sense                        The biochemical changesthat occur
 Here was a horse of a different colour;                                of calm, putting these individuals at risk                  secondary to trauma enhance primitive
 primitive and highly complex pTSD.                                     for repeated self-abusivebehavior.                          (subcorticai) stimulus-response pairing
    Examining BPD in light of the                                          These are just some of the factors that                  of conditioned responsesrelated to
 neuroscience we have reviewed in                                       may be involved in the neurobiology of                      sensation,emotion, and behavior,
 previous chapters, here are a few ofthe                                BPD. Becausethis diagnosis has so far                       These same changes undermine corticaj
  neurobiological processes             that may be                     been outside the purview of neurology,                      systemsdedicated to the integration of
 involved in how these symptoms become                                  little brain researchhas been done                          learning acrosssystems of memory into a
  encoded within neural networks:                                       with BPD patients. Neuropsychological                       coherent and conscious narrative (Siegel,
     . Amygdaloithremory systems
                                                   are                  findings with thesepatients, however,                        I996). As we understand more about the
 traumatically primed during early                                      does suggestdysfunction in the fronral                      neurobiological processesunderlying
 attachment experiences to react to any                                 and temporal lobes (Paris, Zelkowitz,                       PTSD, we will better learn how to treat
 possible indication of abandonment by                               Guzder,loseph,& Feldman, 1999;                                 and possibly prevent this debilitating yet
 triggerin g sympathetic fi ghr or-fl ight                           Swirsky-Sacchettiet al. 1993). Executive                       curable mental illness.
 reaction and raising baselinelevels of                              and memory functions within these                                 Therapiesofalt kinds, especially
 norepinephrine and stresshormones.                                 brain networks do not provide adequate                          those within the cognitive schools,have
     . Orbitofrontal systemsare
                                                                    organization for thesepatients- We                              proven successfulin the reintegration of
 inadequately developed during                                      h a v el e a r n e dt h a t t h e s ef u n c t i o n s a r e   neural processing subsequentto trauma.
 attachment to engagein healthy self-                               built and sculpted in the context of                           Systematicdesensitisation, exposure,
soothing and the inhibition of fear                                 early relationships; it makes sense rhat                       and responseprevention can all enhance
activation by circuits of the amygdala-                             they are impaired in BPD patients. The                         theseintegrative processes.Recognition
    . Orbitofrontal systemsdevelop
                                                                    central concept in the treatment of these                      ofthe risks to neural network integration
separate tracks ofpositive and negative                             individuals is structure and Iimit setting,                    posed by overwhelming stressand
experiencesthat are neverintegrated.                                combined with flexibility and patience                         trauma has resulted in the development
    . Orbitofrontal dissociation may                                (just as it is with raising chiidren). The
                                                     result                                                                        of some newer treatments such as critical
in disconnection between right- and left-                           therapist must provide an external                             incident stressdebriefing (CISD; Mitchell
h e m i s p h e r ea n d t o p - d o w n p r o c e s s i n g ,      scaffolding within which the client can                        & Everly,1993).Using our presentmodel,
partly accounting for rapid and radical                             rebuild these brain networks of memory,                        CISD may help to prevent pTSD by
shifts between positive and negative                                self-organization, and affect regulation.                      e n h a n c i n g h e i n t e r c o n n e c t i o na l n o n g
                                                                                                                                                    t                                 s
appraisalsof relationships.                                         On another level,the therapist servesas                        neural networks - at risk for dissociation

32             PSYCHOTHERAPY                 IN AUSTRALIA           I     VOL   I I NO 3 MAY 2O05
                                                                      A n i s m a n ,H . ( 1 9 7 8 ) .N e u r o c h e m i c a l
      - soonafter trauma                                                                                                                  D e B e l l i s ,M . D . , B a u m ,
                                                                      c n a n g e s e l i c t i e db y s t r e s s :                                                            A.S.,
           CISD moves through phases                                  b e n a v i o u r a lc i r r e l a t e s .                          Birnmaher, ., Kesnavan,
                                             of                                                                In H.                                                               M.S.,
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                                                                      ,:l:., o          r.. urir osy oi "r" i I i "" t                   , ^ " : o , J = : f & R y a nN . D .
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                                         both                         m o t i v a tl, d1b e h a v f o u r ( O n .
                                                                                    e                                     v                                ]t
                                                                                                                                         4 . t r . b e n n e, t r e s e a r c h
     psychoeducationto enhance                                                                                    f f S_lZf;                                                    award.
                                          an                          New      york: plenum.                                             D e v e l o p m e n t atlr a u m a t o l o g y .p a r t
     understanding of the body,s                                                                                                         B i o l o g i c as t r e s s s y s t e m
                                                                                                                                                           l                                     i:
                                         reaction                                                                                                                                ,. E.iotogiiui
     to stressand group processto                                     B r e m n e r J . D . ,S c o t t , T . M . ,                       Psych iatry, 4 S ( 10 L25g-t2j
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     in the onrex,
           c    "r,"0;::,":ili:'""..r, "1,                                                                                              Part II: Brain devel
                                                                                                                                        psy hiatry,4s(1o                n,,,,               "
                                                                                                                                          c             ),'r\Tf_i\u2!,
     understanding fthe entire
                    o            p r o c e s sT h i s
                                              .                     P-r"Tn"r, t.D., Southwick,S.
                                                                    M , . ,J o h n s o n , D . R . , y e h u d a ,
     rs a new treatment modality                                                                                   R., &
                                 for pTSD,                          Charney, D.S. (1993). ChitdhooJ                                    F i e l d ,T . M . ( I g g 7 ) . T h e
                                                                                                                                                                              treatment of
     and conclusive researchconcerning                              physical abuse and comoat_related                                  o e p r e s s e dm o t h e r s a n d
                                                                                                                                                                               t h e i r i n f a n' " s .
    the efficacy of its timing and                                  posttraumtci stress disorder                                       In L. Murray & p.J.Coope,
                                   varioJs                                                                          in                                                             frOll,
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                                                                                                                                       york: G
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         The brain,s reaction ro rrauma                                                                            Vermetten, ',
                                                                    E., Staib, L., Bronen, n.n.,
                                                                                                                   lluzuiu,-                             8.,
                                                                                                                                       liill:l:I. , :.H9glv, Gordsrein,
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                                             to the general                                                       G , I;;;;           :::n:f
    processesoflearning and plasticity.
                                                        The        l.
                                                                        8 . , & C h a r n e yD . S . ( 1 9 9 7 ) .                    Tjtclinn and synchrony in morher_
                                                                   M a g n e t i c r e s o n a n c ei m a g i n g _ b a s e d         I n f a n t i n t e r a c t i o n so f
    b r a i n d o e si n d e e dc h a n g er n                                                                                                                               nond"p."rr"d
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    to environmental events.This                                                                                                                                             Durulop_"ntut
                                                                                                                       volume         Psychotogy, 26 (1), 7_14.
                                                 helps us          rn posttraumatic stress disorder
    to^understand why the suf.                                     related to childhoodphysical
    ofpsychotherapy is able to alter                                                                                  and                       t.": H-ealy, Gotdstein,
                                                  rieural          =-:1:i'.aqu^se: pretimary
                                                                                A          report,                                   5'ul1                B.,
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                                                    not                                                                              Infants of depressed
   conducive to mental health.                                                                                                                                         mothers
                                              From the                                                                               show'depressed, ehavrour
   first moments of life, stressshapes                            ?l^,1-::_*:y:          Braff,
                                                                                                      r.1.,                          with nondepressed adults
                                                                                                                                                                  b               even
                                                      our         JenKtns,M.A., Sprock, J.,                                                                                   . Child
   brains in ways that lead us to                                                                               & Geyer,             Development, 59, 1569_1579.
                                               remember           M - . A .( 1 9 9 0 ) . p h y s i o l o g i c a l
   experiences most important for                                 of
                                                 survival.           . e x a g g e r a t e ds t a r U e r e s p o n s e i n          Fish-I"lurry, C.C., Koby,
  Most of our learningexperiences                                 subgroup of Vietnam vererans                                                                              8.V., & van
                                                   are not                                                           with            d e r K o l k ,B . A . ( 1 9 8 7 ) .
  traumatic but rather subtle, nondramatic,                       combat-related pTSD. American                                                                           E v o t v i n gi d e a s :
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                                                                 r v r elc n a n i s m s f e m o t i o n a l
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