A Trauma-Based Model of Mental Illness (preliminary thoughts)

Here is another section (still in the process of being written) from the paper I have been working on for a couple of months now - or maybe it will be a monograph, since it keeps getting longer and longer.

This section (much of which is still missing citations) proposes a new model of mental illness that does away with many of the diagnoses we now find in the DSM. Rather, it proposes a trauma-based model that sees symptoms as adaptations to the traumatic experience.

As I said, this is VERY preliminary - just began writing it yesterday. Any feedback is welcome.

A Trauma-Based Model of Mental Illness

It is my belief, based on years of reading the trauma literature and working with sexual trauma clients in therapy, that nearly all the traits we label as mental illness are more accurately understood as adaptations (or clusters of adaptations) to traumatic experience, either interpersonal or "shock."

Interpersonal traumas are those occurring between people in relationship, such as neglect, abuse, bullying, and attachment failures. The younger one is when these traumas occur, the more profound their impact on brain development.

"Shock" traumas are those single frightening events that can seriously disrupt our lives and our basic understanding of the world. These may include natural disasters, accidents, stranger rape, muggings, and other unexpected, unpredictable violent disruptions of our lives.

The greater the severity of the trauma, the more extreme the adaptations a survivor makes to cope with the experience. Early interpersonal trauma tends to be more difficult to treat than shock traumas, unless the person experiencing the shock trauma has also experienced adverse child events. I propose that we can create a spectrum of how these adaptations are generated and how they function, ranging from less extreme to more extreme.

At one end we might have the adaptation cluster often labeled as an adjustment disorder, with anxiety or depression being common expressions. Addictions and other forms of self-numbing behavior would also likely be in the first half of the spectrum.

An issue with some of the adaptations, particularly addictions, is that they generally co-occur with other adaptations. For example, post-traumatic stress disorder (PTSD) often co-occurs with mood symptoms, addictions, or disordered personality structures.

PTSD would be somewhere near the middle, although its manifestation can be mild to severe. Further down the spectrum would be dissociative disorders, the most extreme form of PTSD, with the most extreme adaptation being dissociative identity disorder (DID).

At the far end would be full-blown psychosis, representing a cumulative experience so awful and unbearable that reality become intolerable, necessitating a retreat into an alternate reality often imbued with a sense of importance or specialness, which is even true in paranoid iterations of psychosis.

It's important to keep in mind that when these interpersonal traumas occur during development, they create changes in the way the brain is wired, particularly the right hemisphere, the source of affect regulation, interpersonal skills, and body-mind integration.

Likewise, many of the adaptations noted here will manifest in the brain as shrinkage of one set of circuits or enlargement of another. For example, PTSD can produce an enlarged amygdala and a smaller hippocampus. Prolonged environmental stress also generates excessive levels of cortisol and other stress hormones that can damage brain function and leave the survivor in a near constant state of hypervigilance.

How Trauma Changes the Brain

When confronted with a stressor, a series of events occurs in the body that generates what we now call the “fight or flight response.” This process evolved early in the history of life on Earth to allow organisms to act in a situation where their life was in danger. In response, the body generates the energy for either a “fight” or a “flight” through activation of the nervous system and the endocrine system in order to maximize resources for surviving the threat (the stressor).

The following is paraphrased from Neigh, Gillespie, and Nemeroff (2009).

Researchers have identified two phases to this process. When the stressor is detected, the initial phase of the stress response begins. The sympathetic nervous system (associated with action, the "fight or flight" response) releases norepinephrine from nerve terminals and epinephrine from the adrenal medulla into the general circulation. Both of these neurochemicals and stimulants in their effects on the body.

In the secondary phase, moments later, corticotropin releasing factor (CRF) is released by “parvocellular neurons of the hypothalamic paraventricular nucleus into the hypothalamo-hypophyseal portal system for transport to the anterior pituitary gland where it stimulates the release of adrenocorticotropic hormone (ACTH) into the general circulation” (Swanson, Sawchenko, Rivier, & Vale, 1983; cited in Neigh, Gillespie, and Nemeroff, 2009). The ACTH travels to the adrenal cortex where it stimulates the release of glucocorticoids (cortisol is the primary stress hormone in primates). It generally takes several minutes for these processes, which are characteristic of the hypothalamic-pituitary-adrenal (HPA) axis stress response, to become fully activated.

Following the crisis, activity in the HPA axis is dampened through negative feedback (the parasympathetic nervous system, associated with "recuperation") via stimulation of glucocorticoid receptors within the hippocampus, hypothalamus, and anterior pituitary (Jacobson & Sapolsky, 1991). When there is a crisis, this stress response allows an organism to shift biological resources away from whatever activity was the focus and engages physiological functions that promote survival.

However, if the stress response becomes chronic due to repeated exposure to stressors, or a physiological deficit in the negative feedback system (or both), the organism experiences an on-going excess in stress hormone levels, which can trigger pathological changes in a variety of physiological systems, leading to stress-related diseases (McEwen, 2008).

This near-constant state of "activation" also leads to many of the symptoms of PTSD, including anxiety, memory deficits, hypervigilance, and the exaggerated startle response. The inability or failure of the body to metabolize the stress hormones, representing in essence that the situation cannot be escaped, results in the third and fourth of the Four F's - fight, flight, freeze, and fold. The freeze response is the most common experience for those who experienced on-going trauma, and the fold represents complete surrender, a profound state of "giving up."   

Whitehouse and Heller explains it this way:

Part of the problem is that when these states occur, discharge of the intense energies mobilized to meet threat often becomes thwarted. Often we just don't have the time necessary to complete them. Nevertheless, the survival energy has mobilized for fight or flight, but literally has no place to go and ends being converted into symptoms. (Whitehouse & Heller, 2008)

The freeze response (fold is very rare, so it will not be discussed here) is characterized by a simultaneous activation of the sympathetic and parasympathetic nervous systems. According to Peter Levine, the creator of Somatic Experiencing:

We have several synonyms for freeze, including dissociation, immobility, spacing out, deer in the headlights look. In the healthy nervous system it still serves and protects us humans, but often freeze is associated with the residual crippling effects of trauma. Here's what happens that causes humans to get stuck in trauma. (Levine, 1992)

References (partial)

• Neigh, GN, Gillespie, CF, and Nemeroff, CB. (2009, Aug 6). The Neurobiological Toll of Child Abuse and Neglect. Trauma Violence Abuse; 10: 389-410. DOI: 10.1177/1524838009339758
• Jacobson, L., & Sapolsky, R. (1991). The role of the hippocampus in feedback regulation of the hypothalamic-pituitary-adrenocortical axis. Endocrine Reviews, 12, 118-134.
• McEwen, BS. (2008). Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. European Journal of Pharmacology, 583, 174-185.
• Whitehouse, B., & Heller, DP. (2008). Heart Rate in Trauma: Patterns Found in Somatic Experiencing and Trauma Resolution. Biofeedback, 36(1).
• Levine, P. (1992). Somatic Experiencing. The Foundation for Human Enrichment. http://www. traumahealing. com/index. html.

Bessell van der Kolk - The Body Keeps the Score (My Notes, Part 1)

The title of this talk is the nearly identical to that of a new book from Bessel van der Kolk due out in June, 2014 - The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (pre-order at Amazon). I will be excited to see this new work - his research in the recent years has focused on yoga, tapping (Emotional Freedom Technique), chi gong, and neurofeedback, among other body-centered modalities for healing trauma.

What follows are my notes, as best as I can make them sensible from today's 3 hour talk.This is part one - part two will follow soon.

The Body Keeps the Score

In the 1920s, Pavlov's lab was flooded and his dogs ended up standing in cold water for two days before being "rescued." During this time they were in their cages, unable to flee. Pavlov assessed that they were flooded with stress hormones during that time, but they were not able to metabolize them as a result of being caged - they could not fight or flee. His notes on this reveal with physiological impact of unresolved trauma - a definition that remained until the DSM system was created and the trauma response "became" psychological. Until the DSM, trauma was always conceptualized in the body.

BvdK showed some video clips of WWI soldiers with "shell-shock" - man who shot the enemy soldier in the face and now has a compulsive facial tick; a man who lost all function of his limbs after surviving an explosion and years later still could barely walk; a man who was unable to pick himself up off of the floor in the absence of any physical injury. These are examples of how the body re-enacts the trauma, of automatic responses completely outside of conscious control or willpower.

One of many asides on the inadequacy of cognitive behavioral therapy (CBT) for the treatment of trauma (there are a lot of CBT experts here who talk about all the ways to work verbally with trauma, while not understanding that trauma is not a verbal experience - more on this idea below):

CBT is misguided in treating trauma because when the trauma system gets activated, the prefrontal cortex (executive function) goes offline and the limbic system is running the show. CBT works with executive function, not with the body-based emotions encoded by the limbic system.

Even when trauma is long past, it replays itself in the body through pain, anxiety, depression, illness, digestive issues, and so on. We must help the client learn to tolerate the physiological trauma symptoms while remaining in their bodies - since nearly all PTSD is dissociative in some way.

Sleep: Trauma survivors wake themselves from REM sleep when their dreams contain images or scenes or sensations of their trauma. REM sleep is designed to allow us to integrate learning and experience while we sleep, but this gets short-circuited in trauma. The ability to dream may be the best indicator of resilience in survivors.

EMDR is not a verbal therapy, it ignores the linguistic narrative. EMDR works via the anterior cingulate, a brain region responsible for distinguishing past from present, safe from dangerous, or relevant from not relevant, among others. It works with the "that was then, this is now" function of the brain - verbal/talk therapies cannot access this brain module. --- Acute single episode trauma can often be resolved in 6-8 sessions using EMDR. At the end of a successful EMDR treatment for a single-episode trauma, the survivor will be able to tell the story with no emotional overwhelm or activation.

James W. Pennebaker says that if people can write about (journaling) the worst details of their worst experience(s), 15 minutes a day, every day for 4 consecutive days, their lives can improve considerably. This process helps them to know what they know and feel what they feel. Telling themselves the story, confirming their own experience, is much more effective than telling someone else the story. --- The reason for this is that feeling the internal world lights up one part of the brain (medial prefrontal cortex) and talking about that experience lights up another part of the brain (dorsolateral prefrontal cortex, home of Broca's Area). These two parts of the brain are only tenuously connected.

Fight/Flight/Freeze/Fold

All four trauma responses activate the body's stress response system, BUT . . . .

• In fight and flight, the stress hormones get used in the act of fighting or running away. These responses generally do not develop PTSD in a single episode trauma (assuming no trauma history).
• In freeze and fold, all of the stress hormones are released, but they are not metabolized through physical action because the individual freezes or essentially goes limp in surrender. These people are very likely to develop PTSD because the stress response was not discharged and becomes stuck in the body/mind.

If, following trauma, we can go to some version of "home" and be taken care of by others who love or care for us, we get a system reset and the amygdala does not go into hyper-drive - we are much less likely to develop PTSD.

For example, following 9/11 in NYC, citizens banded together and supported each other, not to mention being supported by the nation and people around the world. The most traumatized people were the first responders and rescue workers, and then some of the survivors - but the city itself was not overly traumatized.

On the other hand, with Hurricane Katrina in New Orleans, people were stuck on the roofs of their homes, unable to escape the water, or herded into the Super Dome, which was dark, leaked, and filthy (remember Pavlov's dogs), or prevented from crossing a bridge out of the city. More than 33% of the people in N.O. suffered from PTSD.

In PTSD, the body's instinct to fight or flee is stifled and it freezes (often connected with forms of dissociation) or folds, simply gives up and seemingly says, "take me, I won't resist." These avoidance tactics are not healthy in the long-term, even though they may be the only option in the moment. Survivors in this mode are flooded with all of the same stress hormones again any time they remember or re-experience some aspect of the trauma.

If there was pain involved in the original event, whether it was childhood molestation or being thrown violently from a horse, the body releases opiates to squash the pain. But when we relive the event, the same chemicals are released and in the absence of pain the person feels nausea. I cannot count the number of times a client has said, "I feel sick," referring to nausea when reliving or retelling a traumatic experience that reactivates the limbic system.

Vagus Nerve

Charles Darwin identified the vagus nerve (cranial nerve X) in 1872. He recognized its connection to and central role in expressing and managing emotions. When the mind is strongly activated, the body is immediately affected, and the arousal information is relayed by the vagus nerve.

[Side note: Nearly impossible to be an addict without a trauma history - addiction is a way to manage (self-medicate) intense and overwhelming emotions in the body.]

Stephen Porges is the person who has done the most to bring the physiological facts of the role of the vagus nerve in trauma into the world of trauma treatment.

In the vagus, 80% of the fibers are afferent, meaning they carry information to the central nervous system (brain). Here's more from Health Line:

It extends from the brain stem to the abdomen, via various organs including the heart, esophagus and lungs. Also known as cranial nerve X, the vagus forms part of the involuntary nervous system and commands unconscious body procedures, such as keeping the heart rate constant and controlling food digestion.

The vagus is also responsible for many of the nerves in the mouth, including speech.

Consistent and considerable research has shown that body posture has a LOT to do with affect states and can shape our emotions. Slumping our shoulders forward and looking down at the ground supports and maintains a depressed attitude physiologically and psychologically.

One of the "positive psychology" interventions is to smile even when we are sad, or to laugh when we are depressed. Doing so can shift brain chemicals toward those supporting health and away from those supporting dis-ease.

Finally, depression, joylessness lack of purpose, and so on are all sourced in our disconnection from the body. We disconnect from the body to avoid our pain, our trauma, but in doing so we also lose the body's vitality and passion, and we become depressed.


Go on to part two.