‘Shellshock’ is not the fate of soldiers only

SHE is 79. Let's call her Kay. A few years ago, Kay developed a shake in her hand. The start of Parkinson's disease, the first neurologist says. Essential tremor, says the next. She learns to live with the trembling. Then she has a near-death experience in hospital, and after four weeks in intensive care her tremor becomes wild and uncontrollable. And she develops a whole-body rash which causes her to scratch herself raw.

The dermatologist has no explanation. The itch worsens despite the efforts of numerous doctors and every potion and medication on the market. Finally, Kay approaches Dr J, who runs a “holistic practice" that focuses on mind-body connections and the interplay between psychological and physical illness.

Trauma is not exceptional

Twenty-three years ago, the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatry, officially recognised post-traumatic stress disorder (PTSD) as a diagnosis,  based on the symptoms of psychiatric wounds in Vietnam War veterans. 

Although the diagnosis has its roots in combat, the medical community now recognises that PTSD affects civilians too, and there have been great strides in understanding the effects of trauma outside a combat context.

The contemporary definition of PTSD has expanded to encompass a broader range of experiences, making it more inclusive than ever before. The condition is now recognised among survivors of sexual abuse or assault, individuals who have faced health crises and undergone surgery, those affected by natural disasters, grieving individuals, survivors of mass shootings, victims of accidents, and many others.

PTSD manifests in various ways, with symptoms ranging from distressing flashbacks and nightmares to hypervigilance. Individuals may also experience difficulties concentrating, amnesia, dissociation, and harbour negative beliefs about themselves or others. This comprehensive understanding of PTSD reflects the diverse array of traumatic experiences that can profoundly affect individuals' wellbeing.

Bessel van der Kolk is an American psychiatrist and one of the world's experts on traumatic stress, with research stretching back to the 1970s. Because PTSD has such a complex cluster of symptoms, he says, it often goes undetected. “You’re talking about millions” of people suffering from PTSD without a diagnosis, he says in his acclaimed book The Body Keeps the Score.

PTSD is linked to experiencing, learning about or being exposed to a traumatic event involving “actual or threatened death, serious injury, or sexual violence".

Van der Kolk says the intrusive symptoms experienced by people with PTSD can significantly impair their capacity to manage their lives. But to treat PTSD effectively, there needs to be an understanding of how trauma shapes the brain and “the intricate interplay between attachment, neurobiology, and the developmental aspects of trauma's impact on individuals".

“When we first created this diagnosis of PTSD, we said it came from an extraordinary event outside of the range of human experience,” says Van der Kolk. But today, he says, the understanding is that “trauma is not exceptional".

New understanding of trauma

Research has revealed that trauma produces physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant.

“After trauma, the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases. This explains why it is critical for trauma treatment to engage the entire organism: body, mind and brain."

Stress hormones

In normal circumstances, our hormones provide a lightning-fast response to threats and quickly return us to equilibrium, says Van der Kolk.

When the typical response of the body is blocked — when people are held down or trapped, for example, or otherwise prevented from taking effective action, be it in a war zone, a car accident or a situation of domestic violence or rape — the brain keeps secreting stress chemicals and its electrical circuits continue to fire in vain. Long after the event, the brain may keep sending signals to the body to escape a threat that no longer exists.

The more neuroscience discovers about the brain, says Van der Kolk, “the more we realise that it is a vast network of interconnected parts organised to help us survive and flourish". And trauma can throw the functioning of this network into disarray.

After trauma, the nervous system has an altered perception of risk and safety, and this explains why traumatised individuals become hypervigilant to threats at the expense of spontaneously engaging in their day-to-day lives. It also helps us to understand why traumatised people often keep encountering the same problems and have trouble learning from experience. “We now know that their behaviours are not the result of moral failings or signs of lack of willpower or bad character— they are caused by actual changes in the brain," says Van der Kolk.

Dr J examines the deep welts on Kay's skin. The tremor has also mysteriously moved to her right hand after years of affecting only her left.

The doctor settles the patient into a chair for a chat, starting with a question about her experience in hospital. She starts weeping uncontrollably. She says she can't remember much of the time, then — out of the blue — she tells the story of being held up at gunpoint at the entrance to the farm where she used to stay. And how she managed to escape. The next day, she says, she found the red rope with which the attackers had intended to tie her up.

Mind-body connection

Charles Darwin's theories about body-brain connections are still being explored by psychologists, says Van der Kolk.

“Intense emotions involve not only the mind but also the gut and the heart. [The] heart, guts and brain communicate intimately via the pneumogastric [or vagus] nerve, the critical nerve involved in the expression and management of emotions in both humans and animals.

“Until recently, this bidirectional communication between body and mind was largely ignored by Western science, even as it had long been central to traditional healing practices in many other parts of the world, notably in India and China. Today it is transforming our understanding of trauma and recovery.

“It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion and arousal. Any effective treatment for trauma has to address these basic housekeeping functions of the body.

“The body keeps the score, and if the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/muscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions."

It is as if a dam wall of emotion has broken in Kay. The sympathetic first enquiry about her time in the hospital has leapfrogged to a tremendous unspoken. She keeps apologising for crying; she says she never cries. She tells of the constant fear during more than 40 years on a remote farm. Of the last decade of her husband's degeneration into a brutal form of dementia. Of watching him become an unrecognisable version of himself. Of having to handle his escalating paranoia, fear and accompanying hallucinations. And caring for him on his long journey path to a harrowing death.

For two hours, Dr J draws out a long narrative of trauma going back to Kay's earliest childhood memories in Germany after World War 2. There are stories of extreme hunger, of having never known her father, who died in an internment camp, of being the youngest of seven children when there was never enough food or attention to go around.

Dr J shows Kay how to put one hand on her heart and to cross the other over so that she hugs herself.  She tells her to scan the room. To look everywhere. And to tell herself she is safe. “We have found this to be one of the simplest and most effective exercises for people with post- traumatic stress," she tells Kay.

Feeling safe

Being able to feel safe with other people is probably the single most important aspect of mental health, says Van der Kolk.

“Safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma.

“And if we look beyond the list of specific symptoms that entail formal psychiatric diagnoses, we find that almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (as in the case of habitually becoming enraged, shut down, overexcited or disorganised). Usually, it’s a combination of both.

“The standard medical focus on trying to discover the right drug to treat a particular ‘disorder’ tends to distract us from grappling with how our problems interfere with our functioning as members of our tribe."

♦ VWB ♦

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