When the Past is Always Present Part 14

This book reviews the neurobiology of fear conditioning and extinction as well as the effects of early-life stress on the development of neural systems as they relate to vulnerability for traumatization. It describes the clinical consequences and current treatments for those who struggle with traumatization. This book also examines how ma.s.sive traumatic events come to affect the whole of a society. In this regard, it goes beyond the simple laboratory or clinical descriptions and places traumatization as an engine of societal transformation. I particularly appreciated Rousseau and Meashm's chapter on posttraumatic suffering as a source of transformation.

Van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.). (2007). Traumatic stress. The effects of overwhelming experience on mind, body and society. New York, NY: Guilford Press.

As we journey toward understanding trauma, this book is a must-read. It concerns the prototype of traumatic disorders: posttraumatic stress disorder (PTSD). Bessel A. van der Kolk and his coeditors have collated the knowledge that has accreted through decades of clinical, epidemiological, and neuroscience studies. These authors present new and exciting ideas about the disorder and its impact on the individual, society, and the world. The book discusses potential neurobiological mechanisms and uses these ideas to formulate treatment. This book is the paperback volume of the first edition, published in 1996, and its observations and constructs continue to guide research today. It is easy to become swept away by the sheer magnitude of its scope. Slow, thorough reading and rereading are necessary for an appreciation of what has been accomplished here.

Sarno, J. E. (2006). The divided mind: The epidemic of mindbody disorders. New York, NY: ReganBooks, HarperCollins. John Sarno states (p. 1): "Health care in America is in a state of crisis. Certain segments of American medicine have been transformed into a dysfunctional nightmare of irresponsible practices, dangerous procedures, bureaucratic regulations, and skyrocketing costs. Instead of healing people, the broken health care system is prolonging people's suffering in too many cases. Instead of preventing epidemics, it is generating them.

The enormity of this miscarriage of medical practice may be compared to what would exist if medicine refused to acknowledge the existence of bacteria and viruses. Perhaps the most heinous manifestation of this scientific medievalism has been the elimination of the term psychosomatic from the Diagnostic and Statistical Manual of Mental Disorders (DSM), the official publication of the American Psychiatric a.s.sociation. One might as well eliminate the word infection from medical dictionaries."

While this may seem harsh, Dr. Sarno goes on to show how we have missed what is hidden in plain sight-how the mind and the body are connected. He uses decades of research to explore the origin and treatment of chronic pain, especially back pain, which afflicts millions of people. Every health professional should read this and come to his or her own conclusions.

Scaer, R. C. (2007). The body bears the burden. Trauma, dissociation and disease. Binghamton, NY: Haworth Press.

This breakthrough book, following in the footsteps of Peter Levine (see p. xix in Scaer's book), is a challenging read, but the effort is worthwhile. Its fundamental premise is that a painful physical event that occurs during a traumatization is coencoded during the traumatizing event. The pain may or may not be experienced at the time of the event, but it is nonetheless stored and experienced later. He describes the encoding moment as that of a freeze state, one of tonic immobility. Unless this freeze state is discharged, that is, motoric action taken, the mind keeps the fight-orflight energy internally. It is this undischarged energy that causes the symptoms due to a traumatization. By releasing this energy, the event can be processed, the trauma erased, and the pain eliminated. Scaer brilliantly illuminates the origin of the puzzling picture of somatic problems that arise after a traumatic event.

Gay, P. (1989). The Freud reader. New York, NY: W.W. Norton & Co.

The Western world is infused with Freudian ideas. His most original idea is the supremacy of the unconscious (which in this book we call the subconscious). We are told that the unconscious reveals itself in many ways, by slips of the tongue, by behavior, and by dreams. If we can enter that world and bring the unconscious to awareness, we may be able to affect a cure. Talking was the method Freud and others have used. Some of Freud's views remain with us today, while others have fallen out of favor, but his overall body of ideas remains a most impressive exploration of the human mind.

There are probably hundreds of systems of talk therapy. They are based on a variety of models for understanding the unconscious and how language interacts with the brain. These systems can be accessed and reviewed via Wikipedia.

Wikipedia has an excellent, brief discussion of psychotherapy, the first pillar (http://en.wikipedia.org/wiki/Psychotherapy).

In addition, Freud's work is essential to understanding a central theme in this book, the role of the unconscious. We have chosen to use the word subconscious instead of unconscious so that it includes memories both inaccessible and accessible by conscious thought.

Wikipedia also has an excellent brief discussion of psychopharmacology, the second pillar (http://en.wikipedia.org/wiki/ Psychopharmacology). Discussions of individual medications and where they work in the brain can be found in the many psychopharmacology texts available from online booksellers or medical libraries.

Chapter 2: The Role Emotions Play.

Understanding emotions and the role they play in our lives allows us to appreciate their power and their necessity.

Canon, W. B. (1929). Bodily changes in pain, hunger, fear and rage. New York, NY: Harper Torchbooks. This is the cla.s.sic book on the physiology of emotions. As Canon describes in his preface, "Fear, rage and pain, and the pangs of hunger are all primitive experiences which human beings share with lower animals." Canon then proceeds to illuminate how one maintains the integrity of the body. The concept of homeostasis (homeo, "same"; stasis, "state"), which means "keeping our insides stable," is introduced here. He discusses how our bodies keep us at 98.6 F, regulate our blood sugar, and maintain our blood pressure whether standing, lying, or sitting. Canon describes what happens in our bodies when homeostasis is disturbed and how it reacts to counter these changes. He was the first to describe the effects of fear and hunger on physiological functions and the role of epinephrine. This book, published just under 100 years ago, is full of insights that help explain what we witness every day. It is a book of great medical historical importance, and while it is worthwhile to read, just skimming through the book connects you to the earliest work on stress.

Selye, H. (1978). The stress of life. New York, NY: McGraw-Hill.

This book introduces the term stress to the biological vocabulary. Although some of his ideas are outdated, Selye's book is a thrill to read. Selye takes you through his early research, where he tries to understand why different stressors produced the same response. He was way ahead of his time in describing the role of stress on the immune, cardiovascular, gastrointestinal, musculoskeletal, neurological, and psychiatric systems. This book lays the foundation for mind-brain-body medicine and should be read by everyone interested in psychology.

Fellous, J.-M., & Arbib, M. A. Eds. (2005). Who needs emotions? The brain meets the robot. New York, NY: Oxford University Press.

This remarkable compilation of essays is directed toward trying to understand if robots could be constructed to think and experience emotions. An important idea discussed here is that emotions play many roles in survival. Their primary role is as an amplifier; that is, they increase the importance of an event to an individual and are fundamentally protective and useful for survival. Emotions also have many other secondary roles that are critical.

This book summarizes much of the literature on the organization and basic principles of emotion-producing systems and includes perspectives from a social interaction viewpoint.

The response to fear as described by Fellous and LeDoux in their chapter on emotional processing (p. 87) includes: Defensive behavior Increased arousal Fear Increased pain threshold Release of stress hormones Decreased reflex time These responses are all directed by the amygdala.

Reactive, routine, and reflective emotions are discussed in "Who Needs Emotions," by Ortony, Norman, and Revelle, on p. 179. Ralph Adolphs, in his chapter (pp. 928) "Could a Robot Have Emotions?" describes the various roles emotions provide for survival purposes. Some ideas are included in the main body of the text. A discussion of emotions as part of the motivational system is described by Ann E. Kelly. In her chapter (pp. 2979) she describes the neurochemical networks encoding motivation. Here, both positive and negative emotions are part of this system. This book is remarkably readable and provides an introduction to emotions and their function.

Gazzaniga, M. S., Ivry, R. B., & Mangun, G. R. (2002). Cognitive neuroscience: The biology of the mind. New York, NY: W.W. Norton & Co.

This book introduces one to the field of cognitive neuroscience. Starting from the molecular, cellular, and anatomical aspects, it offers a wonderful overview of perception, encoding, learning, memory, emotion, and other topics now considered to be amenable to scientific study. Cognitive neuroscience explores emotion by studying mind-brain interactions with psychophysical and brain imaging techniques such as fMRI, MRI, PET, and ERPs (event-related potentials). In essence, it reveals what parts of the brain are active when emotions are involved.

Lieberman, M. D., & Eisenberger, N. I. (2009). The pains and pleasures of social life. Science 323:890891.

These scientists describe the neurobiological relationship between physical pains (hunger, thirst) and psychological pains (social exclusion, bereavement, unfairness, negative social comparison). These researchers argue that physical and psychological pain share common brain pathways.

Ruden, R. A., & Byalick, M. (2003). The craving brain. New York, NY: HarperCollins.

This book outlines in detail the consequences of chronic inescapable stress and its effect on the appet.i.tive drive system. It speculates that chronic stress decreases serotonergic activity of the brain. This low level of serotonin sensitizes the nucleus acc.u.mbens so that it reacts compulsively to nonappet.i.tive stimuli. Since these nonappet.i.tive stimuli (e.g., cigarettes, alcohol) do not have a mechanism to shut down their consumption, addictive behavior results. Traumatization produces chronic inescapable stress and can set the stage for addictive behavior.

Chapter 3: Ancient Emotions and Survival.

Fear and rage have been studied in animals, including humans. Some sources are listed below.

McFarland, D. (1987). The Oxford companion to animal behavior. New York, NY: Oxford University Press.

A clear understanding of how and why animals behave is available in this storehouse of information, readily accessible to the general public. Written by an international team of experts, it contains over 200 entries that range from aggression to courtship to facial expressions, flight, navigation, mate selection, and fear.

How fear and physiological changes are produced by sensory input is described in this book. This book describes fear as "a state of motivation that is aroused by certain stimuli and normally gives rise to defensive or escape behavior." In humans, fear has a unique facial expression that involves the platysma muscle and wide-open eyes. A dog's response to a threat is described here (p. 6): When we look at the dog's external appearance in the threatening and defensive postures, they appear to be completely opposite. The threatened dog tries to make itself as large as possible. The self-defense posture is to protect vital parts. In humans, defensive rage is not aggression but it is the equivalent of the threatening posture. As a last resort we are trying to scare our adversary and want to look as ferocious as possible.

Each sense organ has a pathway to the amygdala that engages a fear response, and these are described in this book.

Figure i.1 Charles Darwin showed this picture to 23 people, who were then asked to describe the emotional state of the person. (From Darwin, C., Expression of the Emotions in Man and Animals, D. Appleton & Co., New York, NY, 1898, p. 294.) Darwin, C. (1898). Expression of the emotions in man and animals. New York, NY: D. Appleton & Co.

Darwin showed the picture seen in Figure I.1 (p. 294 of his book) to 23 persons who were asked to describe the emotional state of the person. Thirteen said horror, great pain; three answered extreme fright; six said anger; and one said disgust. All these feelings are closely related to a mental state of fear. This book is also among the cla.s.sics that relate the similarity of human and nonhuman expressions of emotions and how all of us recognize them.

De Becker, G. (1997). The gift of fear. Survival signals that protect us from violence. New York, NY: Little, Brown, & Co.

True fear, De Becker states, is a gift. It is a survival signal that sounds only in the presence of danger. Through story and theory he describes how the subconscious alerts us and why we better pay attention.

LeDoux, J. (1996). The emotional brain. New York, NY: Touchstone Press.

This book, already a cla.s.sic, brings together research on the physiology of emotions and their role in learning. LeDoux describes an experiment conducted by a French physician named Edouard Claparede in the early part of the last century. His patient seemingly lost her ability to make new memories, and each time they met he had to reintroduce himself. On one occasion he placed a pin in his hand such that when they shook hands, the patient received a painful p.r.i.c.k. On the next visit, the patient refused to shake hands with him. She couldn't say why, but obviously the good doctor now came to represent pain and she was afraid.

LeDoux feels that this form of learning does not depend on conscious awareness, and once the learning takes place, the stimulus does not have to be consciously perceived to elicit the emotional response. This experiment sets the theoretical background for subconscious stimuli activating the amygdala.

In another part of the book LeDoux (pps. 258261) describes the descent into panic: "As the amygdala is becoming increasingly active, it makes sense that the thinking portion be diminished and preprogrammed responses to danger take over so that decisions are not delayed because of an evaluation of the available options. This is not a conscious process; it is what Nature did to improve the chances of survival."

This was a groundbreaking book when published in 1996. It contains speculations, some which have been modified, but that is why ongoing research is so important (mostly done by LeDoux and coworkers), and theoretical models are made based on the best available evidence.

Shaikh, M. B., & Siegel, A. (1994). Neuroanatomical and neurochemical mechanisms underlying amygdaloid control of defensive rage behavior in the cat. Braz. J. Med. Bio. Res. 27:27592779.

It is well established that the hypothalamus and the periaqueductal gray (PAG) play important roles in the expression of defensive rage behavior. While defensive rage is not elicited from the amygdala, this region of the limbic system nevertheless serves an important role in the modulation of defensive rage behavior. The experimental data establish that activation of the basomedial region facilitates defensive rage. Activation of the central nucleus suppresses defensive rage. The suppression of defensive rage by the Ce makes sense because that area is used to engage the fight-or-flight mechanism.

Chapter 4: Memory and Emotion.

We remember what arouses us. Without emotion our important memories would be difficult to retrieve.

Harley, C. W. (2004). Norepinephrine and dopamine as learning signals. Neural Plast. 11:191204.

This article reviews the evidence that norepinephrine and dopamine act as learning signals. Both norepinephrine and dopamine are broadly distributed in areas concerned with the representation of the world and with the conjunction of sensory inputs and motor outputs. Both are released at times of novelty, uncertainty, and the emotions of fear and rage, providing a plausible signal for updating representations and a.s.sociations. These substances activate intracellular machinery postulated to serve in the memory formation cascade.

Phelps, E. A. (2004). Human emotion and memory: Interactions of the amygdala and the hippocampus. Curr. Opin. Neurobiol. 14:198204.

The amygdala and hippocampal complex are two structures deep within the medial temporal cortex. In emotional situations, these two systems are linked to each other in subtle but important ways. Specifically, the amygdala can modulate the encoding, storage, and retrieval of hippocampus-dependent memories. The hippocampus, by forming long-term representations of events of emotional significance, can influence the right amygdala's response when emotional stimuli are encountered. These systems act in concert when emotion meets memory.

Cahill, L. (1997). The neurobiology of emotionally influenced memory. Implications for understanding traumatic memory. Ann. N.Y. Acad. Sci. 821:238246.

Substantial evidence from animal and human subject studies converges on the view that memory for emotionally arousing events is modulated by a memory system consisting, at a minimum, of stress hormones, the hippocampus, the amygdala, and the medial prefrontal cortex. Within the normal range of emotions experienced, this system is viewed as an evolutionary adaptive method of creating memory strength that is, in general, proportional to memory importance. In conditions of extreme emotional stress, the dysfunction of this normally adaptive system may underlie the formation of strong, intrusive memories characteristic of PTSD.

McGaugh, J. L. (2004). The amygdala modulates the consolidation of memories of emotionally arousing experience. Annu. Rev. Neurosci. 27:128.

Converging findings of animal and human studies provide compelling evidence that the amygdala is critically involved in enabling us to acquire and retain lasting memories of emotional experiences. Considerable data from animal studies indicate that (1) the amygdala mediates the memory-modulating effects of stress hormones; (2) the effects are selectively mediated by the basolateral complex of the amygdala (BLC); (3) the BLC modulates memory encoding via efferents to other brain regions, including the caudate nucleus, nucleus acc.u.mbens, and cortex; and (4) the BLC modulates the encoding of many different kinds of information. The findings of human brain imaging studies are consistent with those of animal studies, suggesting that activation of the amygdala influences the encoding of long-term emotional memory; the degree of activation of the amygdala by emotional arousal during encoding correlates with ease of subsequent recall. The activation of neuromodulatory systems affecting the BLC and its projections to other brain regions involved in processing different kinds of information plays a key role in enabling emotionally significant experiences to be well remembered.

Anderson, A. K. (2005). Affective influences on the attentional dynamics supporting awareness. J. Exp. Psychol. Gen. 134:258281.

Emotionally arousing stimuli enhance long-term memory of immediately preceding neutral stimuli. The findings fit with the preservation-consolidation hypothesis. This hypothesis states that emotional arousal activates neurobiological processes that modulate the consolidation of memories of recent experiences. This arousal-induced modulation of memory is mediated by norepinephrine activation of the amygdala.

McIntyre, C. K., Power, A. E., Roosendaal, B., & McGaugh, J. L. (2003). Role of basolateral amygdala in memory consolidation. Ann. N.Y. Acad. Sci. 985:273293.

Memories of emotionally arousing events tend to be more vivid and to persist longer than do memories of neutral or trivial events. Moreover, memories of emotionally influenced information may endure after a single experience. Recent findings strongly suggest that the influence of emotional arousal on memory consolidation is meditated by the release of adrenal stress hormones (epinephrine and cortisol) and neurotransmitters that converge on modulating the noradrenergic system within the amygdala. Considerable evidence also indicates that amygdala activation influences memory by regulating consolidation in other brain regions. This work supports the notion that the BLC acts as glue for the components of a traumatic memory.

Morenson, G. J., Jones, D. L., & Yim, C. Y. (1980). From motivation to action: Functional interface between the limbic system and the motor system. Progr. Neurobiol. 14:6797.

This article describes the relationship between emotion and motion. It connects the limbic system with the nucleus acc.u.mbens and other downstream neural components that organize behavior and activate motivational states.

Ordway, G. A., Schwartz, M. A., & Frazer, A. (Eds.). (2007). Brain norepinephrine. Cambridge, UK: Cambridge University Press.

This book is intended for researchers and graduate students. Benno Roozendaal, PhD, writes a chapter on norepinephrine and long-term memory. Gary S. Aston-Johns writes a chapter on the locus coeruleus and regulation of behavioral flexibility and attention. Petrovaara Antti discusses norepinephrine and pain. There are many other excellent chapters. For those readers with a background in neuroscience, the chapters in this book provide a strong argument for norepinephrine as one of the key neurochemicals in encoding a traumatization.

Chapter 5: Encoding a Traumatic Memory.

A single event can change your life. How does the brain make this happen?

Ferreira, T. L., Shammah-Lagnado, S. J., Bueno, O. F., Moreira, K. M., Fornari, & Oliviera, M. G. (2008). The indirect amygdala-striatum pathway mediates conditioned freezing: insights on emotional memory networks. Neuroscience 153(1) 8494.

Where are emotional events stored prior to the hippocampus being operational? The dorsal striatum (made up of caudate and putamen nuclei) is involved with emotional learning. In a previous study (Ferreira, T. L., Moreira, K. M., Ikeda, D. C., Bueno, O. F. A. & Oliviera, M. G. M. (2003). Effects of dorsal striatum lesions in tone fear conditioning and contextual fear conditioning. Brain Res. 987:1724), disruption of both right and left dorsal striatum was shown to disrupt fear tone conditioning. This study demonstrates that lesioning both the Ce of the amygdala and the dorsal striatum on the other side of the brain also impaired the acquisition of tone fear conditioning. This suggests that the striatum may be the location of fear memories in the absence of a functional hippocampus. It also suggests that if the dorsal striatum is intact an event may be accessible via a felt sense and thus be useful for activating the BLC to allow for havening.

Tully, K. Li, Y. Tsvetkov, E. & Bolshakov, V. Y. (2007). Norepinephrine enables the induction of a.s.sociative long-term potentiation at thalamo-amygdala synapses. Proceed. Nat. Acad. Sci. 104(35):1414614150.

This article argues for the role of norepinephrine in the production of long-term potentiation in the lateral nucleus of the amygdala. Information arriving from the thalamus under the influence of norepinephrine overrides GABA inhibition of the neurons leaving the lateral nucleus. This allows for pathways to be generated.

Chapter 6: Causes and Consequences of Traumatization.

Saigh, P. A. (1991). The development of post-traumatic stress disorder following four different types of traumatization. Behav. Res. Ther. 29:213216.

The Children's Post-Traumatic Stress Disorder Inventory was used to identify 230 cases of childhood PTSD. Of these cases, 58 had been traumatized through direct experience, 128 through observation, 13 through verbal mediation, and 31 by combinations thereof.

Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory studies. Retrieved from http://www.trauma-pages.com/vanderk2.htm The nature and reliability of traumatic memories and their role in the development of PTSD are controversial issues in psychiatry. This paper reviews studies collected from people's memories of highly stressful and traumatic experiences. It confirms Janet's clear distinction between a traumatic and an ordinary memory. According to Janet, a traumatic memory consists of images, sensations, and affective and behavioral states that are invariable and do not change over time. In contrast, ordinary memories are semantic and symbolic. These memories are social and adapted to the needs of both the narrator and the listener, and can be expanded, contracted, embellished, or diminished according to social demands. While a traumatic memory may leave indelible sensory and affective imprints, once these are able to become incorporated into a complete personal narrative as a nontraumatic memory (the traumatization is cured), it is subject to degrees of distortion similar to ordinary memory.

Ortiz, J. P., Close, L. N., Heinricher, M. M., & Selden, N. R. (2008). Alpha (2)-noradrenergic antagonist administration into the central nucleus of the amygdala blocks stress-induced hypoalgesia in awake behaving rats. Neuroscience 157:223228.

Researches here tested the hypothesis that stress-induced release of norepinephrine into the central nucleus of the amygdala (Ce) mediates a.n.a.lgesia. Injection of clonidine, which mimics norepinephrine, into the central nucleus of the rat produced a dose-dependent increase in pain relief, compared to salt.w.a.ter control in the tail flick latency test. This test measures how long it takes the rat to move its tail when it is subject to a painful stimulus; the longer it takes to move the tail, the greater the latency and the greater the a.n.a.lgesia. The a.n.a.lgesic effect was blocked by injection of the norepinephrine antagonist idazoxan. Injection of these substances elsewhere in the amygdala, including the BLC, had no effect.

Otis, J. D., Keane, T. M., & Kerns, R. D. (2003). An examination of the relationship between chronic pain and post-traumatic stress disorder. J. Rehab. Res. Dev. 40:397406.

A substantial literature currently exists doc.u.menting the relationship between chronic pain and substance abuse, depression, and anxiety disorders. Several models are proposed and are of interest; however, none have been developed fully or tested.

Ruden, R. A. (2008). Encoding states: A model for the origin and treatment of complex psychogenic pain. Traumatology 14:119126.