When the Past is Always Present Part 5

Regardless of whether the amygdala is activated by memories we actively recall or by stimuli that remain subconscious, the consequences of a traumatization remain the same: Intermittent or persistent activation by a component of a traumatic memory causes the release of stress neurochemicals and the experience of other components. The neurobiological response to the chronic release of stress chemicals soon becomes maladaptive, landscaping the brain to produce strange behavior, strange thinking, and disease and increase vulnerability to further traumatization.

Sensory Input and Emotion.

How does the sensory information about the event get to the amygdala to produce an emotional response and set the stage for traumatization? There are two ways: One is directly from the thalamus. The other way is via the cortical structures after processing.8 All sensory information (except olfactory) arrives at the thalamus unprocessed. As mentioned earlier, certain survival-based stimuli (UFS) (e.g., heights) produce a fear response without further processing. These unconditioned fear stimuli are hardwired, innately recognized as threatening and flow from the thalamus directly to the amygdala for action. It is the way we are able to rapidly respond when there is a stimulus that is perceived as danger. Norepinephrine and cortisol are immediately released.

This thalamic amygdala pathway produces the emotional core. If an event is traumatized, the focus of unimodal sensory input (e.g., a gun, bridge, face, etc.) that a.s.sociates with the UFS also activates the amygdala.

Other, more complex sensory information, such as size, speed, color, shape, pain, visceral sensations, and sounds of the fear-producing stimulus, enters the thalamus and is sent to various parts of the brain (visual cortex for sensory information entering through the eyes, auditory cortex for the ears, and so on), processed, and if appropriate, enters the amygdala via the lateral nucleus (LA). This processed information travels via the cortical route (the long route) arriving at the amygdala milliseconds after the unprocessed thalamic input. The background context goes by the long route and enters an activated BLA via the hippocampus (Figure 5.2).

This is of critical importance for traumatization (see below). Once the amygdala is activated via the short path by sensory input a.s.sociated with a hardwired fear stimulus (UFS), complex content and context, having taken the long route, now enter an activated amygdala. This Figure 5.2 The short path activates the amygdala, which is now receptive to cortically processed information. (Adapted from LeDoux, J. E. 1994. a.s.sociations, memory, and the brain. Scientific American 270:5051.) processed input encounters an amygdala with an elevated norepinephrine and cortisol level and an activated memory trace mediated by a specific glutamate receptor pathway for the UFS. If encoded as a traumatization, these complex content and context then become bound to the emotional core of the event.

Modulation of Response to an Emotional but Nontraumatizing Event.

Imagine you are walking in the woods and see something move on the ground. This activates the amygdala and you jump back, prepared for action. This activated basolateral complex (BLC) sends a signal to the Ce and an inhibitory signal to the medial prefrontal cortex (mPFC), allowing full amygdala outflow. In a very short time, perhaps milliseconds, your cortically processed information recognizes the movement as a stick (complex content). You calm down because the object is no longer viewed as a threat. Alternatively, if the object is a snake and you become frightened but feel you are at a safe distance (context), you will also calm down. Perception of safety inhibits the outflow from the Ce via GABA neurons activated by a signal from the mPFC (Figure 5.3).

Figure 5.3 First, BLC inhibits mPFC, and if safety is perceived (via complex sensory content or context), mPFC inhibits Ce //LC NE. (Adapted from Quirk, G. J. et al. 2003. Stimulation of medial prefrontal cortex decreases the responsiveness of central amygdala output neurons. J. Neurosci. 23:80008807.) Thus, for a short time, emotions rule over the evaluative part of the brain. However, if the evaluation does not reveal a threat or you feel safe, reason prevails, you calm down, and a potentially traumatizing moment is avoided.9

The Traumatization of an Event.

We have described the requirements for traumatization and the components of a traumatic memory. We have discussed the roles of the BLC and hippocampus in a.s.sociating the components of a traumatic event, and the Ce in activating the requisite physiology, the actions of neurotransmitter chemicals such as glutamate, norepinephrine, and cortisol, and the importance of the mPFC. In the event where there is no perceived escape, a pathway lit by glutamate receptors, leading to all components of the traumatizing moment is permanently encoded: Mechanism of Traumatization.

Stimulus [unimodal and UFS] pa.s.s through thalamus Signal to amygdala Fear/defensive rage generated NE and cortisol in amygdala Inhibition of mPFC Complex content and context enter amygdala Four requirements met Glutamate receptors in BLC amygdala potentiated BLC modulates binding of the components of event A traumatic memory is stored

The Timing of Traumatization.

When during an emotional event does the encoding occur? Clinical evidence suggests that it occurs during the moment of flight or fight, when escape is perceived not to be possible or fighting is futile. It is this moment where the stress neurochemicals norepinephrine, dopamine, and cortisol are elevated. Traumatization is a high norepinephrine and dopamine landscape, clear, focused, and in the moment.

References.

1. Adams, S. A., & Riggi, S. A. (2008). An exploratory study of vicarious trauma among therapist trainees. Training Educ. Prof. Psychol. 2:2634. Retrieved from http://www.apa.org/apags/profdev/victrauma.html 2. O'Brien, B. Why do Buddhists avoid attachment? Attachment may not mean what you think it means. Retrieved January 30, 2010, from http:// buddhism.about.com/od/basicbuddhistteachings/a/attachment.htm 3. Galton, F. (1883). Inquiries into human faculty and its development (p. 49). Retrieved from http://galton.org/books/human-faculty/text/html/ galton-1883-human-faculty2.html 4. Chemtob, C. M., Nomura, Y., & Abramovitz, R. A. (2008). Impact of conjoined exposure to the World Trade Center attacks and to other traumatic events on the behavioral problems of preschool children. Arch. Pediatr. Adolesc. Med. 162:126133.

5. LeDoux, J. E. (1996). The emotional brain. The mysterious underpinnings of emotional life. New York, NY: Simon & Shuster.

6. 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 7. Vermetten, E., Dorahy, M. J., & Spiegel, D. (Eds.). (2007). Traumatic dissociation: Neurobiology and treatment. Washington, DC: American Psychiatric Publishing.

8. LeDoux, J. E. (1994). Emotion, memory and the brain. Sci. Am. 279:5057.

9. Quirk, G. J., Likhtik, E., Pelletier, J. G., & Pare, D. (2003). Stimulation of medial prefrontal cortex decreases the responsiveness of central amygdala output neurons. J. Neurosci. 23:88008807.

6.

CAUSES AND CONSEQUENCCES OF TRAUMATIZATION.

What common circ.u.mstances create a landscape permissive for traumatization? It is worthwhile to explore some of these sources, as this will be helpful in leading us to certain core emotional issues that need to be explored if we are to attempt to treat the consequences of traumatization.

Early Events.

The Causes We All Share.

Trauma of birth.

Fear of suffocation.

Fear of abandonment.

Hunger.

Birth is traumatic. Here we were, for many months, in a warm, relaxing sea, being fed, housed, and comforted by the sounds of our mother's heartbeat. We think of attachment as something that is postnatal, but the most critical attachment of our life occurs when the fertilized egg attaches to the mother's womb. This is the primary attachment, and from the comfortable, fully grown fetus's point of view, birth is an unrequested detachment. During labor we are pushed against an opening way too small, and pushed and pushed. This is painful and physiologically arousing for both mother and soon-to-be newborn. Such arousal is necessary because the next few moments are critical.

As a result of the mother's labor, we are literally squeezed out into a strange world, bereft of the most life-sustaining element, oxygen. We rapidly starve for air and, in the most life-affirming moment, we gasp our first breath. The fear of suffocation is avoided. Then we cry out. This is not an ordinary cry: This is a cry for survival. It is resonant and full lunged, demanding attention and compelling action. The mother's brain has also been signaled during labor. During this time, oxytocin, a maternal bonding hormone, is released in huge quant.i.ties into the mother's brain. (Note: In nature's efficiency, oxytocin also causes the uterus to contract to aid in expelling the fetus.) The baby's cry compels the mother to hold the baby. The reunion of mother and baby, the simple touch, and the calming stroking by the mother quiet both, and the trauma of abandonment is avoided.

Finally, the food that the mother's placenta had so generously provided is no longer available. The newborn becomes very hungry as its rapidly growing body demands to be fed. While not imminent, starvation is at stake. At this moment the newborn has only one call for help and it cries. This has worked before to prevent abandonment. This cry has a remarkable effect and milk pours into the mother's breast, causing her pain. We continue to wail until the nipple is in the mouth and food and touch are provided. Nature's wisdom is seen here; the reunion removes both mother and child's pain.

At birth, these sources almost never produce a traumatization. If any one of these events failed to occur, the child died. However, extra ordinary stress (e.g., difficult forceps delivery), may be encoded in procedural memory via an activated amygdala. If encoded as a trauma, it may act as a neuromodulatory landscaper. In the 1950s, hospitalized children were severely restricted from seeing their parents for fear that an infection may be transmitted. These children felt frightened and abandoned. Upon returning home their behavior was disturbed. As reported by a mother: I left John (twenty-one months old), on admittance, happily playing about the ward, quite fearless in his relationship with the nurse and other children. He came home with no confidence at all. He would not go to his daddy and I could not leave him at all, because he screamed and sobbed. He was frightened of being touched by me in any way and he cowered, literally, before neighbors and friends whom he had known before.1 Abandonment is so primal that if it occurs early in development it will impact on all aspects of an individual's life. In seeking a source for the origin of pathological behavior, asking about having experienced abandonment is often fruitful.

For parents of newborns, the baby's cry means it is either hungry, wet, or needs to be comforted. This simple cry, the baby quickly learns, results in relief and, until about six weeks of age, is used as the sole method of motivating parental action. Then something miraculous happens, the baby smiles. It is a smile of recognition and means "I am not abandoned and my discomfort will be removed." It causes the mother to feel attached in a different way. This smile is a new motivation for the mother. The baby is conditioning his or her mother to seek these rewards. A cry and a smile are powerful forces that motivate and shape mother-and-child attachment. The infant starts life as the great natural manipulator, and both the baby and the mother are biologically driven partic.i.p.ants.

As the child grows older, when his or her needs are not met, a new form of communication is devised. It is anger, and we call it a tantrum. From about 1 to 3 years of age, his or her neediness is manifest and, without language, can often go unmet. This leads to frustration for both the mother and child. But this soon pa.s.ses as language develops and, with it, the child's ability to remember and delay gratification. It is during this time we become toilet trained.

Childhood can be a fertile source of traumatization. A child's thinking is both concrete and imaginative. Imagine a parent who frightens you with the threat of a bogeyman-that evil character of supernatural powers who carries naughty children off to who knows where. Imagine you are told you are good for nothing, and then told to pack your bag so you can be sent to the naughty children's home. Imagine the awfulness of a parent, your protector, becoming a predator. Imagine a priest, a teacher, or other figure in whom you have implicit trust becoming someone who hurts you. Where could you hide? Whom could you tell? Where would you be safe? How does one seek safety when there is no safe place? Preceding a divorce where parents argue in front of their children and one then abruptly leaves produces fear and can be traumatizing. Those are the more obvious sources of abandonment trauma, but the simple act of parents going out for an evening at the wrong time may be sufficient.

The achievement of a secure attachment is a much more complex process than avoiding abandonment. This is the process of emotional bonding. Now there is give and take. The child begins to recognize that his or her mother can leave without experiencing a sense of abandonment. Separation anxiety diminishes. The child's and the mother's temperament need to work together for a smooth transition to adulthood. If this does not occur, the potential for the young adult to be unable to modulate emotional responses is present, lowering the threshold to traumatization.

In the extreme, this lack of attachment and nurturing can have devastating effects. Romanian orphanages under Ceausescu allowed parental visits once every six months. Children slept four to a cot, sharing blankets that were soiled, wet with urine, and lice infected. They did not wash because there was no soap or hot water. Children played with dirty needles and violence was rampant. The children were so neglected they showed no emotion at all. The care workers were poorly trained and cruel, giving the orphans less than 10 minutes of attention a day.2 The torn cribs had bars and resembled solitary confinement. Their development was physically and emotionally delayed. The age at adoption correlated with the severity of developmental delay. The oldest were seriously impaired. After adoption, 36% had problems of socialization requiring professional intervention.

My father was an angry man. Things, small things, could set off his rage and I would be beaten. As a very young child, I remember him chopping wood with an axe and he had a look on his face (I thought he was thinking about something that made him mad) that frightened me. I was afraid to express my anger toward him.

In 1979, at the age of 10, I went to have an operation on my left foot. A bone needed to be fused to prevent the development of arthritis. Two weeks before surgery, I fell out of a tree house, breaking my nose and knocking myself out. My brother, who thought I was dead, ran across the field to get my father. I came to and was evidently screaming and I remember my father telling me that he stopped running once he heard my screaming.

I was taken to the hospital and just dropped off by my father. I had two black eyes and a broken nose.

The day of the foot surgery I was given a pill that made me very drowsy and I awoke alone in a very dark recovery room full of pain. I'm not sure how long I spent there. I do know that they would not medicate me for the pain because of my age. This enraged me but I was helpless. After that week I was dropped off at boarding school with my foot in plaster.

Since that time, till today, 30 years later, I cannot touch the scar on my foot or even look at it. If someone talks about it, it begins to hurt and I feel nauseous. If I have bare feet, I have to roll up my pant leg so that the bottom of the pant leg won't rub on my scar. I have spent agonizing sessions in therapy trying to talk about the scar and why I feel this way. Trouble is, to talk about it is excruciatingly painful. I do not eat before a therapy session because I feel sick when talking about it. Even to write about it is painful.

Parents who lack nurturing skills due to mental illness or substance abuse cause great havoc in households. Children cannot understand their parent's unpredictable behavior. These children are frightened, confused, and always under stress. Abuse and abandonment by a parent in childhood is always devastating. The lack of a nurturing figure is of immense consequence. To paraphrase Walt Whitman, childhood is the father to the man. Nothing could be truer.

Later-in-Life Causes.

Motor vehicle accidents, falling down stairs, being called fat, or being learning disabled can be traumatizing. All forms of betrayal, failure or loss, can be traumatizing. Combat can be traumatizing.

My brother returned from the war Iraq. He was a different person. He would always be in a daze. At home he could not sit comfortably next to a window. If he was near a window, he was very alert, looking out as if something was about to happen. He said the enemy could come through a window. There were times when I found him sleeping on the floor because the bed was near a window and any noise would scare him. A friend of his from the Army had the same reaction. I offered him a seat and he said, "I'd rather stand because I am prepared."

There were days when my brother would be so paranoid that if he heard a noise, he would start screaming things like "Go for cover, they're shooting, enemy alert!" Other times he would just go on talking about the people he killed, including children, and he would break down and cry.

Now when we went to the stores or just for a walk he would be looking up at the buildings and the roofs and say, "You never know who's watching your every move to kill you." There was a time when we heard a firecracker and he freaked out, yelling at everyone in the house to close the windows and stay away from him. We had to remind him he was safe, but safe, he felt, he could never be.

Being given a potentially fatal diagnosis stops all other information from being processed and is often traumatizing. A doctor's words or his or her indifference can cut deeper and have longer lasting scars than any knife. The legal system is no different; victims of crimes such as rape and a.s.sault are often blamed for being provocative. Just when support is needed most, the victim feels abandoned and sometimes made to feel guilty and ashamed.

Cultural Sources.

Trauma sources are not just personal. The Great Depression was a source where family men were traumatized by loss of their jobs and their role as providers. Today, many highly successful people who grew up during that time now h.o.a.rd possessions and are frugal-just in case. During those terrible times President Roosevelt provided a brilliant solution. He put people to work and promised something that was genius. He promised Social Security. This program allowed men not to feel terrified that their families would go hungry and allowed families to remain together.

When a haven does not exist, there is the potential for traumatization. The great plague of the Middle Ages was a source for traumatization, as was 9/11, made infinitely worse by repeated showing of the event and by the misguided color threat system where red meant high alert and green meant safety. Where could one find a haven?

Since September 11, 2001, I suffered extreme anxiety and have had difficulty sleeping. Each night I would lie awake, watching airplanes fly up the Hudson River through my bedroom window. Each time one took a flight path I thought to be too low, I would jump out of bed, scurry to my living room, and watch the plane, waiting to see if I needed to wake my family for a quick exit. I thought for sure one of these planes would eventually come straight for my building. I visualized it happening and lived that dreadful moment over and over in my mind.

Slavery was a great source of traumatization, the Holocaust was a great source of traumatization, the destruction of the Native Americans was a great source of traumatization, and through the ages, there were many other societal moments where fear and anger were real and havens did not exist. Thus, not only are there moments that affect the individual, but entire cultures, races, and nationalities can be affected by events.

The media is a constant source of traumatization. Through television and other media outlets, we witness horrific things as they are happening. Its reach is so large that it is arguably the most important source of fear. There are reasons children should not watch certain things until they can place them into perspective.

Being traumatized can inhibit one from seeking a haven. Children who are physically, emotionally, and s.e.xually abused often have difficulty seeking a haven because of shame, anger, and guilt. Battered women, the isolated elderly, and the homeless all may suffer from traumatization and be unable to find a safe place.

With so many potential causes, how is it we do not all experience the consequences of traumatization? The truth is, to a greater or lesser extent, we do.

Consequences of Traumatization.

Why?

Why had Pamela's right hand been killing her for the last three months? She hadn't hurt it, nor was there any sign she accidentally injured it. It was very tender to the touch.

Why couldn't John sleep? Since 9/11, whenever he heard a plane, he would jump out of bed to see if the flight would end up in his apartment.

Why couldn't Mary get on an airplane?

Why wouldn't Joseph speak in public?

Why did Jane have episodes where she couldn't breathe and felt she was going to die?

Why was Arthur too frightened to drive?

Why would Sarah walk up 20 flights rather than use the elevator?

Why couldn't Arnold walk?

Why couldn't Peter sleep near a window and preferred sleeping on the floor of the kitchen after returning from a tour of duty in Iraq?