The Hidden Presence of PTSD

Linnea Butler, LMFT, CCTP
Founder and Clinical Director of Bay Area Mental Health

Section 1: What is Trauma and How does it Cause PTSD?
Section 2: What is Complex PTSD (C-PTSD)?
Section 3: What Trauma does to the Brain and Body
Section 4: What is Trauma Therapy and How Can it Help?

“Everything is going well in my life, why do I feel like I’m falling apart all of a sudden? Why do I feel so ashamed?” The truth is, it’s not all of a sudden. It’s years in the making. And you can heal.

You aren’t broken.
Causes of Trauma and PTSD
An event will most likely lead to emotional or psychological trauma, and possibly PTSD, if:

• It happened unexpectedly.
• You were unprepared for it.
• You felt powerless to prevent it.
• It happened repeatedly.
• Someone was intentionally cruel.
• It happened in childhood.

What is Trauma and How does it Cause PTSD?

"Just get over it." It's one of the worst things someone can say to a trauma survivor. And yet how many times have you heard those words? Emotional and psychological trauma is the result of extraordinarily stressful events that shatter your sense of security, making you feel helpless and vulnerable in a dangerous world. Trauma is typically defined as experiencing a threat to your life or witnessing a threat to someone else, and is typically associated with events such as assault or war (shock trauma).

However trauma is not defined by physical harm and is not limited to shock trauma type events. Any situation that leaves you feeling this way can be traumatic, and may cause PTSD. Chronic trauma that occurs in childhood is often referred to as developmental trauma or Complex PTSD (C­PTSD), which is distinct from shock trauma.

PTSD and C­PTSD is often underdiagnosed or misdiagnosed as something else. That's because trauma from years ago can cause so many different problems in adult life, referred to as "symptoms", which don't always fit neatly into a diagnostic box.

It has been estimated that of people who seek treatment for mental health problems, as many of 90% have an underlying trauma. It’s very common for people to repress trauma symptoms for years and then later in life (often in a person’s 40s) they come bubbling up to the surface and cause lots of confusion.

"Trauma survivors have symptoms, not memories"

Trauma sticks in the brain and the body and it doesn't just go away. You can push it down and choose not to think about it, but it comes up in your life in unexpected ways and can destroy happiness.

Symptoms of PTSD:

• Insomnia
• Flashbacks
• Dissociation
• Emotional numbness and avoiding reminders of the trauma
• Intense distress when reminded of the trauma
• Feeling jumpy
• Difficulty sleeping or concentrating
• Inability to remember parts of the trauma
• Inability to experience positive emotions
• Lack of interest in things you used to enjoy
• Overreactions and sudden floods of emotion
• Self-­destructive and impulsive behavior
• Uncontrollable reactive thoughts
• Inability to make healthy professional or lifestyle choices
• Feelings of shame, despair, hopelessness
• Feeling permanently damaged or “broken”
• Inability to maintain friendship or other relationships
• Sexual problems (hypersexuality or inability to be intimate)
• Isolating yourself from friends or family
• Feeling constantly threatened and that you always have to be on guard
• Substance abuse

The traumatic event doesn’t have to cause physical damage. In fact, some research shows that emotional and verbal abuse of a child (yelling at or humiliating them) can sometimes be more damaging than physical abuse.

Regardless of its source, trauma contains three common elements:

1. it was unexpected;
2. you were unprepared; and
3. there was nothing you could do to prevent it from happening.

What is Complex PTSD (C-PTSD)?

C­PTSD is more complicated than simple PTSD since it involves chronic assaults on your personal integrity and sense of safety, as opposed to shock trauma which typically a single, distinct event.
Repeated and chronic abuse and trauma result in a confusing array of symptoms that you may not even associate with your childhood experiences because they usually show up much later in life.

The symptom clusters for C­PTSD are:

• Alterations in regulation of emotions, emotional displays and impulses
• Changes in relationship with others
• Somatic (body) symptoms ­ body memories, aches and pains, unexplained physical problems such as chronic pain, migraines or stomach problems
• Changes in meaning of events in your life
• Changes in the how you see yourself
• Changes in attention and consciousness ­ dissociation, feeling disconnected, "checking out"
• Difficulty setting or maintaining boundaries
• Difficulty maintaining relationships in your personal life or at work

Unfortunately the current version of the DSM (Diagnostic and Statistical Manual) does not recognize C­PTSD as being distinct from PTSD, even though the symptoms are a bit different and international experts in trauma have been trying to have it included in the DSM for years.

Of people who exhibit symptoms of C­PTSD, 99% meet the criteria for PTSD however people with C­PTSD may require specialized treatment beyond what is effective for PTSD.

What kinds of trauma can lead to C­PTSD?

During long ­term traumas, the victim is generally held in a state of captivity, physically or emotionally, according to Dr. Judith Herman in her book Trauma and Recovery. In these situations the victim is under the control of the perpetrator and unable to get away from the danger.

Examples of such traumatic situations include:

• Concentration camps
• Prisoner of War camps
• Prostitution brothels
• Long ­term domestic violence
• Long ­term child physical abuse
• Long ­term child sexual abuse
• Organized child exploitation rings

What Trauma Does to the Brain and Body

When a traumatic event occurs, a flood of cortisol is released. Cortisol prepares you for action and is a natural defense mechanism. Sometimes the cortisol response becomes "stuck" and your body is continuously overflowing with it, and this results in feeling constantly on edge and susceptible to the slightest possibility of harm, emotional or physical.

In his book Mindsight, Dan Siegel writes "If we face an overwhelming situation in which we cannot adequately cope, cortisol levels may become chronically elevated. Traumatic experiences, in particular, can sensitize [our systems] so that even minor stresses can cause cortisol to spike."

In the Triune Brain Theory, brain functions are categorized according to their evolutionary stage. The Lizard Brain evolved first and controls instinctive behavior. The Mammal Brain is more evolved and is the emotional center, and the Human Brain is the most evolved and controls higher order functions. Each part has a specific function that tries to protect us from the damage of a traumatic experience.
The cortisol response comes the oldest part of our brain, the Lizard Brain, which is where our survival instincts reside. The fight/flight/freeze/submit response comes from the Lizard Brain and are our first defense mechanisms. The Mammal Brain holds images, emotions and the ability to form relationships. Because this part is responsible for forming relationships, any trauma that is held here can interfere with having healthy, satisfying relationships. The Human Brain is where we experience rational thought, analyze situations and make decisions about our lives.

This is where we hold the narrative of our experiences.

The trauma response starts in the Lizard Brain with the fight/flight/freeze/submit response. The Mammal Brain holds the images you saw and the emotions you felt at the time of the trauma. These are non­verbal memories. The Human Brain is verbal and tries to make sense of it all, but often fails because the Lizard Brain and Mammal Brain are pre­verbal. Rational communication from the Human Brain to the parts of the brain that most directly experienced the trauma, the Lizard Brain and Mammal Brain, is difficult to impossible. When someone tells you to "just get over it" they are speaking to the Human Brain and the other parts of the brain can't hear the words or the logic that getting over something would be a good idea.

The Lizard Brain is where our survival instincts live. When shock trauma occurs such as an immediate life threat, sexual abuse or rape, there are a couple of immediate defense mechanisms, previously mentioned, that are deployed that help you live through the moment when you perceive that your life is being threatened. The active defenses are fight and flight and use the cortisol response so beautifully described by Robert Sapolsky in his book Why Zebras Don't Get Ulcers. Either we run away from the danger (flight response) or fight back at it (fight response). If the abuse happened when you were a child you may not have been able to run away and you certainly weren't equipped to fight back. Rape victims often have a similar experience ­ they aren't able to fight back or run away. In these cases, the passive defenses of freeze and submit are deployed.

Freeze is the "deer in the headlights" experience ­ you literally can't move, but inside your thoughts and emotions are a storm of activity. Submit is another defense, like when the antelope goes limp in the lion's jaws. The submit option is to play dead, to give up. The Lizard Brain is
telling you that if you play dead, you might be overlooked and might just survive the encounter.

Trauma survivors hold these primitive defenses in body memory.

When you get triggered cortisol goes rushing through your body and one of the 4 primitive defenses shows up ­ whichever one you experienced at the time of the original trauma. You may not even realize that you have been triggered, but you will experience either a flood of emotions or complete absence of them. You may find yourself lashing out at someone who doesn't really deserve it (fight response), running away from a person or a situation that could be enjoyable (flight response), feeling frozen in a moment unable to speak or move or react (freeze response), or going limp and having zero energy, unable to take any action at all (submit response).  This comes from the Lizard Brain, and there's nothing rational about it. The Human Brain isn't even part of the equation yet. Sound familiar?
Trauma is a visceral, emotional experience. Therefore it makes sense that the memories are held in the Mammal Brain ­ the place that non­verbal memories are stored: images, smells, sounds, emotions. That's why, for example, the color yellow might trigger a freeze moment for a person who was abused in a yellow room or by someone wearing yellow. Again, the Human Brain has little to do with it.

So what does the Human Brain have to do with processing Trauma?

The Human Brain is the most evolved part of the brain.

That's where you evaluate options, make decisions, try to make sense of painful experiences and try to cope with them. When someone tells you to “get over it" they are talking to your Human Brain and telling that part of you to ignore the signals from Lizard Brain and Mammal Brain. This doesn't work. 

The Human Brain is very good at helping you cope with the pain, but it can't make it go away.

What is Trauma Therapy and How Can it Help?

You are not alone.

Talking to and healing the Human Brain comes from talk therapy ­ either individually or in a group. There is a part of survivors that craves to be seen, witnessed in their pain, and absolved of it. Survivors often feel very isolated and ashamed. Support groups led by a qualified professional can be very helpful in reducing shame and allowing survivors to feel re­connected with people.

Healing from trauma (shock trauma and chronic abuse) requires integration of signals from the Lizard Brain, the Mammal Brain and the Human Brain.

It requires that you deal with each of these important parts of you. Each part is responsible for a different function and "speaks" a different language, and so you have to speak to these parts in their native tongue. Lizard Brain speaks instinct. Mammal Brain speaks images and emotions.
Human Brain speaks insights and stories. Traditional psychotherapy talks only to the Human Brain. This can help you put the story together, but can't help you process the pain, the images and the triggers. Healing from traumatic experiences requires working with every part of the trauma experience ­ instinct, emotion, images, and thoughts.
Traditional psychotherapy addresses the Human Brain and can be very helpful. By working with the Human Brain you can begin to piece together the story into what's called a coherent narrative, meaning you have filled in the gaps in memory. You can also learn and practice coping skills, such as deep breathing, guided relaxation, and reality testing (checking to make sure you are in the present and not in danger). You also gets insights from the Human Brain. Recognizing patterns that repeat in your life and connecting those patterns back to experiences you had in the past. This all helps you make sense of the situation.

Trauma therapy with the Human Brain helps with:

• Learning coping skills
• Developing insight
• Getting educated about trauma and sexual abuse and the resulting effects on your life
• Developing a coherent narrative

The Mammal Brain is non­verbal and stores the images, smells, sounds, and emotions from the traumatic event. Art therapy and EMDR are approaches that are sometimes used to helps process information stored in the Mammal Brain. Remember though that these images and emotions are stored in body memory. A somatic (body memory) psychotherapy approach is the most effective one for working through this part of the trauma experience.

For example, remember a time when you were triggered by something. Can you also recall what was happening in your body at the time? Were you sweating? Heart racing?

Was there trembling or were there strange aches showing up? The body has a weird way of telling us that something is going on. It doesn't necessarily make sense to our Human Brain, but it's very real.
When was the last time you got sick from a cold or the flu? Were you going through some kind of stress at the time?

During stressful times our immune system shuts down, making you more susceptible to illness. The same thing happens when you are triggered but a traumatic memory.

Somatic psychotherapy uses mindfulness to help you become aware of what your body is telling you. It's like listening to a little child who is screaming and crying and feels all alone. Often all that child really needs is to be held, listened to and soothed. That's how mindfulness of the body can help you heal.

The Lizard Brain stores instincts for survival. The active defenses of fight and flight are often truncated during sexual abuse or assault. You are in danger and fighting back or running away could actually increase your chances of being hurt. So the passive defenses can sometimes be the best possible response to the threat. Far too many survivors of rape and sexual abuse blame themselves for not fighting back harder. But the truth is, their inner wisdom helped them survive by choosing the best defense in the situation. Re­ activating the active defenses through somatic therapy can help transform the entrenched trauma you experience in the present, to a bad memory from the past. This is how healing from PTSD happens.

Recall a moment that you felt triggered. Perhaps you feel your legs freezing up. In the moment of the assault, you may have wanted to run but couldn't. A somatic psychotherapist can work with body awareness and help you experience that feeling of running or pushing away or fighting back. That's your body communicating to you that today, now is a different moment that back then, and that you are empowered. This is deeply healing and speaks to the deepest part of your psyche.

Using approaches to heal all three parts of the brain­ Human Brain, Mammal Brain and Lizard Brain is a path for deep, transformative healing from chronic abuse, sexual abuse and other chronic traumas as well as shock trauma.

Recognizing and understanding the causes and effects of PTSD, C­PTSD and trauma is the first step. Once you understand that, then you will begin to grasp that if you have PTSD, it isn't your fault. The symptoms are a normal, physiological, and evolutionary response to a terrible experience.