COMMENTARY

The Real Story of PTSD

Robert A. Berezin, MD

Disclosures

August 17, 2018

I was driving in Cambridge in a blinding snowstorm on Thanksgiving Day, 1970. When I braked to slow down, my car didn't stop, it just kept on skidding. I slowly continued on. When I approached the stoplight at Memorial Hall, I braked far in advance of the light and skidded twenty feet until the car thankfully stopped. I was worried that someone coming up from behind would crash into me. I couldn't see out my rearview mirror because of the snow accumulation, so I rolled down my window and stuck my head out to watch what was happening behind me. At that very moment, somebody smashed into my car. My head hit the window frame and knocked me out. The next thing I knew, a stranger was sitting in my passenger seat writing down his insurance information. I didn't know how he got there. Then he was gone. I sat stunned for a while, trying to focus my mind. Finally, I gathered myself and drove over the bridge to Mass General Hospital, semi-blind, to have my concussion evaluated.

Something in me changed. What was it? My reality changed. How did this happen?

For the next few months, whenever I slowed down for a stoplight, I always stared back in my rearview mirror, terrified that I'd be hit again. This wasn't a voluntary decision. I couldn't not do it. I watched the car behind me until it came to a full stop. The absence of snowy conditions made no difference. This mysterious reality held sway for many months. I was, in fact, suffering from the consequences of trauma.

Something in me changed. What was it? My reality changed. How did this happen? Understanding what this was about opens the door to understanding major trauma of all kinds.

Human consciousness is organized as a drama in the theater of the brain, which coalesces at around age six. The brain continues to write its narratives all through our lives. In it, emotional experience is mapped through the limbic system. A formative play written with good enough loving will promote authenticity and love. Our inner brain theater corresponds to the vagaries of outer reality and conforms to our being and our functioning.

The key consequence of trauma is that it overrides the original primary play and rewrites it. In so doing, the overwhelming violating abuse of the traumatic story generates a new and darker narrative. In this new drama, we not only experience the terrifying feelings, but our perceptions and our sense of self are shifted.

First, let's look at my traumatic story. My original driving reality was that it was safe and predictable, that I could step on my brake, slow down, and predictably come to a stop. I was in control of the car. But in the incident, my brakes didn't work. Skidding a long way was very unsafe, and became a world of danger. I had no control. The violent crash was unpredictable and came out of nowhere. I was helpless to prevent it. It was terrifying. I could have been killed. The trauma overrode the original safe and controlled play and rewrote the script. In my brain, I was inhabiting this new, dangerous, and terrifying reality.

The question is, how can people recover from the effects of trauma? Recovery is based on taking leave of the new narrative and returning back to the original one? How can this take place?

Initially, from the brain change I was actually denying reality. I was, in fact, safe, and actually in control as I approached a stoplight. But this was no longer a reality I believed. I was experiencing and inhabiting this other brain-created script. I rationally tried to talk myself out of my fear. I knew the truth, but it didn't work. I came to feel angry that I was subject to this irrational fear and there was nothing I could do about it. But that didn't change anything. I gave up and resigned myself to that this was going to be my new lot in life, staring out my rearview mirror every time I stopped. I accepted that I was powerless to change it, and went on this way for months. One day I noticed I wasn't looking through the rearview mirror anymore. The traumatic play had lost its power and I no longer inhabited it. The trauma was over.

I had shifted back to my old narrative of taking for granted safety and predictability. But the deactivated experience, like all mapped experience, remained present in my limbic brain mappings and is still available to be triggered. Life is hard, and scars inevitably remain. Sometimes, even now, on a snowy day, I still find myself reactively looking back in my mirror.

In fact, it wasn't really the passage of time that deactivated my car crash story. A newly written play operates timelessly. I didn't need an intervention, and was able to mourn it on my own as I repeatedly faced it. That does not happen with major trauma. One is seriously lost in a hellish state.

By understanding the etiology of trauma, we can see that the process of recovering from trauma is to deactivate the rewritten, new play. That is accomplished by mourning the traumatic narrative. Mourning a narrative is the universal agent of change. Mourning is really about a story.

Of course, it is most associated with grief. In grief, one mourns the old play of a life together with a loved one in order to accept a new play in which the loved one is gone, which is emotionally denied. One holds onto the old play. Once accepted after denial, bargaining, rage, and sadness, this then allows the new reality to be accepted. The past life together can then re-emerge and be present in memory and be carried in one's heart. In post-trauma, one does the opposite: one mourns the new traumatic drama that has been activated so that it will get deactivated and lose its power, to get back to the original play.

Recovery from trauma isn't always perfect. It just has to be good enough.

This is accomplished by facing the trauma again. In a safe way, one has to relive the new drama again, over and over. And face and mourn the pain of terror, abuse, fear, and feelings elicited in the body. This reverses the belief in the new story and frees one up for regular reality to emerge again. Major trauma always requires helpful psychiatric intervention. It can't be done alone. Recovery from trauma isn't always perfect. It just has to be good enough.

My car crash story is a minor example of trauma to illuminate its central paradigm: trauma overrides and rewrites a more dangerous and darker internal drama, which is then inhabited and believed. With major trauma, working with a therapist is necessary to deal with, face, and relive the traumatic situation in order to mourn it and return to the old narrative.

What is the impact of trauma on the initial writing of the play of consciousness? Trauma by definition is abuse and deprivation. Child abuse—physical, mental, sexual, and emotional neglect—writes plays that are directly pernicious, as sadistic aggression is infused into the primal play. Its cortical mappings reflect this trauma as mediated by serotonin, adrenaline, and cortisol. When written from trauma, it will generate a darker narrative and a damaged play.

It is trauma itself that warps the writing of our formative play. Likewise, it informs our developing personalities with a sense of badness and shame in our identities, and interferes with attachment. As such, it is the cause of future psychiatric issues. The specific and responsive treatment is psychotherapy, where the trauma is mourned in the context of safe emotional holding with the therapist. In general, the earlier in life one is subject to trauma, the more damaging it is. I have seen incestuous sexual abuse starting at age 4. A child was unable to retain the intactness and cohesion of self, which generated a catatonic, schizophrenic response. Additional trauma in the rest of childhood, adolescence, and adulthood rewrites the already formed internal drama.

Post-traumatic effects are a major issue in our world. My driving story is a very minor example of the consequences of post-trauma. Every day, the news shows us major trauma—rape, wars, and child abuse and neglect. Understanding and addressing trauma is the key to psychiatry. I won't delve into the specific traumatic consequences of rapes and child abuse here, but will limit myself to some observations about war trauma. The other major traumas operate in parallel ways.

Veterans have seen and done things in combat that are well outside the experience of regular life. War is inherently kill or be killed. It is the extreme of violence and sanctioned murder. Combat veterans are very prone to suffer post-trauma. Combat scenarios are commonly replayed dissociatively full of danger and horror. They commonly override reality and can feel like they are happening in the present, as the soldier is lost in traumatic war reality. Veterans inhabit their major traumatic play. The power of war trauma is so destructive and overwhelming. Veterans require psychotherapeutic intervention to deal with their overwhelming pain.

The traumatic situation has to be faced and worked through for the soldier to recover and return to his regular drama. The mourning of such situations is very delicate and should be handled very respectfully. Facing and going back through the experiences is the treatment. It is very difficult. As I said, such experiences leave scars, and people can carry significant damage. And often, this is additionally complicated by drug and alcohol abuse. The suicide rate among veterans is very high. In 2012, more soldiers committed suicide than were killed in combat in the Iraq war. Military records from 1979 to 2014 show that an average of 20 veterans a day die from suicide. And one study showed that a veteran commits suicide every 65 minutes, on average. This is a public health emergency.

As was reported recently in the news, the traumatic separation of children from their parents at our southern border scars these kids deeply for life. It is recognized that their brains change from this traumatic separation. The brain change is actually the new play written from the deprivation of love and the absence of loving safety and holding that is the basic parental provision. Their brain mappings reflect such enduring emotional trauma. There is no way America should ever contribute to such a travesty.

Suffice it to say that post-traumas in all walks of life are a major issue of our times. Trauma and its effects are built into the basic way the brain operates. Traumatic effects are universal. They are not a mystery. And the process of recovery reflects what it takes to undo the damage. When we understand the nature of trauma, the necessary treatment is clear. Psychotherapeutic mourning and reliving is the healing process to deal with the suffering and struggles on every level. Psychiatry is a trauma-informed practice. We as a society need to refocus our treatment priorities.

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