Chapter 2
C O L L A B O R A T I V E T R E A T M E N T O F T R A
U M A T I Z E D
C H I L D R E N A N D T E E N S
S A X E G N , E L L I S H B , K A P L O W J ,
G U I L F O R D P R E S S ( 2 0 0 6 )
Survival Circuits
How traumatic stress is about survival-in-the-moment
LEARNING OBJECTIVES
To understand how traumatic stress responses relate to systems of the brain
developed for survival.
To understand how traumatic stress responses relate to ‘survival-in-the-moment’.
To review neurodevelopmental variables related to traumatic stress responses.
To review the critical relationship between the social environment and the
developing brain.
Icons Used in this Chapter
Essential Point
Academic Point
Quotation
Case Discussion
Traumatic stress is about survival-in-the-moment. Survival-in-the-moment is
controlled by ancient systems of the brain and body that we call the Survival
Circuits. The Survival Circuits control the way we process traumatic events and
the hold that these events may have on us throughout our lives. We begin our
discussion of the foundations of Trauma Systems Therapy (TST) with a review of
these Survival Circuits and their implications for treating traumatic stress.
First, let us briefly think about the survival. Any discussion of survival must
begin with the amazing work of the nineteenth century T
Charles Darwin (1809-1882)
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British naturalist named Charles Darwin (1809-1882). As most of us know, Darwin
proposed his theory of evolution to explain the natural origins of human beings.
Through his observations of animals on the Galapagos Islands, he noted that the
animals who were best equipped to survive were the most likely to live long
enough to pass on their survival enhancing traits to their offspring. Traits
that helped promote survival become maintained and those that did not promote
survival died out. This is a process called adaptation. New traits can suddenly
develop in a given organism out of what is called “chance mutation”. Those new
traits that give their owner enough of an advantage to reproduce become
integrated into the biology of the species. Over many millions of years, this
process creates species with ever increasing advantages for survival.
Although Darwin’s revolutionary proposal, The Origin of Species (859), was
published almost 150 years ago; it anticipated and is supported by
groundbreaking work in genetics, molecular biology, and developmental
neuroscience, published only in the last ten years. The need to survive has
sculpted our biology. This sculpture has occurred over many millions of years
and has given us, in our genes, our cells, our brains, and our bodies, powerful
mechanisms to survive. Survival is at the core of traumatic stress. It is
enacted on the moment we perceive that our life is in danger; and the surival
circuits control it. 1
v
Survival is at the core of traumatic stress. It is enacted on the moment we
perceive that our life is in danger; and the survival circuits control it.
Survival Circuits
We human beings are at the top of the evolutionary ladder. What puts us up
there? We have a biology that has been refined over millions of years giving us
amazing systems
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necessary to master our environments. We have biology’s with the potential to
create great works of art, science, mathematics, technology, and culture. Our
ability to master our environments, and to achieve the enormous advances in
diverse areas of pursuit, requires our evolutionarily advanced neurobiological
systems to be working properly. The main part of our biology that has allowed us
such powerful and flexible adaptive capacities is our brain, particularly the
higher order systems of our brains located in what is called the cerebral
cortex.
Lower order systems of the brain, such as those that control basic emotionality,
physiology, and survival-motivated behavior are found in the brains of lower
animal species and are also powerfully embedded deep within our human brains.
These lower neurobiological systems are largely responsible for maintaining our
survival so that our higher order brain systems can do their great work. One of
the primary ways that these advanced, higher order brain systems become unable
to do their great work is if there is a perceived threat to survival in the
environment. When this occurs, by virtue of millions of years of evolution and
adaptation, all neurobiological systems work at only one goal: to foster
survival-in-the-moment. As described, the survival circuits are responsible for
survival-in-the-moment responses. It is the engagement of these survival
circuits, in situations where life is not actually in danger that causes the
problem of traumatic stress.
One of the primary ways that these advanced, higher order brain systems become
unable to do their great work is if there is a perceived threat to survival in
the environment.
It is therefore extremely important to understand how seemingly innocuous
stimuli can create the extreme survival-motivated responses, in order to help
traumatized children respond in more adaptive ways.
Once these powerful and ancient systems are triggered the brain and the body
enter a state of processing in order to maintain survival against life
threatening events. The problem is, for individuals with traumatic stress, most
of the time there is no current and immediate life threat. The individual’s
brain and body are responding to a past life threat in the present. Almost all
problems in those with traumatic stress relate to these powerful survival
circuits. It is therefore extremely important to understand how seemingly
innocuous stimuli can create the extreme survival-motivated responses, in order
to help traumatized children respond in more adaptive ways.
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The importance of these survival circuits will be integrated into the definition
of traumatic stress in the next version of the Diagnostic and Statistical Manual
of Mental Disorders (DSM V) (First, 2006), the important guidebook that defines
all mental disorders in the United States and in most areas of the world (APA,
1994). The proposed name for the group of disorders that includes fear, anxiety
and Posttraumatic Stress Disorder will be called Stress-induced and Fear
Circuitry Disorders. These disorders can be understood through the descriptions
of the survival circuits detailed in this chapter.
Survival-in-the-Moment
As we will describe, there is a great focus within TST to understand specific
moments in the child’s life. In essence, these moments are when the survival
circuits get engaged. These are the moments when children feel and do things
that become very problematic for themselves and/or others and lead to the need
for mental health intervention. If these moments were somehow, magically,
removed from a child’s life there would be no need for mental health
intervention. Traumatic stress, as described, is about survival-in-the-moment.
TST is about replacing these survival-in-the-moment responses with responses
that allow a child to grow and thrive.
TST is about preventing survival-in-the-moment responses.
The Survival Circuits connote a way in which the brain processes stimuli that
are potentially life threatening, and translates this perception into life
sustaining responses. In traumatic stress, there are fundamental problems with
this type of processing and responses become highly maladaptive. In order to
understand this more fully, it is important to know what goes on within the
brain and body, between the potentially life threatening stimulus and the
potentially life preserving response. We begin the discussion of this
fundamental process with a description of a moment-in-the-life of a child with
traumatic stress. Consider what happens to Denise, in-the-moment:
It is important to know what goes on within the brain and body, between the
potentially life threatening stimulus and the potentially life preserving
response.
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Denise is a 16 year-old girl with a history of sexual abuse from her mother’s
boyfriend. While at a local mall with friends she saw a man who frightened her.
She later reported that this man reminded her of her mother’s boyfriend. Denise
remembers becoming extremely anxious and became flooded with memories of sexual
abuse. She does not remember walking away. Her friends found her curled up in a
bathroom stall, unresponsive.
This is the case of an adolescent with a history of sexual abuse who was
functioning well, until she saw a man who reminded her of the man who abused
her. When she saw this man, her brain rapidly shifted to survival-in-the-moment.
It is exactly this moment that must be understood and treated within TST.
Denise generally functions well. Most of the time, her higher order brain
systems are engaged and doing their great work. Denise was at the mall having
fun with friends. She was happy, socializing, and very calm. At the moment she
saw this man, she entered a state of extreme fear and then dissociation. These
states of extreme fear and dissociation are entirely motivated by survival.
Traumatized children go from the stimulus (a traumatic reminder) to response (an
extreme emotional state) without the ability to think, calm, and sooth. This
response can be immediate, extreme, and outside of conscious control. An
essential part of intervention is to help children to calm themselves when
confronted by a traumatic reminder so that they do not enter these extreme
survival-in-the-moment states. Denise goes immediately from the stimulus to this
extreme state. If treatment could help her to think, before she responded, she
might have the potential to calm and sooth herself so the extreme responses
would not occur.
One of the main goals of intervention is to prevent children from going from
stimulus to immediate extreme response. A critical problem for traumatized
children is that they frequently live in environments riddled with traumatic
reminders. The stresses of ongoing family violence, community violence,
The transition between states of calmness and states of terror when confronted
by a traumatic reminder is the hallmark of traumatic stress.
How do children with such problems managing emotions and behavior when faced
with a threat, navigate a world full of threats?
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parental substance abuse and mental illness, for example, are frequently part of
the everyday life of a traumatized child. How do children with such problems
managing emotions and behavior when faced with a threat, navigate a world full
of threats? All children must learn to identify, manage, and reasonably respond
to signals from his or her social environment. How does a child with traumatic
stress learn to do this, when she hears any loud voice as angry, or
misinterprets a classmate’s playful nudge as aggressive? How much more difficult
is this task when the child is exposed to ongoing domestic or community
violence, endures parental mental illness and substance abuse, or fears
impending homelessness? This is the problem that our intervention model is
designed to address.
If Denise does not immediately respond with extreme emotional or behavioral
changes and can think about the stimuli of a man who reminded her of her
mother’s boyfriend, she could perhaps understand that the man IS NOT her
mother’s boyfriend and that more adaptive responses are possible. Once Denise
has the ability to think in this way, a lot of good things can happen for her.
The ability to think in this way requires the engagement of the higher order
brain systems that we described. Again: These higher order systems are
undermined by the lower order systems in situations of survival-in-the-moment.
How can higher order brain systems STAY engaged in situations of threat, TST is
designed to help traumatized children’s brains do this.
How can higher orderbrain systems STAYengaged in situations ofthreat, TST is
designedto help traumatizedchildren’s brains do this.
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TST starts with the understanding that traumatized children frequently live in
environments saturated with traumatic reminders (the stimulus) and have limited
ability to regulate their emotional and behavioral responses. As figure 1
illustrates, they go from stimulus to extreme immediate responses
(survival-in-the-moment states). Two types of interventions are instituted as
illustrated in figure 2, a) Social Environmental interventions and b)
Self-Regulatory interventions. Social environmental intervention is about
surveying the social environment for sources of traumatic reminders and trying
to diminish these reminders (the stimulus). Self-Regulatory interventions are
about using both psychotherapeutic and psychopharmacological means to enhance
the child’s capacity to control the immediate responding to the stimulus. As
illustrated in the figure 3, when the stimuli are diminished and the child has
increasing capacity to regulate responses, the potential is developed for
thinking about alternative responses. For reasons that are clear in the
illustration, we call this a “wedge” of cognition.
Social-Environmental Self-Regulatory
Social-Environmental Self-Regulatory
Fig 2. Two types of interventions
Intervention
Fig 3. The wedge of cognition
Intervention
Fig 1. From Stimulus to immediate, extreme response
Stimulus
Response
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Your moment in the zoo
In order to best understand how this works, we will take a walk through your
brain in a given moment between a stressful stimulus and a response. Please
imagine yourself in the following situation:
You are walking down a path in your own thoughts. It is a nice, sunny day. You
feel calm. Suddenly you notice an object coming to you from the right. You
freeze. Your feet are planted in the ground. Your heart is pounding. You are
sweating…You then recognize that the object walking towards you is a lion…that
it is in a cage…and that you are in the zoo… You continue walking and continue
to enjoy your pleasant day at the zoo.
The moment described in the above scenario probably would take under 2 seconds.
Within that time, there was a lot of activity that occurred in your brain that
illustrate very important ideas about the emotional nervous system and its
integral role in survival. These ideas are very important to understand when we
consider the nature of traumatic stress. The moment, illustrated in figure 4,
and the following discussion is adapted from the work of Joseph LeDoux, a
neuroscientist at Rockefeller University who has conducted some of the
pioneering work on emotional processing in the brain, particularly related to
fear. His books The Emotional Brain (1998) and The Synaptic Self (2002) are very
important for understanding how the brain processes threatening stimuli and for
understanding survival-in-the-moment. We also rely on Antonio Damasio’s The
Feeling of What Happens (1999) in our discussion of how emotion, memory, and
consciousness fit together. In this brief chapter, it is hard to truly do
justice to these great areas of research, and parts of the discussion
oversimplify. Nevertheless, there are important components of emotional
processing in the brain that help to understand the nature of traumatic stress
and its intervention.
According to LeDoux, there are two emotional processing systems of the brain.
These two systems work closely together such that we are usually unaware that
there are these discrete systems. These systems are critical for our survival
and, more-or-less, detail the
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aforementioned distinction between the higher order and lower order systems of
the brain. LeDoux calls these two systems the “Low road” and “High road” of
emotional processing. We call these systems considered together, the Survival
Circuits.
Figure 4 illustrates these two roads of emotional processing. As can be seen,
the stimulus of the lion in the zoo passes through the sensory thalamus along
two separate paths. One path (the Low Road) goes directly to a structure called
the amygdala that prepares the body for emergency responses. This pathway is
marked by very quick transmission of sensory information to give the organism
basic information about danger. This pathway is unconscious and does not contain
contextual information. It sacrifices the details in the service of speed so
that you can respond before you are eaten! The other path (the high road)
travels to cortical areas (the sensory cortex, the prefrontal cortex, and the
medial temporal lobe memory system) that process the danger signal, assess its
degree of threat, and transmit signals to the amygdala regarding whether the
stimulus signals safety or danger. This type of processing can powerfully
determine the most adaptive response in-the-moment.
Figure 5: The Survival Circuits
Transmission of Danger Information
Transmission of Danger OR Safety Information
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The information processing shared by the sensory cortex, the medial temporal
lobe memory system, and the prefrontal cortex is very important for determining
an accurate perception of the stimulus and for determining an adaptive response
to this perception of the stimulus. The red arrows in figure 4 indicate
transmission of signals indicating danger. The red/green arrows indicate
transmission of signals that may indicate either danger or safety. Safety
information (green) traveling from high road brain systems (the sensory cortex,
the prefrontal cortex, and the medial temporal lobe memory system) to the
amygdala, diminish amygdala responding and serve to regulate emotion. When
danger information (red) is transmitted from these high road systems, it
maintains the Low road, survival-in-the-moment, response. This type of
information could have been transmitted if, for example, the lion you
encountered had actually escaped from its cage. The amygdala also communicates
directly back to high road systems. These upward pathways indicated by the red
arrows are very important for understanding the nature of traumatic memory. The
remainder of this chapter details the relevance of these concepts for traumatic
stress.
Stimulus, Sensation, Context, Consciousness, and Response
As we walk you through your brain between the stimulus of the lion in the zoo
and your emotional and behavioral responses, we will walk through five
constructs related to brain processing that are captured by LeDoux’s High road
and Low road of emotional processing. These five constructs, considered
together, explain many areas of experience, symptoms, and functioning of
individuals with traumatic stress. It is important to note that these five
constructs are not necessarily engaged sequentially but may be involved in
parallel at various times in the processing of the stimuli.
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1) The Stimulus
People’s response to the external world is based on how they appraise external
stimuli. Most stimuli that are processed do not signal a threat to life and
limb. Some stimuli, however, indicate such a threat. The way in which people
make this distinction is critical for survival and for adaptive responding. At
the zoo, you were confronted with a stimulus. How did you eventually decide it
was safe? How much did you need to think about the lion walking toward you
before you knew that you were (very) unlikely to be attacked? What about Denise
in the mall? How did she decide that the stimulus of a man walking toward her
indicated that her life could be threatened? How did that appraisal determine a
response? As will be detailed next, much of this appraisal is done unconsciously
such that we are completely unaware of the information that bears on
survival-laden responses in the moment. It is very fortunate that these
responses can be processed outside of conscious awareness. Conscious processing
takes time. By the time needed to think about whether the Lion walking toward
you was a threat, you might be eaten (if, for example, the lion had escaped from
its cage)!
At the zoo, you wereconfronted with astimulus. How did youeventually decide it
wassafe? How much did youneed to think about thelion walking toward youbefore
you knew that youwere (very) unlikely to beattacked?
2) Sensory Processing
All the stimuli that confront us are processed through a structure called the
sensory thalamus. This structure has components for processing stimuli from the
5 senses. The stimulus that you and Denise processed was visual. Once the visual
stimulus of the lion in the zoo, and the man in the mall, engages the sensory
thalamus, it is transmitted in two possible directions. One direction is to the
sensory cortex for higher order processing including conscious perception of the
stimulus. LeDoux calls this direction the “High Road”. The other possible
direction is straight to the lateral nucleus of the Amygdala (the “Low Road”).
We will review Amygdala processing in more detail when we discuss Emotional and
Behavioral Response Systems a little later. What is important to note is this
“Low Road” is extremely fast and unconscious. Low road processing transmits bits
of threat-related information very quickly to the Amygdala whose job is then to
initiate emergency responses. This type of information does not include the
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contextual details. It sacrifices these details in the service of speed so that
you can respond to maximize your chance of survival given the threat. The High
Road, which includes the sensory cortex, the Medial Temporal Lobe memory system
(especially a structure called the hippocampus), and the prefrontal cortex are
all engaged to help get the details of the situation so that the most adaptive
response is possible given the stimuli. It is these systems, working together
that help an individual know just how threatening the stimuli are. In order to
do this sensory cortex must engage long term memory stores that contain
experience with similar stimuli, the medial temporal memory system must place
the stimulus in the proper context of time and place, and the prefrontal cortex
must put this information into an individual’s direct awareness (working memory)
in order for considered action to occur. The Low Road, Amygdala system responds
rapidly to incomplete bits of information and facilitates memory storage in such
an incomplete way. This is probably why people have flashbacks when they are
reminded of a traumatic event. Flashbacks are, in essence, bits or flashes of
emotionally laden memory. This type of memory storage is unconscious and is
called the Implicit Emotional Memory System. This memory system is critical for
survival because it stores the memory of survival threatening stimuli so that
when such stimuli are re-encountered survival laden responding can be very
quick. Because this storage is so incomplete, it leads to misperception of
threatening stimuli on future occasions. This helps explain why Denise
immediately had a survival-in-the-moment response when she saw the man at the
mall.
3) Contextual Processing
As described, the Low Road, Amygdala system does its work in a contextless way.
It is ONLY concerned with survival. The Medial Temporal Lobe Memory System,
particularly the hippocampus, provides the contextual details. This is the
system that works with the sensory cortex and other areas of the higher order
cerebral cortex to bring accurate context-laden details provided by the long
term memory systems of the cerebral cortex to help an individual
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accurately understand the understand proper time and place of the stimulus.
The ability to accurately place a given stimulus in proper time and place is
extremely important. What made you know that the stimulus of the lion was not
life threatening? You could correctly place it in the zoo and connect it with
your long-term memory stores of your experiences in zoos. To the degree that
none of these memories includes being attacked by a lion in a zoo, but rather
pleasant times in the zoo and the safety of lions in zoos, you will feel safe
and continue to have your current pleasant day at the zoo. In fact, your initial
response (heart pounding, sweating, feet planted, etc) was mediated by the
Amygdala Low Road but terminated so quickly and unconsciously that you could
have continued completely unaware that it occurred. What terminated this
immediate, low road response? The high road medial temporal memory system,
indicating you were safe by allowing you access to information so that you could
correctly recognize the context you were in. This information would include that
you have been to the zoo many times before, that you have never been attacked by
a lion, that you have never before seen anyone attacked by a lion, and that
lions in zoos, generally, do not leave their cages. Access to this information,
diminishes the bodies emergency responses and leads to the sense of calmness
that you felt only moments after you were alarmed. In figure 4, the arrow (when
green) shows this regulation of response from the Medial Temporal Lobe Memory
System to the Amygdala.
The Low Road, Amygdalasystem does its work in acontextless way. It isONLY
concerned withsurvival.
4) Consciousness
Consciousness implies awareness. It is the awareness, in-the-moment, of the
stimulus, the response, and/or the emotional state of the body. It is also,
in-the-moment, the awareness that there is an agent (YOU) that perceives the
stimulus, carries out the response, and/or feels the emotional state of the
body. As Antonio Damasio says, consciousness is the bringing together of the
self and the object (stimulus), in-the-moment. Accordingly consciousness has a
lot to do with our basic sense
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of identity, or the feeling and thought of who we are. As we have described,
there is a great deal of processing of stimuli and executing responses that
occur completely outside of our awareness. Consciousness is when this processing
reaches our awareness or as Demasio says when we ‘step into the light’.
Consciousness is strongly influenced by areas of the brain called the prefrontal
cortex as shown in figure 4. This is related to what is called ‘working memory’
or the capacity to keep information in awareness, in-the-moment.
Consciousness involvesthe ability to shiftattention to the thingswe want to
attend to.When we perceive stimulisuggesting that our life isin danger, however,
it isvery hard to attend toanything else.
Consciousness is very important for traumatic stress. When you were walking in
the zoo you were initially lost in your thoughts and momentarily not really
conscious about being in the zoo. You of course, at any moment could have easily
shifted your attention from your thoughts to what you were doing (walking in the
zoo) but it is a good thing that you did not need to be completely conscious of
the zoo if you did not need to be. If we do not always need to be conscious of
the context we are in, than we can then shift our attention to other things and
let our higher order brain systems do their great work (perhaps while you were
walking in the zoo you were composing a symphony, solving a scientific problem,
or trying to solve an interpersonal conflict). Conscious thought is experimental
action. It allows us to carefully consider our responses before responding. This
is the wedge of cognition described in figure 3. Consciousness involves the
ability to shift attention to the things we want to attend to. When we perceive
stimuli suggesting that our life is in danger, however, it is very hard to
attend to anything else. How might this work for you and for Denise?
You were ‘in your thoughts’ on your walk in the zoo. At some point, the context
of the zoo intruded on your consciousness in the form of a lion walking towards
you. Prior to achieving this consciousness, your Low road system briefly
engaged. Momentarily after your low road system engaged your high road system
processed the sensation of the lion, compared it with previous memories of lions
in zoos, accurately brought your current context (the zoo) to your moment, and
brought some of that information into your consciousness. Each of the high road
systems of Sensory cortex (accurate perception), medial temporal lobe memory
system (context), and prefrontal cortex (consciousness) sent safe signals (green
arrows from Figure 4) to the amygdala, allowing you
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to enjoy your day. Once Denise was stimulated, she was, sadly, far less able to
shift her attention back to her good time at the mall. The stimulus of the man
who reminded her of her stepfather signaled danger, her low road amygdala system
responded rapidly and extremely. Her higher road systems were not able to
accurately perceive the stimulus to tell her that the man is not her stepfather
and to keep her in the safer context of the mall. Accordingly, what entered her
consciousness was only the context of past abuse. Consciousness involves
orientation to time, place, and person. In the moment, she was disoriented to
when this was, where she was, and who she was. She was a little girl, in her
bedroom, being abused.
Another way of describing why your trip to the zoo was calm and peaceful and
Denise’s trip to the mall terrifying is that, as LeDoux puts it, the amygdala
leads a “hostile takeover of consciousness by emotion (p. 226)”. “..the amygdala
leads a hostile takeover of consciousness by emotion (LeDoux, 2002, p. 226)”.
In other words, when presented with a stressful stimulus the emotional nervous
system becomes so overwhelmed that what enters an individual’s awareness is
dominated by amygdala processing (i.e. fast, fragmented, decontextualized,
aroused), rather than high road processing (i.e. slow(er), calm, linear,
contextual, and (more) conscious). When Denise saw the man at the mall, the
amygdala succeeded in its hostile takeover. When you saw the Lion your higher
order systems fought it back (the amygdala… not the lion).
When Denise saw theman at the mall, theamygdala succeeded in itshostile
takeover. Whenyou saw the Lion yourhigher order systemsfought it back (theamygdala…
not the lion).
5) Emotional and Behavioral Response Systems
The Amygdala, via its Low Road pathway, is designed to quickly and powerfully
prepare the body to react and to survive. Accordingly, it
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engages the emotional and behavioral response systems of the body. These systems
are very important for survival as they mobilize the body to respond very
quickly during situations of danger; so quickly that one is not even aware or
conscious of responding. As can be seen in Figure 4, the lateral nucleus of the
amygdala, integrates information from both the sensory thalamus (the low road)
and the sensory cortex, medial temporal lobe memory system, and prefrontal
cortex (the high road) and uses this information to guide powerful,
evolutionarily-driven, bodily responses.
Pathways from the amygdala’s lateral nucleus go to its central nucleus to engage
systems of the body that will react. This includes hormonal systems via the
Hypothalamic-Pituitary-Adrenal (HPA) Axis that releases energy stores using the
hormone cortisol; the Locus Coreuleus,/Norepinepherine System that activates the
heart and focuses attention on the threat, and the polyvagal system which
increases social engagement from the myelinated vagus nerve or immobilization or
freezing from the unmyelinated vagus nerve (Porges, 1996). These systems also
feed back to the amygdala and to the higher order cortical systems and result in
our awareness of the feeling state of our body. An emotion is the awareness of a
feeling state of the body (Damasio, 1999). This process of self-awareness is
extremely adaptive. It allows an individual to use emotions as signals for
effective action and underlies the critical process of emotional regulation that
will be detailed in the next chapter. We use this understanding about
consciousness of one’s own emotional state to build skills in this area in
chapter 12.
This process of self-awareness is extremelyadaptive. It allows anindividual to
use emotionsas signals for effectiveaction and underlies thecritical process
ofemotional regulation.
The emotional response systems mediated by the central nucleus of the amygdala
have strong connections to motivational/behavioral/reward systems mediated by
the basal nucleus of the amygdala. The basal nucleus then initiates a pathway
that leads to behavioral responses (fighting, running, yelling, etc.) to manage
the threatening stimulus. This pathway begins with a structure called the
nucleus accumbens and directs bodily nerves and muscles to manage the threat. It
is also important that the amygdala’s central nucleus emotional response system
is also connected to this behavior/motivation/reward system. This latter pathway
leads to the
Survival-related emotioncan clearly cause survival-related behavior. Inchildren
with traumaticstress, this survival-related behavior can beviolence, self-mutilation,and
suicide. This behaviorusually follows extremeemotional states such aspanic,
rage, dissociation,and depression.
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release of dopamine in the nucleus accumbens which facilitates its response to
signals from the basal amygdala (LeDoux, 2002). One important practical
implication of this connection is that survival-related emotion can clearly
cause survival-related behavior. In children with traumatic stress, this
survival-related behavior can be violence, self-mutilation, and suicide. This
behavior usually follows extreme emotional states such as panic, rage,
dissociation, and depression. As will be detailed in chapter 7, our assessment
approach operationalizes these basic neurobiological processes.
What about Denise? Denise, as described, does not have a high road system that
will help her correctly identify the stimulus and bring the context of the mall
to the moment. Her responses are thus entirely mediated by the very quick
pathway from the sensory thalamus to the lateral nucleus of the amygdala.
Behavioral/Motivational systems activated while in this emotional state include
running to the bathroom and freezing (as she lay on the bathroom floor). As
described, for Denise this emotional state represented survival-in-the-moment.
The March of the Moments
Traumatic stress in the past, present, and future
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We began this chapter with a discussion of how traumatic stress responses can be
understood via survival-in-the-moment. Our detailing of Denise’ response in the
mall and your response in the zoo allowed us to describe the neurobiology of
these moments through what can be called survival circuits. This way of thinking
about traumatic stress is really built on top of how people are put together
through the very long process of evolution. This also brings us to an
interesting and important idea about human emotion, consciousness, memory, and
sense-of-self; and has important implications for treatment:
Everything-is-in-the-moment!
Everything-is-in-the-moment!
As described, consciousness involves the capacity (through working memory) to
keep only a small set of things in awareness in any given moment. Human
consciousness is ONLY a construct for the present. Human consciousness, and
therefore, the organization of human experience are moment-by-moment. Memory is
the laying down of these present, conscious moments in the brain so that they
can be accessible if we need them.
What happens to themoment that has justpast? What makes usknow that these
momentsjoined together make upourselves as entities thattravel through time
witha continuity of memoryand identity?
What happens to the moment that has just past? What makes us know that these
moments joined together make up ourselves as entities that travel through time
with a continuity of memory and identity? Our ability to know these critical
things requires a process of these moments being laid down, with proper
contextual information and relative continuity of emotional experience between
moments. In other words, the development of a clear and coherent sense-of-self
requires that the high road systems lay down these moments in memory rather than
the low road systems. As described, if the pathway from the amygdala to the
higher order systems is very active, than the memory that gets laid down is
fragmented, disoriented, and decontextualized. Individuals construct a sense of
themselves through the stringing together of moments. This is what has been
called autobiographical memory. The ability to consciously access memory in a
given moment is greatly facilitated if the memory was laid down in a clear,
linear, and context-related way. The emotional state a person is in,
in-the-moment, facilitates this access. If an individual is in an anxious
T R A U M A S Y S T E M S T H E R A P Y
state, for example, it is much easier to access anxiety related memories than
calmness memories. When an individual is in a survival-in-the-moment phase, it
is very hard to access memories of calm moments. One of the main functions of
psychotherapy is to help an individual have access to these memories,
in-the-moment.
Present
Moment
Past
Memory
Anticipated
Future
This person occasionally has another, non-extreme, feeling state indicated by
the change in color (say, sadness). There is no problem or pathology associated
with this feeling state, as it is largely laid down through the higher order
systems. The present moment of sadness is experienced with relative calmness,
and linear, contextual processing.
To the degree that there is continuity between feeling states in-the-moment,
past memory is laid down with relative coherence and is joined with an awareness
of the self that is relatively stable over time. In fact, for individuals whose
life moments are, more-or-less, laid down in such calm, contextual, and linear
ways, their self experience looks more like figure 6. Even though consciousness
works moment-by-moment, the brain has a way of blending moments so that self
experience is continuous.
Present
Moment
Figure 5
Consider the string of boxes in figure 5. Each box indicates a separate moment
in time. Each moment in time is marked by a feeling state indicated by a
respective color. Most people have moments and feelings states that look like
figure 5. Moments consist of relatively stable, calm feeling states (blue
boxes).
Figure 6
Past
Memory
Anticipated
Future
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This fundamental neurological capacity to blend moments is critical for our
ability to form a coherent sense of ourselves over time. This capacity is not
unlike the way the brain is able to take frame-by-frame images of a movie and
construct a complete and continuous story. Consciousness is the
movie-of-our-lives. As Damasio says:
“…the neurobiology of consciousness faces two problems: the problem of how the
movie-in-the-brain is generated, and the problem of how the brain also generates
the sense that there is an owner and observer for that movie.”
Damasio, 1999, pg. 11.
What happens if there is a moment in which survival appears to be threatened?
T R A U M A S Y S T E M S T H E R A P Y
Past
Memory
Anticipated
Future
A moment in which survival is perceived as threatened is indicated in figure 7,
where blue boxes indicate moments of relative calmness and the red box indicates
a survival-in-the-moment state. This experience, like Denise’ moment in the mall
is experienced in a highly fragmented, disoriented way. It then gets laid down
in memory in such a way so that when some of the contextual signals recur on
future occasions, there is a higher likelihood of this survival-in-the-moment
state recurring. This is why Denise will have such states of survival related
emotion whenever she experiences stimuli of a man reminiscent of her stepfather.
This is also why Denise will have such difficulty blending moments as
illustrated in figure 6. Denise’ internal world actually looks more like figure
7. Her experience is riddled with episodes of survival-in-the-moment.
As we described, in states of survival-in-the-moment, individuals like Denise
can become disoriented to time, place, and person. Denise in these moments feels
like a little girl out of control and about to be raped. This is very different
from how she feels in her ‘blue’ moments when she feels calm, happy, and like a
competent girl who is in control of her life. In a way Denise’ emotional life
looks more like figure 9.
Figure 7
Figure 8
Figure 9
Present
Moment
Denise lives parallel lives. Her sense-of-self cannot transition between
emotional state, and she grows up with a very fragmented sense of herself. This
type of problem occurs in conditions of psychopathology such as the dissociative
disorders and some of the personality disorders. The essence of these types of
problems have at various times been called Disorders of Extreme Stress, Complex
PTSD, and Developmental Trauma Disorder where an individuals sense of self can
become state dependant instead of being state independent. Given the obvious
corollary difficulties of forming stable relationships when ones own
sense-of-self is unstable, and the emotional fluctuations that are part of this
instability, children with traumatic stress often grow up with patterns of
painful, unstable relationships. Chapter 3, on emotional regulation, describes
Given the obvious corollary difficulties of forming stable relationships when
ones own sense-of-self is unstable, and the emotional fluctuations that are part
of this instability, children with traumatic stress often grow up with patterns
of painful, unstable relationships.
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some details of this process, including its implications for psychiatric
diagnosis of traumatized individuals. Chapter 5, on interpersonal relationships
details how this pattern of unstable emotion and sense-of-self can lead to
significant difficulties with relationships. As we will describe, perhaps the
child with traumatic stresses only hope of recovery is the development of stable
relationships. It is therefore extremely important that these patterns of
survival-in-the moment are addressed in treatment.
Marching into the Future
One of the most devastating effects of traumatic stress is about its effect on
children’s ability to think into the future. If consciousness is about the
present, and memory is about the past, then planning and anticipation are about
the future. This is about the use of present consciousness, and long term memory
stores, to anticipate the risk and reward of future events and to plan so that
ones needs are met into the future.
One of the most devastating effects of traumatic stress is about its affect on
children’s ability to think into the future.
This ability to see into the future is one of the most powerful functions of the
human brain. At a basic level, this ability maximizes survival through the
ability to calculate survival-related risk given the ever changing environmental
variables that are encountered in everyday life. At the zoo, for example, you
unconsciously performed a calculation that the lion walking towards you was not
likely to pose a risk to your survival because there were a series of metal bars
mediating your relationship with the lion. This calculation also extended into
the future. You (unconsciously) calculated that for the time you would stay in
the zoo, you would be safe. This calculation helped preserve your sense of calm
safety at the zoo but was also made with incomplete information. You had no
information, for example, about whether the lion’s cage was locked or unlocked.
You bet your life that it was locked. Our ability to continually calculate risk
is fundamental for our ability to productively navigate our world. This
calculation of risk always
T R A U M A S Y S T E M S T H E R A P Y
involves incomplete information (your ignorance of whether the cage was actually
locked). We must be able to do this well or we will live lives completely
restricted by survival-related concerns. Our ability to calculate the likely
reward inherent to specific events in the future is critical for our sense of
happiness and pleasure; and to the degree that it motivates behavior to increase
the likely reward of future events, it motivates creativity.
The parts of the brain that perform these calculations are located in the area
called the parietal cortex. The parietal cortex (most specifically the posterior
parietal cortex) performs calculations of the likely risk and reward involved in
future events. We need to be able to do this effectively. This calculation of
‘high-risk’ of the future event influences the behavioral/motivational/reward
circuits to avoid this event. This calculation of low-risk influences the
behavioral/motivational/reward circuits to engage with this event if there is a
sufficient calculation of the probability of reward related to the event. The
posterior parietal cortex calculates probabilities of risk/reward. The results
of these calculations strongly influence emotion and behavior. Neuroscientists
have become very interested in understanding these types of calculations as a
way to understand how the brain influences motivated behavior. This area of
neuroscience has been called ‘Neuroeconomics’ (Glimcher, 2003).
In children with traumatic stress these calculations are extremely important. An
overestimate of the likely risk in events leads to the serious problem of
avoidance of people, places, and things that might remind the child of the
trauma. Traumatized children can, therefore, lead overly restrictive lives. It
is also clinically important that traumatized children can underestimate the
risk of danger and to put themselves in highly dangerous situations. This can
happen when the child is not able to act on interpersonal warning signs and
therefore forms relationships with individuals who repeat the trauma.
Traumatized children also have trouble calculating the likely reward inherent in
future events. They underestimate the pleasure that they might experience in
relationships and activities. The parietal lobes’ calculations of the
probability of risk and reward of future events are a part of an individual’s
ability to visualize
T R A U M A S Y S T E M S T H E R A P Y
Traumatized children will not be able to see their futures if they are fighting
for their lives in the present and if they have trouble seeing any likelihood of
rewards or pleasure in future events.
themselves into the future. One of the tragic problems of traumatic stress is
this lack of ability to see oneself into the future or as Lenore Terr (1990) has
described this sense of a ‘foreshortened future’. Traumatized children will not
be able to see their futures if they are fighting for their lives in the present
and if they have trouble seeing any likelihood of rewards or pleasure in future
events.
A Picture of the Brain
In order to see how closely many of the areas of the Survival Circuits work
together, it is important to see how close they are to each other in the brain.
This is illustrated in figure 11 from the journal ‘CNS Forum’ where the areas of
the brain known to be related to traumatic stress are shown.
As can be seen, the low road, amygdala is situated right beside the high road
hippocampus, a critical part of the medial temporal memory system. Both of these
areas are in close proximity to the sensory thalamus which passes sensory
information to the low road and high road systems, respectively. The emotional
and behavioral response systems are also closely related anatomically. The
hypothalamus is the lead of the HPA axis, which regulates the stress hormones,
required for fight-or-flight. Similarly, the locus coeruleus leads the
norepinepherine systems response, which causes heightened attention to the
threatening stimulus and increases heart rate to help the body respond to the
threat. The prefrontal cortex, as described is critical for holding information
in consciousness.
T R A U M A S Y S T E M S T H E R A P Y
Although, this chapter is not focused on a full research review of the
psychobiology of traumatic stress, it is important to know that many of these
systems are affected and even damaged by trauma. Many MRI studies have reported
that the amygdala is active during memory of the trauma (e.g. Rauch et. al,
1996; Rauch et. al, 2000; Shin et. al, 2004), other studies have reported a
smaller hippocampal size and diminished hippocampal function in those with
traumatic stress (e.g. Bremner et al, 1995, Stein et. al, 1997) although this
finding has not been replicated in children (Carrion et. al, 2001, DeBellis et.
al, 1999) Although a smaller hippocampal size was not found, these investigators
did report a smaller volume of the cerebral cortex in general (Carrion et. al,
2001, DeBellis et. al, 1999). There is a large literature on the dysfunction of
the HPA axis (e.g. Yehuda et. al, 1990; Yehuda et. al, 1993) and the locus
coruleus/norepinepherine system in those with PTSD (e.g. Kosten et. al, 1987;
Southwick, et. al, 2003). Newer research has focused on the relationship between
the ‘high road’ and ‘low road’ as described in this chapter. Shin and colleagues
(2004) found that during a memory of a traumatic event the prefrontal cortex was
less active in those with traumatic stress compared to traumatized individuals
without traumatic stress. This lower activity of parts of the prefrontal cortex
was related to higher activity of the amygdala. Importantly this lower level of
prefrontal activity was also related to the degree of traumatic stress symptoms.
In other words, this important functional MRI study reported that the high road
has difficulty regulating the low road in those with traumatic stress.
Beyond Survival
TST is about understanding how the child’s developing nervous system and its
social ecology interact.
TST is about understanding how the child’s developing nervous system and the
social environment interact. This is reflected in our description of the Trauma
System. In chapter 1, we defined this trauma system as:
T R A U M A S Y S T E M S T H E R A P Y
1) A traumatized child who has difficulty regulating emotional states,
2) A social environment and/or system of care that is not sufficiently able to
help contain this dysregulation
The social ecology (Bronfenbrenner, 1972) of traumatic stress places the child
and his or her developing brain in the center of nested levels of a social
environment. The parts of the brain described by the Survival Circuits are at
the center of the trauma system. One of the most important implications of the
discussion in this chapter on Survival Circuits is how closely linked these
circuits are to social environmental stimuli. Some of the details of the trauma
system will be fleshed out in the next few chapters. Chapter 3 will detail how
the critical developmental construct called emotional regulation works for the
traumatized child. As will be seen, ideas of emotional regulation are highly
related to the Survival circuits described in this chapter. Chapter 4 details
the importance of the social environment and system-of-care for child
development and how, exactly, these systems can go wrong for traumatized
children. Chapter 5 details the importance of interpersonal relationships for
helping or hindering the healthy development of traumatized children. As will be
described these interpersonal relationships are considered to be the cusp of the
trauma system and strongly mediate the relationship between emotional regulation
and the social environment/system-of-care.
The quality of earliest interpersonal relationships sculpts the brains’ Survival
circuits to make the child more or less able to regulate emotion when faced with
a stress. These ‘working models’ of relationships described in the attachment
literature help or hinder the regulation of emotion in future relationships. We
will call strong attachment relationships “Signals of Care” because they work,
exactly, to counteract survival-in-the-moment when a child is confronted with
signals of danger. As will be described, if children live in social environments
and systems-of-care that contain sufficient “Signals of
The quality of earliest interpersonal relationships sculpts the brains’ Survival
circuits to make the child more or less able to regulate emotion when faced with
a stress.
T R A U M A S Y S T E M S T H E R A P Y
Care” this will go a long way to minimizing the risk of a survival-in-the-moment
response. Trauma Systems Therapy has a strong focus on building these signals of
care in the lives of traumatized children.
Finally we end this chapter with some evidence that the Survival Circuits can be
changed through the right type of experiences. Peter Kirsh and colleagues (2005)
at the National Institute of Mental Health recently reported that the amygdala,
the lead of the low road system, can be regulated by a chemical called Oxytocin.
Oxytocin is critical in human life for a lot of reasons. It strongly influences
a woman’s labor and delivery of her baby. It also strongly mediates
breast-feeding and is a chemical know to be critical in animal and human
research for bonding and healthy attachment. Oxytocin is naturally released
during social bonding from the earliest phases of development and is one of the
critical mediators of social attachments. The release of Oxytocin during safe
social contact causes a sense of calmness. Figure 12 shows the results of the
Kirsh experiment.
Individuals were shown pictures of frightening faces and of frightening scenes.
In the placebo condition the areas of the brain that were most active, indicated
by the red color, was the amygdala on both sides of the brain. When these same
individuals were given a dose of Oxytocin and shown the exact same frightening
pictures, the amygdala was no longer active.
Figure 12
T R A U M A S Y S T E M S T H E R A P Y
The profound implications of this experiment go way beyond the possible
therapeutic value of giving frightened people injections of Oxytocin. We all
release Oxytocin naturally in the context of safe and caring relationships and
the release of this chemical leads to our feelings of calm contentment, in these
safe and caring relationships. If the lead of the Survival Circuit is the Low
Road Amygdala, and the Amygdala is regulated by Oxytocin; than strong, safe,
caring relationships will help to regulate the Amygdala and therefore the
Survival Circuit.
The silver lining in this cloud of trauma is that just as bad events can change
the brain in deleterious ways, good events can change the brain in beneficial
ways.
The silver lining in the cloud of trauma is that just as bad events can change
the brain in deleterious ways, good events can change the brain in beneficial
ways. We designed TST to help get the brain, and the child who owns it, to have
experiences that will help them have the future they deserve.
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