Making It All Up
As we have discussed, individuals who have experienced severe and repeated trauma typically struggle with a range of serious physical and emotional symptoms. Some of these symptoms include feeling chronically on edge, chronically numb and flat, or alternating between the two; feeling like previously experienced traumas are happening again in the present (re-experiencing emotions and/or sensations); spacing out or detaching from reality; difficulties with thinking or attention; unusual sensory experiences; and physical experiences like pain, difficulty breathing, digestive problems, or sexual problems. Those who are not knowledgeable about complex trauma may conclude that such a severe and varied constellation of symptoms must be inexplicable, unrelated, exaggerated, or even completely made up. Many patients with trauma-related disorders (TRDs) have spent years hearing and believing such messages from health care providers and possibly friends and family. This often leaves them in a state of confusion and distress in which they may belittle and disrespect themselves and their experiences. They may feel they are “making it all up,” are “too sensitive” or maybe are even “crazy.” Therapists working with chronically traumatized individuals must have a coherent theoretical framework for understanding these symptoms in order to educate their patients and to guide their response to what can seem like a baffling level of wide-ranging problems.
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Clinical Example: A client is in the bathroom when her partner comes up behind her and unexpectedly touches her shoulder. It is very important to her to never perpetrate violence toward anyone, but she suddenly shoves him into the wall and runs out of the room. Later, she feels intense shame and cannot explain why she behaved aggressively, when she knows that her partner is a safe person who did not mean any harm toward her. You are able to explain to her that at times, subcortical areas of her brain might respond extremely quickly to cues related to past trauma, to the point where her cerebral cortex is not able to inhibit the automatic defensive reaction that comes from a more primitive brain area. You are able to help her see that while she is responsible for helping her nervous system to recover from trauma, her actions in that moment were not a reflection on her personality and do not mean that she is a violent person. This reduces her shame and confusion.
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Clinical Example: A patient has a disagreement with his partner. His partner raises her voice, and the patient collapses into a chair and stops responding verbally. His partner becomes more upset with him, believing that he is ignoring her on purpose, which causes further tension in their relationship. The patient later insists that he was unable to speak or move in that moment, but cannot explain why. In your next session, you are able to educate the patient about defensive responses and help him to explain to his partner that in moments of distress, survival responses are activated by more primitive brain areas that are not under conscious control. This helps both of them to interpret his behavior from a trauma-informed lens and reduces conflict between them.
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Clinical Example: A patient feels constantly on edge when he is outside of his home. He startles in response to any noise and feels edgy if there are people close to him or if there is any unexpected movement, even if he is in a familiar environment. He does not understand why he cannot “just calm down.” He tells himself that he is relatively safe and that there is no reason to be anxious, but no matter what he tells himself, he continues to experience high arousal in his body and intense reactivity to any sensory stimuli. You talk to him about the innate alarm system and explain to him that in people with TRD, the brain is excessively alert to any possible threat even when someone is in a situation that they intellectually know to be safe. You explain to him that part of the work of the therapy is to learn new strategies to calm his nervous system in more effective ways than just telling himself to calm down, which implicitly involves some degree of shaming himself for having a reaction that is understandable based on his history.
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People often think that fear is the biggest problem that occurs after trauma, and they might have heard about parts of the brain like the limbic system or the amygdala and how these are involved in TRD. We know, however, that people who have been through trauma often have just as many problems with many other emotions like shame, sadness, or anger. We also know that trauma is not just about feeling too much; many people who have been through trauma have difficulties with feeling too little, or being numb most of the time. One way of understanding this is through the corticolimbic inhibition model. This model suggests that one part of the brain (the cerebral cortex) excessively “turns down the volume” (i.e., activation) on the parts of the brain that experience emotions, including the limbic system and the periaqueductal gray, as well as other areas that are involved in emotions. This can be triggered by trauma-related cues. Therefore, instead of feeling fear, there is numbness and absence of emotion, including pleasant emotions. The cerebral cortex seems to turn down the volume on other parts of the brain, too, including parts of the brain like the insula that are involved in how we perceive our bodies and surroundings. This can explain why, along with the feeling of numbness, there might be feelings that one’s own body or surroundings are unfamiliar or strange. Chronic numbness is also related to chemicals produced in the body, including opioid-like substances.