Why the symptoms of trauma make sense
I looked again at the list of symptoms. It was long, and overwhelming, and ran to more than two pages. ‘Signs you’ve been traumatised’ promised the infographic. Many of them were cross-referenced – meticulously, helpfully, well-meaningly – to the diagnostic criteria for PTSD in the psychiatric ‘bibles’ of mental disorders, the DSM-5 and the ICD-11. This was an impressive, and somewhat intimidating list. More worrying was that I identified with so many of the items on it.
So this was me, then: a tick-box list of symptoms demonstrating how screwed up I was. ‘Loser!!’ it screamed at me, casually. The more items I ticked, the more it screamed: ‘Bigger loser!’ Forty items – tick, tick, tick: ‘Biggest loser in the world!’ And so shame sat like a heavy puddle of tar in my stomach. I didn’t want to admit to anyone that I had flashbacks, that I was constantly hyperaroused and hyper-vigilant, that I had problems sleeping, that I felt perpetually depressed or agitated, that I had ‘labile affect’ (whatever that was), that I had low self-esteem, that I had amnesia, that I had difficulties in relationships, that I had struggled to maintain a ‘sense of self’. In short, I didn’t want to admit that I was quite as much a loser as this list implied.
Trauma affects us in multiple ways, and delineating its ‘signs and symptoms’ like this can be utterly devastating. Our minuscule hope for recovery is annihilated by the enormity of the problem.
Do lists of symptoms actually help us to recover? I wondered. When they have no core organising principle – nothing to explain why – do they engender understanding and hope? Or do they instead convince us that we are too broken to repair? After all, look at how many things are wrong with us. Surely we’re a write-off, aren’t we? With so many defects, surely it will take forever and a day to make us roadworthy, won’t it?
It certainly feels like that when the symptoms are so numerous and the hope so sparse.
But there’s a flip-side to symptom-lists too: they can help us see when our behaviours originate in trauma, rather than as a shameful character defect. In not understanding trauma, we believe we have a random ‘anger issue’ rather than that we’re stuck in the ‘fight’ response of trauma. We believe we’re just ‘one of those wired kind of people who doesn’t need much sleep’ rather than stuck in the hyperarousal of the ‘flight’ response. We believe we’re lazy and unmotivated rather than stuck in the ‘freeze’ response of the red zone.
So we need to understand how trauma manifests in our lives, but do ‘lists of symptoms’ actually help? In fact, the very word ‘symptom’ hails from the medical model which at its core pathologises our experiences: ‘What is wrong with you?’ it asks, rather than ‘What has happened to you?’
But what if there’s another way of looking at things? What if our ‘symptoms’, rather than being a list of defects, are in fact our best attempts to survive? What if they are the brain and body’s best and most valiant efforts to keep us alive in the face of life threat? What if they are adaptations, both in the moment of trauma and in its eternal aftermath, to help us navigate a dangerous world where adversity is predicted to recur? What if, instead of the brain and body going wrong during trauma, we see their adaptations as best attempts to steer us to safety?
This framework appeals to me mainly because it respects the inherent wisdom of my brain and body. It doesn’t assume that I am sick or defective, or requiring the help of drugs or experts simply to function. Being ‘broken’ and ‘diseased’ is a fundamentally shaming way to view ourselves. It is both painful and it impedes recovery, which requires safety. Shame and self-blame are not, I have found, great ways to feel safe – and both therefore keep us stuck.
And another thought nags away at me: how as human beings did we navigate trauma before the existence of infographics and diagnostic textbooks? As humans, we didn’t ‘Adam and Eve’ into existence in 1980 when PTSD first appeared in the DSM-III. Our existence as a species predates the scientific revolution by roughly two million years. The whole of that time, we have been faced with life threat and yet somehow we have survived. Surely if our responses to trauma are inbuilt and instinctive, so too is its healing?
Perhaps the answer lies more in respecting our ‘symptoms’ as messengers, hearing what they have to say, and working with them to achieve their aims, rather than simply viewing them as brain errors in need of correction?
In fact, if we drill down into what trauma actually is, then its symptoms – what happens in our brain and body afterwards – make a lot more sense. As I’ve discussed elsewhere, trauma is not just a distressing event. Trauma is an experience or environment of life-threatening powerlessness which changes our neurobiology. It takes us out of the confident, relaxed assumption that the world is fundamentally safe, out of ‘daily life mode’ where we are able to focus on relationships and building a better future. Instead, we get stuck in ‘danger mode’ where our body and brain are wired for threat. Trauma is in the persistent prediction of a lack of safety. The purpose of our symptoms is to keep us safe in that dangerous world.
When we exercise, we burn energy. We got hot. We breathe more heavily. We sweat. And we all understand this. When we break into a run (the epitome, some of us may think, of insanity) we don’t freak out at the ‘symptoms’ of heat, breath, sweat. We know that we are heating up because we’re producing more energy for movement, that we’re breathing more heavily to suck up more oxygen to fuel that energy, and that we’re sweating in order to evaporate heat and cool down. No disorder there. No dysfunction. Just an entirely predictable response to a demand placed upon the body.
So why don’t we view the symptoms of trauma in the same way?
The answer probably lies in the way that traditionally we have viewed trauma as a distressing event and that societally we would rather not be distressed – so the pressure is always to ‘get over it’, to go back to normal, to put it behind us. But trauma is an experience or environment of life-threatening powerlessness and its symptoms are warning us not to go back to normal – but to be better safe than sorry. Our survival depends on us taking the threat seriously, and our symptoms are messengers of that state of threat. Our symptoms are trying to keep us alive.
I don’t therefore view our symptoms of trauma as signs that our brains and bodies have developed a fault – in fact, quite the opposite. They’re trying to help. But the symptoms of trauma often don’t look like they’re trying to help, and they result in what instead looks a lot like disordered behaviour. It’s natural that we want rid of these symptoms and to go back to the orderly green zone. But in order to do so we often try to shortcut the process and suppress our symptoms rather than solving our unsafety. That is like turning up the air-con, using an oxygen mask, and constantly dabbing ourselves with towels when exercising – rather than actually getting off the Peloton. With trauma, we need to deal with the root cause of what’s causing the symptoms – a perceived or real lack of safety – rather than just masking those symptoms and calling that ‘recovery’.
The symptoms of trauma are an attempt to stay safe in the face of threat. We need those symptoms to occur because we need to stay safe. And they make perfect sense if we cluster them within the framework of this survival attempt. One way of organising the lists of symptoms therefore is to put them into three categories:
- symptoms of our threat response, leading to a need for safety
- symptoms of dysregulation, leading to a need for soothing
- symptoms of altered memory processing, leading to a need for solutions.
After trauma, the body and brain adapt to an experience or environment of unsafety. It therefore makes sense that we adjust to become more alert to threat. If we can sense it early, maybe we can escape or evade. This lies behind our hyper-vigilance (the way we’re wired to notice everything and be unable to relax), our bias towards negativity (what we often call depression, or hopelessness, or feeling like nothing will ever get better), our sense of foreboding fear (what we often call anxiety), the reluctance to do anything new (our stuckness and resistance to change), our multiple avoidances (avoiding triggers, avoiding people, avoiding emotions, avoiding our own inner experience). The best way to stay alive, our brain reasons, is to avoid anything that resembles the threat in the first place. We avoid the trauma, and we avoid all reminders of it. And we stay on high levels of alert, looking for danger, assuming that every stick is a snake, just to be on the safe side. These aren’t crazy behaviours. They make perfect sense.
Given that the world is dangerous and our brain loads every neutral stimulus with fear, it also makes sense that we’re so dysregulated. We use lots of words to describe this experience – distressed, upset, in a state, on edge, in crisis, numb. Our body is primed ahead of time to deal with ever-imminent threat. Nothing has happened yet, but our body is stretched and ready and on the starting line just in case, because it calculates that that’s the best way to stay ahead of danger. Keep us in amber – in hyperarousal, jittery, anxious, stressed, scared, paranoid – and we’ll be ready for fight or flight in the blink of an eye. Or keep us in red – in hypoarousal, deadened, depressed, unfeeling, unmotivated, stuck in freeze and helplessness and despair – and maybe we’ll conserve energy to get through this; we’ll be flooded with pain relief in anticipation of being swiped at and injured; or the predator won’t either detect us or chase us.
Hyperarousal and hypoarousal, both physiologically dysregulated states, are adaptive responses to a dangerous world where something bad is always just about to happen. They just don’t sit well with a life beyond surviving – a life where we’re trying to thrive, which requires us to be in the green zone with our front brain online. But trauma teaches us that surviving is for now and thriving is for later – even if that later never comes.
Trauma fundamentally impacts our memory too. It has to – this life-threat we’ve experienced needs to dominate our learning. No learning, no life: we’ll be dead. We don’t always need to learn it in explicit, narrative memory comprising facts and knowledge and stories – that part of the brain can be turned off during extreme threat – but we do need to learn it in our bones and guts, in our instincts and reactions. Triggers and flashbacks alert us to even vague reminiscences of the original trauma because they generalise and overestimate just to be on the safe side: we are not triggered by the exact replica of circumstances and experiences of prior trauma. Instead we are triggered by anything that matches an algorithm of ‘near enough’. Triggers cause us both to avoid, and then if that fails to react – which is why they’re so unpleasant. It’s the aversiveness that teaches us to keep our distance, and so our memory is geared towards avoidance of threat.
And sometimes it’s more adaptive for our memory not to remember in a joined-up, explicit, narrative way at all – what we call amnesia. Memory that depends on words and stories is a luxury of being safe, and will slow us down in the face of real threat. And sometimes it’s adaptive for us not to remember – especially when predatory bears live inside the camp and there’s nothing we can do about it. If we don’t want to provoke them, if we need them (because for example they’re our parents), then we need to not react to them and just go along with what they want. The best way of doing this, rather than depending on self-control, is for us not to know, not to remember, that they are bears in the first place. This is what Jennifer Freyd termed ‘betrayal trauma’, and it occurs when we’re abused, for example, by an attachment figure. The memory of the abuse doesn’t help to keep us in relationship with the attachment figure, and so we push it out of conscious awareness: amnesia. Trauma and memory are intimately connected, because both are part of our survival repertoire.
Instead of long lists, therefore, we can cluster our experiences into three simple categories: threat response, dysregulation and memory. All three attempt to keep us safe from future threats. After trauma our brains make a lot of errors, because better safe than sorry: they plan for the worst. They predict that the bad thing is going to happen again, and probably in the next five seconds. And they get us prepped for that, to give us the maximum response time. But in that sense, our brains and bodies haven’t gone wrong. In trying to keep us alive (even if alive means life is grim), they have a preference for safety over reality.
And anyway it’s hard for them to be sure that we are in fact safe now. Our brain is a prediction and risk assessment machine, and it bases decisions on what’s already happened to us and how dangerous that event was. When a lot of big, bad, life-threatening stuff has happened, of course it’s going to assume the worst. It’s trying by doing so to keep us alive.
When we’re not actually safe – when we continue to be in contact with our abusers, or ongoingly subject to repeated victimisation, or stressed beyond our limits – it’s little wonder that the symptoms of trauma persist: they’re supposed to. Dissociation, for example, is the physiological and psychological manifestation of the red zone of freeze, mediated by endogenous opioids flooding our bloodstream. We keep dissociating when we keep experiencing that too-familiar feeling of unsafety. Rather than getting rid of the dissociation, we need to build a sense of safety so that we don’t need to dissociate in the first place.
And that’s true of all our symptoms. The symptoms themselves don’t need fixing. They need to be heard, respected, and responded to.
Threat response = the need for safety
Our heightened threat response indicates our need for safety in every aspect of our life – real and perceived, external and internal. We won’t stop scanning for threat while the threat exists. What I’ve seen repeatedly in my life is that when my symptoms flare, it’s because I feel unsafe – and, rather than it simply being an artefact of the past, very often it is an unsafe situation or relationship in the present that is triggering that response from the past. We are often too quick to blame it on the past and dismiss it as us ‘over-reacting’. But something has triggered it: that’s what needs dealing with. Deal with the threat – take action to become safe and to feel safe – and the symptoms recede. As messengers, triggers and other symptoms go quiet once we respond to their message.
Dysregulation = the need for soothing
Dysregulation speaks of our need for soothing. Again, safety is a prerequisite – it’s folly to relax with a sniper’s scope still trained on us. But having achieved safety, we then need to train our bodies to come back into the green zone again (a process, incidentally, often omitted for troops returning from war). We need to re-regulate what has become dysregulated. We often need to ‘feel it to heal it’ – to let our emotions out, to distress-signal, to be comforted and soothed by the presence of safe people, rather than trying simply to do it all on our own. The work of re-regulation can take a long time – it is a developmental achievement rather than a once-and-done event, because we are shifting our default physiological zone and establishing new neural networks.
Trauma trains us to be in amber or red – we need to train our bodies instead to be in green, and as with all training that takes time and persistence. Medication and other substances can help in the short-term but don’t enable us to grow the neural networks needed for emotional regulation, so can keep us stuck, replicating merely the numbness of the red zone. Our bodies have evolved to be regulated first by other humans, before we can learn to do it for ourselves – and yet beyond childhood this is somehow frowned upon. I believe that we need to revisit the developmental stages we have missed out on in childhood, of learning to be soothed and developing the brain apparatus then to do this for ourselves. The blockage to this is often in finding other humans who will facilitate this, without us becoming unsafe through revictimisation, exploitation or abandonment.
Memory = the need for solutions
The memory adaptations of trauma speak of our need for solutions. Memory is about learning, and learning in this context is about getting better at staying alive. What actions do we need to take, to promote our survival and reduce threat in the future? This is why we often feel the need to tell our story, to talk about what happened to us. It is when we process the memory with another person, going back over the past, that we are able to make sense of it and learn from it. By telling the story of what happened – a process which sometimes can only be pieced together painfully over time, as we try to make sense of fragments of memory, flashbacks and dissociated parts of our personality – we not only make meaning for ourselves, but we also signal to our tribe about the dangers, so that action can be taken by all of us, together. Do we need to erect barriers against the bears who have abused or neglected us? Do we need to set up camp elsewhere? Do we need to go on a bear hunt? Trauma requires a solution – action, not just ‘recovery’. It is adaptive for our survival to find better ways of dealing with threats from bears, but in our 21st century we deem trauma to be a personal matter, and a psychological one only, rather than a societal one. It’s what Judith Lewis Herman referred to in her seminal book Trauma and Recovery as a ‘survivor mission’ and I believe it’s a key part of healing.
If we don’t work with traumatic memory to figure out in some measure what happened to us, we will never be able to learn from it adequately enough to make wise choices in the future. I needed to understand the role of my family in the abuse I suffered in order to put some distance between me and them. Until I had processed that series of traumatic memories, I was constantly vulnerable to their influence and impact. Dealing with traumatic memory calls for us to find solutions – many of them deeply uncomfortable. It is not enough for us to tell our stories: we need to act on them too.
The lists and infographics and diagnostic criteria of everything that is ‘wrong’ with us are one way of conceptualising the impact of trauma, but I don’t think they’re the most helpful. Instead I see our symptoms as representing our best attempts to stay safe in an unsafe world. Seen through this lens, they start to make sense. And in reducing them down to just three clusters, it helps to cut through the noise and confusion:
- Trauma impacts our threat response system, making us avoidant and hyper alert, resulting in the need for safety.
- Trauma impacts our nervous system and leaves us dysregulated, so that we’re ready to respond to threat in the blink of an eye: resulting in the need for soothing.
- Trauma impacts our memory, helping us to stay alive by learning from the threat and putting it front and centre in our brain and body for the future, resulting in the need for solutions: taking action to keep ourselves safe from predators in the future.
How we frame our symptoms will massively impact how we feel about ourselves – as broken, damaged and defective, or as resourceful human beings whose evolutionary journey over two million years has facilitated our survival through these natural, instinctive, in-built responses to trauma. Our symptoms are merely our best, primitive attempts at staying alive – neither a sign of badness nor of madness. Our symptoms are messengers, guiding us towards safety.
And, more than anything, the symptoms of trauma make sense.