Body and Self in the Aftermath of Trauma

New Findings in the Neuroscience of PTSD

New research is beginning to map how trauma fragments the bodily self and with it, our core sense of aliveness in PTSD. This piece explores the research and what it means for healing.

---

The insight that trauma manifests in the body has long been understood by clinicians as well as survivors.

And yet, the mental health field has historically diagnosed posttraumatic stress disorder (PTSD) primarily in cognitive terms.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, updated in 2022, reinforces this orientation. Its diagnostic criteria for PTSD remain exclusively focused on cognition, affect, and behavior.

The symptoms are listed as:

• recurrent and intrusive distressing memories of the event, including:

  • distressing dreams

  • dissociative states or flashbacks

  • psychological distress at exposure to internal or external cues

  • physiological reactions to internal or external cues

• avoidance of stimuli associated with the events

• negative changes in cognition (including memory) or mood

• persistent or exaggerated negative beliefs about oneself, others, or the world

• marked arousal changes (e.g. hypervigilance, sleep disturbance)

Even the inclusion of “marked arousal changes” implies that nervous system hyperarousal and disrupted sleep are psychological and behavioral in nature.

What’s more, the neurobiological foundations that of trauma have long eluded researchers. This has reinforced the notion that bodily aspects of trauma are not evidenced based—a kind of “issues in your tissues” folk understanding.

But a new series of elegant scientific studies is poised to change that.

The studies illuminate beautifully the neural underpinnings of trauma, and the strategies used by the mind, brain, and body in response.

This piece will focus on one strand of this growing body of research: how trauma disrupts the bodily self and its sense of aliveness.

Trauma, Aliveness, and the Bodily Self

The first study maps the mind, brain, and body disruption in trauma with striking clarity, and links it to specific changes in brain activity and network connectivity.

In the paper that accompanied the study, Ruth Lanius and her colleagues reference alterations in the bodily sense of self, including pervasive feelings of disembodiment. She shares the body-based language that many survivors report, such as, “I feel dead on the inside,” or “I feel as though my body does not belong to me.”

And in my clinical work as a psychologist and personal experience as a survivor of sexual assault, disruptions in the bodily self also take other forms:

• lowered interoception (ability to receive and respond to signals from the body)

• compromised proprioception (awareness of movement and space)

• a reduced sense of agency

• anomalies in the vestibular system that helps us keep our balance

• a lowered sense of global desire (which includes motivation, engagement, the seeking out and enjoyment of rewarding experiences, passion for our work and our relationships, and the way we relate to the experience of surprise).

The bodily self is not just personal but social.

Therefore, trauma also disturbs our social body, the mutual attunement we have with others and they have with us that is often referred to in philosophy as intersubjectivity.

(I’ll be unpacking more of this—including interoception, proprioception, vestibular disruption, and peripersonal space—in a 2.5-hour Masterclass this coming Tuesday, June 17. Details below.)

What makes these insights so crucial is that our bodily sense of self isn’t just a secondary version of who we are.

Our bodily sense of self is our sense of self.

It is the foundation for the relationship we have with ourselves and the way we relate to others and the world around us.

Back to the two studies. Ruth Lanius and her colleagues set out to map the neural networks that underpin the sense of self in trauma.

To help hammer a frame around the insights of the first study, let me say that our brains map our conceptual sense of self, often called the narrative self, in regions that differ from those of the bodily sense of self or somatic self.

This may sound like a contradiction to the idea that our bodily self and sense of self are one, but that’s not the case. Science used to “map” brain function by stimulating parts of the brain, noting the response, and then crediting that region of the brain with that response.

Now we know that what drives direct experience isn’t about whether one part of the brain lights up versus another, but their connectivity—that is to say, when and how they “play together,” like families of instruments in an orchestra.

Scientific studies show that self-related processes and autobiographical memories are facilitated by a large-scale network (a grouping of areas) along the midline of our prefrontal cortex known as the default mode network (DMN).

We can think of this area and its processes as the scaffold for our continued experience of the self across time.

Interestingly, for most people the default mode network is at its most active when we’re at rest, which is when we’re not actively focused on something. For this reason, the default mode network often gets equated with mind-wandering. It also comes online when we’re asked to reflect on ourselves or interpret the thought processes of others.

When the default mode network is intact, it helps us to contextualize experience. It tells us that what we feel in any given moment, particularly in the body, is in the present. And by extension, it helps us situate our memories in the past.

But that’s not what happens in trauma.

Ruth Lanius and her colleagues used functional MRI, or fMRI, to image the brains of people with PTSD.

They found that in people with PTSD, the front portion of the default mode network, the one that provides context for experience, goes offline.

The back part, the one involved in reliving memories (called the posterior cingulate cortex), surges into action.

This dysregulation doesn’t just distort memory. It warps time, space, and bodily presence.

This pattern, Ruth told me in an interview, leaves survivors trapped in the past without the context of a present moment or the future.

Survivors may find themselves overwhelmed by visceral flashbacks. And they’ve temporarily lost the cognitive scaffolding that would help them say to themselves, "This is not happening now."

This helps explain why sensory reminders of trauma have feel so immediate and can cause overwhelming fear or panic.

A 2023 study published in the prestigious journal Nature Neuroscience corroborated these findings.

The study showed that unlike sad or happy memories, traumatic recollections—think sexual assaults, natural disasters, school shootings, or terrorist attacks—don’t involve the hippocampus, which regulates long-term memory recall.

Instead, they involve the same region that Ruth Lanius and her colleagues studied: the posterior cingulate cortex. “Traumatic memories are not experienced as memories” per se, the authors wrote in the paper, “but as fragments of prior events” that subsume the present moment.

Daniela Schiller, a neuroscientist at Mount Sinai’s Icahn School of Medicine and an author of the study, said in an interview with the New York Times, “The brain doesn’t look like it’s in a state of memory; it looks like it is a state of present experience.”

Critically, the the stronger reductions in resting-state connectivity across the default mode network, the greater the severity of PTSD symptoms. This holds true across multiple forms of trauma, including combat exposure, interpersonal trauma (think domestic violence and sexual assault) and acute trauma.

And it turns out, Ruth told me, that one particular stimulus brings the default mode network to life: when we’re under threat or dealing with a conscious or unconscious trigger of our trauma.

High levels of arousal animate the bodily self (and sense of self).

Ruth shared a striking example of a long-time patient who reflected on the way heightened arousal, even in the form of risk-taking, can strengthen the sense of self. (Ruth’s patient gave full permission for her to use this anecdote in teaching.)

“I started shoplifting when I was five. I shoplifted well into my adulthood at great risk to me, were I to be caught. It was always confusing why I did this. It was so, so risky. I knew that. But I think the adrenaline organized me, rising it seemed from my belly through my brain, from the back to the front. I felt my feet, I knew my hands and fingers. I had eyes. I was agency. It lit me up. It was essential at five and still at 50. I didn't exist to myself except as that artful dodger. At these moments, I existed. All of me in the act of stealing, I would come online.”

“Isn’t that brilliant?” Ruth asked me, praising both her patient’s coping strategy and the insight she had in reflecting on it. (This illustrates her skill not just as a prominent neuroscientist, but as an empathic and connected clinician.)

“Trauma-related affect and arousal,” she explained, “become coupled with our sense of self.”

This explained a pattern I’d long seen as a clinician and experienced in my own life. Many survivors are drawn to intense forms of physical movement like endurance running, heavy weightlifting, open-water swimming (my preference), rock climbing, martial arts, trail hiking, and extreme sports with an element of danger.

This kind of exercise, Ruth explained, allows people to feel their “edges” or boundaries, which can become unformed in survivors.

Not All PTSD Involves Fight or Flight

What about people for whom hyperarousal is not the primary manifestation of PTSD?

For a long time, the field of mental health treated posttraumatic stress disorder (PTSD) as a uniform experience, encompassing both hyperarousal and hyperemotionality.

Recently, however, the field has recognized a dissociative subtype, D-PTSD. (Despite this, proposals from prominent researchers and clinicians in the field starting in 2012 have not yet convinced the American Psychiatric Association to include the diagnosis in the diagnostic manual.)

While the “classic” subtype of PTSD is characterized by fight-or-flight, D-PTSD is marked by the “freeze” mechanism, and by experiences of depersonalization, derealization, hypo-emotionality, and emotional detachment.

Depersonalization includes the sense that one’s body and one’s self are not real, while derealization makes the environment around us feel as though it’s occurring in a dream. (For more about depersonalization, see this article.)

The dissociative subtype of PTSD may account for as much as 44 percent of all PTSD cases. People with D-PTSD reportedly have a greater severity of symptoms and a higher incidence of additional diagnosis of anxiety, depression, and substance use disorders.

Ruth Lanius and her colleagues have mapped the neural regions that underpin both types of responses, which they call the defense cascade.

A brain region known as the periaqueductal gray (PAG) regulates the defense cascade.

The PAG is one of the brain’s most evolutionarily ancient structures, responsible for coordinating life-preserving responses like fight, flight, or freeze. Interestingly, it also plays a role in the regulation of pain, and therefore in the body’s opioid or pain regulation system.

In hyperarousal, the PAG activates sympathetic-adrenal responses.

In dissociation, it engages the parasympathetic-dominant shutdown or freeze response.

Implications for the Treatment of PTSD

This duet of studies lays a foundation for understanding the bodily roots of PTSD. It also offers alternatives to exposure therapy, which involves gradually exposing people to trauma triggers to reduce the alarm response.

These studies and a host of follow-up experiments explore key elements of embodiment such as proprioception, vestibulation, peripersonal space, and more.

(If you’re interested, I’ll be presenting on these in this Tuesday’s Masterclass.)

These studies also point to innovative ways to address the bodily aspects of PTSD.

Lanius and her colleagues mention breath-based practices, trauma-sensitive yoga, neurofeedback, exercise-based interventions, and deep brain stimulation.

And Negar Fani, a neuroscientist-clinician at Emory University in Atlanta, Georgia, who I also interviewed for the book, is pioneering work with vibro-acoustic therapies paired with breathing in the treatment of PTSD.

There is a revolution happening right now in body-based treatments for trauma.

And it’s not a moment too soon.

---

Sources:

The Diagnostic and Statistical Manual of Mental Disorders: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 See also: Treatment (US), C. for S. A. (2014). Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD [Text]. Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK207191/

In the article, Lanius and her colleagues reference alterations in the bodily sense: Lanius, R. A., Terpou, B. A., & McKinnon, M. C. (2020). The sense of self in the aftermath of trauma: lessons from the default mode network in posttraumatic stress disorder. European journal of psychotraumatology, 11(1), 1807703. https://doi.org/10.1080/20008198.2020.1807703 See also: Frewen, P. A., & Lanius, R. A. (2015). Healing the traumatized self: Consciousness, neuroscience, treatment. New York: W. W. Norton & Company.

Scientific studies show that self-related processes and autobiographical memories: Raichle M. E. (2015). The brain's default mode network. Annual review of neuroscience, 38, 433–447. https://doi.org/10.1146/annurev-neuro-071013-014030

We can think of these processes collectively as scaffolding our continued experience: Lanius, R. A., Terpou, B. A., & McKinnon, M. C. (2020). The sense of self in the aftermath of trauma: lessons from the default mode network in posttraumatic stress disorder. European journal of psychotraumatology, 11(1), 1807703. https://doi.org/10.1080/20008198.2020.1807703

Interestingly, for most of us the default mode network is most active at rest: The brain's default mode network. Annual review of neuroscience, 38, 433–447. https://doi.org/10.1146/annurev-neuro-071013-014030

They found that in people with PTSD, the front portion of the default mode network: Personal interview. March 22, 2024.

Critically, stronger reductions in resting-state connectivity across the default mode: Lanius, R. A., Bluhm, R. L., Coupland, N. J., Hegadoren, K. M., Rowe, B., Théberge, J., Neufeld, R. W., Williamson, P. C., & Brimson, M. (2010). Default mode network connectivity as a predictor of post-traumatic stress disorder symptom severity in acutely traumatized subjects. Acta psychiatrica Scandinavica, 121(1), 33–40. https://doi.org/10.1111/j.1600-0447.2009.01391.x See also: Lanius, R. A., Terpou, B. A., & McKinnon, M. C. (2020). The sense of self in the aftermath of trauma: lessons from the default mode network in posttraumatic stress disorder. European journal of psychotraumatology, 11(1), 1807703. https://doi.org/10.1080/20008198.2020.1807703

This pattern, Ruth added, leaves survivors trapped in the past without the context: Personal interview. March 22, 2024.

A 2023 study published in the prestigious journal Nature Neuroscience corroborated: Perl, O., Duek, O., Kulkarni, K. R., Gordon, C., Krystal, J. H., Levy, I., Harpaz-Rotem, I., & Schiller, D. (2023). Neural patterns differentiate traumatic from sad autobiographical memories in PTSD. Nature Neuroscience, 26(12), 2226–2236. https://doi.org/10.1038/s41593-023-01483-5

Daniela Schiller, a neuroscientist at the Icahn School of Medicine at Mount Sinai and one of the authors: Barry, E. (2023, November 30). Brain Study Suggests Traumatic Memories Are Processed as Present Experience. The New York Times. https://www.nytimes.com/2023/11/30/health/ptsd-memories-brain-trauma.html

(Gift Article: https://www.nytimes.com/2023/11/30/health/ptsd-memories-brain-trauma.html?unlocked_article_code=1.OU8.zdMa.fH0k1QLN2zSG&smid=url-share)

Recently, however, the field has recognized a dissociative subtype of posttraumatic stress disorder: Kearney, B. E., & Lanius, R. A. (2022). The brain-body disconnect: A somatic sensory basis for trauma-related disorders. Frontiers in neuroscience, 16, 1015749. https://doi.org/10.3389/fnins.2022.1015749 See also: Cramer, A. O. J., Leertouwer, I., Lanius, R., & Frewen, P. (2020). A Network Approach to Studying the Associations Between Posttraumatic Stress Disorder Symptoms and Dissociative Experiences. Journal of traumatic stress, 33(1), 19–28. https://doi.org/10.1002/jts.22488

Despite this, proposals from prominent researchers and clinicians: Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The Dissociative Subtype of Posttraumatic Stress Disorder: Rationale, Clinical and Neurobiological Evidence, and Implications. Depression and Anxiety, 29(8), 701–708. https://doi.org/10.1002/da.21889

But the “freeze” mechanism, also called “tonic immobility,” turns out: Terpou, B. A., Harricharan, S., McKinnon, M. C., Frewen, P., Jetly, R., & Lanius, R. A. (2019). The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray. Journal of neuroscience research, 97(9), 1110–1140. https://doi.org/10.1002/jnr.24447

The dissociative subtype of PTSD may account for as many as 44 percent: Kearney, B. E., & Lanius, R. A. (2022). The brain-body disconnect: A somatic sensory basis for trauma-related disorders. Frontiers in Neuroscience, 16, 1015749. https://doi.org/10.3389/fnins.2022.1015749 See also: Terpou, B. A., Harricharan, S., McKinnon, M. C., Frewen, P., Jetly, R., & Lanius, R. A. (2019). The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray. Journal of neuroscience research, 97(9), 1110–1140. https://doi.org/10.1002/jnr.24447

Lanius and her colleagues mention breath-based practices, trauma-sensitive yoga, neurofeedback: Kearney, B. E., & Lanius, R. A. (2022). The brain-body disconnect: A somatic sensory basis for trauma-related disorders. Frontiers in neuroscience, 16, 1015749. https://doi.org/10.3389/fnins.2022.1015749

And Negar Fani, a neuroscientist-clinician at Emory University in Atlanta, Georgia: Fani, N., Guelfo, A., Barrie, D. L. L., Teer, A. P., Clendinen, C., Karimzadeh, L., Jain, J., Ely, T. D., Powers, A., Kaslow, N. J., Bradley, B., & Siegle, G. J. (2023). Neurophysiological changes associated with vibroacoustically-augmented breath-focused mindfulness for dissociation: Targeting interoception and attention. Psychological Medicine, 53(16), 7550–7560. https://doi.org/10.1017/S0033291723001277