Over a hundred years ago, Joseph Breuer and Sigmund Freud wrote that ‘hysterics suffer mainly from reminiscences’. Hysteria, as a medical diagnosis, has gone out of fashion, outlawed by the psychiatric establishment as imprecise, misogynistic and pejorative. Nevertheless hysteria as well as other outmoded generic diagnoses (neurasthenia, melancholia, hypochondriasis, irritable weakness) were useful inasmuch as they attempted to characterise under a single term those vague unexplained illnesses that had a range of unexplained bodily and psychological symptoms.
Hysteria was therefore medicalised and split into a number of specific but overlapping conditions, which include IBS, CFS/ME, fibromyalgia, functional dyspepsia, migraine, and so on; every speciality has its own unexplained illnesses. Life trauma can feature as an instigator in all of them, especially when the range of symptoms indicate somatisation (several different unexplained diagnoses). They suffer from the ‘visceral tyranny of past events’.
Tense, exhausted and demoralized, otherwise minor setbacks can became major frustrations, amplifying feelings of tension to levels that are manifested as heart palpitations, pressure in the chest, aches in the muscles, diarrhea, abdominal bloating or pain, sickness, headaches and difficulty sleeping. The memory of what happened may not be clear, but the body remembers and ‘keeps the score’.
Even when IBS commences with an attack of gastroenteritis, prospective studies have shown that anxiety, depression or some distressing life situation occurring at the time of the infection predisposes to persistence of bowel symptoms. The same appears to apply to persistent pain following surgery or injury or persistent tiredness following an infectious illness.
In the last few weeks, three British scientists (Tim Bliss, Graham Collingridge and Richard Morris), were jointly awarded the Lundbeck Foundation Brain Prize for their work on long term potentiation (LTP), as a mechanism for learning and memory. Their work described how the things that happen to us on a daily basis leave a memory trace of interconnected neurons in the hippocampus, that part of the emotional limbic system that resembles a sea horse and is situated under the temporal cortex. This memory trace represents what has happened and can be recalled for a short while given appropriate cues – such as ‘what did you have for breakfast this morning?’. Studies using trains of electrical stimuli suggest that the more emotionally significant the event is, the stronger the memory trace. Emotion not only strengthens the memory, but it reinforces it through a cognitive-emotional process of ‘rumination’. The three scientists also discovered that the neurotransmitter, L-glutamate, plays a vital role in the encoding and potentiation of memory acting on two main receptor systems called NMDA (n-methyl D-aspartate) and AMPA. This discovery afforded the opportunity to investigate in experimental animals the behavioural responses to drugs that blocked these receptors.
Although the hippocampus plays a key role in the initial recording of experience, it has a limited capacity and seems to function more as a receiver and relay. When we go to sleep, we reactivate recent memories transferring those that are more significant to the wider neuronal networks in the neo-cortex, that encode and store memories, thus wiping the hippocampal slate clean. This would explain why dreams incorporate aspects of what happened the previous day seemingly categorized by meaningful themes.
Bliss and his colleagues were describing what happens with everyday explicit, declarative memories. When something happens that is so unacceptable to our notion of who we are, it prevents sleep and seems to overwhelm this explicit hippocampal memory storage and spill over into the implicit, unconscious, feeling/body based memory system, based in the amygdala. This explains why the body keeps the score (and never lies). Long term potentiation has also been shown to apply to the amygdala and probably plays a crucial role in PTSD and the storage of implicit, traumatic memories involving the body. This could therefore explain how gastrointestinal symptoms occurring at the time of trauma could be incorporated into a long lasting synaptic loop, which is later reactivated by associations with the context and meaning of the original event. This possibility is not contradicted by observations of immune hyperactivity and changes in permeability and sensitivity since these can all be instigated by trauma and reactivated by the implicit memory of the trauma. In this way the illness appears to have a life of its own, arising spontaneously without any explicit reason. Moreover, the suggestion that long term potentiation is stronger in women might help to explain why IBS and many other unexplained illnesses are more prevalent in women?.
If long term potentiation of traumatic memories is implicated in IBS, it begs the question: how can we extinguish it? Drugs are being developed to modify the NMDA, AMPA or other receptors in order to prevent reconsolidation of a retrieved memory, but to me that approach seems a blunt instrument fraught with the risk of side effects.
Agony aunts and advice columns often counsel people, who split up after a traumatic love affair, to throw away anything that reminds them about their erstwhile partner and move on, but does that just hide the memory from consciousness. Freud described such memories, saboteurs; fifth columnists that always threatened to undermine the body politic. The protagonists in the film, ‘Eternal Sunshine of the Spotless Mind’ erased their traumatic memories using brain stimulation, but they met again by chance and were instantly drawn to each other.
Psychotherapy offers a way of working through the traumatic memory to erase much of the guilt and shame so it is rendered acceptable and harmless while the symptoms associated with it become redundant. Memory is mutable (and unreliable). Every time the gist of a traumatic memory is brought back to mind, it is reworked, added to and changed to make a better story. People don’t so much recall the details of the original event, they only remember the way they last thought about it. So the aim of therapy might be to provide the safe enough environment to help the person rework their story so that it becomes something they can live with and grow from, but does not necessarily need to be factually accurate.
This has to take time. If the nature of the trauma is explored too soon, the feelings of guilt and shame can be so overwhelming that the patient may feel traumatized all over again. When psychological debriefing was proposed as a means of treating people immediately after trauma, it plunged too many into breakdown. Talking about normal everyday events, even playing computer games can help to build the trust that may facilitate disclosure.
Finally there is a rapidly growing interest in the idea of using body based therapies to treat the symptoms of psychological trauma. Techniques that encourage mindfulness: meditation, yoga, EMDR, or focused activities such as cooking, needlework, art, music, jogging, swimming can all help people get in contact with the real world, where their trauma may be viewed from a more healthy perspective. Sensorimotor Psychotherapy encourages clients to become aware of emotional and physical responses to certain triggers by realizing that these once had an adaptive function and to make the necessary changes in body tension and function that facilitate understanding and resolution. There is even a computer game to help people connect more with their body and regain normal function; Nintendo Wii allows the subjects to control activities on through movements of their own body
The good news is that one need not be persecuted by the tyranny of what happened so long ago. Greater understanding of the nature of trauma and its management can help people to move on in health with understanding, wisdom and forgiveness.