Professor Gordon Turnbull on how trauma impacts the imagination

Professor Gordon Turnbull is someone I wanted to interview for this book project for a long time.  He is a consultant psychiatrist who has spent a lot of his career in the Royal Airforce before going into civvy street, where he continues to work as a consultant psychiatrist.  In 2011 he wrote a brilliant book ‘Trauma: from Lockerbie to 7/7: how trauma affects our minds and how we fight back’ which I highly recommend. He pioneered a recognition of Post Traumatic Stress Disorder (PTSD) in the armed services and more widely in society.

He sees trauma, as he told me, as “part of the human condition.  It’s actually the way we learn about things, particularly under duress”.   “It’s oddly not right to see PTSD as a disease”, he continued, “as an aberrant reaction.  It’s actually a normal reaction to an abnormal stimulus.  An abnormally long life threatening experience, so that we actually make the most of that experience to learn a new skill”.  We chatted by Skype, and here is an edited version of our conversation.  I started by asking him just how prevalent, in society, he believes trauma is today:

“Trauma is very, very, very common.  Although the journals and the researchers tell us that it’s about 10% – in America it’s 10%, but of course in this country, where we make an issue out of denying things, the stiff upper lip and what have you is a very real thing, then we tend to put it down more like 1% per lifetime. 1% of people in a lifetime will actually suffer from a trauma reaction.  But it’s much, much greater than that.

So where would you put it?

I would put it up to about 50%.

Really?  Wow..

Yes.  It’s huge.  Because life in itself is a bit of a struggle.  Life, as we live it anyway, is something where we do tend to be exposed to trauma in its different guises.  It may not be that we’ve been shot or involved in some plane crash, or we’ve been in a car that was involved in a collision or anything like that, but it can be something as simple as over-control.  The tendency for some people to want to over-control other people.

For example, while I have worked with many people returning from hostage situations, in reality there are many people who are involved in hostage situations which are not defined as hostage situations in domestic situations in this country.  Where you can have an over-dominating husband, or an over-dominating wife, or even children, who can hold their parents hostage, where the degree of control is too great, and that can have quite a far reaching effect on the normal development of people’s psychology and their maturation.

When people experience trauma, what happens to the hippocampus?  And how vulnerable and fragile is it to trauma?

We shouldn’t see the hippocampus as being damaged by trauma.  When the hippocampus is affected by trauma it loses cells, which make it less conductive.  The hippocampus is really a cable, made of nerve tissue, that transmits information which has come into the non-dominant hemisphere, which is the right hemisphere in a right handed person and vice-versa in a left handed person.

So information, what you see, hear, smell, taste and touch, they all come in to the right hemisphere, where there’s an attempt made to put them together, in an effort to help us feel orientated in the world.  It allows us to have an individual perspective which allows us to have relationships with others.  When you have PTSD, the problem is that the information that’s come in is of a highly traumatic nature, and the hippocampus is actually burnt down, to the extent that it narrows so that the information which is highly toxic remains in the right hemisphere for longer than it would otherwise.

This is actually where it’s at with trauma reactions, and other forms of stress reaction too, which are less severe.  PTSD is really at the end of the spectrum as far as we know, so far, of stress reactions in terms of severity and the way it affects our function.

I saw something where you had said that the hippocampus acts as a ‘fuse’ during PTSD.  Could you say a little bit about that?

It narrows down, through the impact of stress, when you’re traumatised.  You actually go into survival mode, which naturally means that your adrenal glands, which are absolutely at the very core of this reaction, pump out a lot of adrenaline, the flight and fight hormone, and a lot of cortisol, which is the healing hormone, the steroid hormone, into the blood.

When that gets into the brain circulation they both have different functions.  The brain doesn’t want to forget the experience, because it wants to absorb it and process it for survival purposes, for the future, it wants to store up the energy.  So the adrenaline in fact increases the adhesiveness of the memory, like an electrical circuit into the brain’s surface, on the right side of the brain if you’re right handed.  So the memory is more deeply embedded, cut more deeply into the brain substance, so that you probably won’t forget it very easily.  But the other hormone, the cortisol, actually has an effect.  If it goes above a certain threshold level for more than a certain length of time, it actually burns into the hippocampus, the middle part of the hippocampus, which is a cable, and it actually kills cells in the hippocampus.

That has the effect of narrowing the hippocampus down so that you can’t in fact get the information that’s come into the right hemisphere so easily over to the left.  The reason for that is, we think, that the left hemisphere has a different function altogether.  The right hemisphere is an A drive, like one of the old fashioned floppy disks.  The left hemisphere in a right handed person is a C drive, a database.  The brain is trying to protect its database by not letting unprocessed, or under processed, material that’s highly toxic travel from the receptor part of the brain, the right hemisphere, into the left, where it will never be changed.

So the whole system of the hippocampus slows down and you can see this on the MRI scans.  The MRI scan will reveal, in a traumatised person, that the hippocampus has narrowed, when they’re having those symptoms.  When those symptoms go away, that means that the flashbacks and nightmares, the imprint of the trauma has been processed, it actually moves across in an understandable form, onto the left hemisphere, where it’s actually imprinted there permanently.  Therefore the C drive preserves its integrity.

Would you say that it would be a great leap of fantasy to imagine that if you had a population who were experiencing trauma from various directions, that the same things would apply?  That your imagination and ability to positively imagine the future would  decline?

That’s absolutely spot on from my understanding of what happens, because some people have actually ventured that PTSD has the ability to be able to provide a language for people who are in a community which has been traumatised, and which they are all experiencing at the same time, that allows them to actually grow their way out of it.  It’s the language.

Individuals who are psychologically traumatised, they tend to feel like victims.  They tend to feel that they are people who are very, very unlucky, and individually so, and that there’s nothing very much they can do about it.  But a community of people who have been through a traumatic experience, they share the trauma.  They all have a similar reaction, to varying degrees of course, but they do have that, and it can be used as a sort of a language to be able to communicate how they feel to other people, at a time when they’re relatively inarticulate.

If a journalist pokes a microphone in the face of somebody who has been involved in something awful, and they still do that unfortunately, the person who’s been involved will hardly be able to articulate who they are, never mind what they have just been through, because of the horror of it all.  They become inarticulate.  There is a physiological reason for that too.  A lot of things connect together here, but actually there are a lot of neural biological mechanisms that are carrying on.

For example, if we look at the inability to be able to articulate feelings, even in somebody who has been a poet beforehand, somebody who has a special skill in being able to articulate their inner feelings to other people, the pathway, the artery that actually goes into the speech centre, which is in the left hand side of the brain in right handed people, in fact closes down.  The reason for that, we are told by evolutionary psychologists, is that when confronted with a predator, human beings will in fact shut down, including the inability to be able to shriek, shout, shout for help, make any loud sound, because that would simply attract the predator to them, and it would also know they were alive.

Predators tend not to like to eat dead flesh, because they might have been diseased.  The cause of death is not known to them, so they’ll usually shun that.  They like to catch their prey while it’s living and then kill it, and then eat it.  When we didn’t have as many resources as we have now to protect ourselves with predators, then we would be unable to shout or shriek or warn other people that there was a sabre tooth tiger round the rock because it would actually endanger ourselves, and also them.

The way that we respond to shock is governed very much by a nervous system called the autonomic nervous system.  The autonomic nervous system is the nervous system that controls functions which we do not need to control consciously.  They happen as a matter of course.

For example, the respiratory system.  We don’t need to tell ourselves to breathe, and we don’t need to tell our hearts to beat, we don’t need to tell our stomachs to digest food.  So it controls just about everything that goes on in the chest, and everything that goes on in in the abdomen that allows us to continue to live, to create the materials for our brains to work on.

You have a central nervous system which has a conscious part to it, and you have another part of the nervous system called the autonomic nervous system, the automatic nervous system if you like, but it’s called the autonomic nervous system, that has two bits to it.  There’s a brake, and there’s an accelerator.  These are obviously useful to us because they actually gauge our response to things in the most helpful way to be able to survive.

If adrenaline is flooding your system and it’s making you seek opportunities to fight or flee – that‘s what it does, fight or flight hormone – then it will actually change the body function into a mode that actually encourages survival, by either fighting back, hence the part in my title in my book, and actually fight or flee to live to fight another day, to escape.

But the other hormone which controls the slowing down of the autonomic nervous system, and all the organs involved in its control, will actually prevent you from doing that.  It makes you basically freeze and fold.  So you actually play dead.  If that’s the only that you can do, and you’re totally helpless to do otherwise, and you can’t fight and you can’t flee, and the tiger is still there, then the one thing you can do is to drop down onto the ground and play dead.  Play possum if you like.  That is the parasympathetic nervous system.

It’s the part of the nervous system that actually makes us freeze.  So you’ve got those four Fs that govern it.  There’s the fight and the flight, and then there’s the freeze and then there’s the fold, which means we have got an armamentarium of responses which can help us to survive even in the most difficult situations.

You see this in war.  You see this in combat, where soldiers do in fact freeze in battle.  Especially if they have not been in battle before, or if something very unusual happens, like in an ambush.  They see their comrade falling down dead beside them.  They in fact can sometimes fall even though they have not been injured, and the body pretends that they’re dead, until they then in fact get themselves together when the danger is over, and they’ve lived to fight another day.

Writer and rapper Darren McGarvey talks about how in the poor neighbourhood of Glasgow he grew up in, people live in states of ‘hyper-vigilance’, similar to Vietnam vets when they return home… 

Being hyper vigilant means that you’ve had some sort of trigger that’s switched on your survival instincts, and your survival mechanisms, and it’s never been switched off completely, so it actually is triggered off quickly.  It’s there, ready, to be triggered off all the time, so you’re on the lookout, you’re on the watch.

It’s often mistaken for paranoia actually.  I’ve seen quite a lot of people in my clinical work who I had to give a second opinion on who I didn’t think actually had developed schizophrenia or a psychotic illness where they were paranoid, which is part of that particular condition.  And they were paranoid, but they were not really paranoid, they were actually hyper vigilant instead.  But it takes a similar form.  But all that adrenaline surging through your system for many, many years afterwards, can actually lead to high blood pressure, heart disease.  The things that people try to do to calm themselves down, like smoking and drinking, can lead to their own problems.  People develop respiratory diseases and gastro-intestinal diseases, and neurological diseases as a result of it.

So populations of people who have got a history – maybe an accumulative history of historical trauma – will actually have bad health records for that reason.  If you look at nations of the world who do have these records – highly developed societies, so-called, which have a history of war and conquest and having empires, and what have you, you do find high incidences of heart disease and high blood pressure, and diabetes and those particular things.  Whereas if you look at tribes of nomads in Africa, where conflict is very rare, they don’t have responsibilities for harvests because they move around, so they’re relatively stress free, they in fact have very low levels of these particular conditions.

Might I try a hypothesis out on you?  Could  it be that the further we get into a crisis like climate change, into an emergency like that, then actually the less able we are to imagine a way out of it, due to how trauma shuts down our imagination?  Does that sound logical to you?

Yes.  Connecting the hippocampus to that process is actually realistic in populations who are dejected and depressed.  They lose the ability to be able to imagine their way out of a situation, because they lose their creative thinking ability.

If you take an organisation which is known to be really under great stress and pressure, like the National Health Service in this country, then you can imagine that the people who work within that community are actually going to have hippocampi which are not working at their optimum.  They’ll be sub-optimally functioning as a result of that, and therefore they’ll be losing their ability to think of new things imaginatively which would create solutions to problems.  So we seem to get stuck with them, andyou do see in these organisations the same mistakes, or similar mistakes, being made time after time after time.  A repetitive pattern.

And people despair who are outside that organisation who actually think, “Why can’t they think of this?”, and, “Why didn’t they think of that?” But it’s possibly because they’ve lost the ability to be able to be creative and imaginative in that way.  So that would be a process that would go on.

Do you know of any research on populations that shows that kind of impact we were talking about, where you have a situation that gets worse and the hippocampus shrinks and the creativity drops?

Israel might well be a good example if we’re talking about trauma, because Israel seems to be stuck in its range of ways of thinking about solving, or helping to solve, the problems in its part of the world, in the Middle East.  And the same things just go on and on and on.

People outside that region actually lose faith in the ability of the people who are there to actually do something about it.  So from time to time, other countries actually do get involved in the negotiations with them, but none of them, although promising to begin with, none of them have actually produced the goods.  Even when they left the negotiations feeling quite optimistic, hopeful about the future, it hasn’t actually happened when the people who have got to apply those new ideas to their futures have actually got down to the work of applying it.  They keep coming up against the same resistance.

It’s almost like the main players in the Middle East problems can only really resolve them if they are at the same point in their discovery of what they might do.  If their imaginations all light up at the same time, and they can then communicate those ideas to each other, and it then actually spreads.  But you can identify in many Israelis – many of the people who live there now are the descendants of people who were involved in the Holocaust of course.

We know from the literature’s point of view, that transgenerational transmission of trauma is in fact very possible, and has been very studied.  Rachel Yehuda is somebody to look up.  She is a psychiatrist and researcher who actually was a neuroscientist before she became a psychiatrist.  She’s been studying the effects of trauma on people who were holocaust survivors to being with.

That was her first population, in Mount Sinai in New York, where a lot of them, the population of that area of New York, was largely Jewish, and many of them in fact, went there after World War 2.  She was intrigued by the way that the descendants, they themselves, and the descendants of the holocaust survivors, the children, and now the grandchildren, possibly even great-grandchildren now, in fact respond to adversity.

They don’t seem to have very much in the way of resilience.  The natural resilience you would expect from somebody who’s failed an exam, or failed a driving test, is to suck it up and just carry on.  But these descendants don’t do that, they tend to develop the exact symptoms of PTSD.  So that if they went to court with it, they would actually have PTSD, because it would be reliable diagnosis according to the encyclopaedia.  They would have the flashbacks and the nightmares and the avoidance features and the hypervigilance and the hyperactivity that goes along with people with PTSD.

It seems to be way over the top, and it seems to be because the genes are affected by experience. And the genes that control the behaviour for PTSD in fact seem to be susceptible to change from the environment on their ability to be able to control those genes.

In his book ‘The Body Keeps the Score’, Bessel van der Kolk writes “recovery from trauma involves reconnecting with our fellow human beings”.  At the moment we have what sociologists call an ‘epidemic of loneliness’ in this country.  How do loneliness and trauma feed each other?

At its most simple, I suppose that people feel, if they’ve been individually traumatised, i.e. not traumatised as a group, they will actually feel inferior, or they’ll feel like freaks, if you see what I mean.  They’ll actually feel different from other people and therefore inadequate, and they will tend not to mix with other people because they’ll continue to feel that they’ll fail in their eyes, and actually feel more and more depressed about that.

But if you take a group of people who are regularly traumatised, like police officers, or military people, they in fact see around them people who appear to be resilient, and unaffected by the trauma that they’ve been through as well, maybe the same trauma, so they feel inadequate because they’re not actually up to scratch.  And they try to pretend that they’re not affected, which is one of the main reasons that military officers and police officers won’t come forward with their trauma, because it’s an acceptance within themselves that they have behaved differently.

That’s one of the things we try to teach them during their treatment, that they are in fact affected in a normal way to the traumas that their kith and kin, their colleagues, have in fact been affected by as well.  But the manifestation of that trauma is different.  Some people can disguise their trauma for quite a long time by using substances that dampen down the natural physiological responses, like alcohol, tobacco and so-called illicit drugs, things like morphine, opiates, that in fact cause addictions.  So, a lot of addictions, way beyond addictions as we see them commonly.  If you ask the man at the bus stop, can he give you a list of five addictions, he would reel off things like alcohol, cocaine, morphine, things like that, but they forget about things like gambling.

Online shopping.

Yes, yes, buying things.

Facebook.

Sexual addictions and things.  We’re in an age when we’re actually beginning to recognise that.  It’s a huge subject and actually people sometimes say to me, “with such a broad field as psychiatry, how can you be satisfied with working in the field of trauma, because it’s a narrow field within a big, big one?  Does it not make you yearn to actually expand a bit?”

But actually most of the people in the other parts of psychiatry in fact are suffering from trauma, in different disguises.