Informed Treatment for PTSD

The neurobiology of trauma guides effective healing and recovery. Unresolved PTSD can leave you feeling both overwhelmed and shut down and it is beneficial to know not only why this is happening but how to most effectively respond.

If you have heard of stress you likely are familiar with the notion of fight or flight; or the body’s built in protection mechanism to flee from fight against a dangerous situation or predator. PTSD researchers and treatment providers have also taken a strong interest in the “immobilization” responses that typically occur when fight or flight do not restore safety. Immobilization can present in different ways. Sometimes as a high alert stillness or a freeze of the body, sometimes as a state of fright, and sometimes as dissociation in a flag or faint response.

“We must look beyond fight and flight in the healing of PTSD. Whether you are an individual healing from trauma or a therapist in the role of helping others, this post will help you better understand the stages of trauma response. The neurobiology of trauma provides valuable information to not only understand symptoms but also to guide effective treatment.”

-Dr. Arielle Schwartz

Nervous System 101

The autonomic nervous system (ANS) plays a significant role in our emotional and physiological responses to stress and trauma. The ANS is understood to have two primary systems: the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system is associated with the fight or flight response and the release of cortisol throughout the bloodstream. The parasympathetic nervous system puts the brakes on the sympathetic nervous system, so the body stops releasing stress chemicals and shifts toward relaxation, digestion, and regeneration. The sympathetic and parasympathetic nervous systems are meant to work in a rhythmic alternation that supports healthy digestion, sleep, and immune system functioning.

Beyond Fight and Flight

Trauma interferes with the rhythmic balance of sympathetic and parasympathetic nervous system actions. Furthermore, the parasympathetic nervous system is not only associated with regenerative functions but is involved with immobilization and dissociation. If you are healing from PTSD or are a therapist in the role of helping others it is essential to recognize these two aspects of the parasympathetic nervous system. You can read more about this in my post on Dr. Stephen Porges’ polyvagal theory as related to healing PTSD.

It is helpful to think of the neurobiology of trauma as occurring in stages with degrees of dissociation occurring in later stages. Dissociation is a biological protection mechanism that separates your conscious awareness from frightening feelings or memories. Symptoms exist on a continuum from relatively mild sensations of fogginess, sleepiness, or difficulty concentrating to feeling numb or cut off. In the most extreme situations, you might have lapses of memory or “lost time.” Schauer & Elbert (2010) refer to the stages of trauma responses as the 6 “F”s: Freeze, Flight, Fight, Fright, Flag, and Faint. Let’s take a closer look at their model:

Freeze : The initial stage of responding to potential danger involves freeze. Like a deer caught in the headlights, freeze involves the orienting reflex, an inborn impulse to turn your sensory organs towards a source of stimulation. Here the goal is to “stop, look, and listen” to better understand the situation and to determine if there is a threat. Your pupils will dilate as you turn your head towards the sound or sights that sparked your interest or concern. Most importantly, freeze occurs in preparation for action and is short lived.

: The initial stage of responding to potential danger involves freeze. Like a deer caught in the headlights, freeze involves the orienting reflex, an inborn impulse to turn your sensory organs towards a source of stimulation. Here the goal is to “stop, look, and listen” to better understand the situation and to determine if there is a threat. Your pupils will dilate as you turn your head towards the sound or sights that sparked your interest or concern. Most importantly, freeze occurs in preparation for action and is short lived. Flight and Fight : The second and third stages of responding are maintained by the sympathetic nervous system in which you are mobilized into flight or fight responses. This process involves initial attempts to flee danger; however, if it is impossible to escape you will resort to fight. The sympathetic nervous system increases blood flow to the heart and muscles of the arms and legs accompanied by faster and deeper breathing. Simultaneously, skin will grow cold and digestion is inhibited.

: The second and third stages of responding are maintained by the sympathetic nervous system in which you are mobilized into flight or fight responses. This process involves initial attempts to flee danger; however, if it is impossible to escape you will resort to fight. The sympathetic nervous system increases blood flow to the heart and muscles of the arms and legs accompanied by faster and deeper breathing. Simultaneously, skin will grow cold and digestion is inhibited. Fright : As we look further into the progression of trauma responses, we see that the fourth stage sets in when flight or fight do not restore safety. When there is no escape a “fright” takes over with feelings of panic dizziness, nausea, lightheadedness, tingling, and numbing. According to Schauer & Elbert (2010), this stage is considered to have “dual autonomic activation” seen in abrupt and disjointed alternations between sympathetic and parasympathetic nervous system actions. It is in this stage that we see the initial symptoms of dissociation.

: As we look further into the progression of trauma responses, we see that the fourth stage sets in when flight or fight do not restore safety. When there is no escape a “fright” takes over with feelings of panic dizziness, nausea, lightheadedness, tingling, and numbing. According to Schauer & Elbert (2010), this stage is considered to have “dual autonomic activation” seen in abrupt and disjointed alternations between sympathetic and parasympathetic nervous system actions. It is in this stage that we see the initial symptoms of dissociation. Flag : If there is still no resolution of the threatening situation you will progress into the fifth stage, “flag,” which is the collapse, helplessness, and despair that signals parasympathetic based nervous system shut-down and immobilization. Dissociative reactions dominate this phase. Voluntary movements including speech become more difficult, sounds become distant, vision blurs, and numbness prevails. The heart rate and blood pressure drop, sometimes rapidly, which in some cases leads to the sixth stage, “faint.”

: If there is still no resolution of the threatening situation you will progress into the fifth stage, “flag,” which is the collapse, helplessness, and despair that signals parasympathetic based nervous system shut-down and immobilization. Dissociative reactions dominate this phase. Voluntary movements including speech become more difficult, sounds become distant, vision blurs, and numbness prevails. The heart rate and blood pressure drop, sometimes rapidly, which in some cases leads to the sixth stage, “faint.” Faint: The “faint” response appears to serve several purposes from an evolutionary and survival perspective. When the body succumbs to a horizontal position blood supply increases to the brain. Furthermore, fainting is connected to disgust; an emotional response which rejects toxic or poisonous material. According to Schauer & Elbert, experiencing or even witnessing horrific events such as forced physical or sexual violence can trigger vasovagal syncope (vagus nerve dysregulation) which promotes nausea, loss of bowel control, vomiting, and fainting.

Re-Experiencing and Trauma Conditioning

Chronic, ongoing trauma exposure, such as the case in repeated childhood abuse, can lead to the development of complex PTSD. In such situations repeated fearful experiences or dissociation become conditioned in the nervous system. In adulthood, stressful events, even those sufficiently removed from the original traumatic events, can trigger symptoms of PTSD. If the original traumatic events led to primary conditioning of flight or fight a triggering event may produce anxiety and high arousal. In contrast, if the conditioning was fright, flag, or faint it is more likely to experience dissociative symptoms which may include feeling overwhelmed, foggy, tired, shut-down, light-headed, nauseous, or numb. Such re-experiencing can take minutes or hours to recover from.

The re-emergence of symptoms can lead to re-traumatization, even in a therapeutic environment. Therefore, it is essential that therapists have an understanding of dissociation and knowledge of how to pace therapeutic interventions to create a safe healing environment.

Healing Trauma and PTSD

When healing from a traumatic memory it is necessary to connect to your emotional and somatic responses in a safe and healing environment. Recovery from trauma, especially complex PTSD, requires working with a practitioner who can effectively help you avoid re-enactment of dissociative conditioning during treatment. Here are several keys to successful treatment of PTSD:

Assess for Dissociation : When healing from trauma it is essential that you and your treatment provider complete a thorough trauma history. Assess for situations that may have evoked freeze, flight, and fight but also for those situations that may have evoked the later stages of fright, flag, and faint. Identify current events that trigger re-experiencing of traumatic memories, high arousal emotions such as anxiety or panic, and low arousal symptoms including dissociation.

: When healing from trauma it is essential that you and your treatment provider complete a thorough trauma history. Assess for situations that may have evoked freeze, flight, and fight but also for those situations that may have evoked the later stages of fright, flag, and faint. Identify current events that trigger re-experiencing of traumatic memories, high arousal emotions such as anxiety or panic, and low arousal symptoms including dissociation. Know your “window of tolerance” : The “window of tolerance” was developed by clinical psychiatrist Dr. Daniel Siegel. It refers to an optimal zone of nervous system arousal where you are able to respond effectively to your emotions. When you are outside of your window of tolerance, you will go into survival modes. Feeling anxious, overwhelmed, or panicked is a sign that you are hyper- or over-aroused. Alternatively, feeling shut down, numb, or disconnected is a sign that you are hypo- or under-aroused. Finding a therapist who is actively engaged in tracking early signs of dissociative symptoms of flight and flag, and faint is essential.

: The “window of tolerance” was developed by clinical psychiatrist Dr. Daniel Siegel. It refers to an optimal zone of nervous system arousal where you are able to respond effectively to your emotions. When you are outside of your window of tolerance, you will go into survival modes. Feeling anxious, overwhelmed, or panicked is a sign that you are hyper- or over-aroused. Alternatively, feeling shut down, numb, or disconnected is a sign that you are hypo- or under-aroused. Finding a therapist who is actively engaged in tracking early signs of dissociative symptoms of flight and flag, and faint is essential. Body Centered : It is essential that therapy help you develop mindful awareness of your body in the midst of trauma processing. Awareness of body sensations can help you to regulate (respond effectively) to emotional intensity by recognizing subtle signals of overwhelm or shut-down helping you stay in your window of tolerance. Body awareness helps to pace the process of healing trauma. Engaging in somatic therapy (body centered) interventions during treatment can help to reduce the likelihood of an immobilization response. For example, it can be contraindicated to use relaxation techniques with dissociative symptoms. At such a time, activation by moving your arms and legs brings in mobilization to inhibit immobilization, and keep you grounded in the present moment.

: It is essential that therapy help you develop mindful awareness of your body in the midst of trauma processing. Awareness of body sensations can help you to regulate (respond effectively) to emotional intensity by recognizing subtle signals of overwhelm or shut-down helping you stay in your window of tolerance. Body awareness helps to pace the process of healing trauma. Engaging in somatic therapy (body centered) interventions during treatment can help to reduce the likelihood of an immobilization response. For example, it can be contraindicated to use relaxation techniques with dissociative symptoms. At such a time, activation by moving your arms and legs brings in mobilization to inhibit immobilization, and keep you grounded in the present moment. Dual Awareness : EMDR therapy emphasizes that trauma recovery is the result of your innate capacity to adapt to adversity and process difficult life events. This process is based upon developing a dual awareness state (DAS). You can think of this as having one foot in the present moment and one foot in the past trauma memory. If you step both feet into the feelings, sensations, and images of your traumatic past, you are more likely to become flooded, overwhelmed, or dissociated. In EMDR therapy DAS is achieved through the use of bilateral stimulation as you focus on an image associated with the trauma. You can further increase dual awareness by amplifying present moment sensory awareness using a stimulating scent such as an essential oil, taste such as peppermint gum, or sound such as music.

: EMDR therapy emphasizes that trauma recovery is the result of your innate capacity to adapt to adversity and process difficult life events. This process is based upon developing a dual awareness state (DAS). You can think of this as having one foot in the present moment and one foot in the past trauma memory. If you step both feet into the feelings, sensations, and images of your traumatic past, you are more likely to become flooded, overwhelmed, or dissociated. In EMDR therapy DAS is achieved through the use of bilateral stimulation as you focus on an image associated with the trauma. You can further increase dual awareness by amplifying present moment sensory awareness using a stimulating scent such as an essential oil, taste such as peppermint gum, or sound such as music. Social Engagement: In order to regulate your autonomic nervous system, you need to engage the most recently evolved parasympathetic branch of the vagus nerve called the “ventral vagal complex” or “social nervous system.” This branch functions as a highly refined brake on sympathetic activation and can mediate the abrupt and primitive parasympathetic shut down. Your social nervous system increases your ability to respond effectively when you feel keyed up with anxiety or shut-down with depression. The social nervous system is engaged when you focus on the present moment, breathe fully and deeply, and when you connect lovingly with other people, animals, or yourself via self-compassion.

Reference: Schauer, M. & Elbert, T. (2010) Dissociation following traumatic stress: Etiology and Treatment. Journal of Psychology, 218(2), 109-127

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About Dr. Arielle Schwartz