This chapter focuses on identifying and working with dissociative symptoms and dissociative disorders in a therapeutic context, providing a road map to assist with the pacing and planning of clinical interventions. Rapid eye movement (REM) sleep can be conceptualized as a household strength processor that can accommodate the usual processing requirements of daily life. Posttraumatic stress disorder (PTSD) has been historically defined as requiring a trauma that is outside the range of normal human experience. Hypoarousal and parasympathetic activation that are an intrinsic part of dissociative symptoms are much more difficult to assess. The original painful memories live on in flashbacks and nightmares as well as in reenactments of the unconscious dynamics captured from the family of origin’s enactments of perpetration, victimization, rescuing, and neglect. Excessive sympathetic nervous system activation is easily construed to be an indicator of psychopathology.
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This book was conceived out of the authors' shared vision to synthesize key neurobiological developments with effective developments in clinical practice to offer both understanding and practical guidance for the many practitioners working to heal people burdened with traumatic sequelae. It is unique in bringing in all levels of the brain from the brainstem, through the thalamus and basal ganglia, to the limbic structures, including the older forms of cortex, to the neocortex. The book looks at the neurochemistry of peritraumatic dissociation (PD) and explores the effects on neuroplasticity and the eventual structural dissociation. Individual chapters focus on the definition of PD and tonic immobility (TI) and their associations with posttraumatic psychopathology, and review disturbances in self-referential processing and social cognition in posttraumatic stress disorder (PTSD) related to early-life trauma. Separate chapters focus on the modulatory role of the neuropetides in attachment as well as autonomic regulation, and highlight mesolimbic dopamine (ML-DA) system as central to the experiences of affiliation, attachment urge when under threat, attachment urge during experience of safety, and to the distress of isolation and/or submission. The book while increasing awareness of different parts of the self and ultimately creating a more stable sense of self, also incorporates psychoanalytic, cognitive behavioral, and hypnotic methods, as well as specific ego state, somatic/sensorimotor therapies, eye movement desensitization and reprocessing (EMDR), and variations of EMDR suitable for working with trauma in the attachment period. The latter methods are explicitly information-processing methods that address affective and somatic modes of processing.
This chapter reviews a range of tools and approaches for the stabilization of traumatized patients and the containment of eruptions of traumatic material until they can be effectively addressed in a later phase of treatment. The International Society for the Study of Trauma and Dissociation (ISSTD) Treatment Guidelines describe the consensus model in three phases, to include stabilization, trauma metabolization, and integration phases of treatment. Many patients experience continuous swings from one extreme of arousal to the other or have lives characterized by chronic shutdown, punctuated with occasional explosions of high arousal. Consistent with the theory of optimal arousal level, the patient must have the capacity to tolerate somatic sensation and affective awareness in order to process through any channels of information that comprise traumatic memory. Therapy will often need to help establish resources for traumatized patients through basic psychoeducation, an essential feature of preparation for poststabilization trauma reduction work.
- Go to chapter: Alexithymia, Affective Dysregulation, and the Imaginal: Resetting the Subcortical Affective Circuits
Alexithymia, Affective Dysregulation, and the Imaginal: Resetting the Subcortical Affective Circuits
This chapter focuses on the strategies that use neocortical resources of imagery to increase affective mentalization as well as, possibly reset them to allow increased adaptive, relational, and intersubjectivity capacity. Brain organization reflects self-organization; and human emotions constitute the fundamental basis the brain uses to organize its functioning where parent-child communication with regard to emotions directly affects the child's ability to organize his- or herself. Alexithymia and affective dysregulation play a significant role in that they constitute profound barriers for the effective treatment of traumatic stress syndromes and dissociative disorders by directly interfering with emotional processing as well as contributing to emotional destabilization. Traumatic stress and early childhood trauma has been associated with alexithymia, affective dysregulation, and deficits with regard to affective mentalization. Mentalization has been described as the ability to read the mental states of others through the brain’s mirror system.
This chapter suggests that multiple animal models are relevant to our understanding of the phenomenology of traumatic dissociation. It includes the literature of learned helplessness (LH), stress-induced analgesia (SIA), as well as tonic immobility (TI). The opioid-mediated stress response is evident in all humans, though the extent and severity of it ultimately determines to what extent structural and pathological dissociation arises. The peritraumatic opioid activation is a probable functional mechanism for the development of phenomena related to pathological dissociation, structural dissociation, and somatoform dissociation. The endogenous opioid system is part of a stress-response mechanism that has its origins in the invertebrate nervous system. Prolonged stress appears to exacerbate the organism’s response to endogenous opioids. Catalepsy is a phenomenon related to immobilization that can be induced by emotional shock. The autonomic nervous system will respond to stress with both sympathetic and parasympathetic activation.
- Go to chapter: The Clinical Sequelae of Dysfunctional Defense Responses: Dissociative Amnesia, Pain and Somatization, Emotional Motor Memory, and Interoceptive Loops
The Clinical Sequelae of Dysfunctional Defense Responses: Dissociative Amnesia, Pain and Somatization, Emotional Motor Memory, and Interoceptive Loops
A posttraumatic disruption of personal memory in dissociative amnesia has also been linked to underactivity in the right inferolateral prefrontal cortex (PFC), an area described by the authors as strongly interconnected with the amygdala and participating in the retrieval of negatively valenced autobiographical memories. The role of endocannabinoids in stress-induced analgesia (SIA) was confirmed by studies of brief, continuous electric foot shock applied to rats. Many trauma survivors have somatoform features that, by their subjective nature, are difficult to study in animal models. A severe pain etched in the mind/brain through the emotional memory system embodies a compartmentalization, which allows life to continue otherwise as apparently normal. The medically unexplained symptoms are the result of trauma-induced changes in pain and inflammation mediators at diverse parts of the interoceptive loops instantiated at different developmental stages. The memory system for emotionally charged uncompleted sequences of movements overlaps with procedural memory.
This chapter addresses crises precipitated by problems in the relationships among the patient's internal states. It focuses on increasing awareness of different parts of the self and ultimately creating a more stable sense of self. The chapter describes interventions into instability or crises related to an internal locus of disturbance. An important early-stage approach to increasing patient stability involves the application of ego state therapy's conceptual framework and tools in an effort to reduce conflict among parts of self. A beneficial strategy in the treatment of shame involves approaching the damaged sense of self using object awareness, rather than ego awareness to evoke a tolerably remote, quasi-objective stance. When the locus of an ongoing or acute disturbance in a patient's life is centered in relationships among his or her states, systematically addressing that internal conflict can greatly increase stability.
This chapter describes two of the frequently occurring and important peritraumatic responses, namely, peritraumatic dissociation (PD) and tonic immobility (TI). It focuses on the definition of each phenomenon and their associations with posttraumatic psychopathology as it considers the relevant neurobiology. Dissociative reactions that may occur during trauma exposure include emotional numbing or detachment, reduced awareness, and distortions of reality. The main feature of TI is reversible physical immobility and muscular rigidity, which can last from a few seconds to many hours. Research regarding the basis, function, and mechanisms underlying the TI response has resulted in the acceptance of the fear hypothesis (FH), a multidimensional model of TI. Researchers have also examined the brain structures involved in the expression of TI, and three regions appear to be the most relevant to the induction and inhibition of this phenomenon: the frontal lobes, the limbic system, and the brainstem.
Safe embodiment is a concept that is at the core of successful treatment of traumatic stress syndromes and dissociation. Therapy with eye movement desensitization and reprocessing (EMDR) requires a potential patient or client to have access to an imaginary safe place to support calming if there is a danger of overwhelm. The experiences of belonging, safety, mindful awareness, and compassion for self and others create or restore the body state of security displaced by trauma, abuse, or neglect. Neuroplasticity can also promote some degree of repair to the brain, not only through altered function of specific brain areas but also through neurogenesis. The primary advanced human awareness may be that engendered in the anterior insular cortex (AIC) with the experience of one’s own existence as a sentient being. The evolution of the cortical mantle provides ample scope for the compartmentalization of areas of conscious awareness in the dissociative disorders.