This chapter describes maneuvers to access the internal system of the patient as well as means to accelerate or decelerate the work in that process of accessing the self-system. Eye movement desensitization and reprocessing (EMDR), ego state therapy, and somatic therapy fit together like hand and glove. An extended preparation phase is often necessary before trauma processing in complex traumatic stress presentations and attachment-related syndromes, particularly when dealing with the sequelae of chronic early trauma. Clinical practice suggests that the adjunctive use of body therapy and ego state interventions can be useful, during stabilization and later on in increasing the treatment response to EMDR. Traditional treatment of complex posttraumatic stress disorder (PTSD) and dissociative disorders has usually included hypnoanalytic interventions, during which abreaction is considered an important part of treatment.

This chapter focuses on the modulatory role of the neuropetides in attachment as well as autonomic regulation, discussing sympathetic and parasympathetic arousal, particularly dorsal vagal and ventral vagal regulation as suggested by polyvagal theory. The probable role of the endogenous opioid system in the modulation of oxytocin and vasopressin release is discussed with a view toward the elicitation of both relational and active defensive responses are reviewed. Porges’ Polyvagal Theory delineates two parasympathetic medullary systems, the ventral and dorsal vagal. Brain circuits involved in the maintenance of affiliative behavior are precisely those most richly endowed with opioid receptors. Avoidant attachment is commonly associated with parental figures that have been rejecting or unavailable and refers to a pattern of attachment where the child avoids contact with the parent. The similarity of severe posttraumatic presentations to autism suggests that the research with regard to social affiliation in autism spectrum.

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.

This chapter reviews the disturbances in self-referential processing and social cognition in posttraumatic stress disorder (PTSD) related to early-life trauma. It talks about the neural underpinnings of self-referential processing and examines how they may relate the integrity of the default mode network (DMN). The chapter describes the deficits in social cognition, with a particular focus on theory of mind in PTSD and the neural circuitry underlying direct versus avert eye contact. It then addresses the implications for assessment and treatment. Johnson demonstrated that self-referential processing is associated with the activation of cortical midline structures and therefore overlaps with key areas of the DMN in healthy individuals. Healthy individuals exhibited faster responses to the self-relevance of personal characteristics than to the accuracy of general facts. Less activation of the medial prefrontal cortex (PFC) was observed for the contrast of self-relevance of personal characteristics relative to general facts as compared to controls.

This chapter focuses on educational purposes for the promotion of research. It helps the practitioners to study the available evidence and use professional discretion in their prescribing decisions, being fully aware of known potential risks as well as benefits. The literature describes the use of opioid antagonists in a number of different disorders, some of them traumatic stress and attachment-related disorders, as well as dissociative disorders. Self-injurious behavior is common in the more severe traumatic stress syndromes. It also happens to be one of the diagnostic criteria of borderline personality disorder (BPD), a diagnosis that has been associated with childhood abuse and attachment conflicts. Pathological gambling is thought to provide rewards through endogenous opioid effects on the mesolimbic dopamine system. Fibromyalgia is a chronic pain disorder that is thought to result from the type of autonomic system dysfunction to which traumatic stress disposes.

This chapter highlights 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. As the midbrain defense centers hold the capacity for stress-induced analgesia (SIA), the tendency to dissociation, which is established with disorganized attachment in very early life, is considered to be secondary to modifications of their sensitivity. Trauma survivors have a default setting that keeps them in threat mode, whether triggered easily by memories of physical danger or separation distress. In a secure attachment relationship, the child can learn the rewards of interaction without threat. The frozen indecision is replaced by a disconnection from the experience of the moment, which relieves the distress. Environmental stress alters the nursing behavior of the mother rat so that she ceases to do so much licking/grooming.

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.

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.

This chapter focuses on the relationship between dissociative parts of the self or personality and discrete psychobiological behavioral or "action" systems that are aroused in response to conflicting demands of defense and avoidance. Psychobiological systems that organize responses to both internal and environmental stimuli can help unravel the complexity of trauma-related dissociation. The chapter presents approaches from sensorimotor psychotherapy (SP) that highlights the use of controlled actions to help overcome traumatic repetitions and fixed defenses. Each daily life action system is characterized not only by specific behaviors but also by emotions typical of that system. The curiosity of the exploration system fuels seeking and orienting movements that enable the investigation of novelty: learning opportunities, challenges at work, the tasks of parenting. In traumatogenic environments where attachment figures are abusive and/or neglectful, full engagement in daily life action systems is disrupted by dysregulated arousal and animal defenses.

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.

This chapter describes different approaches to fractionating and titrating trauma processing to facilitate efficient information processing. Fractionation in the treatment of dissociative disorders specifically refers to the direction of attention to aspects of traumatic experience to attenuate the intensity of abreaction. In eye movement desensitization and reprocessing (EMDR) parlance, refers to setting up a "target" for trauma processing specifying the image, cognitions, affect/emotions, and sensations associated with the traumatic memory. A strategy in somatic work involves oscillation between the traumatic state and the resourced state. Bottom-up processing is characterized by an absence of higher level direction in sensory processing, whereas top-down processing reflects higher level neocortical processes such as cognitions. TOTEMSPOTS uses channels as described in the approaches noted earlier to fractionate an intense traumatic memory, to make it more manageable. Somatosensory processing is bottom-up, as it is suggested that sensation is foundational to the experience of emotion.

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.

There is a range of immediate orienting and defense responses available when a threat is perceived, and a separate but overlapping system of vigilance when there is awareness of a potential threat. Vogt, Aston-Jones, and Vogt propose that the reduced anterior cingulate functioning repeatedly demonstrated in posttraumatic stress disorder (PTSD) during emotional tasks facilitates the firing of locus coeruleus (LC) neurons to create a state of hyperarousal. The noncognitive suppression of emotions in young trauma sufferers is based in the areas of the ventral prefrontal cortex (PFC), which has outputs to the defense response and threat evaluation regions of the amygdala, the periaqueductal gray (PAG), and the nucleus accumbens, among others. Deep brain stimulation can be used clinically without activation of a fearful freeze response, so ventral areas of the PAG are also involved in physiological states of relaxation, comfort, and soothing from pain.

Working toward an understanding of the nature of information processing, as purported to occur in eye movement desensitization and reprocessing (EMDR) can ultimately enhance our understanding of traumatic stress syndromes and dissociative disorders. Impaired information processing reflects the inability of the brain to recognize and integrate external stimuli. The hyperpolarization of the thalamus is likely associated with profound effects on brain wave activity. The adaptive information processing (AIP) model is a neurobiological heuristic based on the notion of neural networks and represents a paradigm shift from psychological theory toward neuroscience. Shapiro argues that pathology results when traumatic or stressful events interfere with information processing and the forging of connections between different neural networks. This chapter reviews the literature on sensory stimulation and suggests that sensory stimulation and associated sensory awareness are involved in modulating oscillatory activity in the brain, which has been linked to information processing.

This chapter describes an approach to fractionation and titration of traumatic material, specifically the use of the time domain. The approach is informed by our understanding of neural development and the integration of mental experience using developmental time sequence. The chapter explains the early trauma (ET) approach of complex cases, specifically dissociative disorders. Maladaptive lessons learned at very early ages will effect decisions for a lifetime and form the basis for certain Axis I and Axis II symptom configurations. Temporal integrationism is the term established by Paulsen to describe the approach to resolving very ET and attachment injury, including neglect in the absence of declarative or explicit memories. For eye movement desensitization and reprocessing (EMDR) practitioners, it is challenging to obtain subjective units of disturbance (SUD) levels and usually impossible to derive cognitions or narratives for very ET and neglect.

Conditioned emotional responses are generated by the actions of the hippocampus and septum on the amygdala, which induces physiological change through its midbrain projections. An emotional response to a social threat involves the appropriate sensory cortices, frontal cortex, hippocampus and septum, midbrain, and hypothalamus. The affective experience of abandonment can be followed by the separation distress sequence of protest and despair or it can initiate shame. Shame recruits circuits formed for hiding from physical danger for avoidant responses to the failure of social belonging. Attachment typically begins in the mother-infant dyad but broadens to promote and reward inclusion in a larger social group as the individual grows. The social attachments, fears of ostracism, and feelings of distress at loss of inclusion have their neurobiological bases in brain systems designed to ensure healthy attachment, learning of emotion regulation, and development of socialized behaviors, from infancy onwards.

This chapter highlights the neurobiology of the whole spectrum of defense responses to threats: near or distant, immediate or potential, physical or social. It focuses on vigilance, fight, flight, freeze, hide, cringe, submit, and avoid behaviors. When survival is threatened by physical injury, death, or social exclusion, the brain has well-established responses, immediate and sequential, to promote safety. These defense responses are based in the emotion-generating regions of the brainstem but are rapidly modified and modulated by the more developed and evolved cortical capacities. The chapter focuses on clinical observations, brain imaging studies in humans, and animal studies of responses to trauma to promote testable conclusions on the likely neurochemical mediators of the key components of posttraumatic stress disorders (PTSD). Chronic characterological changes arising from alterations in self-perception with guilt and shame, self-blame, feelings of ineffectiveness, and loss of trust are part of the long-term damage caused by early trauma.

This chapter suggests neurobiological mechanisms to account for dissociative symptoms in general and structural dissociation in particular. Peritraumatic dissociation (PD) is associated with the release of endogenous opioids and other anesthetic neurochemicals that alter communication between lower and higher brain structures. MacLean's triune brain model provides a structure for the understanding of emotional functioning and dissociation. The integration of brain functioning both horizontally and vertically at different levels of the brain is at the core of information processing. The thalamus also plays a role in cortical oscillations, a phenomenon that has been related to cognitive-temporal binding and information processing, thus affecting cortical connectivity. The corpus callosum is the largest connective pathway in the human brain, constituted of nerve fibers that connect the left and right hemispheres, thus facilitating interhemispheric communication. Disruption of thalamocortical communication is a key component of anesthetic-induced unconsciousness.

This chapter focuses on how to effectively integrate somatic interventions during the different stages of trauma treatment, such as stabilization, trauma processing, and reconnection, and how to integrate their use to maximize the effectiveness of eye movement desensitization and reprocessing (EMDR). Ventral vagal connectedness between and within people is the name of the game to enhance association and integration. The EMDR standard protocol integrates cognitive, emotional, and sensory information. Information processing breaks down, likely due to significant peritraumatic dissociation (PD) that co occurs with the apparent hyperarousal. Social engagement reflects a ventral vagal response that results in increased self-regulation and calming, thereby decreasing the likelihood of a dorsal vagal response. To facilitate both dual focus and body mindfulness, both exteroceptive and interoceptive awareness are required. Olfactory pathways travel directly to the limbic system and amygdala, and from there olfactory information is likely conveyed to lower brain structures.