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.
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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 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 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.
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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.