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Post Traumatic Stress Disorder
Table of Contents Introduction Theory       The Triune Brain: Hierarchical Processing       The Window of Tolerance: The Polyvagal Theory       Early Attachment: The Neuroscience of Relationships       The Orienting Response: The Narrowing of Attention       The Defense Response: Immobilization and Mobilization       Action Systems: Adapting to the Environment       Neurological Effects of Psychological Trauma: Axes of Intervention Practice       Step 1: Stabilization       Step 2: Traumatic Memory Processing       Step 3: Integration Resources       Neurofeedback Procedure and Software Description       Possible Mechanisms for Alpha-Theta Training Effects Introduction   [] Overwhelming trauma changes the brains, behavior, and lives of its victims, whether it be combat, rape, torture, disaster, near death experience, abuse, or even childhood neglect. Some victims, if resilient and fortunate, can carry on. For others, intensive psychotherapy plus medication and family support may enable them to cope. Many others, unfortunately, become progressively disabled and dysfunctional. PTSD is usually diagnosed following the criteria of the DSM-IV (The Diagnostic and Statistics Manual published by the American Psychiatric Association).  Individuals with PTSD often have severely dysregulated arousal, overactive defensive systems, and can not participate in normal life because of their nearly constant focus on signs of danger or their own internal dysfunction. Sleep, when possible, is characterized by signs of over-activation of the fight-or-flight mechanism. The chronic high levels of stress hormones lead to verifiable damage to crucial brain areas, such as the hippocampus, involved in memory, fear, and orientation. The prefrontal cortex, the seat of many of the highest emotional, intellectual, and stabilizing influences, becomes easily disconnected as the victim alternates between hyperarousal and withdrawal. The Clinical Practice Guideline for the Management of Post-Traumatic Stress published by The Department of Veterans Affairs and The Department of Defense HERE lists psychotherapies for PTSD that primarily involve talking about and/or re- experiencing the trauma while in a “safe” clinical environment. This approach is too intense for many clients who, understandably, terminate therapy. It is also contraindicated for those victims living in unsafe environments (domestic or workplace violence), with ongoing substance abuse problems, or where anger, guilt and shame are issues. EMDR (Eye Movement Desensitization and Reprogramming) involves less re-exposure and is better tolerated, but still does not work for everyone. A relatively recent treatment for PTSD is EEG Biofeedback, also known as Neurofeedback. Alpha-Theta training, a particular type of neurofeedback, is gaining acceptance as an alternative treatment for PTSD, substance abuse, and anxiety, as well as a way to enhance creativity and peak performance. Neurofeedback has been found to be effective in many conditions. You can find out more in the San Francisco Bay area at growing.com/mind, or nationally at ISNR.org, at EEGSpectrum.com, or at EEGInfo.com. In the late 1980’s Eugene Peniston (Ft. Lyon Colorado Veterans Hospital) and Paul Kulkosky (University of Southern Colorado) developed a protocol (Peniston-Kulkosky protocol) for training clients to self-regulate their production of brain waves in the alpha (8-12 Hz) and theta (4-8 Hz) ranges. (Hz, pronounced Hertz, means the number of cycles [or brain waves] per second). Peniston and Kulkosky found a trainable state of consciousness which appears to optimize the surfacing and integration of ‘abreactive’ images (traumatic memories) while minimizing the discomfort and re-traumatization of the client. In one study (1995) they trained twenty male Vietnam combat veterans with dual diagnoses of PTSD and alcohol abuse. At follow-up, over 2 years later, only 3 of the 20 experimental patients had relapsed. In addition, neurofeedback resulted in decreases in MMPI scores on the clinical scales labeled Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity-Femininity, Paranoia, Psychasthenia, Schizophrenia, Hypomania, and Social Introversion-Extraversion. In contrast, the control group (receiving standard group therapy) showed decreases only on the Schizophrenia scale. For those readers unfamiliar with tests such as the MMPI, please do not think that having a score on one of the scales, such as 'paranoia' is the same as being diagnosed or labeled paranoid. It is a mere convenience to allow such tests to be used with a wide variety of individuals from 'normal' to quite disturbed. New studies are suggesting possible mechanisms for the effects observed with neurofeedback. They will be discussed throughout the following text and also in the final 'resources' section. You have just read the introduction to this brief publication. This is a work in progress and I expect it will take several months to complete. In the meantime I am placing brief comments under each topic for the benefit of clients and students who want to consider this approach further. Theory    []

The Triune Brain: Hierarchical Processing    

Questions of evolution aside, it becomes clear when comparing the brains of reptiles, small mammals, and humans, that humans have three brains (a triune brain). The deepest brain is similar in function and structure to that of reptiles, caring mostly for basic survival needs and physiological regulation. The reptilian brain of humans is surrounded by a proto- mammalian "limbic" brain that provides for more memory, learning, emotional, and social/herd behaviors. The outermost brain, the neocortex, reaches its highest development in humans. It attempts to oversee the 2 lower brains by processing thought, symbols, planning, morals, intuition, inhibition, and other high functions of self-awareness. In small, primitive animals, the right and left sides of the brain share very similar functions. For larger animals, the distance between the right and left sides of the brains becomes large enough to cause timing problems in signal transfer. That is why brains of reptiles and small creatures are similar on the right and left sides. But the brains of large mammals and primates have developed different functions on the right and left sides. Coordination between right and left becomes more problematic because of the relatively large distance between cortices. In whales, for example, only one side of the brain sleeps at a time. Consider, then, when a person is confronted with an overwhelming life-threatening and uncontrollable trauma. The highest brain cannot reason with predators or nature. The middle social brain cannot cry out and be heard. The lowest reflexive reptilian brain may try to survive through flight, fight, or feigning death. If it survives, then this primitive response becomes a highly valued and automatic resource to be recalled under all future threats. This 'resource' takes on a wordless life of its own, disrupting higher functions, and causing us to react in ways we cannot understand. When lower reflexes become habitual (in response to trauma or threat), we use a part of the brain that does not take advantage of all the different neocortical resources in the higher right and left hemispheres. These complex functions such as reading, visualization, interpretation, insight, motivation, planning, evaluation, etc., are disturbed and uncoordinated. The focus remains on the wordless primitive low-level emergency survival mechanisms and whatever emotional and mental ghosts they project to the higher levels. Neurofeedback appears to routinely affect the network hubs in the brainstem and lower brain, thus gently affecting arousal and alertness and allowing re-integration of all three levels of processing.

The Window of Tolerance: The Polyvagal Theory    []

  When a creature (such as a human) needs to fight or flee, a part of the nervous system called the "sympathetic nervous system" coordinates the activity. If the threat is overwhelming and uncontrollable, this 'sympathetic' response may be coordinated without the help of the highest neocortical resources. And if a creature is terrorized into 'freezing' or playing dead as a last resort, this activity is carried out by a coordinating subsystem called the dorsal (back side) "vagal parasympathetic nervous system", again, often without the highest neocortical levels which can provide language, insight, planning, narrative, etc. Higher primates also have a so-called "ventral (front-side) myelinated (fast) vagal parasympathetic system". This system has high speed nerves which connect the brain with the muscles of expression in the face, with the muscles of expression in the 'voice box', with muscles that tune the activity of the middle ear to tune-in (or out) the human voice, etc. This is called the "social engagement system". This system allows us to communicate through facial and vocal patterns, and to tune into the speech of other humans. This system allows us to negotiate with family, predators, and, ostensibly, God. Unfortunately, all too often, under overwhelming circumstances, the social engagement system fails. We are left to depend upon primitive reptilian mechanisms. We all have a 'window of tolerance' outside of which we fall into wordless (hence non-rational) reflexive attempts at survival. For healthy individuals, this window is wide. But for those with PTSD a shadow, a distant sound, a glance can all trigger the shut-off of the higher functions of intelligence and personality and trigger the activation of primitive defensive systems. Much of the work with traumatized individuals involves helping them to keep the social engagement system active when they perceive clues that would take them outside their window of tolerance. With bio- and neurofeedback the client has the opportunity to alter his or her own neurophysiological state outside the window of tolerance. If done with the help of a skilled trainer, the client can keep the higher executive centers functioning and thus come to understand that the disturbing reactions are simply reflexes that have served their purposes in the past. These past reflexes do not need to define who the person is or forever determine how they feel and respond. By staying 'engaged' with the trainer, process, and environment, the client learns to tolerate progressively wider windows of arousal. The trauma does not go away. It just becomes more appropriately framed in a wider, more comprehensive and capable life.

Early Attachment: The Neuroscience of Relationships    []

For the first 18 months of a newborn's life it is primarily the non-verbal right side of the cortex which develops. Throughout the remainder of life the right cortex will have a unique role in processing fearful, painful, and extreme states of emotion and arousal. The mother's brain, especially on the right, functions as an 'auxiliary cortex' for the child, helping the child learn tolerance and self-regulation, and promoting the eventual development of such action systems as attachment, curiosity, play, socialization, sexuality, and care giving. These early experiences (or their absence) actually shape the ongoing physical development of the child's nervous system, setting the stage for traits that will last a lifetime. Disorders of such early attachment set the stage for profound difficulties in emotional regulation, learning, socialization, trust, motivation, and caring for one's own children later in life. We may be witnessing an epidemic in attachment disorders. Families have been torn apart by wars, incarceration, drugs, illness. Mothers may themselves perpetuate their own early emotional traumas, or may be unable to bond due to addictions to relationships, drugs, religion, etc. Even trends and myths of childcare methods may cause infants to lack the contact, comfort, and communication needed to grow up into capable, self-assured, emotionally healthy adults. Common (and profitable) ritual circumcision of a male infant without anesthesia has been shown to damage bonding. The traumas of neglect, abuse (physical, mental, emotional, or sexual), natural disaster, surgery, family emotional illness, separation, bullying, etc., all affect the structure, functioning and stability of these essential early neural circuits. In bio- and neurofeedback, the trainer and computer also act as 'auxiliary cortices (brains)' and help the client explore wider extremes of neurophysiological states while remaining safe and, ultimately, in control. The client develops a wider window of tolerance for deviations in arousal, and learns to self-regulate back to a state of integrated comfortable functioning.

The Orienting Response: The Narrowing of Attention    []

  Victims of overwhelming trauma will unconsciously and reflexively alter their orienting responses. These responses originate so deeply in the brain that even with severe loss of cortex a nearly brain dead victim may eerily and reflexively follow movement with his eyes. In PTSD a victim may seek, focus upon, and over-react to cues only remotely related to danger or trauma, thus constantly reacting as though under threat. Or the victim may dissociate (shut down) from his or her own feelings and observations. This can lead to revictimization or careless re-exposure to danger, or can render a victim unable to sense pleasure, safety, and opportunity upon their return to their homes and families. A skilled neurofeedback trainer can track a client's orienting responses to subtle shifts in internal state during the sessions. The traumatized client learns to keep orientation flexible and appropriate by starting easily with an attitude of curiosity toward his own internal changes of state, as fed-back by the trainer's equipment and guidance.

The Defense Response: Immobilization and Mobilization    []

  In the face of a powerful predator most animals reflexively initiate a defense response - immobilization with alertness when the predator is detected, fight or flight when danger is immanent, and finally, profound immobilization and neurophysiological suppression, feigning death, from the instinctual-reflexive knowledge that predators often will not eat dead animals they have not themselves killed, since such dead animals might be diseased. A unique characteristic of well-adjusted humans is the ability to make 'top-down' conscious decisions about how to react to danger. If they survive relatively intact, there is a sense of triumph and competency. These triumphant feelings are absent in the PTSD victim who, often dazed and injured, barely survived, and now repeatedly reapplies the same wordless low-level reflexes in the presence of any clue related to danger. In combat and even in rape, the social engagement system may be ineffective or even increase the danger, and only the most primitive reflexes of flight, freezing, or submission may be available. At the same time the orienting system narrows attention to only those environmental factors that may aid survival. In total submission the body is flooded with endorphins to block the pain of being devoured, memory is blocked, the mind becomes dissociated and blunted. And yet, somehow, the victim survives. Now the wordless primal reflex has become the most important action system for survival, and over months and years stress hormones will interfere with normal neural plasticity, functioning and recovery. During bio- and neurofeedback training the client can observe the indications of his or her physiology going into hyper- or hypo-mobilization from minimal reminders of threat. The trainer can observe beginning signs of defensive or submissive postures and mirror these to the client. By learning to share the trainers interest in the origins of the defensive response, the client learns to re-apply such non-defensive action systems as exploration, social engagement, and perhaps even play. Eventually, hopefully, the client learns to recognize the overactive defensive actions as resources that are not likely to be needed again and that do not define who the client is.

Action Systems: Adapting to the Environment    [] 

Based on secure attachment with a well-adjusted mother, and in the absence of early overwhelming trauma, a child will develop 'action systems' which will serve many personal and social functions. These systems include orientation, defense, attachment, energy regulation, exploration, play, socialization, sexuality, and care giving. Although 'hard-wired' into our neurophysiology, these systems are also susceptible to conditioning and adaptation. These systems are of the utmost value in preparing and enabling humans to bond, solve problems together, care for families, recuperate, play, and find higher understanding and meaning in life. In the PTSD client, the orienting and defense systems intrude upon and over-ride the functioning of the other systems, severely interfering with love, work, knowledge, play, personal growth, and family and social relations. The bio- or neurofeedback trainer can help the client observe and modulate arousal states accompanying any of the action systems. When the client develops curious, open, nonjudgmental exploration of his or her own action systems, these systems become more robust and immune to take-over by defensive systems.

Neurological Effects of Psychological Trauma: Axes of Intervention    [] 

The symptoms of PTSD are thought by many to result from stress-induced changes in the hippocampus, amygdala, prefrontal cortex, and anterior cingulate, as well as maladaptive changes in the cortisol and norepinephrine systems. PTSD is associated with long-term dysregulation of the HPA (hypothalamic-pituitary-adrenal) axis, leading to hypercortisolemia and consequent damage to neurons in the hippocampus and inhibition of neural plasticity. The noradrenergic system (from the locus coeruleus) is also activated leading to increased alertness and vigilance and reduced extinction of fear responses by the prefrontal cortex. The effects on the hippocampus seem to lead to specific deficits in verbal declarative memory function, with relative sparing of visual memory and IQ. With such increased vigilance, perpetuated fear responses, reduction of declarative memory, and exaggerated stress response, the PTSD client is in a vicious cycle of progressively smaller stresses causing progressively larger and prolonged stress responses. Such stress responses have been shown to lead to inflammation, atrophy and death of vulnerable neurons in the prefrontal cortex (home to the highest cognitive functions). This stress also causes atrophy and changes in the hippocampus and amygdala, important structures in memory, learning, and fear processing. Much current research is seeking a way to minimize the damages of an unmodulated cortisol system and enhance the protective effects of natural substances such as DHEA (dihydroepiandosterone). Several studies have already documented the effects of heart rate variability biofeedback on normalization of the ratio of cortisol to DHEA. Recent studies have also shown that the heart rate variability of PTSD clients is disordered during sleep, suggesting that the client continues to suffer from over-activated stress mechanisms when they should be sleeping. Anecdotal evidence is beginning to suggest that specific sensor placement in neurofeedback can target selected cortical areas in need of regulation in PTSD. However, it may be found that the most comprehensive set of resources the client can develop is the ability to observe and detach from his or her own habitual defense system reactions, and learn to cultivate the other action systems. By widening the 'window of tolerance' of arousal, the social engagement system reconnects the client with the care given by friends and family, as well as the enjoyment and meaningfulness possible by a fuller participation in life. Practice    []      Under Construction       Step 1: Stabilization       Step 2: Traumatic Memory Processing       Step 3: Integration

Neurofeedback Procedure and Software Description    [] 

As always with neurofeedback, no signals nor energy nor chemicals go into your body. Instead, sterile sensors monitor shifts in your brainwaves measured at different spots on your scalp. A computer displays your changing brain waves in a way (e.g., video 'game') that enables you to learn to modify the frequency and size (amplitude) of the different brainwaves. Most often clients will notice that it feels different when they increase different frequencies of brain waves. These feelings become states that can be entered, when necessary, to help you function more efficiently under different stressful conditions. In most cases I will start with several sessions designed to find the optimal balance between alertness (without tenseness) and relaxation (without grogginess). This is accomplished with a single neurofeedback channel (2 sensors) with one sensor placed on each side of the head. Over the first few sessions we fine tune the 'reward' frequency for the optimum state of relaxed alertness. This particular technique, which tends to be calming and relaxing while promoting easy focus and awareness, may be repeated as needed throughout the remaining sessions. The remaining sessions use 2 neurofeedback channels (4 sensors) with two on each side of the head. Technically it is called a 2-channel referential montage at P3 and P4. The 2-channel sessions 'reward' (using audio-visual display) both an alpha frequency, 8.5-11.5 Hz, and a theta frequency, 5.5-8.5 Hz. "Hz" is pronounced "Hertz" and means the number of cycles (or brain waves) that occur per second.

Possible Mechanisms for Alpha-Theta Training Effects on PTSD, Mood, and Performance    [] 

1 – Alpha-theta training reduces fast beta activity []

The impact of alpha-theta training on the topography of the EEG spectrum is characterized by a reduction in fast beta band activity in the executive prefrontal cortical regions. Egner T, Zech TF, Gruzelier JH. The effects of neurofeedback training on the spectral topography of the electroencephalogram. Clin Neurophysiol. 2004 Nov;115(11):2452-60. Elevated frontal fast beta activity is related to the experience of anxiety and posttraumatic stress disorder (PTSD). The role of anxiety as ‘stage fright’ is well known to many performers. It is less widely known that posttraumatic stress disorder can cause perplexing intrusive images that interfere with focus, immersion, and the flow of performance. PTSD can also cause an otherwise gifted performer to be cut off from those around him as well as the sources of experience and inspiration. PTSD can exist without one’s knowledge if the original trauma was too overwhelming, occurred during unconsciousness (surgery) or under the influence of drugs, or when a person was too young to have words to create a comprehensible narrative. Elevated frontal beta activity can be observed in healthy individuals during the stress caused by ongoing pain. Kiloh L, McComas A, Osselton J et al. Clinical Electroencephalography. New York, Appleton-Century-Crofts [1972] 3rd edition. Begic D, Hotujac L, Jokic-Begic N. Electroencephalographic comparison of veterans with combat-related post-traumatic stress disorder and healthy subjects. Int J Psychophysiol. 2001 Mar;40(2):167-72. Chen AC, Dworkin SF, Haug J, Gehrig J. Topographic brain measures of human pain and pain responsivity. Pain. 1993 Apr;53(1):112-4.

2 – Alpha-theta training enhances fronto-central theta []

Normal (or enhanced) fronto-central theta activity has been associated with states of focused attention such as immersive- meditative concentration (as in creative performance) as well as in working memory tasks. Gevins A, Smith ME, McEvoy L, Yu D. High-resolution EEG mapping of cortical activation related to working memory: effects of task difficulty, type of processing, and practice. Cereb Cortex. 1997 Jun;7(4):374-85. Aftanas LI, Golocheikine SA. Human anterior and frontal midline theta and lower alpha reflect emotionally positive state and internalized attention: high-resolution EEG investigation of meditation. Neurosci Lett. 2001 Sep 7;310(1):57-60. Normal (or enhanced) frontal theta activity has been associated with feelings of well-being, relief from anxiety, and reduced activation of the sympathetic (fight or flight) nervous system. Mizuki Y, Hashimoto M, Tanaka T, Inanaga K, Tanaka M. A new physiological tool for assessing anxiolytic effects in humans: frontal midline theta activity. Psychopharmacology (Berl). 1983;80(4):311-4.

3 – Enhanced fronto-central theta under task improves regulation of autonomic function []

Frontal midline theta rhythm (Fm theta), recognized as distinct theta activity on EEG in the frontal midline area, reflects mental concentration as well as meditative state or relief from anxiety. Theta band activities in the frontal area were correlated negatively with sympathetic (“fight-or-flight”) activation. The results suggest a close relationship between cardiac autonomic function and activity of medial frontal neural circuitry. Kubota Y, Sato W, Toichi M, Murai T, Okada T, Hayashi A, Sengoku A. Frontal midline theta rhythm is correlated with cardiac autonomic activities during the performance of an attention demanding meditation procedure. Brain Res Cogn Brain Res. 2001 Apr;11(2):281-7.

4 – Appearance of fronto-central theta rhythm is related to personality traits [] 

“The distinct theta rhythm in the frontal midline area during a performance of mental tasks has been called Fm theta. However, Fm theta shows individual differences in its appearance. The relationship between the appearance of Fm theta and the subject personality was investigated in the present study. … those subjects who showed high scores on the anxiety scale, low scores on the extraversion scale and high scores on the neuroticism scale showed smaller amounts of Fm theta or none. These results suggest that the appearance of Fm theta is closely related to the subject personality traits.” Mizuki Y, Kajimura N, Nishikori S, Imaizumi J, Yamada M. Appearance of frontal midline theta rhythm and personality traits. Folia Psychiatr Neurol Jpn. 1984;38(4):451-8   Note: This material was written in 2008 when I first started practice of neurofeedback. There have been many discoveries and changes since then. Complete revision is scheduled for 2013.  
Neuromodulation Copyright  2013 by Douglas Dailey