What Are Flashbacks and Why Do They Happen?

Experienced trauma therapists know that persistent flashbacks are incredibly toxic; they frequently cause counter-productive coping, escalating depression, suicidality, clinical emergencies, and hospitalizations. Today’s question is not how to manage flashbacks, but something much more fundamental: “What the heck are they?” We know what they look like. We know their clinical impact. We have a fair idea how to help our patients with them. But what are flashbacks, really? Why do they happen? What is their function? Do they even have one?

When Is Dissociation Not a Defense?

My previous post challenged the concept of dissociation-as-a-defense by asking, “Are flashbacks dissociative?” Our discussion of this question produced an unanticipated (at least by me) outcome.

Therapists (including me) repeatedly insisted that some flashbacks (i.e., those characterized by a complete loss of contact with the here-and-now) are unquestionably dissociative. On the other hand, therapists had almost nothing to say about the fact that flashbacks are not a defense. Their comments suggest that, for them, the most salient feature of flashbacks is the patient’s complete loss of contact with present-day reality.

In contrast to therapists, dissociative individuals had a very different point of view. These ‘insiders’ insisted that flashbacks are not dissociative. In fact, they pronounced flashbacks to be “the opposite of dissociation.” I take this to mean that they are highly aware of the defensive, protective function of dissociation. And why not? After all, they have a personal stake in the matter. Flashbacks have all the subtlety of being blindsided by an 18-wheeler. They know damned well that flashbacks represent a failure or collapse of their dissociative defenses.

Neuroimaging Studies of Flashbacks and Dissociative Symptoms

Functional magnetic resonance imaging (fMRI) studies of PTSD patients have repeatedly shown startlingly different patterns of brain activity during flashbacks versus during acute incidents of dissociation. In these studies, PTSD patients and trauma-exposed persons without PTSD listened to scripts of their worst trauma and visualized the trauma while being scanned in an fMRI machine.

This procedure triggered flashbacks and hyperarousal in about 70% of the PTSD patients, and an episode of acute dissociative distancing in the remaining 30%. In the lead article of the July issue of the American Journal of Psychiatry, Ruth Lanius and colleagues reviewed this body of literature and analyzed its implications (Lanius, Vermetten, Loewenstein, Brand, Schmahl, Bremner & Spiegel, 2010).

The flashback/hyperarousal PTSD patients exhibited a pattern of brain activity which indicated a failure of corticolimbic inhibition. Specifically, the flashback/hyperarousal PTSD patients exhibited (1) an abnormally low activation in the ventromedial prefrontal cortex and the rostral anterior cingulate, and (2) increased activation of the limbic system, especially the amygdala and the right anterior insula.

Translation: The brain regions associated with modulation of arousal and regulation of emotions were largely shut down, while the brain regions associated with emotion, fight/flight responses, and the experience of these reactions were highly activated.

The PTSD patients with dissociative distancing exhibited a pattern of brain activity which indicated excessive corticolimbic suppression. That is, they exhibited (1) an abnormally high activation the dorsal anterior cingulate and the medial prefrontal cortex, and (2) decreased activity in the amygdala and right anterior insula.

Translation: The brain regions associated with modulation of arousal and regulation of emotion were abnormally activated, while the brain regions associated with emotion and its experience were substantially inactivated.

A Dissociative Subtype of PTSD

Lanius and colleagues concluded that there is a dissociative subtype of PTSD which is quite different from the more common re-experiencing/hyperarousal type of PTSD that is so well described by the DSM-IV criteria for PTSD. Both types of PTSD undergo flashbacks, but only the dissociative subtype frequently experiences a spontaneous dissociative distancing of the memory of the trauma. Moreover, as one ‘insider’ member of our community of dissociation aficionados has noted, and as Lanius et al. also reported, a person who has the dissociative subtype of PTSD may simultaneously experience a flashback and a dissociative distancing from that flashback.

Finally, as that same aficionado wryly asked, if we are going to call flashbacks a form of dissociation, does dissociative distancing from a flashback = “dissociating from the dissociation”? Flashbacks and dissociative distancing really are very different. And it is very confusing to call both of these things “dissociation.”

Finally, it may be worthwhile to know that Lanius and colleagues define dissociation as “detachment from the overwhelming emotional content of the [traumatic] experience” (p. 640). This is certainly a reasonable description of dissociative distancing (but a very poor description of a flashback).

Final Comment: Well, we have covered a fair amount of material about the relationship between flashbacks and dissociation, but we still don’t know exactly what a flashback is. And we certainly don’t know why they occur.

PS. I know they are triggered by a reminder of the trauma. The important question is,“Why does the reminder of trauma trigger a flashback (instead of just a memory)?”

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18 Responses to What Are Flashbacks and Why Do They Happen?

  1. Karin Dyhr says:

    Paul –

    I can only agree that flashbacks certainly don’t feel like a defense, but quite the contrary. But if you look at it from a different angle, I suppose it really is a kind of defense, although not exactly a pleasant one, and certainly not distancing.
    My thoughts are:

    Your last question, “Why does the reminder of trauma trigger a flashback (instead of just a memory)?” makes me think that since we have earlier been in utmost danger (repeated and often confusing and incomprehensible), it is hardly surprising that our mind/brain is wise enough to let us know that a certain smell or sound or touch or word (or whatever our particular trigger might be) is likely to destroy us, so we had better take action NOW. Not very useful to bring up excessive corticolimbic suppression, when what we need is the possibly life-saving increased activation of the limbic system. At least IMO.
    As I gradually got better, my experience in this matter was that what I used to experience as flashbacks, slowly changed into memories. Unpleasant memories, certainly, but nothing like the danger-here-and-now-feeling of a flashback. As I began to be able to hear my therapist’s voice during the flashback, the voice of an adult that I (who at this moment was the child of the past, frozen in time and space) trusted as someone who would help and protect me, I also slowly (veeeery slowly) began to feel the quality change, so to speak, from flashback to memory. Quite a change, needless to say! Not in the throes of Then, only in the pain of Now…

    As usual you must excuse my clumsy English ;-)

    • Karin,

      Your English is fine. Really!

      Our memory for dangerous situations should be more than sufficient to help protect and defend us. After all, the entire history of natural selection — long, long before the phylogenetic evolution of humans — has built into every organism with a nervous system the ability to ‘remember’ (and subsequently avoid) dangerous situations. What I still don’t understand is, “Why do we have flashbacks?” What do they do or add that memory doesn’t already do? Do flashbacks have any adaptive function at all? If so, what?

      Thank you for sharing your personal experiences with flashbacks and their slow transformation into memory during the process of your recovery. Such sharing is an extremely helpful aspect of UnderstandingDissociation.com’s conversations and discussions. Sharing your personal experience is a gift to us all.

  2. “Why does the reminder of trauma trigger a flashback (instead of just a memory)?”

    Because the flashbacks are related to emotional rather than intellectual material? Memories seem to be more framed in thoughts, while flashbacks seem to be framed in feelings, often physical as well as emotional feelings.

    It would be interesting to see if others have experienced this about flashbacks, and it might help identify what they are and why they occur:

    For me, flashbacks (especially the first few related to a particular event or type of event, and especially early childhood events) can be overwhelmingly sensory in nature and may not relate exactly what occurred in a way that’s easy to identify and explain. For example, I might suddenly feel terrified and helpless (skipping more detailed description of sensations because they may be too triggering) maybe see a shadowy image or two and hear a word or sound… but it all comes in bits and pieces roiling in an emotional avalanche.

    I’ve had to think about this when trying to script a flashback for film or television because it’s so obvious to me that there is no way to share the true emotional and sensory nature of it on film. We’re limited to using imagery, sound, and language. But the feelings are so much more of the experience, in my opinion. It isn’t really about remembering something. It’s more like re-experiencing it.

    It’s uncontrolled and often disorganized feeling, whereas memories tend to have more of a sense of order to them. Memories also seem to be delivered in a “narrative” of thought-based words, while I’ve found flashbacks may be disconnected from word-thoughts entirely.

    It’s possible that this is simply a quirk of mine because I’m extremely speech-inhibited and didn’t learn to think in words until well into my teens. I used to think mostly in images, and still do when I’m stressed. So I don’t know if others typically experience the loss of “word thoughts” with flashbacks or not.

    Memories may be accompanied by feelings but there’s something very different going on there. For me, the emotions connected to memories generally make sense – they’re in proportion to what we know happened, and there’s a sense of perspective, which you lose real quick in a flashback.

    Nevertheless, having dealt with this for awhile now, I’ve come to believe that flashbacks serve an important function – to bring our attention to unresolved emotional material. After all, we’re humans, not Vulcans, so we have all these emotional processes going on inside. Besides potentially warning us and getting us to connect past to current/future dangers, I have a feeling the flashbacks are a symptom of shattered minds trying to connect the dots, more on an emotional level than an intellectual one.

    It’s as if there’s a program running in the background of our minds that’s always trying to reconcile the elements of life. We crave balance. Trying to find internal balance with extreme experiences can feel like trying to steer a lightning bolt. But maybe that lightning bolt will illuminate the room long enough for us to find a light switch.

    • Lots of carefully considered thoughts! Two things. First, your experiences with flashbacks are not specific to you. Your descriptions of what they are like, what they feel like, and so on, are ‘textbook’ descriptions. So, you have ‘normal’ flashbacks. :-)

      Second, you suggest that “there’s a program running in the background of our minds that’s always trying to reconcile the elements of life.” I quite agree. The question then becomes: “What happens to the unmetabolized trauma when the program tries once again to reconcile the elements of your life (i.e., when the next flashback happens)?”

      There are at least two, not mutually exclusive, answers to this question: (1) the flashback, again, overwhelms the psyche/mind and reconciliation is not possible (This is sort of a Janetian ‘take’ on the most common fate of flashbacks); or (2) the person, again, recoils from the unacceptable traumatic reality and defensively pushes the flashback away (This ‘take’ includes [a] Freud’s motivated ‘pushing away,’ [b] the contemporary view of dissociation as a defense, and [c] the reported experience of at least some persons with severe PTSD and dissociation).

      • I *really* like the way you think =)

        What happens to the unmetabolized trauma when the program tries once again to reconcile the elements of your life (i.e., when the next flashback happens)?”

        Wait, isn’t there at least one more possibility besides the 2 you listed above? How about when the “flashback program” runs and you finally have the resources available to begin “metabolizing” the trauma? Maybe a knowledgeable therapist or even just a steady, supportive person who’s come into your life? Maybe you’ve gained enough perspective, experience and confidence over the years to start sorting it out?

        That might explain why the flashbacks seemed to start later in life for me. My life finally seemed to come together, great job, beautiful house, the kids all grown up and succeeding in their lives… and all of a sudden I was LOSING IT??? It was a particularly bad flashback (while I was driving, mind you!) that made me decide I needed to find HELP. I didn’t know what happened, that it was a flashback, but couldn’t deny that something was obviously wrong. My therapist said it’s not unusual for people to have this happen – everything finally seems to be going “right” in their lives but inside they finally kind of crash. (And yes I’m lucky I didn’t literally crash the car, having a freaking flashback while doing 70mph towards rush hour weeeeeeee…)

        So maybe that’s part of the “program” to try at different times, under different circumstances, testing for the possibility of new resources that will support healing?

        • Hi,

          I consistently enjoy the richness of your thinking about all this. You said:

          “Wait, isn’t there at least one more possibility besides the 2 you listed above? How about when the “flashback program” runs and you finally have the resources available to begin “metabolizing” the trauma? Maybe a knowledgeable therapist or even just a steady, supportive person who’s come into your life? Maybe you’ve gained enough perspective, experience and confidence over the years to start sorting it out?”

          Yes, certainly that is possible. I also think it is, unfortunately, infrequent. You have an optimistic outlook on these matters which I think is a wonderful resource, all by itself. You have a positive outlook on why things fell apart when your life seemed to be going so well. As a result, you wonder if perhaps your mind or internal program ‘thought,’ “Maybe, now it’s possible to finally deal with this stuff.”

          Maybe. I’d love to know what others think about your idea.

          Here is a different (but not mutually exclusive) view of your sudden onset of “losing it.” You and your life were doing well, but ‘the guys inside’ were still stuck holding the same ‘bags’ of trauma that they had been carrying for about 30 years. Maybe, the sudden surge of flashbacks was a nonverbal, “Hey! What about me (us)?” Or, “Hey! What do you mean everything is great? Remember THIS?”

          I don’t really know. You are the expert on you. My ‘take’ on your sudden surge of flashbacks is an idea that frequently comes to my mind when this happens with folks that I am seeing in therapy. I also tend to think of the sudden onset of flashbacks as being accompanied by (abetted by?) the cumulative exhaustion of containing that stuff for so many years.

          • This post is made of YES!!! :)

            I definitely had a sense of mental/emotional exhaustion when the flashbacks began. On the outside things were going well in my life, but that doesn’t mean I was happy. I had a growing conviction that I’d been pretending my way through life forever. The success on the outside almost seemed a cruel joke in the face of an escalating sense of failure and despair inside.

            You’re also right about the “Hey, what about us?” part of the equation. It was there, I just wasn’t able/willing to hear it until much later. Obviously I had (and still have) a lot to learn about what’s going on inside. I had no idea how dismissive and lacking in compassion I tend to be towards other parts of myself until just recently. Sometimes I still am :( but at least if someone points it out now I recognize it’s important for me to pay attention to this.

            As for the positive outlook you noted, it didn’t happen overnight. I used to have a rather dark, negative, deeply distrusting view of almost everything and everyone, and I’d get really upset and stressed out about flashbacks, losing time, etc. We can thank a verrrrry patient, talented, and tenacious therapist for infusing me with a much more positive, inquisitive, and appreciative point of view over the past few years. I’m very grateful for people like you and her, making such an effort for those of us who are trying to get a handle on this from the inside out.

        • Holly Gray says:

          I had a similar experience. My life was going along relatively well and, at 29, I felt stronger mentally and more “together” than I ever had before. That’s when everything fell apart for me. Flashbacks, nightmares, intrusive thoughts and images … all of that and more began disrupting my life and shaking my strength and stability to such a degree that I genuinely wondered if I’d survive. It didn’t make sense. I was doing so well! Then all of a sudden, the bottom dropped out.

          I don’t believe that was a coincidence. I believe that it was precisely because I was so mentally strong and stable that all of that intrusive material began shouting at me. The dissociative walls could afford to relax a little. Unfortunately, it nearly did me in. Even so, I don’t think all of that would have happened if I hadn’t been doing so well.

          I have no idea if that conclusion holds water with non-dissociative PTSD though. As someone with DID, it’s not at all unlikely that parts of my system made the deliberate choice to share all of that intrusive material at a time when I was feeling so strong. And I’ve since learned that that’s precisely what happened. But that doesn’t really translate to non-dissociative PTSD.

          Maybe that’s a conceptual issue. Or maybe flashbacks are just flat-out different for people with dissociative disorders as opposed to people without.

          • Very very interesting. See, I don’t perceive myself as having been “mentally strong” at all when I finally started falling apart, but the outer trappings of my life had all come together. I’d worked really hard to achieve the success, get the home, raise my sons to be strong, healthy adults. It was like I’d been running a marathon with a broken leg. I made it across the finish line and then BAM! But I was in my mid-40′s, not my late 20′s, and I was emotionally exhausted even if I didn’t know enough to realize it.

            You raise some excellent questions about the possible differences with non-dissociative PTSD. Ima ponder that awhile, lol.

  3. Holly Gray says:

    I think of flashbacks like I think of any other intrusive material – as demands for attention. Not that they’re purposeful demands, although sometimes that might be true. For the purposes of this discussion, I’m referring more to something akin to physical pain. Pain is a message from the body: a demand, a warning, a ‘hey look over here!’ I think of flashbacks and other spontaneously intrusive material the same way.

    As someone with DID, my mind is designed to protect me from material that it deems intolerable. At this stage – that is to say, as an adult who has had DID for most of my life – it has an annoying habit of protecting me from all sorts of material, not just that which is intolerable and disruptive to my ability to function. The point I’m making is, dissociation is something I do very well. I am a compartmentalizing machine.

    So why do I have flashbacks?

    A flashback is a temporary failure of my dissociative mind to accomplish its goal: removing the intolerable from conscious awareness. A body can only withstand so much pain and a dissociative mind can only effectively compartmentalize so much before, with the former – your brain starts screaming at you with pain signals, and with the latter – you experience flashbacks or other intrusive phenomena.

    Maybe I’m saying this badly … what I’m trying to express is that I don’t necessarily believe that flashbacks happen because something from outside the brain triggers them, although that’s certainly part of the reason sometimes. I think they happen primarily because they’re bound to. The dissociative mind is constantly keeping a lid on things that are threatening to bubble to the surface. A flashback is just that – a bubbling to the surface, a bleed through, a rupture in the wall. I can encounter potential triggers that might remind some part of me of a traumatic memory on a daily basis and not experience a flashback. Then one day, for no apparent reason, a flashback does occur. Why? If it’s just about triggers people would be having flashbacks all the time. But I don’t believe flashbacks are solely the result of reminders. I think they’re what happens when you try to keep a pot of boiling water from bubbling over. Sometimes things spill out.

    • Holly,

      Analogizing flashbacks to physical pain is an interesting idea. There are two more steps, however, with physical pain and usually only one more (effective) step with flashbacks. Pain serves to (1) make the person immediately stop doing whatever is causing the pain; and (2) rest up and recuperate (which, by the way, is an animal defense). Flashbacks also cause the person to stop doing whatever seemed to trigger the flashback ( = the classic PTSD symptom of avoidance), but rest and recuperation does not heal the flashback.

      For a person with DID, a flashback looks and feel like a failure of the person’s dissociative mind. For a person with simple, nondissociative PTSD, a flashback is ????

      I am also convinced that you are right when you argue that triggers are NOT the whole story about why flashbacks happen. It is certainly true that a person may not be triggered by a particular cue for years, and then, suddenly they are triggered by it.

      I am also sure that you are right about the role of periodic failure (exhaustion?) of a person’s dissociative ‘compartments.’

      • Holly Gray says:

        Excellent point about the difference between pain as a messenger and flashbacks as messengers. I think the reason rest and recuperation doesn’t heal the flashback is because, metaphorically, your hand is still on the stove. Somewhere in the mind, the trauma lives on. The flashbacks seem to occur when the trauma, for whatever reason – and triggers don’t seem to be the only reason, gets too close to conscious awareness.

        However, your reminder that DID flashbacks and PTSD flashbacks are different is noted. The way I conceptualize flashbacks has to do with my experience of them as someone with DID. But you’re 100% correct in pointing out that it’s different for folks who do not have DID. Which in turn has me wondering if the way I view flashbacks is too colored by DID even for those who actually have DID. I’ll have to think about it from a different perspective.

      • M F says:

        I am really interested in what you say here:

        “For a person with DID, a flashback looks and feel like a failure of the person’s dissociative mind. For a person with simple, nondissociative PTSD, a flashback is ????”

        If another “self-state” intrudes, bringing with him/her all the emotion, thoughts, images, etc of his/her time, is it still a flashback, or simply their reality intruding into another (current) self-state’s life? These experiences I don’t find to fully fit what I read on flashbacks – certainly I am still aware of where I am as well as what is coming from whatever this experience would be called. The worst for me is that it does satisfy the “overwhelming” description of flashbacks. It certainly is completely overwhelming and that can last for quite some time.

        As others have said above, I guess this is a “failure” of the dissociative system I built up as a child.

  4. Sarita Overton PhD says:

    I am commenting on the question-why does a reminder of trauma trigger a flashback vs a memory? I think that a flashback is an indicator of a set of emotions and sensations related to a traumatic event, that are stuck in the limbic system of the brain. This information has not been integrated into the neocortex, where there are words. The absence of words and narrative are what distinguishes a flashback from a memory. This is my opinion.
    I also think that some critical grouping of triggers pulls a flashback. These can be internal or external.

    • Hi Sarita, Welcome to Understanding Dissociation.com!

      Your view about flashbacks echoes what I hear from many experienced trauma/dissociation therapists and what i read in the publications of expert trauma/dissociation researchers. I have been encouraging a sustained discussion of flashbacks, by (a) clinicians and (b) members of the UnderstandingDissociation.com community who possess expert ‘insider’ knowledge about flashbacks and dissociation, because I think that our understanding of flashbacks can be deepened/improved, and because a contingent of academics have been questioning (respectfully) our clinical theories about flashbacks. I want us all to think about and discuss flashbacks as rigorously as we can. I hope that you will continue to participate in our discussions.

  5. Professor says:

    Wonderful board. I’m late to the party, but here goes nuthin’. For me, flashbacks are fragments of raw, unmitigated sensory “sound bites” of trauma sensory intake/imprint. Not memory. Memory, to me, is the “interpreting self” at ease, assimilating the data into a narrative. Flashbacks take various forms in isolation from the traumatic experiencing self: just auditory, just sensory, just visual, just emotions…followed by subsequent juxtapositions of these (if dissociation doesn’t draw the veil). These are “memories” encoded by the “experiencing self” that were never handed off to the interpretive self during their conjugal visits every few minutes, weaving the narrative in the verbal/film-making brain of synthesis. That weaver didn’t want any business with the “experiencing self.” How dare she! They were cast off as unhelpful to the weaving of the story; perhaps they threatened to rend the cloth into an insane, unmentionable babble. The “experiencing” self retained the traumatic memories without a loom. She is a disorderly one! There, bits of trauma were not connected up to the mainframe of the “interpreting self” who dominates. The “experiencing self” has been trying to get the other’s attention for some time, in her chaotic way, every time she sees a chance to unburden herself of her full bladder! When the story is unfolding safely and there is more time to lunch leisurely, the two begin to contemplate retirement and look at their portfolios. They see they have some unfinished business. Flashbacks come. They are quickly dissociated. Later, they are explained away as indigestion, supernatural phenonema, or something other than literal. They are symbolized and woven into the “interpreting self’s” monologue once again as trivia. But after this has happened enough that a synthesis of trauma begins to come together with data that aligns from the interpreter/narrator, the two have to agree to share at least some of the files they have though unfit to join forces over. Now their harvest is largely in, they know it won’t totally upset the apple cart.

    Flashbacks are not the presence or absence of dissociation. They are memories the interpreting self has not had cause to force previously into the narrative. And they will remain trivia (albeit of the most disturbing kind) until they are heeded as literal memory. (Dreams are sleeping flashbacks of another kind, but that is another layer of the tapestry, isn’t it?) The body re-experiences the shock (somatic flashbacks, please! Nothing will touch that pain!) the person grieves, and the tapestry is woven stronger to accommodate the conflict…until more comes up, if it does, that needs to be integrated.

    I find it interesting that people say things were going well. They were going a little too well, and there was a lot of “good stress.” State dependent memory (flashbacks) require a mixed state in which everything seemed fine, then “wham!’ We feel that everything “seems” fine again. Flashbacks provide the “wham.” And history repeats itself, for we do love patterns in our weaving. :) I jest. Humor is a safe distance in this kind of narrative; I try to keep it light and impersonal to show, by contract, how heavy it has been.

    My regards to those with trauma, and those trying to figure it out,
    Professor

  6. simmy says:

    I think that flashbacks are “trapped trauma events” in a part of the brain….and until they are “resolved”….they will not be stored as “explicit memories”….they will stay “trapped” in the area of the brain (the amygdala?..I dont know) ….as they were not able to be processed in the right way (not in fight or flight mode-and body with increased cortisol) in a short time frame after the trauma. My understanding of PTSD is that the person is still suffering Trauma Stress, post trauma, therefore they are still carrying the “trapped stress”. How can you have an explicit memory of somethng that you did not experience under the same conditions as normal memories? Its not possible…..UNLESS you go back and process the trauma under SAFE and SUPPORTIVE clinical therapuetic conditions. Once this has been done, the “trigger” that leads to a flashback will disappear…because the brain will recognise the trauma and trapped emotions and energy has been released and the flashback will evaporate. How do I know? Thats what I do, and so far,,,most of my flash backs around a particular trauma have gone,,,,,,,,and I now have a narrative and explicit memory around the events and reminders of the event. Its not possible to store explicit memories under the cortisol response in the brain during fight and flight, as that part of the brain shuts down to allow the fight or flight response. The answer is intergration.

  7. sally says:

    The notion that flashbacks are not yet memories strikes me as making perfect sense. People going through them say that it feels like a current event, not a memory. I think many of think of them as being encapsulated, untouched memories buried deep in a hard drive. Reading these comments, it strikes me that perhaps the encapsulated memories are hiding out in RAM, never having been processed into actual memories that can be saved on a hard drive, so to speak. I cringe at the notion of using a computer analogy to explain human experiences, but jumps out at me as I read these comments.

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