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)?”