Forging a Deeper Understanding of Flashbacks: Part II

Flashbacks have at least four striking features:

1. Flashbacks are experiential, marked by a sense of reliving, accompanied by sensations and affects).

2. Flashbacks are distinctly fragmentary.

3. Flashbacks are autonomous and involuntary.

4. Flashbacks are frequently associated with dissociative amnesia.

In this post, I will focus solely on the first of these — the experiential/reliving quality of flashbacks.

Why Are Flashbacks Experiential Rather Than Cognitive?

Perhaps the best current answer to this question comes from Chris Brewin in England (Brewin, Gregory, Lipton & Burgess, 2010). Brewin is one of the leading cognitive psychologists in the world. He has been studying PTSD and its intrusive symptoms for the last 15 years or so (see also Brewin, Dalgleich & Joseph, 1996). Brewin proposes that humans have two memory systems for episodic and autobiographical memory: (1) a contextual memory system that represents an event via abstract, contextually-bound representations of the event (“C-reps”), and (2) a low-level sensation-based memory system that represents events via their sensations (“S-reps”).

Although Brewin prefers to characterize these two memory system in terms of whether the context of the event IS associated with the memory representation (C-reps) or IS NOT associated with it (S-reps), he is basically talking about the difference between verbal memory and imagistic sensation memory. In a nutshell, Brewin says that both of these memory systems are part of our normal functioning. They work together.

An extreme event (i.e., trauma), however, may produce very strong imagistic sensation memory (S-reps) and weak/disconnected or even absent verbal contextualized memory (C-reps) of the event. Brewin refers to this situation as “pathological encoding.”

Brewin’s explanation of flashbacks. If a person has:

(1) a weak/disconnected or absent verbal contextual memory of an event (C-rep), AND

(2) a strong imagistic sensation memory of the event (S-rep), THEN

(3) whenever the the imagistic sensation memory is activated, “it is vividly re-experienced in the present” (Brewin et al., 2010, p. 224). AND,

(4) if the verbal contextual memory is completely absent, it will produce “extreme reexperiencing, in which all contact with the current environment is temporarily suspended” (p. 225) [i.e., a dissociative flashback]

Brewin also considers flashbacks to be adaptive:

Flashbacks are an adaptive process in which stored information can be re-presented and processed in greater depth once the danger is past” (p. 221)

From this point of view, PTSD develops when a person fails to process the information contained in the S-reps. Brewin is quite clear in stating that such a failure is AN ACTIVE PROCESS which prevents integration of the information and perpetuates the flashbacks:

“If flashbacks are to persist. there must be mechanisms to perpetuate this lack of integration. PTSD sufferers show marked behavioral and cognitive avoidance and find their intrusions (or certain parts of them) too unpleasant to attend to, which could plausibly account for the fact that the corresponding C-rep [verbal contextualized memory] remains incomplete.” (p. 225)

I think that Brewin’s model has a clean and simple elegance. In terms of the parsimony that is highly valued in science, Brewin’s model is quite nice. Nevertheless, I have a few reservations.

1. Brewin considers flashbacks to be adaptive. This position has always bothered me and, perhaps, I now understand better why I feel that way. Certainly, part of this idea –that flashbacks are adaptive — must be correct. Certainly, we have an innate tendency to find consistency in our minds and to resolve things that don’t fit. The part of this that bothers me is that flashbacks are NOT the same as normal intrusive thoughts (which Horowitz talked about in terms of “the completion principle” and coming to terms with major life events). Flashbacks are not cognitive; they are experiential. Flashbacks are not thoughts; they are (often) a bit like sticking your finger in an empty light bulb socket. I find it hard to consider electric mental shocks to be ADAPTIVE.

2. Brewin states that flashbacks are caused by pathological encoding of an event. By this, he means that an event can be so extreme that it produces very strong imagistic sensation memory (S-reps) and weak/disconnected verbal contextual memory (C-reps). So far, I like this description of flashbacks a lot. My apprehension is about the next step in Brewin’s reasoning. In his view, all that is needed for a flashback to occur is for the imagistic sensory memory to be activated. Boom! Flashback!

I feel a bit like Peggy Lee — “Is that all there is?” Is there no other factor involved? I feel like something is missing. I feel this even more strongly when Brewin uses this same formula to explain dissociative flashbacks. According to Brewin, if the verbal contextual memory is completely absent, then any activation of the S-rep will cause a flashback that produces a complete loss of contact with the here-and-now.

What is the something else that might be missing? In nondissociative flashbacks, I think the missing piece is affect — usually fear. Have you noticed that both flashbacks and their treatment (i.e., some form of prolonged exposure) operate according to the model of a simple phobia. I think that flashbacks are a perverse positive feedback loop among the amygdala and the decontextualized S-reps (and perhaps the insula as well). This is basically a phobic reaction to the images and sensations associated with the traumatic event. In short, I think flashbacks are driven by a ‘pulsing’ amygdala.

I also think that there is something missing in Brewin’s explanation of dissociative flashbacks — namely, a hypnotic brain. I would be willing to bet that dissociative flashbacks only occur in PTSD patients with high hypnotizability. High hypnotizability is a normal trait, but I think a flashback operates as something of an implicit ‘suggestion’ to remember/reexperience the event. If this is correct, then  dissociative flashbacks are a binary phenomenon (flashback + hypnotic response). Elsewhere, I have described this binary phenomenon in terms of the flashback ‘hijacking’ a normal ability (i.e., high hypnotizability) or a normal mechanism (i.e., a hypnotic brain).

Time to end this post. It has gotten too long.

But, for the research mavens in our midst, there is a bonus round.

RESEARCH IDEAS: There are surprisingly few empirical publications on flashbacks. There are even fewer articles on the phenomenology of flashbacks.

1. If PTSD patients who report having dissociative flashbacks are compared to PTSD patients with no history of dissociative flashbacks, will these two groups differ in their hypnotizability?

2. What is the difference, if any, between the flashbacks (that are experienced in the first month after trauma) of those who go on to develop PTSD and those who do not develop PTSD?

3. What is the difference, if any, between the flashbacks of trauma survivors who develop Acute Stress Disorder (ASD) and those who do not?

4. What is the difference in the flashbacks that are experienced by PTSD patients with low dissociation scores vs. those that are experienced by PTSD patients with high dissociation scores?

5. What is the difference in the flashbacks that are experienced by PTSD patients with high hypnotizability and those that are experienced by PTSD patients with low hypnotizability?

6. What is the difference in the flashbacks of ASD patients with high hypnotizability and those of ASD patients with low hypnotizability?

7. What is the difference between the flashbacks of persons with DID and the flashbacks of persons with PTSD only (and are there two identifiable subgroups among the PTSD patients — dissociative and nondissociative)?

Note: The key issue in each of the above research questions is the phenomenology of the flashbacks. Not all flashbacks are the same. There is a great need for all kinds of phenomenological research on flashbacks.

Skepticism About Trauma and PTSD

Graduate students who are interested in such research topics are counseled to beware of skeptics in academia. Graduate students should know that there are some academics with highly jaundiced views about the reality of trauma, the reality of flashbacks, and the very existence of PTSD. These skeptics can be found in some clinical psychology programs in the US and especially in academic settings in the UK. Even Chris Brewin, a very well-respected British researcher of PTSD, found it necessary to title his recent book: Posttraumatic Stress Disorder: Malady or Myth. ‘Nuf said for now.

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10 Responses to Forging a Deeper Understanding of Flashbacks: Part II

  1. Flashbacks are adaptive only in the sense that they indicate the unprocessed raw traumatic experience is trying to get processed, part of the body’s innate healing tendency. If one targets a true flashback with EMDR, it no longer flashes. Rather, the memory will be processed in fullness and take its place in the fund of knowledge. This happens very reliably. so to EMDR therapists, flashbacks are very much evidence that the traumatic material is trying to work its way out but can’t. Insufficient processing capacity. But when we add bilateral stimulation and the presence of the other to help maintain present orientation during the processing, the processing is no longer overwhelming, and becomes quite manageable. Exception: with DID, system structure interferes with this plan until and unless the various parts are oriented to present person place and time, and loyalty to the perpetrator (as evidenced in perpetrator introjects) is handled.

    • Sandra,

      I agree that there is an innate tendency toward cognitive consistency (what you call “the body’s innate healing tendency”). The mind does ‘want’ to achieve some equilibrium. The problem, of course, is that flashbacks tend to be destabilizing or disequilibrating. And yes, the therapeutic task is to find a way so that the person can tolerate the information enough to make headway in ‘digesting’ or assimilating it. You have found that EMDR is a good way to do that.

      • I’ve also found EMDR to be helpful, from the experiencing side of the equation. Now I need to figure out how to explain why I suspect that nature expected circumstances to eventually provide us with the support to “digest” or “assimilate” the flashback experience.

        One is that over the course of human evolution, we surely got a LOT more exercise than most people have in the past few generations. Immediately after my first EMDR experience, I connected the “bilateral stimulation” effect with something I’d already noticed on my own: it’s similar to walking.

        Actually I think walking may be our most natural form of bilateral stimulation. I’ve certainly found it helpful for dealing with a lot of this internal churning and chaos since I started walking a LOT within the past 2 years. We walk a minimum of 90 minutes every morning, and most evenings we’re doing another 60-90 minutes unless the schedule won’t allow it. Originally it was for weight loss – we lost 90 pounds in 18 months! Now it’s for weight maintenance but also for “mental equilibrium” because it definitely helps our system stay calmer and deal with this mess in smaller, less painful, more manageable bits and pieces.

        The other thing I think nature expected is that we would eventually join a supportive community of other humans. Personally I don’t think it’s natural for humans to be severely abusive to others in their community. Animals don’t act that way, and it doesn’t make sense, historically, for humans to act that way either. An ages past, which our brains probably are still oriented to, people more likely relied on each other a lot more for survival and needed to cooperate.

        I sense both of these “needs” being met via therapy, at least with the psychologist we’ve seen in the past couple of years. She uses EMDR quite a bit, which again, I think is keying right into nature. (We can’t do the eye movement type of EMDR – that causes problems for us, but tapping has worked out very well.) And she’s provided a supportive, encouraging environment, giving us confidence to try and a sense of safety.

        Maybe in ages past, a few simple “needs” like that being met would have been sufficient to lead to healing over time. Or maybe I’ve just been working too much this week and am rambling, LOL

  2. John O'Neil, MD says:

    Incisive post about flashbacks. I agree with you completely, but have a few areas (6) of comment and query:

    Point 1: definition
    “1. Flashbacks are experiential … often accompanied by sensations and affects.”
    Shouldn’t it read: “… always accompanied by sensations and/or affects”?
    because if a flashback has neither sensation nor affect, then how is it experiential?

    Point 2: volition
    “3. Flashbacks are autonomous and involuntary.”
    Generally, yes, though in working with DID patients I have encountered alters who claim that they ‘give’ a flashback to the host on purpose. So this isn’t purely involuntary, though it is experienced that way by the host.

    Point 3: semantic memory
    Brewin’s dichotomy between C-rep and S-rep leaves out an enormous middle ground by lumping semantic and autobiographical memory together – they are both abstract (verbal, conceptual), not sensation-based, but the former is not contextual, and the latter is. Semantic memory is like knowing that … whatever … without remembering the event or context of the learning (comprising almost all knowledge). So where would that fit into the schema? One may have flashbacks of an event; one may also know something one didn’t know before, without recall of the event (new semantic knowledge); and finally one may remember the event (autobiography). For example, I have no memory whatever of the events around my first learning of the distinction between semantic and autobiographical memory.

    Point 4: Unformulated experience
    How close is Brewin’s concept of S-rep to Stern’s unformulated experience?

    Point 5: adaptation; active vs passive; defence vs defect…
    If a flashback isn’t adaptive per se, then might it be an attempt at adaptation (resolution) that doesn’t work? Much like repetition compulsion, where unfinished business is repeated over and over in an attempt at mastery?
    You quote Brewin: “If flashbacks are to persist, there must be mechanisms to perpetuate this lack of integration.” Notice how that’s the Freudian view, whereas the Janetian one would be: “If flashbacks are to persist, there must be a lack of integrative mechanisms.” So Brewin is more Freudian than Janetian in this regard.

    Point 6: dissociative flashbacks
    Your dichotomy seems to be the extent to which the flashback is accompanied by some altered state of Csness. Clinically, I find that this is on a continuum, and the more salient dichotomy is “one’s own” flashback vs an intrusion from another of one’s self states or ego states. So the former could be a flashback in either PTSD or DID, whereas the latter would only occur in DID.

  3. Hi John,

    Welcome to UnderstandingDissociation.com! Come on in, the water’s fine.

    1. Yes, since flashbacks are experiential, I should not have qualified them as “often” accompanied by sensations and affects.

    2. This is an interesting point. I, too, have encountered DID alters who claimed that they could impose flashbacks on the host alter. In therapy, I take them at their word. In my head, I reserve judgment about the accuracy/reality of their claim. Maybe yes, maybe no. Bottom line: I don’t really know.

    3. Actually, Brewin focuses specifically on episodic and autobiographical memory. He stays away from semantic and declarative memory.

    4. I don’t know how Brewin’s S-reps relate to Donnel Stern’s concept of “unformulated experience.”

    5. I agree that Brewin is more Freudian than Janetian. The only way that I see flashbacks as being adaptive is when I construe them as “memory.” Memory, per se, is deeply adaptive. But… flashbacks seem to be so much more than just memory — i.e., repetitive, painful, and (when they persist) frankly pathogenic. They make the person sicker.

    6. Certainly, there is a continuum of flashbacks, from relatively mild intrusions into consciousness to full-blown dissociative flashbacks that may entirely supplant consciousness. Finally, yes, you are speaking DID language when you note that the alter who is ‘out’ may have his/her own flashback or may experience intruding flashbacks from an alter (who is strongly in flashback about that particular event).

  4. FRANCISCO ORENGO says:

    I will come back to John O´Neils point 5: “Adaptation; active vs passive; defence vs defect…If a flashback isn’t adaptive per se, then might it be an attempt at adaptation (resolution) that doesn’t work? Much like repetition compulsion, where unfinished business is repeated over and over in an attempt at mastery?”

    It also seems to me that flashbacks are adaptive and most probably an attempt at adaptation (resolution) that doesn’t work…but I would add that the adaptation intent per se is effective, indeed, and reflects the body vitality. What doesn’t work is the level or state to which the system wants to return. The whole brain-mind status is altered, unstable, disordered… this is why the attempts fail.

    The psychophysiological system tries once and again to readapt the altered physiology, but the trauma(s) have disintegrated the whole system in such a degree that the pretraumatic, stable status, cannot be achieved. Mutatis mutandis, it would be like a causalgic, phantom limb-like phenomenon that, through a new representation of what has been injured, mutilated, tries to reproduce the lost function, even anatomical structure.

  5. test says:

    Between me and my husband we’ve owned more MP3 players over the years than I can count, including Sansas, iRivers, iPods (classic & touch), the Ibiza Rhapsody, etc. But, the last few years I’ve settled down to one line of players. Why? Because I was happy to discover how well-designed and fun to use the underappreciated (and widely mocked) Zunes are

  6. great blog – and John O’Neil’s comments also give much to think about, reblogging this.

  7. Reblogged this on Trauma and Dissociation and commented:
    Understanding Flashbacks: Part II – from Paul F. Dell

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