Part II: Hypervigilance in PTSD
The Nature of PTSD
As we discussed in Part I on anxiety, Post-Traumatic Stress Disorder is a straightforward response to perceived threats in the environment, that are not actually present to the degree they are experienced. Usually, these threats have existed at some point in the past and the person with PTSD is responding to past threats to their survival. In PTSD, the person takes those threats out of the original context and applies them in another context where they may not represent an actual threat to life/existence. PTSD responses are usually more about the meaning of a traumatic experience than simply the event itself.
Trauma Triggers
Most of us are familiar with the idea of being ‘triggered’, it is an excellent and appropriate connotation. The gun has already been loaded, the hammer is cocked and now something has caused us to pull the trigger and the bullet (trauma response) has now left the gun and is impacting the environment. PastTrauma Event(s) + meaning = Traumatic Experience(s) >PresentTrigger (cue) > Response to past experience
Let us think of PTSD this way: The traumatic event occurs, which prompts the person to develop a meaning about themselves connected to their survival. The traumatic event now becomes a traumatic experience (event + meaning). That meaning usually has grown out of earlier events and situations that have combined in this case to create strong meanings about the person. The traumatic experience includes specific pieces that the brain has captured as being related to the traumatic event – for example time of day, day of the week, smells, lighting, colors, weather, etc. We do not know what all our minds have connected to the events and the meanings, but the brain is now on the lookout for these cues, or ‘triggers’ that indicate a traumatic event is about to re-occur.
Definition of Hypervigilance
There are many definitions of hypervigilance. The problem with most of these definitions is that they are rational – the subject is ‘hyper-alert’ or constantly ‘on-guard’, etc. Any/all of these convey that the hypervigilance is more than typical. Let us expand this into a concrete definition we can use to understand what happens in PTSD:
Hypervigilance is the KNOWLEDGE that the trauma WILL happen again
On examination, we see that no one knows what WILL happen in the future. This definition is irrational but closer to the experience. In treating PTSD, we focus on what we call ‘maladaptive beliefs’. We develop maladaptive beliefs to protect ourselves however, the belief, if it was ever productive, has become unproductive. Thee belief does not help the person adapt productively to the environment. If we consider a person who was raped or abused by a man or men while growing up, they may develop an ADAPTIVE belief that they have to be cautious in certain circumstances. A MALADAPTIVE belief would be that “all men are unsafe”. This black and white belief serves to keep the person safe from their trauma. If they NEVER associate with men, they will be safe from men. Most maladaptive beliefs have this black and white quality because it is much easier to implement a black and white solution than something gray and conditional. The earlier adaptive belief – “I have to be cautious in certain situations” is full of gray areas and risk – however, it is not rational to assume you can live a full life and never interact with men.
In this example, if the person were on an elevator and a man entered the elevator with them, their threat response would be triggered, and their hypervigilance would now be looking for the cues that indicate their trauma is about to re-occur. Since this is (now) a survival situation, the body goes into a physical threat response. If any of the cues are present, the person may respond to protect themselves from a threat that is not present. Colors, clothing, proximity, smells, speech, race – any of these things, and more could be cues that trigger the response even if the person is unaware that is what is happening. When they arrive on their floor, they may be experiencing a “panic” or “anxiety” attack which is just a normal mammalian response to a threat situation. They may be upset for some time without realizing the causes, or they may fall back on their belief that they were not safe.
The Role of Hypervigilance in PTSD
When we define hypervigilance like this, hypervigilance begins to take on a much bigger role in PTSD. It is not merely a symptom. It is the central feature of PTSD – the maladaptive belief that I need to be in constant preparation to keep myself safe from a specific traumatic experience, even when it cannot reasonably happen. Hypervigilance is the belief set and responses that will keep me safe.
Triggers and Hypervigilance
Day to day, the person with PTSD is waiting for their trauma to re-occur. They KNOW it will re-occur. Separate and stronger than believing or thinking, this is a perseverating KNOWLEDGE that must be honored to stay safe. It is not an afterthought; it is a constant presence. It is difficult to challenge because it keeps the person safe. It is difficult for others to challenge because the person with PTSD is not going to trust the opinions of others against their own survival.
The person is constantly on the lookout for those cues or triggers that signal the event is about to re-occur. We do not know the extent of how the brain has cataloged these cues, but it is constantly filtering sensory information against the ‘list’ of cues looking for those signs. Depending on the trigger and the context, a person with PTSD may respond to a single cue or trigger or it may take an emerging pattern. A single smell may be enough to trigger a severe trauma response, or it may take a combination of time of day, certain colors, smells, sounds, etc. to come together and trigger a trauma response.
The Importance of Understanding Triggers
As we can see, hypervigilance can trigger a trauma response with just minimal information. If a person is unaware of their triggers, it may seem arbitrary or random. There may be no realization that it is based on events from the past. The person may recognize the trigger but believe that there is nothing they can do to prevent the trauma response, or even that they have no internal control over their triggers and responses at all. Since, often, the meaning of the traumatic experience connects to how the person with PTSD understands or believes others acted or reacted during the traumatic event, they may see all of this as something that happens external to them and they are not in control of their own safety.
By processing and studying the trauma (a practice that is difficult with PTSD) the person begins to see the patterns within the traumatic event or experience. They begin to recognize and understand the triggers. When they know some of their triggers, they are more able to understand and intervene in their trauma responses.
Hypervigilance and Recovery
The person recovering from PTSD can learn their triggers and share them with others in their circle of friends and family. They do not need to share the trauma details, per se, but rather what specific triggers they respond to. In doing this they can attempt to minimize the triggers in their environment and also work to reduce their responses to the triggers. The people around them can help them challenge the triggers – are they really happening, is the trauma recurring, is the trigger real in the situation or just reminiscent of the trauma events? Through this, the person can work to self soothe and calm and they can have new experiences around these old triggers and begin to challenge the black and white beliefs that they once thought protected them from harm.
Treatment
There are several treatments for PTSD. The most lasting and effective seem to center on processing the trauma, understanding the beliefs that grew out of the traumatic experiences, and learning to recognize and challenge those beliefs to take risks and learn new beliefs to replace the old. There are many treatment modalities that include this, there are also treatment modalities that supplement these specific steps. Challenging beliefs can be long-term work, but the skills that allow the person to calm and soothe, alongside the skills to challenge the beliefs (within healthy relationships that offer other experiences) can be developed rather quickly. Medication has a role in the treatment, but no medication can resolve or ‘cure’ PTSD. Since healthy relationships are critical, a treatment that includes recognizing, establishing, and maintaining healthy relationships is a critical element of treatment.
For me, as a therapist, while there are a lot of tools in treating PTSD and a lot of theories, PTSD still boils down to meaning. Where in the body is meaning held? The meaning comes out of relationships and possibly the only real way to challenge that meaning is in other relationships that offer a different outcome. We learn more about the body and mind every day, but we cannot exclude meaning from the treatment of PTSD and expect lasting results.
Part I: Anxiety in PTSD
The Nature of PTSD
Post-Traumatic Stress Disorder is a fairly straightforward mental health disorder. The origin of PTSD is the natural protective response to life threats in the environment. In PTSD, the person takes those threats out of the direct context and applies them in another context where they may not represent and actual threat to life/existence. PTSD responses are usually more about the meaning of a traumatic experience than simply the event itself. For instance, we might understand that a parent who lost their brother to drowning as a child might not let their children go to the pool or go boating with friends. But if that parent believes, because of the trauma, that they did not keep their brother safe, they may react to that meaning in ways that are not directly related to swimming. They may rage at a missed curfew or even rage at a chore their child did not complete. In one instance, they may see their child as ‘deliberately’ doing dangerous things or staying out of touch—not allowing the parent to protect them. In the other instance, the parent is upset with the child who ignores their directions, which can lead to life and death situations. In this situation, it only leads to a bed not being made or a garbage can that is not emptied. To the child or the other parent, the response is unreasonable and out of proportion. At the moment, the parent with PTSD is merely reacting to cues connected to the meaning of their trauma (I can’t keep people safe). It is even possible that after some time, the parent with PTSD will agree with the idea that their reaction was inappropriate and find ways to connect their overreaction to their belief that they cannot keep people safe. Their PTSD responses and belief about themselves are subtly reinforced. We call these beliefs ‘maladaptive’ because they are working against the person, as opposed to an ‘adaptive’ belief which would better help us cope. Many times, a maladaptive belief grows out of a belief that kept us safe in the past but now works against us.
Hypervigilance is at the core of PTSD. We will address how hypervigilance can feed into the other symptoms of PTSD, but first, we must understand the role of anxiety and even what anxiety is when we are talking about PTSD.
How Anxiety Relates to PTSD
In the Diagnostic and Statistical Manual of Mental Disorders (DSM) fourth edition, you would find PTSD under anxiety disorders. As we will see from a good definition of anxiety, it IS an anxiety disorder. However, PTSD is differentiated from all else by the presence of a life/existence-threatening trauma and the duration of the meaning of that trauma. Therefore, the DSM fifth edition (DSM 5) developers created a separate diagnostic category for those disorders which are centered around trauma and stress responses. However, the issue of anxiety is critical to understanding PTSD.
A Definition of Anxiety
There are many definitions of anxiety. I might agree that it is an overused word, or that we need a way to discriminate between different degrees of anxiety. Anxiety is not stress and it is not simply worry. When I hear people define anxiety, they do a pretty good job of introducing the idea of uncertainty. In studying the work of Harry Stack Sullivan and Karen Horney in the 1930s and 1940s, I arrived at a simple working definition of anxiety:
Anxiety is the fear of a non-present danger.
Ok, what is the fear of a present danger? Well, that is simply – fear. In PTSD the non-present dangers are those traumatic events and traumatic experiences (events and meanings) from the past. The danger actually existed at some point. The mind and body processed the patterns present in those events/meanings and are now on the lookout for cues that those events are about to happen again. When we discuss hypervigilance, we will see how this works day today. To experience anxiety is to feel overwhelmed. Humans will usually act to reduce anxiety where possible.
Anxiety Triggers
Thus, anxiety is based on ‘triggers’ or the cues that signal the mind and body that a life-threatening / existence-threatening event is unfolding or will unfold. But the dangers that the triggers are pointing to, in the case of PTSD, are usually not present. Some of what the body has stored as cues/triggers might have had no real relevance to the traumatic event, for instance, the color of someone’s clothes may be a trigger but not related to the trauma except by coincidence.
Life and Death Anxiety
In the example above, the parent experiences the children not honoring their directions to do their chores. In reality, not cleaning their room is not life-threatening. However, the parent who may have ignored their own parents’ warnings about taking their brother swimming, believes that they are not able to keep their kids safe. They may even believe that the drowning accident was their fault. At this moment, children ignoring their parents’ instructions could mean that the parent is unable to keep them safe and reacts to the life and death fear that is triggered in the moment. The life and death anxiety of PTSD.
Unknown Triggers
One of the difficult issues in treating PTSD is that the clients are often unaware of their triggers. They are not connected to the life and death meaning of their trauma and the triggers. They feel the anxiety in their bodies and react to the anxiety or seek to curb the anxiety through medication, substance abuse, or behaviors that are calming (but can also be maladaptive). They may feel the anxiety comes “out of the blue” because they are not connected to the triggers. One symptom of PTSD is to ignore or forget parts of the original pain and trauma itself because it creates pain within the body. Thus, often, the PTSD client is literally out of touch with their reactions as trauma responses. They believe that the feelings they have are inappropriate. However, given their trauma, the feelings would be appropriate if the danger were actually present as it was in the past.
Anxiety, the Original Emotion?
Harry Stack Sullivan thought that anxiety might be one of the first emotions we experience. Within the womb we are experiencing the world through our mothers, but indirectly. We may hear a voice or feel a movement and then experience the mother’s physical reaction – heartbeat, breathing, expression, etc. When we are born, we are thrust into a new, strange world where everything may appear dangerous because we do not know what it is. We are overwhelmed and possibly in danger. A human baby suffers constantly from the threat of annihilation and, thus, anxiety. We assess our world by looking back to our mothers and gauge her reaction to situations to know what is appropriate. Think of the baby who runs and falls and then looks at mother for a reaction. If mother is shocked, the baby reacts with fear and shock, if mother takes it in stride so, usually, does the baby.
Relieving Anxiety
In PTSD, an actual threat is experienced in one situation. However, the client carried the context over to another situation where it is not a threat. Their response to triggers causes them to feel that they are again in the original situation. The police officer who loses a brother in a swimming accident and blames himself, arrives at an accident where a young child, the same age as his daughter is killed. The officer is too late to save her and somehow believes that he should have arrived earlier. Later he goes home and drinks to fall asleep because he believes that he will eventually lose his own daughter that he cannot protect. Perhaps he begins to distance himself from her because he knows he will only lose her, or she might be safer if she is not around him. While the loss of his brother and the other child are real, his future loss of his own daughter is not. He is faced with his anxiety, not an actual danger.
His very real fear of a non-present danger is based on life and death experiences. His reaction is out of place because the danger is not present, however, the anxiety is real. How will he relieve this anxiety? He could get a prescription, self-medicate, take risks and use the adrenaline and endorphins that the body will produce. He could seek out other relationships where he does not need to get close. Or, he could challenge his maladaptive beliefs in therapy, identify the origins and sources of his beliefs, and learn to accept and cope with some levels of anxiety, knowing them for what they are. Only one solution can actually resolve his maladaptive beliefs and increase his resilience in future situations.
Hypervigilance is the body’s way of protecting you from threatening situations.
Chronic hypervigilance is a common consequence of CPTSD, particularly in people who have been in dangerous environments for a long time.
Anxious hypervigilance is marked by sensitized sensory-perceptual processes and attentional biases to potential danger cues in the environment.
Anxious hypervigilance is marked by sensitized sensory-perceptual processes and attentional biases to potential danger cues in the environment. How this is realized at the neurocomputational level is unknown but could clarify the brain mechanisms disrupted in psychiatric conditions such as posttraumatic stress disorder. Predictive coding, instantiated by dynamic causal models, provides a promising framework to ground these state-related changes in the dynamic interactions of reciprocally connected brain areas.
Methods
Anxiety states were elicited in healthy participants (n = 19) by exposure to the threat of unpredictable, aversive shocks while undergoing magnetoencephalography. An auditory oddball sequence was presented to measure cortical responses related to deviance detection, and dynamic causal models quantified deviance-related changes in effective connectivity. Participants were also administered alprazolam (double-blinded, placebo-controlled crossover) to determine whether the cortical effects of threat-induced anxiety are reversed by acute anxiolytic treatment.
Results
Deviant tones elicited increased auditory cortical responses under threat. Bayesian analyses revealed that hypervigilant responding was best explained by increased postsynaptic gain in primary auditory cortex activity as well as modulation of feedforward, but not feedback, coupling within a temporofrontal cortical network. Increasing inhibitory gamma-aminobutyric acidergic action with alprazolam reduced anxiety and restored feedback modulation within the network.
Conclusions
Threat-induced anxiety produced unbalanced feedforward signaling in response to deviations in predicable sensory input. Amplifying ascending sensory prediction error signals may optimize stimulus detection in the face of impending threats. At the same time, diminished descending sensory prediction signals impede perceptual learning and may, therefore, underpin some of the deleterious effects of anxiety on higher-order cognition.
The Unpredictive Brain Under Threat: A Neurocomputational Account of Anxious Hypervigilance
When someone experiences hypervigilance, their subconscious is constantly anticipating danger. As a result, their senses are on high alert, ready to spot and respond to any danger.
Understanding the neurobiological correlates of childhood maltreatment is critical to delineating stress-related psychopathology. The acoustic startle response (ASR) is a subcortical reflex modulated by neural systems implicated in posttraumatic stress disorder (PTSD
There are three brain structures that play key roles in the science behind PTSD. They are the amygdala, hippocampus and prefrontal cortex.
The amygdala is the stress evaluator. It continuously monitors all situations for danger and decides when to react. The sights, sounds and smells of frightening and dangerous memories are stored here. When the brain recognizes similar situations, the amygdala sends out danger signals and gets the body ready for a flight or fight response.
The hippocampus stores and retrieves memories, everything from where you attended second grade to where you parked your car three hours ago. If your brain is a computer, the hippocampus is the hard drive.
The prefrontal cortex is the large part of the brain sitting right behind your forehead. This is the executive-functioning area responsible for rational thought and decision making. In the computer analogy this is the central processing unit running the programs.
In the moment of a traumatic experience the hippocampus frantically tries to cope and calm the amygdala alarm circuit. In some cases the hippocampus is not able to calm the amygdala, resulting in damage to the hippocampus region of the brain, which lessens the ability of the amygdala to produce calming thoughts.
With PTSD, the nerve circuits connecting the amygdala, hippocampus and prefrontal cortex aren’t working correctly. The hippocampus can’t store the memory and the prefrontal cortex can’t override the hippocampus to tell the amygdala to calm down when there is no danger.
PTSD is a cluster of symptoms that occur for at least a month or more. When someone has PTSD they persistently re-experience the traumatic event, through recurring thoughts, nightmares and flashbacks because the hippocampus is not storing memories correctly. They will also experience persistent avoidance of stimuli associated with the trauma such as connected thoughts, feelings or places because the amygdala is essentially yelling, “danger!” Additionally, a patient with PTSD will have persistent increased arousal that may cause hypervigilance, irritability, difficulty sleeping or an exaggerated tendency to be easily startled.