The Neurobiology of

Dissociation
Current Findings and
Treatment Approaches

Ulrich F. Lanius, Ph.D.

8/20/08
8/20/08
 Goals
Describe a model based on recent
developments in neuroscience and the
neurobiology of dissociation, that
guides therapeutic interventions in
general and EMDR treatment in
particular.

8/20/08
 Objectives

Familiarize participants with interventions

that minimize dissociative symptoms.
Aid therapists in enhancing efficient
information processing during EMDR
treatment.
Acquaint participants with techniques that
aid clients in becoming reconnected, once
dissociative processes have occurred.

8/20/08
 What is
Dissociation?
The escape when there is
no escape.

Putnam, 1997

8/20/08
 What is
Dissociation?
Dissociation in response to early
trauma that is experienced as
"psychic catastrophe", has been
described as "detachment from an
unbearable situation" and "a last
resort defensive strategy (from
Schore 2001).
8/20/08
 Dissociation
Disturbance and/or alteration in the
normally integrative functions of:
Identity
Memory
Consciousness.
Disrupts the integration of information.

8/20/08
 Dissociation

Dissociation includes three distinct but

related mental phenomena:
Primary dissociation.
Secondary dissociation.
Tertiary dissociation.

8/20/08
 Primary Dissociation
Inability to integrate what is happening
into consciousness.
Sensory and emotional elements of the
event not being integrated into personal
memory and identity.
Experience remains isolated from ordinary
consciousness.
Peritraumatic dissociation.

8/20/08
 Secondary Dissociation
Dissociation between observing ego and
experiencing ego.
E.g. mentally leaving ones body at the
moment of the trauma.
Observing what happens from a distance.

8/20/08
 Tertiary Dissociation
Development of distinct ego-states.
Contain traumatic experiences.
Consist of complex identities with distinct
cognitive, affective, and behavioral
patterns.

8/20/08
 Dissociative Phenomena
Perceptual alterations (e.g. flashbacks).
Changes in self-experience (e.g.
depersonalization).
Perception of reality (e.g. derealization).
Amnesia.
Fugue states.

8/20/08
 Somatoform Dissociation
Somatoform dissociation (Nijenhuis, 1999).
Somatic and sensorimotor phenomena.
Can present in a variety of ways that include
sensory distortions, motor weakness,
freezing, numbing, paralysis, tremors,
Shaking and convulsions are also common.
Sleepiness, attentional impairment.
Headaches, pain sensations.
Cataplexy.

8/20/08
 Dissociation
&
Information
Processing

8/20/08
 Dissociation & Information
Processing
Interferes with psychotherapeutic process.
Interferes with affective regulation.
Interferes with experiencing emotion.
Results in unpredictable ego-state shifts.
Interferes with continuity of self.

8/20/08
 EMDR
&
Dissociation

8/20/08
 EMDR and Dissociation
EMDR breaks through dissociative barriers.
Appears to directly affect dissociative processes.
May affect the underlying neurological
mechanism of dissociation.
Extensive precautions emphasized in Part I and
II training with regard to the use of EMDR in
individuals with significant dissociative
symptoms.

8/20/08
 EMDR and Dissociation -
contd
EMDR may work exactly because it breaks
through dissociative barriers.
Increases connectivity in the brain.
With limited traumatic material,
information processing typically occurs
rapidly without overwhelming the
system.

8/20/08
 EMDR and Dissociation -
contd
calossal connectivity
interhemispheric connectivity? (Christman et al. 2001,
2003).
Improved episodic memory (Christman et al. 2003).
retrieval, associative & contextual information
(Parker et al. 2008).
false recognition (Parker et al 2007).

8/20/08
 EMDR and Dissociation -
contd
When traumatic material is too extensive it cannot be
integrated with the Standard Protocol
Hyperarousal and/or dissociation triggered.
Impaired information processing.
Powertool vs. chainsaw.

8/20/08
 EMDR and Dissociation -
contd
When traumatic material is too extensive it
cannot be integrated with the Standard
Protocol.
Hyperarousal and/or dissociation triggered.
Loss of mindfulness/dual awareness.
Impaired information processing.
Power tool vs. chainsaw.

8/20/08
 Dissociation
&
EMDR
The Need for Stabilization

8/20/08
Three Stages of Trauma Treatment

Stage 1: Stabilization

Stage 2: Trauma focused therapy

Stage 3: Reconnection

8/20/08
 Need for Stabilization
Ensure client is sufficiently stabilized prior
to proceeding with EMDR.
Clients who do not have internal
resources, ego strength and who cannot
identify emotions, body sensations. The
use of the full protocol can produce
feelings of failure, frustration and
regression.

8/20/08
 Need for Stabilization - contd

Clients need a life and support system

outside therapy.
Do not use EMDR when clients are
experiencing real-life problems which
overwhelm their ability to cope.

8/20/08
 DISSOCIATION
Towards
a
Neurobiological Model

8/20/08
 Triune Brain

8/20/08
 The Triune Brain - A Model
Evolutionary development has resulted in
three layers (McLean, 1990).
Reptilian Brain (sensorimotor).
Limbic System (emotions).
Neo-cortex (cognitive).
Interact, and affect each other - cohesive
whole.

8/20/08
8/20/08
 EMDR Protocol & the Triune
Brain
Cognition.
Emotion.
Somatosensory (Image & Body Sensation).
Top-down.
Bottom-up.

8/20/08
 PTSD, Dissociation
&
Neuroimaging
What Happens in the Brain

8/20/08
Dissociation - What happens in
the brain

Lanius et al (2001).
fMRI: recall of traumatic memories in
PTSD - script driven imagery.
Decrease in brain activity.
Amygdala inactive - implications for
fear conditioning.

8/20/08
8/20/08
 Lanius et al (2001)
fMRI: recall of traumatic memories in PTSD -
script driven imagery.
Prefrontal cortex , anterior cingulate ,
thalamus .
These are also some of the very areas that
have the highest densities of opiate receptors
(Kling et al. 2000) (see table).
Thalamic function has been related to
neuroplasticity (e.g., Llinas et al, 1999).

8/20/08
8/20/08
 Opiates & Brain
Functioning
Neuroscience Research

8/20/08
 Opiates & Brain Functioning

Local cerebral glucose utilization .

Thalamus , limbic , forebrain regions
(Fanelli et al, 1987; Kimes et al, 1989).
Inhibition of entire thalamus (Brunton et al,
1998).
Shift of cell firing from tonic to bursting
mode.
Endogenous opioids affect specific thalamic
nuclei depending on the origin of the
presynaptic input.
8/20/08
 Medial Prefrontal Cortex
Monitoring and modulation of emotions.
Exercises inhibitory mechanisms on the emotional
limbic system.
Mindfulness.

Medial Prefrontal Cortex

8/20/08
 Anterior Cingulate Gyrus
Regulates autonomic changes to emotional
stimuli.
Attention.
Involved in integration of cognitive and
emotional aspects of experience.

Anterior Cingulate

8/20/08
 Amygdala(e)
Inactive vs. active (Gilboa et al 2004;
Britton et al. 2005)
Implications for fear conditioning.
Indelible nature of traumatic memory.
Attachment?
Severity?
Multiple traumatization?

8/20/08
 The Thalamus

8/20/08
 The Thalamus
Located deep in the core of the brain.
Gateway of sensory information into the
cerebral cortex.
Implicated in temporal/cognitive binding.

8/20/08
8/20/08
 Function of the Thalamus
Relay station (top-down, bottom-up).
Integration of information.
Consciousness (e.g. absence seizures).
Alertness.
Arousal.
Neuroplasticity.

8/20/08
 The Thalamus - contd

Sensory gateway to cortex.

Principal synaptic relay for information
reaching the cortex.
All sensory information, except for
olfaction, is routed through the
thalamus to cerebral cortex

8/20/08
8/20/08
 The Thalamus - contd

Main source for the external stimulation of

the cortex - activates transient complexes of
neurons.
Mediates the interaction between attention
and arousal - relevant to the phenomenology
of traumatic stress syndromes.

8/20/08
 Primary Dissociation
The brain shuts down.
Disconnects lower brain structures from
the limbic system and neo-cortex.
Relay station between them, the thalamus,
goes off-line.
Sensory information no longer relayed
from there to the appropriate areas of the
cerebral cortex.

8/20/08
8/20/08
 Primary Dissociation - contd
Disrupts information processing.
Higher-level thought processes are
disrupted.
Reptilian brain functioning.

8/20/08
 Thalamus BA 47 Inferior Frontal Gyrus

BA 19 Occipital BA 32 Anterior Cingulate

BA 11 Middle Frontal Gyrus
Regions of activation during traumatic memory recall versus implicit baseline where the
comparison group (n=13) shows greater activation than the hyperaroused/flashback/reliving
PTSD8/20/08
group (n=11) k>10.
 Secondary Dissociation
Increased brain activation compared to Primary
Dissociation.
Change in body awareness.
Parasympathetic activation.
Decreased or unchanged heart rate.
Out-of body experience.
Compensatory mechanism?
Temporal lobe hyperactivity.
Relationship to seizure-like symptoms.

8/20/08
 Secondary Dissociation -
contd
I was outside my body looking down at
myself. It was too overwhelming to recall
the traumatic memory.
I was completely zoned out and could
not tell what I was feeling.
I was looking down at my own body
while I was back reliving the car
accident.

8/20/08
8/20/08
BA 38 Superior Temporal Gyrus BA 9, 10 Medial Frontal Gyrus

BA 39 Middle Temporal BA 24 Anterior Cingulate

Gyrus
BA 7 Medial Parietal Lobe
Regions of activation during traumatic memory recall versus implicit baseline where the
dissociated PTSD group (n=10) shows greater activation than the comparison group
8/20/08
(n=10), k>10.
 Tertiary Dissociation
Structural Dissociation Model.
Increased brain activation compared to
Primary Dissociation in Medial Prefrontal
Cortex.
Distinct ego states.
Reinders et al. (2003).
Yet another compensatory process.

8/20/08
 Heart Rate

70% increase (hyperarousal).

30% no change or decrease
(dissociative).
Sympathetic vs. parasympathetic.
Issue re: diagnostic errors.
Different variances between groups.

8/20/08
 Heart Rate Responses
35

30

25

20
Heart Rate

15
Control(13)
10
Hyperaroused(11)
Dissociated(11)
5

-5

-10

-15
Subjects
8/20/08
 PTSD & Emotion

Impaired ability to experience all

emotions.
Alexithymia.
Decreased thalamic activation.
Decreased anterior cingulate activation.
Large part of variance on CAPS accounted
for by alexithymia.

8/20/08
 Alexithymia & PTSD
Inability to read emotion.
Inability to feel.
Impairment in relationships.
Impairment in emotional functioning in
general.
Affect freefloating.

8/20/08
8/20/08
 Attachment

8/20/08
 Orienting Response,
Attachment & EMDR
EMDR facilitates attentional orienting
(Kuiken et al. 2001)
Alerting vs. investigatory (Sokolov 1963).
Investigatory orienting response
explanation for EMDR effect?
(MacCulloch & Feldman (1996).
Polyvagal theory: dorsal vagal vs. ventral
vagal vs. sympathetic (Porges, 2001).

8/20/08
 The Role of Attachment
Previously described processes
exacerbated by a previous history of
attachment trauma.
Top-down processing .
Cognition .
Modulation of affect .
Self regulation .

8/20/08
 The Role of Attachment -
contd
Relational trauma in the first through third
quarters of the first year negatively impacts the
experience-dependent maturation of the anterior
cingulate limbic circuits (Schore 2001a).
Abuse and/or neglect over the first two years
negatively impacts the major regulatory system
in the human brain, the orbital prefrontolimbic
system (Schore, 2001b).
Decreased amygdala activity (Chugani et al,
2001).

8/20/08
8/20/08
 The Orbitofrontal Cortex
(OFC)
Part of the frontal lobe that lies superior to
the orbit of the eyes.

Connections with the cingulate cortex

provides a way for it to influence both
behavior and the autonomic nervous
system.

8/20/08
 The Orbitofrontal Cortex
(OFC) - contd
Receives direct inputs from the dorsomedial
thalamus, temporal cortex, ventral tegmental
area, olfactory system, and the amygdala.
Outputs go to several brain regions,
including the cingulate cortex, hippocampal
formation, temporal cortex, lateral
hypothalamus, and amygdala.
Communicates with other regions of the
frontal cortex.

8/20/08
8/20/08
 The Orbitofrontal Cortex
(OFC) - contd
Inputs provide it with information about
what is happening in the environment and
what plans are being made by the rest of
the frontal lobes.
Outputs permit it to affect a variety of
behaviors and physiological responses,
including emotional responses organized
by the amygdala.

8/20/08
Functions of the Frontal Cortex
Attention/Concentration
Dual Attention.
Working Memory.
Executive Functioning.
Top-down processing.
Inhibitory functioning.
Affective regulation.

8/20/08
 The Orbitofrontal Cortex
(OFC) and Child Development
In early postnatal life, maintenance of critical
levels of tactile input of specific quality and
emotional content is important for normal
brain maturation (Martin, Spicer, Lewis,
Gluck, & Cork; 1991).
Sensory input derived from contact with the
mother during nursing has been suggested to
shape dendritic growth (Greenough & Black;
1992).

8/20/08
 Attachment and Endogenous
Opiates
Human attachment is, in part, mediated
by the endogenous opiate system.
Brain circuits involved in the maintenance
of affiliative behavior are those most richly
endowed with opioid receptors (Kling et
al, 1976).

8/20/08
 The Foundation of the
Vulnerability to Dissociate?

Lack of caregiving during the first few weeks

of life decreases the number of opioid
receptors in the cingulate gyrus & thalamus in
mice (Bonnet et al, 1976).
Stress results in release of endogenous opioids.
Fewer receptors to bind released opioids.
Decreased modulation.

8/20/08
 Effects of Early Relational
Trauma
Infants lose postural control, withdraw,
and self-comfort.
Reminiscent of the withdrawal of
Harlows isolated monkey or of the infants
in institutions observed by Bowlby and
Spitz (e.g. Bowlby, 1978).
Profound detachment" of dissociation
(Barach, 1991).

8/20/08
 Effects of Early Relational
Trauma contd
Vagal tone .
Blood pressure .
Heart rate .
Despite circulating adrenaline .
Parasympathetic regulatory strategy.

8/20/08
 Effects of Early Relational
Trauma contd
Decreased blood pressure and heart rate,
despite increases in circulating adrenaline.
Infant posttraumatic stress disorder of
hyperarousal and dissociation.
Sets the template for later childhood,
adolescent, and adult PTSD (Schore,
2001b).

8/20/08
The Profound Detachment" of
Dissociation
In this passive state pain numbing and
blunting endogenous opiates are elevated.
These opioids, especially enkephalins,
instantly trigger pain-reducing analgesia and
immobility (Fanselow, 1986).
Inhibition of cries for help (Kalin, 1993).
Bradycardia, cataplexy and paralysis are
opioid-mediated dissociative responses to
childhood trauma (Perry et al., unpublished
manuscript).
8/20/08
 Psychiatric Sequelae of
Chronic Early Trauma

Substance Use Disorders

Anxiety Disorders Somatisation
Disorders
Depression
Repeated Eating
PTSD Disorders
Early Trauma
Dissociative
Brief Psychoses Disorders

Borderline Personality Disorder

8/20/08 Chu, 1998
 Learned
Helplessness -
A Model of
Dissociation?

8/20/08
 Disengagement "to conserve
energiesto foster survival by the
risky posture of feigning death, to
allow healing of wounds and
restitution of depleted resources by
immobility" (Powles, 1992, p. 213).

8/20/08
 Learned Helplessness &
Endogenous Opiates
Endogenous opiate systems involved in
the induction and expression of learned
helplessness (LH) and stress-induced
analgesia (SIA) (Hemingway et al 1987).
Animals exposed to inescapable shock
develop stress-induced analgesia (SIA)
when re-exposed to stress shortly
afterward.

8/20/08
 Learned Helplessness &
Opioid Antagonists
Conditioned and unconditioned freezing
reversed by naltrexone/naloxone.
Naltrexone blocks immobility in a forced
swimming test (Makino et al, 2000).
Analgesic response is readily reversible by
naloxone (Kelly, 1982).
Anhedonia and enhanced emotional reactions
to novel stressors secondary to early exposure
to chronic variable stress reversed by opioid
antagonists (Zurita et al. 2000).
8/20/08
 Repeated Traumatization
Mice are defeated daily several times.
Develop a very high tolerance to release of
their own opioids.
At this point even high doses of morphine
cause no analgesia.
Naloxone induces withdrawal
The animal has become dependent on its
own opioids.

8/20/08
 Opioids and Defeat
Massive release of endogenous opioids.
Subsequently fall to low levels.
Broken down faster than they can be
synthesized.
Subsequent lack of endogenous opioids
may create predisposition towards
depression.

8/20/08
 Opioid Activation
&
PTSD
Human Studies

8/20/08
 Gold et al, 1982
People traumatized as adults, re-exposure to
situations reminiscent of the trauma evokes
as endogenous opioid response analogous to
that of animals exposed to mild shock
subsequent to inescapable shock.
Re-exposure to stress may have the same
effect as the temporary application of
exogenous opioids, providing a similar relief
from anxiety.

8/20/08
Pitman et al 1990; van der Kolk
et al 1989
Vietnam veterans with PTSD.
30 percent reduction in perception of pain
when viewing a movie depicting combat
in Vietnam.
Analgesia produced was equivalent to
that which follows the injection of 8 mg of
morphine.
Reversed with naloxone.

8/20/08
 Case Study
The Effects of Attachment
Lanius et al. 2003.
Couple.
Exposure to same traumatic event
Multi-vehicle MVA.
Trapped in vehicle.
Person burned to death outside vehicle.
Both meet DSM-IV criteria for PTSD.

8/20/08
 Case Study
The Effects of Attachment
Male Female
Professional Professional
No psych hx Post-partum
Loving parental Cold, distant
relationship relationship with
mother
Fight & flight Freezing/numbing
response
response

8/20/08
 Simple PTSD with uneventful childhood hx

8/20/08
 Simple PTSD with hx of Attachment
Problems

8/20/08
 Figure 1 (A=Male; B=Female) Regions of significantly (p<0.05)
increased BOLD response during the traumatic memory recall versus
8/20/08 implicit baseline.
 Preparing for EMDR
treatment

8/20/08
 Working with
Dissociative Clients
Therapist Considerations

8/20/08
 Therapist Considerations
Feel comfortable with client population.
Feel comfortable with EMDR.
Good rapport and sense of safety is
essential.
Affective Attunement (Schore, 2001a)
Do your own work to avoid being
triggered and triggering your client.
Transference/Countertransference.

8/20/08
 Working with
Dissociative Clients
Physical Environment

8/20/08
 Physical Environment
Comfortable and non-institutional.
Client needs to feel valued (attachment
issues).
Adequate Lighting.
Physical distance.
Seating on floor vs. chair, regression vs.
grounding.
Textures and objects with sensory quality.

8/20/08
 Additional Considerations
Transitional object; e.g. tape with
therapists voice.
Aromatherapy.
Art supplies.
Allow for extended sessions in the
beginning to complete sessions and deal
with incomplete processing.

8/20/08
 Assessment of
Dissociation

8/20/08
8/20/08
 Behavioral Signs
Staring into space.
Speech trails off, attention is gone.
Trancing behaviours such as repetitive
rocking and/or leg bouncing.
Self destructive behaviours often
performed in an automated fashion.

8/20/08
 Behavioral Signs contd
Alterations in presentation such as speech
pattern, sophistication of level of
language, postural changes, personality
change.
Changes in behavior such as suddenly
wanting to leave the session, changing the
topic, becoming aggressive.
Childlike behavior.

8/20/08
8/20/08
 Assessment - Planning
Minimally necessary information versus extensive
history.
It is worth taking the time to gather an adequate
history and formulating a treatment plan that starts
with assuring or developing resources needed for
processing traumatic material.
Detailed trauma history may be overwhelming
during early stages of treatment and/or inaccessible
because of amnestic barriers.

8/20/08
 Assessment - Planning
Assume client dissociates.
Watch carefully for signs of hyperarousal,
hypoarousal and dissociation.
Always identify strengths.
Polyfragmented DID.
Ego state mapping may be destabilizing.
Genograms.

8/20/08
 Client example - Genogram
Genogram as a trigger.
1st Nations community.
Referrals from other therapists.
Integrative.
Can be too fast.

8/20/08
 Assessment - Psychometric
Trauma measures not always reliable.
Dissociative processes do occur in the
absence of significant scores on either of
these measures.
A number of individuals with severe
dissociation appear to show no
psychometric evidence.

8/20/08
 Psychometric Assessment -
contd
A functional part of the system may be
responding.
Current substance abuse may be
associated with spuriously low scores on
measures of dissociation.
Do not necessarily rely on psychometric
measures alone; clients will often
underreport unaware themselves;
collateral information.

8/20/08
 Assessment - Psychometric
TSI and DES recommended. ATR on TSI elevated.
SCID-D or DDIS are often helpful, but in some cases
there is underreporting of symptoms if there is
insufficient rapport developed with the clinician.
DDIS has many items focusing on somatization.
available at
http://www.rossinst.com/dddquest.htm).
SDQ-20 (Nijenhuis, 1999) (available at
http://www.psychotherapist.org/Sdq20.PDF
Invalid MMPI profiles suggestive of Dissociative
Disorder. Elevated F-scale (North et al., 1993).

8/20/08
 Stabilization Techniques as
Diagnostic Indicators
Inability to do safe place exercise is to
some extent diagnostic.
Flipping into trauma on resource
installation protocol.
Difficulty, inability, unwillingness to use
self stabilization techniques.
Inner Child Work.

8/20/08
 Other Potential Indicators
Multiple previous diagnoses.
Schneiderian first rank symptoms (Kluft,
1987).
Evidence for seizure-like symptoms
(Lanius et al, 2000) and soft neurological
symptoms (Gurvits et al, 2000).
Going blank, sticky eyes.
Headaches.

8/20/08
 Brief Screening
Do people ever tell you that you have said
things that you cannot remember?
Do any parts of your body ever go numb?
Do you ever have any out-of-body
experiences, like looking at yourself from
the top of the ceiling?

8/20/08
 Demand Characteristics and
Expectancy
The importance of hope.
Demand characteristics and suggestion about the
probable length of treatment.
Premature and/or partial integration in severe
Dissociative Disorders.
Cognitive factors like expectation appear to trigger
endogenous opioid systems - reversible by naloxone
(Amanzio et al , 1999).
Stabilization vs. increased dissociation.

8/20/08
 Consent
Ensure informed consent.
If necessary from different parts of the system in DID
clients. Is this OK with all of you all parts of you
any part object?
Prepare client with information material regarding
effects of EMDR: may trigger dissociative processes,
flashbacks, nightmares, and physical symptoms.
EMDR trial run with minor traumatic event.

8/20/08
 Client Example
Single handed sailor.
Encounter group.
Referred for EMDR.
Triggered by information material.

8/20/08
 Working with
Dissociative Clients
Client Considerations
The Need for Stabilization

8/20/08
 Alterations in Self Regulation
Need for Stabilization

8/20/08
 Indications for Stabilization
Easily flooded with overwhelming feelings.
Inability to experience positive emotions.
Unable to identify feelings.
Actively suicidal/homicidal.
Poor impulse control.
Significant dissociative symptoms.
Unstable therapeutic alliance.
Current life crisis.

8/20/08
 The Need for Stabilization
Ensure client is sufficiently stabilized prior
to proceeding with EMDR.
Clients who do not have internal
resources, ego strength and who cannot
identify emotions, body sensations, the
use of the full protocol can produce
feelings of failure, frustration and
regression.

8/20/08
 The Need for Stabilization -
contd
Clients need a life and support system
outside therapy.
Do not use EMDR when clients are
experiencing real-life problems which
overwhelm their ability to cope.
Availability to clients.
Phone contact between sessions.

8/20/08
 The Need for Stabilization -
contd

Good rapport and sense of safety is

essential.
Affective attunement - beginning and end
of session.
Boundaries & transference.

8/20/08
 Preparatory Work
The Stabilization Phase

8/20/08
 Self-Soothing, Containment &
Grounding
Focus on stabilization will often result in
the spontaneous integration of parts.
Integration vs. improved level of
functioning.
Keep client functioning sometimes means
enhancing dissociative defenses.
Safe place exercise; inability to do may be
diagnostic.

8/20/08
 Self-Soothing, Containment &
Grounding
It may be necessary to replace "safe" with
"relaxing", "comforting".
If safe place inappropriate, try lightstream.
Safe place with bubble.
Container.
Inability to use self-soothing usually
precludes use of EMDR; more work on
safety necessary.

8/20/08
 Safe Place Modifications
It may be necessary to replace "safe" with
"relaxing", "comforting".
Safe place with bubble.
If safe place inappropriate, try lightstream.
Inability to use self-soothing usually
precludes use of EMDR; more work on
safety necessary.

8/20/08
 Self-Soothing, Containment &
Grounding
Grounding techniques, sensory (e.g.,
Linehan, 1993a).
DBT (Linehan, 1993b).
DeTur - Desensitization of Triggers and Urge
Reprocessing (Popky, 1998).
Practice going in and out of dissociation with
client.
Use containment technique at beginning and
end of session.

8/20/08
 Resource Development
Resource Development (e.g., Leeds, 2000).
Reduces dissociative symptoms (Korn & Leeds)
Start with minimal bilateral stimulation.
Consider using crosslateral stimulation.
Focus on body sensation.
Diagnostic with regard to positive affect
intolerance: probable Attachment Disorder.

8/20/08
 Inner Child Work
Ask client for permission before
proceeding.
Empathy for the child self.
Inability to do will require extensive
preparation.

8/20/08
 Physical Boundaries
Body therapy approaches (e.g. Ogden).
Drawing circle around self.
Pushing.

8/20/08
 Mindfulness
Awareness of being in the here and now.
Provides the traumatized individual with the all
important context that it is not happening all
over again but that the event is in the past, it is
just a memory.
Mindfulness is correlated with an increase in
frontal functioning, engaging working memory,
allowing the person to keep track of several
events at the same time.

8/20/08
 Mindfulness
Does not cure traumatic stress syndromes.
the ability to be mindful is a precondition to the
successful working through of traumatic material.
Being present in the here and now rather than being
drawn to the past or alternatively driving yourself to
distraction.
Being grounded in the present allows the freedom of
choice and the ability to purposefully direct ones
attention to wherever one chooses.

8/20/08
 Mindfulness - contd
Four general areas:
Activities of the body, including the rise and fall of the
movements of breathing.
Sensation. Sensations are noted to arise, and to pass
away.
Emotion. Anger and pleasure, greed and the absence of
greed, are registered, recognized, and seen to be
transient ripples atop the deeper, mental seascape.
Cognition and other mental contents or concepts They
are noted, traced back to their origin, and then seem to
pass away.

8/20/08
 Mindfulness & Stabilization

Interoceptive/Exteroceptive Awareness.
Sense of ones body/body awareness.
Boundaries.
Safety.
Somatic Tolerance.
Affect Tolerance.
Affect regulation.
Trauma/attachment education.
Self-soothing.
Empathy for the self.
8/20/08
 Body Mindfulness
Yoga.
Pilates.
Getting in touch with body (e.g. Levine,
1997); can combine with bilateral stimulation.
Exercise Ball.
Balance Board.
Other activities.

8/20/08
 Ego State Therapy
Fragmentation of the self (Watkins &
Watkins, 1997).
Parts, self states, internal objects/family,
etc. (Forgash & Bergman, 1999).
Segmentation of personality into ego
states at points of the dissociation
continuum due to normal differentiation
or trauma.

8/20/08
 Ego State Continuum

8/20/08
 Ego State Therapy - contd
Boundaries vary from fluid to permeable to
rigid.
May be organized to enhance adaptability in
coping with specific events or problems.
May be delineated by time dimensions,
signifying the age at which formation occurred,
i.e. child, adolescent or adult, affect, cognition,
etc.

8/20/08
 Ego State Work
Ego state techniques prior can reduce conflict between
parts and may aid in containing session but may also be
problematic early on in treament.
For polyfragmented Dissociative Disorders (commonly
meet criteria either for DDNOS or DID) identification of
parts during the early stages of treatment is sometimes
impossible due to the sheer complexity of the system
(Rounzoin, 1994).
Can be destabilizing if initiated too early in treatment.

8/20/08
 Case Example
Female early 40s
DID
Unable to use containment techniques.
Lightstream holding inner child.
Tape.
Soothing, though occasional vomiting.

8/20/08
 Talking Through
Talk to all parts of the system.
Useful for contracts, boundary setting, etc.
I want all parts to be listening.
Ask client to ensure that all parts have
received and understood information.
Acknowledge that different parts may
have problems following through, but
make system responsible for the person as
a whole.
8/20/08
 Pets as Helper States
Help bring client into the here-and-now.
Identify dissociation and intervene.
Attachment issues.
Frightened and Disavowed child parts.
Often able to connect to and be soothed by
pet.
Protector for child parts.
May allow connection to adult ego state.

8/20/08
 Use of e-mail
Be aware of confidentiality/legal issues.
Helpful with communicating material to
and from ego states.
Aids with shame affect.
Use for stabilization.
Boundary setting.
Payment.

8/20/08
 Towards a Treatment
Model
Basic Principles

8/20/08
 Biphasic Response to Trauma
Van der Kolk (1987) has cogently argued
for a bi-phasic response to trauma.
Hyperarousal.
Freezing, numbing, and catatonia.

8/20/08
 Modulation Model
Ogden and Minton (2000)
Hyperarousal and Dissociation.
Visual representation of the bi-phasic
response to trauma.

8/20/08
 Modulation Model - contd
Normal range of activation.
Within window of tolerance.
Information processing is optimized.
Persons feel comfortable enough with their level
of activation.
Allows processing of somatic, perceptual,
affective, and cognitive information.
The clinician is to aid the client to stay within
their optimal level of arousal to enhance efficient
information processing.

8/20/08
 Within Window of Tolerance

From Ogden & Minton, 2000

8/20/08
 Modulation Model - contd
Dysregulated Arousal.
Hyperarousal results in tension reduction
behaviors.
Leads to increased dissociation.
Freezing and numbing response.
No further processing of information.
Entire brain shuts down.
In clients with extensive trauma histories, when
such trauma is accessed, hypoarousal may occur
as a conditioned response rather than secondary
to excessive hyperarousal.
8/20/08
 Dysregulated Arousal

From Ogden & Minton, 2000

8/20/08
 Abreaction vs. Synthesis
Van der Hart et al. (1993) have cogently
argued that the notion of abreaction be
replaced by one of synthesis.
Discharge vs. Information Processing.
During synthesis unprocessed memory
traces are integrated and processed.
Abreaction per se does not necessarily
result in processing of information.

8/20/08
 Dual Awareness
The client, in addition to focusing on the
information from the past being processed
internally, should always be able to attend to the
stimuli presented by the clinician.
Provides context to the memory.
Its not happening now.
Dual focus and the here and now aids in
efficient information processing during EMDR
treatment. It is essential that the dual focus be
maintained by titrating traumatic material.
Staying present is paramount.
8/20/08
 Dual Attention & Mindfulness
Mindfulness during the therapeutic process is
essential.
Engagement of the the prefrontal cortex.
Mindful attention.
client learns to witness affect and sensation,
rather than being overwhelmed by them.
Eye movements activate frontal, temporal,
parietal cortices (Corbetta et al., 1998).

8/20/08
 Going Slow is Faster
The Need for Titration of
Traumatic Material

8/20/08
 EMDR & Synthesis
The goal of EMDR treatment is effective
information processing.
Synthesis of dysfunctionally and
incompletely processed information.
In individuals who do not experience
major dissociative processes, this usually
occurs in an efficient manner.

8/20/08
 Nervous System Overwhelm
When a large amount of dysfunctionally and
incompletely processed information is held
within the nervous system, the rapid synthesis
of such information results in a hyperarousal
response with a subsequent shutting down of
the nervous system, i.e., Primary or Secondary
Dissociation, as well as unpredictable ego state
shifts (Tertiary Dissociation). The nervous system
is overwhelmed by the information load and
shuts down.

8/20/08
 Optimizing Information
Processing
Avoid such shutting down of the nervous
system.
Careful and slow introduction of the
minimally required amount of accessed
information to allow processing piece by
piece, that is titration of information.
The smallest amount of a reagent, e.g.,
unprocessed information, to bring about a
given effect.

8/20/08
 Therapists Role
The therapist needs to take responsibility to
keep the client with processing one aspect of the
trauma, rather than letting the client free-
associate into additional traumatic material,
even to the point of targeting just one small
aspect of the traumatic experience.
The majority of techniques described are used to
break down large chunks of traumatic
information in order to make them more easy to
metabolize to allow what has been described as
fractionated abreaction (Lazrove & Fine, 1996).

8/20/08
 Basic Interventions

8/20/08
 DAS Modalities
Attempt different modalities.
Different ego states may respond
differently.
Taps or auditory tones seem to be less
stimulating.
Eye movements may activate more areas
of the brain due to complexity of
underlying neural circuitry.

8/20/08
 DAS Modalities - contd
Taps or auditory stimulation may be more
appropriate for dissociation.
Bilateral recordings with music may facilitate
processing in individuals possibly by enhancing
relaxation due to the bilateral stimulation being
embedded in pieces of music.
Hand taps seem to work extremely well in most
cases, but make sure that the client is
comfortable with touch.

8/20/08
 Hand Taps & Touch
Touch, unless it is specifically triggering to
the client is usually profoundly
grounding.
Touch is a primary reinforcer (Francis et
al, 1999).
Quality of touch is related to extent of
orbitofrontal cortex activation (Francis et
al, 1999).

8/20/08
 Hand Taps & Touch (contd)
Therapeutic touch if appropriately exercised
may provide a relief from profound shame,
as clients with a history of sexual abuse will
often literally experience themselves as
untouchable.
Provides the client with a learning experience
in that touch does not have to be sexual.
Be aware of ethical issues. If in doubt, dont.

8/20/08
 Length of Sets
Short sets can be used to titrate material.
Only limited new material is introduced
during each set.
If the client is able to remain present,
sometimes extremely long sets are
required due to the extensive traumatic
material accessed by the client.

8/20/08
 Length of Sets - contd
Use nonverbal cues to gauge the length of
set, e.g. changes in eye movement, facial
tension, body posture, breathing rate,
facial color, swallowing, etc.
Frequently check with the client.
Negotiate stop and continue sign.

8/20/08
 Change of Direction
When using eye movements, try to change
direction more frequently.
This aids with facilitating blocked
processing, as well as to integrate
dysfunctionally stored information.
It can be used in combination with Spatial
Mapping.

8/20/08
 Focus on the Body
Ask client what they are experiencing in
their body and where.
Focus on physical sensation.
Minimalist approach to ego state
interventions: If this physical sensation
had a voice, what would it say?
Consider Bottom-up Processing.

8/20/08
 Interweaves
Islands in a Bottomless Sea

8/20/08
 Resource Installation
Interweaves
Resource Development installation (Leeds,
2000) prior to trauma focused processing.
Allows the clinician to interweave positive
experiences when continuing processing
of traumatic material become too
disturbing to the client.

8/20/08
 Resource Installation
Interweaves - contd
Therapist functions as an external affect
regulator, similar to a parent during early
childhood.
While some clients spontaneously access
positive self states, self soothing, safe place, etc.,
when processing.
Individuals with a history of severe childhood
neglect lack such self soothing capacity, most
likely due to insufficient development of
relevant frontal brain structures (Schore, 1994).

8/20/08
 Pets as a Resource
Changes on neurochemical and
psychophysiological measures (Odendaal,
2003)
Ego state interventions.
Child ego states.
Nurturing by animal.
Connect with adult states through animal.

8/20/08
 Pendulating
Used in conjunction with resource states.
Client accesses previous resource state.
Simultaneous focus on traumatic material.
Going back and forth
like a pendulum

8/20/08
 Containment & Grounding
Interweaves
Ask client to use containment technique when
client is at risk of getting stuck in a dissociative
state.
Ask client to process material in their safe place,
behind bubble, etc.
Can be combined with Ego State Interventions
and Distancing Techniques: e.g. ask all the
parts to join in the safe place; the ones who feel
safe enough to do so, watch material coming up
on the screen.
Focus on senses smell, taste, sound, touch,
vision.
8/20/08
 Cognitive Interweaves
Safety, Responsibility, Choices.
Frequent educational interweaves are necessary
sometimes extensive.
New Information.
Im confused.
What if it were your child.
Metaphor.
Lets pretend.
Socratic method.

8/20/08
 Floatback
aka Affect bridge.
Can be used with cognition, affect and
somatic sensation.
This intervention usually increases
connectivity.
Extremely effective with relatively mild
dissociative symptoms.

8/20/08
 Floatback - contd
In severe dissociative Disorders it needs to be
used with caution, as it is may increase access
to traumatic material, thus potentially
overwhelming the client.
Bottom-up hijacking.
Spontaneous affective bridging after EMDR
treatment outside the therapists office likely
accounts for the majority of cases where
emergency care and/or hospitalization is
required between sessions.

8/20/08
 Humour
Humour is integrative (e.g., Goel & Dolan,
2001).
Stimulates frontal cortex.
Related to reward processing.

8/20/08
 Distancing
Interventions

8/20/08
 Screen Techniques I
Aids client in obtaining psychological
distance from the traumatic event
(Putnam, 1989).
Thus allows titration of traumatic
material.
The client is asked to visualize a big screen
onto which the material to be processed is
projected.

8/20/08
 Screen Techniques II
Imagine a remote control similar to a
video machine.
Images can be speeded up, slowed down,
freeze framed, fast forwarded or reversed,
there is a pause and stop, color, sound
brightness, etc.
Zoom in on the image or even split the
screen and view different events
simultaneously.

8/20/08
 Screen Techniques III
In cases where different ego states or parts have
been identified, the therapist can work together
with the client, which ego-states and/or parts
will partake in viewing the screen.
Split screen can occur spontaneously.
Parallel processing with incomplete co-
consciousness.
Extremely frightening.
Fear of going crazy.

8/20/08
 Barriers
Barriers can also aid clients in titrating traumatic
material by increasing psychological distance.
Ask client to imagine themselves either behind a
glass wall, or inside a glass bubble.
Some clients, in order to feel safe need further
enhancements like foundations, venting
systems, etc. The glass can be made bullet and
shatterproof, and it can be colored in the clients
favorite colour they associate with healing (as in
the Lightstream Technique).
The client processes material behind this barrier.
8/20/08
 Protocol Variations
The Importance of Targeting

8/20/08
 Standard Protocols
Shapiro's 1995 text advises when working with
multiple traumas to start with the ten most
disturbing memories.
While the latter always need to be incorporated
into the treatment plan, they should not
necessarily be addressed first.
Shapiro's 1995 model also clearly recognizes the
importance of addressing earlier less traumatic
memories in certain cases.
This is pointed out in the phobia protocol which
begins with ancillary events and then the first
rather than the worst experiences.
8/20/08
 Targeting in Developmental
Sequence
Emphasized in Kitchur's Strategic
Developmental Model.
Clients with significant dissociative symptoms
frequently harbor fears about treatment and
have developmental distortions that need to be
addressed before attempting to process their
worst memories.
The more the history and symptom picture is
complex, the more it tends to involve early
problems with attachment and early self-
development, it is worthwhile to start the
processing with the earliest material.
8/20/08
 Targeting in Developmental
Sequence - contd
Taking the material in the sequence in which it
was experienced and contributed to the
formation of schemas and defenses will tend to
reduce the occurrence of incomplete sessions
due to feeder (earlier) memories or blocking
beliefs (from earlier memories).
Emphasis on maternal, paternal, parental
experiences. Include other relevant attachment
figures.
Targeting of earliest memory is not always
possible and/or sometimes ill advised in very
severe Dissociative Disorders.
8/20/08
 Targeting Prenatal and
Perinatal Experience
Enquire about prenatal or perinatal
complications.
If possible get client to obtain corroborating
information from parent(s).
Usually, target any perinatal or neonatal trauma
(Becker, 2000) prior to parental relationship, i.e.
in developmental sequence.
Resource development using prenatal
experience prior to trauma (OShea, Lynn).

8/20/08
 Case Example - prenatal 1
Male in early 20s.
Has never had remunerative employment.
Born with chord around neck.
Circumcision.
Mothers parents holocaust survivors.
Mother had conflictual relationship with
Joshuas father.
Client feels that he was never accepted as male
by mother.

8/20/08
 Case Example - prenatal 2
Female mid 40s.
Thalidomide.
Perinatal complications.
Heart defect - self corrects.
Probable in utero NDE.

8/20/08
 The Body

8/20/08
 Bottom-up Processing
Client needs to experience themselves
within their body for effective EMDR
processing.
Out of body experiences one of the more
common dissociative symptoms.
If this state persists for any length of time,
effective processing cannot occur. That is,
while the client is dissociating no
information processing can occur.

8/20/08
 Bottom-up Processing - contd
Targeting physical sensations only, as is
frequently done in body therapies,
whereas the standard EMDR protocol
integrates all levels of processing.
Top-down vs. bottom-up processing
sensorimotor sequencing (Ogden &
Minton, 2000).
Bottom-up Hijacking.

8/20/08
 Bottom-up Processing - contd
Focus the standard protocol on physical
sensations alone, or alternatively modify the
standard protocol, so that neither traumatic
events, associated cognitions, and/or emotions
are targeted initially.
All unprocessed traumatic experience is to some
extent pre-verbal (e.g. speechless terror) and/or
pre-cortical.
EMDR can be utilized to aid clients to stay in
touch with their bodies and develop
mindfulness re: the body.
8/20/08
 Bottom-up Processing - contd
Use Active Stance.
Focus on physical/body sensations alone.
Titration of information.
Slowing of spontaneous integration of
affect, cognition, and sensory experience.
Decreased probability of intense
abreaction.

8/20/08
 Bottom-up Processing - contd
Focus on your body.
Where in your body do you notice that?
Stay with your body.
Just follow/track the physical sensations
in your body.
Notice whether it (the body sensation)
increases, decreases, or stays the same.

8/20/08
 Bottom-up Processing - contd
This fractionates traumatic material by
separating somatosensory from cognitive and
affective processing.
The voice of the therapist reflects an Active
Stance, as well as Grounding.
It facilitates processing at the most basic and
primitive level, i.e. somatosensory level.
This type of processing is usually insufficient for
the complete resolution of the trauma, but it
develops mindfulness and it is a preparatory
step for later affective and cognitive processing.
8/20/08
 Bottom-up Processing contd
If the client has difficulty locating the
body sensation or is experiencing multiple
body sensations, ask the client to put their
hand where they are experiencing the
most intense physical sensation.
Can be integrated with Ego State work.

8/20/08
 Active Stance
Dont just go with that as in the standard
protocol.
Keep client engaged in the process.
Increased use of the relationship.
Ongoing dialogue with client while they are
processing with bilateral stimulation.
Aids dual focus during processing if client is
likely to dissociate by increasing sensory input.
Therapist can check verbally with client whether
it is ok to continue on a frequent basis.

8/20/08
 Active Stance - contd
Soothing voice its ok its just old stuff,
repeat the standard instructions at regular
intervals like just stay with that, just notice.
The therapist may remind the client of
metaphors initially described in the preparation
phase (e.g. train, video machine).
Reminders to breathe through it.
Suggestions what material to focus on to titrate
information processing.

8/20/08
 Ego State Interventions

8/20/08
 Ego State Work
Enhances communication between
dissociated parts, as well as aiding to
reduce amnestic barriers.
Can increase disturbance during early
stages of treatment.
Aids in the metabolization of traumatic
material during later stages.
Provides material for target selection.
Provides narrative, identity, sense of self.
8/20/08
 Ego State Work - contd
Mapping.
Allows titration of information processing
by focusing on different parts of the self.
Therapist may suggest to the client to
focus on different ego-states or parts.
Talking Through vs. titration.
Top-down processing.

8/20/08
 Ego State Work - contd
Frequently used with either Dissociative
Table and Conference Room Techniques.
Healing circle.
Often impossible in poly-fragmented DID
due to the sheer complexity that can be
involved and possibly destabilizing
during early stages of treatment.

8/20/08
 Dissociative Table and
Conference Room Techniques

Imaginary conference room with table and

chairs for the parts (Fraser, Paulsen).
Use in combination with Screen Techniques.
Stronger parts can support weaker ones.
Child parts may need to be protected from
angry/hostile parts.
Healing circle.
Parts holding hands supporting each other.

8/20/08
 Dissociative Table and
Conference Room

Work with specific parts.

Check if all parts show a decrease in
SUDS.
Then move to standard protocol.
Do body scan for all the parts.
Only after complete trauma processing
we are as one (Rounzoin, 1994).

8/20/08
 Inner Child Work
Use of Interweaves
Hold, hug, comfort, caress, soothe.
Use with Active Stance.
Provide inner child with information: Its safe now
its not happening anymore, etc.
Lightstream, adult holding the inner child.
Can be destabilizing during early stages of treatment.
Some clients unwilling to access.

8/20/08
 Serial vs. Parallel EMDR
Working with one part at a time.
Let each part process the memory separately, one after
another.
Different parts may require separate VOC, SUD, NC and
PC.
EMDR processing can also occur in parallel through
Shared Eyes by several parts who are involved in a
memory by using Screen Techniques, Dissociative
Table, and Talking Through.
Often spontaneous.

8/20/08
 Dual Processing
Bring in a helper or positive affective state that has
previously been developed using the resource
installation protocol.
Alternate focus on the latter with processing of traumatic
material.
Preexisting internal helper state (common in Dissociative
Identity Disorders).
Serene, rational, and objective commentators, e.g. wise
self, wise woman.
Both require the therapist to take an Active Stance and
cue the client what to focus on at a given time.

8/20/08
 Art Work
Can be utilized as target for EMDR
processing.
Also useful when the client has inadvertently
entered a state of speechless terror, while at
the same time indicating that processing is
continuing.
Rather than have client verbalize their
experience, ask them to use a sketchpad and
some pencils and/or crayons to draw what
they are experiencing.
Subsequently target the image produced by

8/20/08
the client.
 Art Work & Ego States
Ego state mapping.
Representations of self, metaphors, ego
states.
Allows some distancing for the client by
attributing sensations, emotions, and
cognitions to representations of the self,
rather than to the immediate self.

8/20/08
 Case Example
Female with polyfragmented DID.
Referred for PTSD after being held at
gunpoint.
Initial DES score 76.
Hx of severe physical, emotional,
psychological and sexual trauma
through out her life.

8/20/08
 Silent Processing
Can help reduce intense affect.
Commonly related to intense shame.
Give client permission not to produce a verbal
report and process the material quietly.
Also is useful in processing of speechless terror.
Therapist needs to ensure that processing
occurs.
Later re-process this material with verbal report
when the client is ready to do so.

8/20/08
 One Eye Technique &
Unilateral Sensory Stimulation
Lateralized sensory stimulation can be used as an
effective adjunct to psychotherapy (Schiffer, 2000).
Cook & Bradshaw (2000) have developed a
technique that essentially does EMDR with one eye
at a time.
Other types of bilateral stimulation can be
substituted, particularly when unilateral sensory
loss other than vision is evident.
Aids in the titration of disturbing material, less
activating.
Processing of a numbing response.
8/20/08
 Spatial Mapping
Alternatively, ask the client to move their eyes
into different directions and let them notice their
physical sensations, emotions, thoughts, images
etc.
Many individuals will report different
experiences depending where they direct their
gaze, some of them will report different parts or
ego states.
Using simple gridlines to produce a spatial map.
Use to process and access specific material by
asking the client to gaze in a certain direction,
access the material, and then process.
8/20/08
 SUDS=4 SUDS=2 SUDS=1

SUDS=1 SUDS=5 SUDS=6

SUDS=2 SUDS=6 SUDS=9

8/20/08
 Age Progression
If client is experiencing high distress and unable
to continue processing, they may be stuck in a
child state.
Ask client how old they feel. If theres no
answer, ask them to take out their ID or drivers
license and check their age.
If client is unable to connect with their adult self.
Ask them to grow up and experience their body
getting older and older, noticing their birthday,
developmental stages etc. At the end check with
the client how old they feel again.
In extreme cases combine with use of Smell and
Cross
8/20/08
Crawl .
 OTHER
STRATEGIES

8/20/08
 Headache Activity
Often at base of skull at the back of the neck.
Often suggestive of dissociative process.
Evaluate for non-cooperative ego-state.
Ask client to focus on pain and ask what the
pain is trying to tell them.
Headaches seem to respond well to circular or
figure 8 eye-movements - integrative?

8/20/08
 Smell
Only sensory modality whose sensory
pathways do not solely travel through the
thalamus, but go directly to the limbic
system and to the frontal cortex and from
there back to the thalamus.
Smelling salts in Victorian times.
Ask the client to bring their favorite
fragrance with them, and use it if there are
signs of dissociation.

8/20/08
 Smell - contd
Essential oils, as used in aromatherapy,
such as jasmine, rose, and vanilla work.
Frankincense works particularly well (do
not use Frankincense during pregnancy -
may induce spontaneous miscarriage).
Test prior to use to avoid possible
triggering with smell.

8/20/08
 Cross Crawl
Educational Kinesiology technique
(Dennison & Hargrove, 1985)
Unusual, crossed bilateral stimulation.
Touch each knee with the opposite elbow.

8/20/08
 Balance & body mindfulness
The use of a balance board as used in
treatment of developmental and learning
disabilities can be helpful in keeping a
client from dissociating (A. Cook, personal
communication).
Use of exercise ball during processing.

8/20/08
 Smell
Only sensory modality whose sensory
pathways do not solely travel through the
thalamus
Pathways go directly to the limbic system
and to the frontal cortex and from there
back to the thalamus.
When dissociating usually sesne of smell
reduced in one nostril (commonly left
side).

8/20/08
 Psychopharmacology

8/20/08
 Stabilization vs. Reduced
Processing

Stabilizing client more important than

efficient processing.
When client is more stable, reprocess
material with reduced medication.

8/20/08
 Unusual Medication Effects

DID clients may have variable responses

to medication including paradoxical
effects.
Changes in absorption secondary to
dissociation.
Ego state intervention (Twombly, personal
communication).
Ask all parts to take their medication.
8/20/08
 Reduction of Dissociation &
Increased Processing
Atypical neuroleptics appear to reduce
dissociative symptoms and have been
reported to increase frontal functioning.
Opioid antagonists decrease dissociation.
Decreased dissociation results in
improved EMDR processing.

8/20/08
 Antidepressants
SSRIs appear to reduce dissociative
symptoms markedly in some but not all
clients.
Appear to increase connectivity.
Can be overwhelming anxiety, suicidality.
Mirtazepine less activating than other
SSRIs?

8/20/08
 Neuroleptics
Atypical vs. Typical.
Atypical enhance frontal functioning in lower
doses.
Atypical neuroleptics may be indicated in severe
trauma related disorders with severe
dissociation.
Low dose before bedtime to aid sleep.
Increased affect regulation.
Behave more like typical in higher doses.

8/20/08
 Neuroleptics - contd
Risperidone (Risperdal) and olanzepine
(Zyprexa) seem particularly helpful.
Side effect weight gain - not related to dose.
Ulcer drug nizatidine (Axid) may reduce the
weight gain associated with olanzapine
(Zyprexa) by as much as 50% without affecting
efficacy.
Co-administration of topiramate also reduces
weight gain.

8/20/08
 Anxiolytics
Benzodiazepines interfere with EMDR
processing to some extent.
Modern anxiolytics do not seem to
interfere (e.g. Buspar).
Low-dose atypical neuroleptic may be
preferable to benzodiazepines

8/20/08
 Opiates
Indicated during acute pain to reduce
later PTSD.
Continuous dosing preferable to PRN
dosing.
Blocks EMDR processing.

8/20/08
 Beta Blockers
Traditionally used in behaviour therapy.
Cap physiological arousal secondary to
anxiety, and thus limit the overall anxiety
response.
Effectiveness with dissociative symptoms
appears marginal.

8/20/08
 Alpha Blockers
Clonidine - experimental emergency
intervention for PTSD.
May prevent freezing response and
traumatic memories.
Prazosin - useful for nightmare activity
(Raskind et al 2003).
Blocking adrenergic response may reduce
subsequent primary dissociation.

8/20/08
 Cholinesterase Inhibitors
Anti-Alzheimers medication.
Preliminary results suggest improvement
in attentional functioning (McFarlane).

8/20/08
 Stimulants
May be helpful for clients with significant
attentional dysfunction.
Some clients with treatment resistant
depression sometimes benefit from
stimulant therapy.
Abuse potential.

8/20/08
 Opioid Antagonists &
Dissociation
Naltrexone, an opioid antagonist helpful
in reducing dissociative symptoms.
(Bohus et al., 1999).
Opioid receptor blockade appears to block
dissociative symptoms.
Opioid Antagonists facilitate EMDR
processing (Ferrie & Lanius, 2001, 2002).
Low dose naltrexone for stabilization.

8/20/08
 Rainer Maria Rilke
8/20/08
 Ulrich F. Lanius, Ph.D.
104 - 1590 Bellevue Avenue
West Vancouver, BC

604-925-6246
ulanius@direct.ca

8/20/08