Hello, students, faculty, dear esteemed colleagues. This is the second winter semester lecture, and today we are going to focus on flashbacks.
Flashbacks in post-traumatic stress disorder and the new construct of emotional flashbacks in CPTSD.
Is this construct valid, or is it yet another example of internet hype with no clinical significance or meaning?
We are going to delve deep into the issues of trauma and dissociation, especially in victims of various forms of abuse.
So it's going to be a bumpy ride. I hope all of you don't end up the lecture feeling that you have been victimized.
One service announcement before we start.
This is a joint lecture, both from Southern Federal University in Rostov-on-Don in Russia, Russian Federation, and for the outreach program of CIAPS, Center for International Advanced Professional Studies.
Now, those of you who are enrolled in the CIAPS program, you're completing your doctorates and post-doctorates, please do not submit your assignments via your alma mater. Log it into your student accounts, click on outreach, identify and isolate CIAPS. You'll find me there in the Faculty of Finance and the Faculty of Psychology.
Please submit your assignments via the outreach program of CIAPS, not directly via your university because I'm not going to get them. I don't have access to all the universities which participate in the consortium of CEPS. I have access only to the outreach program.
Okay, enough traumatizing you with all kinds of announcements.
Let's get to the point.
Long ago, to be precise, 25 years ago, I had suggested that the human mind works with three processes, not two.
Until recently, we thought that people interact with the environment and with each other via cognitions or via emotions.
And then there's a school, the new thinking is that emotions are actually subspecies of cognitions. They are a form of cognition.
So whether you subscribe to this school and consider emotions a type of cognition and whether you don't, I suggested to add a third way of relating to the world and interacting with it.
And that is trauma.
So I suggested three processes, not two, cognition, emotion, and trauma or dissociation. And I suggested that all three are arranged in arranging what we call memories.
Traumas override cognitions, they override emotions with new content.
That is not an original insight of mine. That was described amply and vividly and thoroughly by Schneider.
And Schneider called it silencing. It's a process where cognitions and emotions are not deleted. They don't disappear. They don't vanish. They are overwritten. They are replaced with other cognitions and emotions, which are essentially dissociative or dissociated.
So trauma is an entirely separate, distinct mental universe.
Trauma is not the absence of something. It's a presence in its own way.
People react to the world by thinking about it, cognition, by feeling something, emotion, and by dissociating, by rewriting reality, by bearing, ignoring, denying, reframing, and replacing reality with internally generated cognitions and emotions.
And of course, in this particular case, we would have dissociation of reality, but not dissociation of internal objects.
This is a very, very crucial distinction.
Dissociation pertains to external objects. You can have a situation where you dissociate external objects and reality, but you are fully in touch with and interact with internal objects, which would lead us a bit later to the issue of emotional flashbacks.
I refer in the meantime to work by Vasquez, Hervas, Schneider, Dell, and Perez-Sales. All these scholars have dedicated their work to the issue of thought suppression. Schneider came with a pretty amazing construct of silencing.
Trauma, therefore, is a language. It's a language of dissociation. It's a language that deals exclusively with internal objects while fending off, firewalling, denying, reframing, eliminating, ignoring external objects. It's a solipsistic inner landscape, inner world language.
And this, of course, immediately reminds us of the unconscious. This is what psychoanalysis had described as the unconscious.
And when we look at defense mechanisms, I have to remind you, defense mechanisms, the main function of defense mechanisms, is to reframe reality in a way that will not be injurious, in a way that will not damage the individual, to change the perception of reality, to change analytic cognitions and emotions in ways which would conform to, would be egosyntonic, conform to self-perception, what Freud called ego ideal and so on and so forth.
So defense mechanisms allow us to survive in the world by essentially falsifying it.
And so defense mechanisms, if we accept this new proposition that I'm making, that cognition, emotion, and trauma are three languages, we immediately see that there are defense mechanisms dedicated to falsifying cognitions.
One example, rationalization or intellectualization. There's a cognitive defense mechanism, usually intended to resolve cognitive dissonance.
And then we see another group of defense mechanisms which have to do with emotions, denial, projection. And finally, we see defense mechanisms, which are exclusively dedicated to the processing of trauma.
One very early example is repression.
So trauma is a language. It's a language that we use to make sense of the world, to organize it, to imbue it with meaning, to obtain and to secure self efficacious outcomes, and thereby enhance our agency.
And so if this is right, and if trauma is on par with emotions, same as cognitions, then trauma should be very frequent.
And indeed, I claim in my early work and in my recent work, I claim that trauma is as frequent as emotions, as common as cognitions.
And I refer you to earlier videos I've made, they're all available on my YouTube channel, and start with the one about structural dissociation.
In 1995, when I started my work, my initial focus was on victims of abuse, especially narcissistic abuse. In 1995, I was the first to suggest that victims of narcissistic abuse suffer from complex trauma or complex post traumatic stress disorder.
This was five years after Judith Herman proposed this new diagnosis.
Judith Herman worked with veterans of war, especially the Vietnam War. But she hinted in her early work in 1991, that CPTSD could in principle also be applied to domestic violence victims.
So I took the ball and ran with it. And I suggested that CPTSD is a common outcome of narcissistic abuse. But I didn't develop it further. And I shifted my focus to narcissism.
So now before we start with flashbacks, I would like to introduce you to the taxonomy, the terminological classification, which was proposed six years ago by Kvavilashvili.
I don't know why all psychologists have these names. I think they may have become psychologists because they have these names. These names are seriously traumatic.
Anyhow, Kvavilashvili in 2014 suggested a consistent terminology.
First of all, there are involuntary autobiographical memory. This is an everyday memory phenomenon. Very often, we keep being reminded of something which we would rather forget.
And Boone and Draijer, in 1993, they noticed that when there's PTSD, we have these involuntary autobiographical memories.
So this is the first class.
Then there are intrusive memories. While the involuntary autobiographical memories are an everyday phenomenon, intrusive memories are involuntary memories with repeated and usually distressing content, generally associated with psychological disorders.
So involuntary autobiographical memories, we all have them.
Then intrusive memories, which are beginning to be a pathology, we are transitioning now from mental health to mental illness.
And finally, the cherry on the top is flashbacks.
Flashbacks are involuntary memories involving re-experiencing distressing events in the present thought to occur right now.
So this is very typical of post-traumatic stress disorder.
Now the three are not interchangeable. Flashbacks are not involuntary autobiographical memories. Involuntary autobiographical memories are not intrusive memories. And flashbacks are not intrusive memories. It's wrong to confuse these three or to conflate them or even to imply that they contain elements of each other. They don't.
These are three extremely distinct phenomena, as I will demonstrate throughout this lecture.
When we discuss flashbacks, which is the topic of this lecture, we need to consider several aspects and parameters and dimensions of flashbacks.
For example, how frequent are they? How toxic? Psychologically toxic. And do they create any functional impairment?
When we conceive of flashbacks using these three parameters, they begin to look a lot like dissociative disorders. Post-traumatic stress disorder usually involves dissociation. Again, Boone and Drager in 1993. Coons, in 1996. Middleton and Butler in 1998, where all of them were scholars who had first suggested the affinity and even the comorbidity between flashbacks and dissociative phenomena, dissociative symptoms or dissociative disorders.
They made early claims that both flashbacks and dissociative disorders are elements of PTSD, a claim that today is much disputed, as you will see.
As a good introduction, I would refer you to Paul F. Dell.
Paul F. Dell is one of the preeminent scholars of dissociation in the world. He had written a chapter titled Understanding Dissociation, and it was published in the Bible of Dissociation. It's a book called Dissociation and the Dissociative Disorders, DSM-5 and Beyond.
And in this chapter, he suggested that, I quote, dissociative flashbacks are a type of hallucination triggered by amygdala amplified intrusive memories of post-traumatic stress disorder.
They are not a valid indicator of blocked or dissociated trauma. This was written a few years back. Today we know that patients with post-traumatic stress disorder, patients who have dissociated trauma, they manifest flashbacks more often than patients who don't have dissociated trauma.
So people with post-traumatic stress disorder can have dissociation where they took the trauma and they buried it, they forgot it, they dissociated it, they eliminated it from their conscious memories. So this is one type of PTSD with dissociated trauma.
And another type of PTSD is without dissociated trauma.
And people who have PTSD with dissociated trauma, they have very frequent flashbacks, much more frequently than people who did not exercise dissociation.
And so there are several possible explanations of flashbacks.
And these are all hypotheses you should realize or you should know that the topic of flashbacks is understudied. We don't know a lot about flashbacks. We definitely don't know anything or very little about the etiology of flashbacks, how they're brought about. Functional magnetic resonance imaging of the brain of people experiencing flashbacks had shown amazing mayhem and upheaval, upheaval not necessarily in the amygdala, but strangely in the prefrontal cortex and other parts of the brain involved with learning and memory. So we were surprised.
This is another argument in favor of my suggestion, my proposal.
I don't think that flashbacks have a lot to do with emotions or with the amygdala. I think they're actually a third type of language, a third type of communication, a third framework of relating to the world. And as a third language, as a language, they would tend to use the prefrontal cortex, not the amygdala.
Anyway, there are five schools as to the origin, etiology of flashbacks and how they come about.
The first one is that flashbacks are dissociation, potentiated repression.
Second school says that it's an intrusion from a dissociated structure. So both these schools associate flashbacks with dissociation.
The third school says that it's an evolutionary form of dissociation.
The fourth group of scholars suggest that flashbacks are actually depersonalization or derealization. And if they happen very frequently, then it's a form, a subspecies of depersonalization disorder.
That's not saying much because depersonalization and derealization together with amnesia are dissociative symptoms.
Again, we come full circle to dissociation.
Finally, the last school of thought is that flashbacks are a conversion disorder without unconscious motivation and purpose.
It's like the body goes on automatic pilot and reacts without any motivation, goal direction or context, reason or rhyme. The body just takes over.
Pete Walker, who had written a very popular book about complex post-traumatic stress disorder, calls it amygdala hijacking.
Regrettably, functional magnetic resonance imaging doesn't tend to support this particular phrase. It's not the amygdala that's hijacked, it's other parts of the brain.
But still, the fifth school believed that the body suddenly erupts like a volcano or an earthquake and takes over. The flashbacks are actually when the body takes over from the mind and does whatever it wants. So conversion disorder.
Dell proposes three or four types of post-traumatic stress disorder and he conflicts directly with the accepted classification, which is essentially Bremner, the Bremner classification.
Dell proposes that there are four types.
Type number one is overuse of dissociation. And here, he is supported. This claim is supported by work done early on by Lanius and Frewan.
These two scholars demonstrated that when there is an overuse of dissociation, when the use of dissociation becomes too frequent, almost automatic, then it provokes flashbacks. And it provokes post-traumatic stress disorder.
So this is the first type of PTSD.
Second type of PTSD, according to Dell.
And to remind you, the accepted classification is Bremner, not Dell. But I think Dell's classification is much more nuanced, much more subtle, and captures clinical groups that are not captured by Bremner's black and white, one of two types of PTSD.
So I prefer Dell's classification.
So the first type of PTSD, overuse of dissociation.
Second type, defensive compartmentalization of trauma. This was suggested decades ago by Spiegel in 1980 that actually PTSD is when we compartmentalize trauma, when we isolate it, we put it in a drawer, and then we shut the drawer with a bang. And that creates PTSD.
Our constant effort, attempt, energy depleting investment of resources in shutting off the trauma is essentially what we call PTSD.
And then the third type, according to Dell, is hijacked neurobiology with hallucinations. This comes very close to Walker's amygdala hijacking.
And Dell, at the time, 12 years ago, also believed that it was the amygdala that's involved.
As I said, to remind you, fMRI studies had conclusively demonstrated that the amygdala, although involved tangentially, is not the critical part.
And finally, the fourth type of PTSD, according to Dell, is numbing. Numbing is a form of depersonalization disorder.
PTSD, the dissociation, the various schools, the various etiologies, and so on, so forth.
So let's get to the point.
What about emotional flashbacks?
To make clear, since we are in a university setting right now, the academic community had resoundingly and uniformly rejected the construct of emotional flashback. And if I have to look objectively, or try to look objectively, of course, I would also tend to reject it. Not entirely though, not entirely, and this is the topic of this lecture, but in large measure.
One of the main reasons I find it very difficult to accept the construct of emotional flashback is that emotions are forms of cognitions, and they are not stable across time.
When we dredge up emotions, when we have emotional recall, when we remember emotions, autobiographical intrusive memories, you remember the classification.
So we actually invent them, we recreate them, we reassemble them. Memories are not stable across time.
Emotions are not stable across time.
And memories of emotions have totally, have very little to do with the original emotion. This had been demonstrated in hundreds of studies.
When we remember something, even if it is a cognition, which is much easier to remember, even if it's an event, even if it's something that happened to us autobiographically, even if it's an accident we saw, even if it was an imprinting event, like the assassination of John F. Kennedy, or 9-11, even then we remember wrongly. We tend to get 50% of the content of the memory wrong within one year, and 90% of the content of the memory wrong in 10 years.
Let me be clear, 90% of what you think you remember is factually wrong, is counterfactual.
The figure is much higher if you are trying to recall your emotions, because there are defenses involved.
There's a falsification of reality, you remember, we discussed it a few minutes ago.
So when we try to recall emotions, this is totally made up. This has totally nothing to do with how we had really felt at the time.
This is what we think we had felt. This is how we feel today about what we had felt.
But it's not how we had felt.
We can never recall emotions properly, really, faithfully, loyally, accurately, no way.
The emotions, when you think right now about an unpleasant event, a traumatic event, a happy event, you re-experience emotions, you experience pain, shame, happiness, but they are not the same emotions that you had experienced then. They're not even close to the same emotions that you had experienced then.
You cannot recall emotions. You cannot dredge them up.
What you do is reconstruct them, reframe, recreate, and this applies to memories as well.
Since this is the case, emotional flashbacks is an oxymoron. Flashbacks is not the clinical term.
The clinical term is revividness. Revividness, living again, re-living, re-experiencing. Flashbacks are authentic, faithful, loyal, super-accurate recreations of a moment in time, of an experience, especially a traumatic experience, but not necessarily.
99% of the cases is a traumatic experience, but the experience is recreated so correctly, so precisely, so vividly, so colorfully that the person experiencing a flashback is thrown back in time and is again there and then, and his recollection, his recall is perfect. His recall is perfect.
In this sense, Dell is right. It's a kind of hypnotic hallucination. It's akin to hypnosis.
Indeed, studies have shown that people who are easily hypnotizable suffer many more flashbacks following a traumatic event than people who are not suggestible, cannot be hypnotized.
It seems that flashbacks are hypnosis, a form of hypnosis, but with accurate, faithful content. Emotions never have, are never accurate, never precise, never faithful to the original.
So how can you have emotional flashbacks? You can't. You simply can't. They don't sit well together.
What you have is maybe painful emotional recall. You remember the classification by Kvavilashvili?
You may have involuntary autobiographical memories. You may even have intrusive memories of emotions. These are involuntary emotional memories with repeated and usually distressing content, but these are not flashbacks.
These are not flashbacks because they're false. They're wrong. They're erroneous. They're mistaken.
The emotions you feel today about your divorce 10 years ago are not the same emotions you had felt during the divorce.
They're your emotions today, and they're very little to do with your emotions then, because time has passed, cognitive processing had happened, defense mechanisms kicked in. A lot has been delegated to the unconscious via trauma, traumatic dissociation.
So your state of mind right now, even if you feel that your state of mind is being hijacked by some overwhelming and overpowering emotion, this state of mind has nothing to do with the original state of mind.
Therefore, and for this reason only, I mean, this reason only is sufficient to disqualify the concept of emotional flashbacks.
There are many other reasons. There are many other reasons to conclude that emotional flashbacks are a very, very wrong construct.
But to be fair, to be fair, I would like to quote Pete Walker's suggestion, things he had written about emotional flashbacks.
This was published in Psychotherapy.net. And he wrote an article titled emotional flashbacks and complex PTSD, etc. And this is what he had written, Pete Walker.
Emotional flashbacks, sudden and often prolonged regressions, amygdala hijackings, to the frightening and abandoned feeling states of childhood.
They are accompanied by inappropriate and intense arousal of the fight flight instinct and the sympathetic nervous system. Typically they manifest as intense and confusing episodes of fear, toxic shame, and or despair, which often beget angry reactions against the self or others.
When fear is a dominant emotion in an emotional flashback, the individual feels overwhelmed, panicky, or even suicidal. When despair predominates, it creates a sense of profound numbness, paralysis, and an urgent need to hide.
Feeling small, young, fragile, powerless, and helpless is also common in emotional flashbacks. Such experiences are typically overlaid with toxic shame, which as described in John Bradshaw's Healing the Shame That Binds You, obliterates an individual's self-esteem with an overpowering sense that she is as worthless, stupid, contemptible, or fatally flawed as she was viewed by her original caregivers.
Toxic shame inhibits the individual from seeking comfort and support.
In a reenactment of the childhood abandonment, she's flashing back to, isolates her in an overwhelming and humiliating sense of defectiveness.
Clients who view themselves as worthless, defective, ugly, or despicable are showing signs of being lost in an emotional flashback.
When stuck in this state, they often polarize, effectively, into intense self-hate and self-disgust and cognitively into extreme and virulent self-criticism.
Numerous clients tell me, says Pete Walker, that the concept of an emotional flashback brings them a great sense of relief.
They report that for the first time they are able to make sense of their extremely troubled lives.
Some get that their emotional flashbacks can best be understood as the key symptoms of complex post-traumatic stress disorder, a syndrome afflicting many adults who experienced ongoing abuse or neglect in childhood.
Addictions are misguided attempts to self-medicate.
Some understand the inefficacy of the myriad psychological and spiritual answers they pursued, and are in turn feel liberated from a shaming plethora of misdiagnoses.
Some can now frame their extreme episodes of risk-taking and self-destructiveness as desperate attempts to distract themselves from their pain.
Many experience hope that they can rid themselves of the habit of amassing evidence of defectiveness or craziness.
Many report a budding recognition that they can challenge the self-hate and self-disgust that typically thwarts their progress in therapy.
Very often a construct that is clinically invalid and relies on absolutely wrong information is very soothing to clients and patients.
But we should never confuse something that works with something that's true.
Falsities, pretensions, faking, outright lies work very well in calming people down, in making them feel content and happy, in restoring inner peace. This is known as the placebo or even nocebo effect.
People want to be lied to. Clients are comforting. They want to find meaning in a meaningless universe. And they love labels.
But we, as scientists, or aspiring scientists, or at the very least as scholars of the human mind, we must be much more rigorous. And we must reject and exclude and suppress anything, anything that is not evidence-based, anything that cannot be repeated and reproduced in experiments and tests, anything that relies on patently wrong information.
And the parts of the text here that mentioned events in the brain are wrong, simply wrong.
Moreover, the text, as I've read it now by Pete Walker, is a god-awful confusion between PTSD, dissociation, childhood abuse, trauma. I'm sure he's a nice guy. And I'm sure many people feel that they have been helped by him.
But he has a long way to go. There's a lot to learn about trauma, dissociation, PTSD, CPTSD, and so on and so forth.
I'm sorry, but I would have failed him had he been in my class.
So now, let's move from a pop-hype YouTube scholar to, or wannabe scholar, to be precise, to real scholars.
I'm going to refer you to a few articles, and then we're going to delve deeper into the talk.
Start with the Journal of Child Psychology and Psychiatry. I suggest that you read the article, article title, Dysfunctional posttraumatic cognitions, posttraumatic stress and depression in children and adolescents exposed to trauma: a network analysis.
The chief authors, the main authors, Anke de Haan and Markus Landolt, together with many, many others. It was published in November 2019.
And I would like to quote a single paragraph.
The latest version of the International Classification of Diseases, ICD-11, proposes a post-traumatic stress disorder, PTSD diagnosis, reduced to its core symptoms within the symptom clusters, re-experiencing avoidance and hyperarousal.
Since children and adolescents often show a variety of internalizing and externalizing symptoms in the aftermath of traumatic events, the question arises whether such a conceptualization of the PTSD diagnosis is supported in children and adolescents.
Furthermore, although dysfunctional post-traumatic stress cognitions, PTCS, appear to play an important role in the development and persistence of PTSD in children and adolescents, their function within diagnostic frameworks requires clarification.
And so the results of their study were that the PTSD re-experiencing symptoms, strong or overwhelming emotions and strong physical sensations and the depression symptoms, difficultly concentrating, emerged as most central to PTSD.
Items from the same construct were more strongly connected with each other than with items from the other constructs. Dysfunctional cognitions were not more strongly connected to core PTSD symptoms than to depression symptoms.
The conclusions are that our findings provide support that a PTSD diagnosis reduced to its core symptoms could help to disentangle PTSD depression and dysfunctional cognitions.
Using longitudinal data and complementing between subject analysis might provide further insight into the relationship between dysfunctional PTCS, PTSD and depression.
A second article I would like to refer you to is An item response theory analysis of the PTSD checklist for DSM-5: Implications for DSM-5 and ICD-11. And it was written by Madison Silverstein, Jessica Petri, Kramer, Weathers and others.
Again, it was published in March 2020 in the Journal of Anxiety Disorders, Journal of Anxiety Disorders volume 70, an item response theory.
So again, a single quote, the PTSD checklist is widely used, extensively validated questionnaire for post-traumatic stress disorder.
The PCL was revised for Diagnostic and Statistical Manual of Mental Disorders fifth edition, 2013. And in the updated version, the PCL-5 has continued the strong psychometric performance of the original version.
To further explore the PCL-5 psychometric properties, we used item response theory, IRT, to examine item difficulty and discrimination parameters in separate samples of trauma-exposed undergraduates and community members.
Considering item difficulty, nightmares, flashbacks and reckless or self-destructive behavior emerged among the most difficult items across samples and internal avoidance emerged as the least difficult items across samples.
In terms of item discrimination, inability to experience positive emotions, detachment from others, diminished interest and negative emotions emerged as highly discriminating items in both samples.
And traumatic amnesia and reckless or self-destructive behavior emerged as the least discriminating items in both samples.
The results have implications for the divergent conceptualizations of PTSD in DSM versus ICD.
Okay.
And another article I would like to recommend to you. It was published by the American Psychiatric Association. It's titled, Positive side effects in trauma-focusing PTSD treatment: Reduction of attendant symptoms and enhancement of affective and structural regulation. It was authored, co-authored by Singl, Hanewald, Kruse and Sack. It was published in 2020.
Again, I've written a paragraph.
Trauma focusing treatments, such as eye movement desensitization and reprocessing, EMDR, are highly effective in reducing the core symptoms of post-traumatic stress disorder, for example, intrusive memories and flashbacks, hyperarousal and avoidance.
Additionally, suffering from PTSD is often accompanied by a broader set of mental comorbidities and complaints, such as depression, anxiety disorders, or somatization and disturbed self-regulation abilities.
According to the Adaptive Information Processing Model, Shapiro, 2010, the processing of pathogenic memories can help not only to reduce the PTSD symptoms, but also accompanying complaints additionally.
So the method used in this study was an EMDR study of people with PTSD. And then they used these questionnaires to study the effects.
One of the reasons I'm recommending this article to you is that they used multiple types of questionnaires. So they attacked PTSD symptoms from every possible direction.
They used the checklist 90, SCL 90. They used the Beck depression inventory, Toronto Alexithymia Scale-20. They used the Hanover self-regulation inventory, etc.
So they used many, many.
And when you go through the paper, you will get acquainted with the variety of tools we have, diagnostic tools we have.
The results of the study showed that apart from alleviating the PTSD symptoms, exposure-based treatment of pathogenic memories led to a significant decrease in accompanying symptoms such as depression, anxiety, and somatization.
Remember how I started this lecture? When I suggested that trauma is actually a language and that it is intimately connected not with cognition, not with emotion, but with memories.
Furthermore, patients improved their structural abilities with regard to emotional perception and differentiation, controlling impulses, tolerating frustration and regulating self-esteem.
Therefore, treatment concepts should explicitly foster emotional processing and structural abilities to target the post-traumatic stress responses entirely.
One classic article which still is the gift that keeps on giving, and I strongly recommend that you start your tour of this world of PTSD, flashbacks, and so on. With this article, it's titled Re-experiencing traumatic events in PTSD: new avenues in research on intrusive memories and flashbacks, and it was written by Chris Brewin in the European Journal of Psychotraumatology in May 2015.
So this is a very interesting article.
First of all, he puts emphasis on the fact that post-traumatic flashbacks are intrusive, and they entail the re-experiencing of traumatic events in the present. So it's the equivalent of time travel.
And if we travel back in time or forward in time, we expect to get to the real period, not to an imitation of the period or reconstruction of the period or a facade of the period, but to the real period in time.
So it's mental time travel. The reconstruction is faithful, and it's not felt as reconstruction.
It's so intrusive, it feels real, and it feels real because it is real, in every sense of the word, almost.
It's not real ontologically, it's not real out there, but it's real inside.
That's why emotional flashbacks are a contradiction in terms. Emotions are never, never faithful. They're always processed. They're always recreated. They're always invented.
Emotional recall involves memories. Memories involve invention, creativity, imagination, fantasy, other defense mechanisms.
So you never get to experience the same emotion twice. So you never get to have an emotional flashback. You get to have unpleasant emotional recall, but not an emotional flashback. Post-traumatic flashbacks of all kinds, including in CPTSD.
And here I recommend scholars, not pop culture personalities, even if they are therapists. I recommend real scholars like Judith Herman.
So flashbacks must include these elements of re-experience and the Diagnostic and Statistical Manual Edition 5, which was published seven years ago in 2013. It's the first time, believe it or not, since 1980, I mean PTSD has made its appearance in the 1980 edition of the DSM.
And yet, flashbacks made it into the DSM as a unique symptom of post-traumatic stress disorder only recently in the fifth edition. And it will make its appearance in the 11th edition of the ICD. It didn't until now.
So the clinical status of flashbacks, even classical intrusive, revivid flashbacks, the whole concept of revividness was very disputed. And the majority of the profession didn't believe in flashbacks, didn't think that they are real phenomena, real separate clinical entities, and let alone emotional flashbacks. And only recently and gradually, they were introduced as a symptom of PTSD.
And consequently, over the past 40 or 50 years, there's almost no research into flashbacks. Research is starting right now. We're trying to understand the cognitive, neurological, biological basis. And we also don't know how to assess flashbacks, how to measure them, how to ascertain that they are happening, how not to confuse and conflate flashbacks with other phenomena, like intrusive memories.
And what about psychosis? And what about people in intensive care? They also have, you know, when people say my whole life flashed in front of my eyes, is this a flashback?
What about psychosis? When there are hallucinations that are so vivid, that the psychotic patient feels he's really there. He feels that he's in an alternative reality, an alternative universe, body and mind. Is this flashback?
Or should we have a psychotic flashback, which is essentially non-traumatic, but the outcome of confusion between internal and external objects, which is where I'm driving.
I'm trying to say that trauma is a language element also in healthy people. Everyone has cognitions, emotions and traumas.
And so when there is confusion between internal and external objects, flashbacks are inevitable.
Therefore, we can predict that people with borderline personality disorder will have flashbacks. People with psychotic disorders will have flashbacks, and people with narcissistic personality disorder will have flashbacks.
And the whole concept of narcissistic mortification. Narcissistic mortification can be reconceived and redescribed as a flashback, a flashback into a period before the existence of the false self.
So it's a very new field.
When we have frequent intrusive recollections of a traumatic event, and when we act and feel as though it were happening again right now, this is dissociative flashback, because we dissociate from current reality. We retreat, we withdraw, we regroup inside so as to avoid the outside.
And if we have frequent intrusive recollections of stressful and unpleasant events, many of them traumatic, this becomes a psychopathology.
Some scholars tried to re-describe or re-conceive of the whole concept of psychopathology as essentially a huge giant flashback.
So we have work by Gregory, Lipton, Burgess and even Brewin himself in 2010, suggesting actually that psychopathology is this, is the inability to work well with internal and external, and the objects that reside, that inhabit these zones, and consequently having flashbacks, losing track of time, so to speak, re-experiencing, reviving, relieving your past.
And as you can immediately see, emotional flashbacks is a highly inadequate way and also manifestly wrong way to describe this, to capture the essence of flashbacks.
It is the relieving in the present, as Brewin says, it is the relieving in the present that distinguishes intrusive memories in PTSD from intrusive memories in other disorders.
That's another article of his in 2014.
And this insight, as he says, this insight has been incorporated in proposed revisions to the PTSD diagnosis in the ICD-11.
I also refer you to work by Maercker. He has written a series of papers, seminal papers in 2013, which fed into the committee process of the ICD.
Brewin says, traumatic re-experiencing in PTSD are its involuntary and uncontrollable nature, the strong sensory impressions and the sense of nowness or of the event occurring in the presence. Deja vu, yes, we all know this term.
I refer you to work by Dalgleish, Joseph in 1996, Ehlers, Hackmann and Michael in 2004. I mean, it's quite well documented.
These are phenomena that, Brewin continues, these are phenomena that can be equally observed in children with post-traumatic conditions. And he is right.
A few years before he had written this article in 2014, few years before in 2008, there was a big study by McKinnon, Nixon and Brewer. And there was another study the year before that in 2007 by Meiser‐Stedman, Dalgleish, Smith, Yule and Glucksman.
And they have demonstrated conclusively that flashbacks can occur in very young children, which again leads me to my original proposition. We are born with trauma.
The process of birth, of course, is traumatic, and then every stage, separation, individuation. These are all traumas.
And we experience thousands of mini traumas a day.
Trauma is not a cataclysmic life-shattering watershed moment or event. Trauma is a way of relating to the world.
When the world traumatizes us, it's because it is unwieldy. It is unpredictable. It is shocking. It is extraneous because we can't control it, etc.
We react with grandiosity to trauma. So this is our way of taking on the world.
So it seems that even very, very young children already have traumatic dissociative responses, flashbacks included. So it must be something very fundamental. It's not something we develop as adults. It's not late onset. It's not something that happens to us because life is tough and life sucks.
It's a tool, a fundamental tool that we have, we are born with. We are born with a toolkit that includes trauma and dissociation as ways of relating to the world and mediating and reframing experience.
Brewin says, the sense of nowness also distinguishes involuntary memories in PTSD from the involuntary memories reported by depressed patients or individuals who are exposed to trauma without developing PTSD.
And here I refer to work by Birrer, Michael, Munch, Reynolds. I mean, all these scholars have dealt with this.
If we believe that re-experiencing traumatic memories, flashbacks, nowness, déjà vu, presence, faithful, authentic, total replica, if we believe that this is an unmutated version, what we are experiencing in the flashback is an unmutated version of what had happened before, then re-experiencing, going through flashbacks, is not a negative thing, as Pete Walker suggests, and others. It's a very positive thing. It is an integral part of processing the trauma.
Indeed, Brewin says, re-experiencing trauma memories in the present is predictive of the course of the disorder over and above the effects of initial symptom levels.
I refer you to literature by Klein, Ehlers, Glucksman, Halligan and others who had demonstrated, pretty conclusively to my mind, that flashbacks are therapeutic and have healing effects.
I incorporated this insight into cold therapy, where I induce flashbacks. I re-traumatize the patient in order to induce healing or therapeutic flashbacks, but they are flashbacks. I force the patient to relieve and re-experience the trauma.
As the treatment proceeds, as the therapy proceeds, and not only cold therapy, but EMDR, schema therapy, Gestalt, and many other types of therapies that deal with trauma. As the treatment proceeds, of course, the frequency of the flashbacks diminishes.
But we tend to confuse the horse and the cart.
The frequency of flashbacks diminishes because the treatment is successful and there's no need for flashbacks.
Flashbacks is like adhesive tape. It's like plaster. It's like self-administered, self-medication.
The patient copes with mind, soul-shattering and wounding trauma, which is inside him.
The pent-up energy of the trauma is inside, as Freud had observed.
Freud himself coined the word abreaction. That's when in treatment, this power, this energy of the trauma explodes like a nuclear bomb.
So, the patient is aware dimly of this energy. It's very negative, very pernicious, very insidious, very disruptive, and dysfunctional.
To cope with this, the patient administers, uses, leverages flashbacks.
The main role of flashbacks, in my view, is to suspend the distinction between now and then, external and internal, out there and in here, reality and my mind.
Flashbacks eliminate boundaries and borders and demarcations.
Flashbacks allow us for a little while to not cope with intolerable, unbearable reality, but to go back to something we had already coped with.
It's not pleasant, it's devastating, it's re-traumatizing, it's painful, it's shocking, but it's familiar.
Flashbacks are trips to the familiar in order to avoid the world, as the world is perceived as hostile, dangerous, unpredictable, capricious, arbitrary, the enemy, a jungle out there.
So, we retreat.
And in this sense, I agree with Del, there is a strong hallucinatory or fantastic element in flashbacks.
Not in the sense that the content is fantastic, the content is faithful and authentic, faithful to the original, but in the emotional reaction to the flashback, there is an element of escape, an element of fantasy.
I'm no longer here, I'm back in Vietnam.
Why is Vietnam preferable? To right here and right now?
Because right here and right now, I have Vietnam plus, I carry Vietnam with me in my mind, the shouts, the screams, the wounds, the blood, I carry all of it in my mind.
And then, in addition to that, on top of that, I have to cope with challenges that reality, the real world is posing.
So, sometimes it becomes overwhelming. The PTSD patient is overwhelmed.
And this is why it's very difficult to tell apart victims of complex trauma from patients with borderline personality disorder.
It's the critical element in borderline personality disorder is emotional dysregulation, when emotions overwhelm the patient.
And the same thing happens with PTSD.
The combination of the past, memories of the past, images of the past, smells of the past, all the triggers, the past, plus the demands of the present, put together, it's too much.
And the only way to avoid being overwhelmed is to avoid being.
Flashbacks allow you to not be.
By going back to the past, you cease to exist in the present, of course.
So, as long as the underlying PTSD is not treated, of course, flashbacks will continue.
It's the only medicine, the only cure and healing tactic and strategy available to the traumatized person, addressing flashbacks in therapy, contributes to better outcomes of the therapy.
Because we replace self-administered amateur medication, which is very disruptive and dangerous in the long term, because the association becomes a habit, it's addictive, like everything else.
And all flashbacks are dissociated by definition.
So, the person becomes addicted, the frequency of flashbacks increases, never decreases.
So, we try to substitute professional clinical treatment for self-administered flashbacks.
I refer you to work by Nijdam, Baas, Olff, and Gersons, when they analyze the relationship between reduction in the frequency, intensity, toxicity, and so on of flashbacks and treatment outcomes.
And continuing to experience flashbacks, it's a specific indicator of PTSD, of course.
No one is disputing that flashbacks is a dissociative and therefore a pathological manifestation of a massive disruption to the inner organization and hermeneutic environment, ambience inside the mind.
I refer you to work by Bryant, O'Donnell, Creamer, McFarlane, and Silove.
So, Brewin writes, lack of any formal definition of flashbacks or dissociative re-experiencing resulted in uncertainty about whether the term should be reserved for extreme episodes in which individuals completely lose contact with their surroundings for periods of minutes or more, or whether flashbacks should include all intrusive memories that are accompanied by a sense of reliving the event, reliving the event, revividness in the present, even if only fleeting.
And I think we have fleeting flashbacks, hundreds, if not thousands of times a day, exactly as we have fleeting emotions and fleeting cognitions.
Both the DSM-5 and the ICD-11 have new definitions of PTSD, and they have opted actually for a much more inclusive view where flashbacks are seen as existing on a continuum between constant, you know, a barrage of flashbacks as a daily occurrence, hundreds, thousands of times a day, and once in a lifetime, revivid or reliving of a traumatic event somewhere in between.
There are three ways, cognition, emotion, dissociation, or trauma.
Recently, for completeness sake, because this is an academic setting, I need to review all the literature. That's one of the requirements in my job description.
So I refer to the work of Rubin, Berntsen, Bohni, etc. And they are trying to contest the construct of flashbacks. They say there is no such thing as flashbacks. They are no different in principle from autobiographical memories.
I leave it to you to read their work. I am not impressed.
So in 2002, Hellawell and Brewin conducted a massive study of PTSD, dissociation, and flashbacks. And in this study, they included a definition of flashbacks, which I think is the best definition ever written. It was 2002, almost 20 years ago. It was one of the pioneering studies of flashbacks and so on. And this is the definition they used.
A type of memory that you experience as markedly different from those memories of the event that you can retrieve at will. The difference might be a marked sense of a reliving of the traumatic experiences.
Some report complete reliving, whereas other people report more momentary or partial reliving or perhaps just one aspect of the original experience.
For some people, flashback memories take them by surprise or swamp their mind. Finally, some people report a sense of time distortion and, for example, react to the flashback memory as though it was an event that was happening in the present. That captures and encapsulates everything we still know about flashbacks.
There's no new knowledge since then. So this was a study in 2002.
And they observed the patients. They asked the patients to classify their traumatic memories. They asked them to classify the traumatic memories as just memories, sometimes intrusive memories, and flashbacks.
So when the patients, when the people who were subjected to the study, with the study participants, were describing flashbacks, they had involuntary motor responses. They had ticks. Their hand moved. Their faces convulsed. They lost control over the bodies. When they were just describing flashbacks in hindsight, working backwards, memories of flashbacks.
And they were not able to perform visual spatial tasks. So their cognition was severely impaired.
Other patients who were describing very difficult traumatic memories, anything from rape to worse, but had no flashbacks, had no problem to perform the visual spatial tasks. And their body did not react at all.
So flashbacks are in the nexus between body and mind. As many trauma scholars keep saying, the body remembers.
Flashbacks are like body memories. And that's why I think emotional flashback is very misleading.
The whole body must be involved. Their body and the mind collaborate or collude to induce a flashback.
We can say the same thing about emotions and the same thing about cognitions. These are systems that are body-mind systems.
And body-mind systems invariably involve identity elements. They are identity congruent. They involve identity elements, foremost of which is memory.
But it's not limited only to memory.
Subject for another, another perhaps, lecture.
Flashbacks are almost never, if ever, described as positive. They're always negative. And they're always arousing. They create hyperarousal.
I refer you to word by Huntley, Whalley, and others.
Scholars like Chou, La Marca, Stepto, they documented increases in heart rate. And flashbacks, when they're described, they contain sensory words, words that pertain to the senses, sensa.
Much less to emotions, by the way.
When people are asked to describe flashbacks, they rarely use emotional words. They use body words, mentions of death, fear, helplessness, and horror, but body-based, like they're about to die, or something very bad is going to happen to them.
I refer you to word by Hellowon in 2004.
And Brewin says like the real life situations PTSD patients encounter, the same words and phrases tend to elicit flashbacks repeatedly, but not invariably.
Flashback elicitation is probabilistic, rather than a predictable process.
So what's the difference between flashbacks and normal memory, or normal episodic memory?
It's because in flashbacks, conscious attention is directed, channeled, like a laser beam, onto objects and scenes, such that by virtue of sharing the same location in space, individual features are bound together to create a stable, contextualized representation that can be retrieved or inhibited at will.
That is normal episodic memory.
So memory is an act of will. In typical memory, we first want to remember, then what we do, we collect all kinds of data items, location, smells, sights, we put them together, we bind them together, and we embed them in a context, and then we retrieve this totally confabulated and invented story, narrative, that usually is counterfactual.
90% of memories are wrong after 10 years, 50% are wrong after one year.
So there are studies by Treisman and Gelade as early as 1980 that demonstrate this.
But when there is a traumatic event, there's a problem with attention.
I refer you to my video where I describe the affinity between attention deficit hyperactivity disorder, trauma dissociation, and personality disorder.
Attention is critical. When we form memories, our attention is usually focused. Our attention shuts out, eliminates 95% of the information. We absorb at any given time less than 5% of the information that reality offers us on a silver plate.
We have very selective attention leads to selective memory. And based on this process of selectivity, we generate memories that sit well with, that conform to a narrative, a storyline, the script of our lives.
We struggle very hard to maintain a coherent and cohesive story of who we are, what we are, where we are going, and when we're going to get there, and who other people are in our lives. Maintaining the internal consistency and external consistency of the story of our lives, these stories, that's the main mental and psychological occupation that we have.
And so trauma disrupts this process.
I'll quote from Brewin.
During traumatic events, however, attention tends to be restricted and focused on the main source of danger so that sensory elements from the wider scene encoded by the perceptual memory system will be less effectively bound together, producing fragmented and poorly contextualized memories that are difficult to control.
Laboratory research has shown that such unattended patterns or events providing they're sufficiently novel produce long-term memory traces. The existence of these traces can be detected, for example, through facilitation or negative priming effects or representation of the stimuli, even though a memory of the original pattern cannot be deliberately retrieved.
I refer you to studies by Treisman, aforementioned Treisman, and Shepard starting in 1996.
So there is an involuntary element in flashbacks, and flashbacks depend on involvement of an involuntary perceptual memory system that is distinct from ordinary episodic memory. And Brewin called it in 2010, 2014, he called it the revised dual representation model.
It's like we have a two-track system, voluntary and involuntary.
The voluntary system is what we call ordinary episodic memory. And the involuntary perceptual memory system is, copes, deals with trauma.
I would reverse the order. I would say the trauma uses the second memory system to relate to the world.
This is the track of the trauma. This is the pathway, the trajectory of trauma.
So cognition and emotion, they use episodic memory formation, while trauma uses the second perceptual track.
So I agree with Bremen that there is a dual representation, but I disagree that the dual representation is an outcome of the trauma.
I think the trauma is fundamental, is initial, as we are born with trauma. I think we are born with the capacity to be traumatized.
And we use the second system of perceptual memory.
Now, this system is much less organized. It has no narrative. It has no control. It's out of control, literally out of control. That's why we have flashbacks.
And it's out of control because it's not embedded in a context. It's not part of a narrative.
When something is out of context, out of the blue, out in the air, I mean, it's very bothering. It's very disturbing. And you tend to think about it a lot more.
If someone you know well suddenly behaves in a way which shocks you, you would tend to think about this misbehavior a lot more than you would think about his other behaviors.
Pain flashbacks have been described in which it is somatic rather than visual sensations that are repeatedly re-experienced as though they were happening in the presence.
So I refer you to Salomons, Osterman, Gagliese, Katz, and others. They describe pain flashbacks.
It seems that the body itself, divorced from the mind, has its own kind of memory, bodily memory, if you wish, the body remembers. Van der Kolk. So bodily memory, and that bodies also have flashbacks. We all acquainted with the phantom organ or phantom pain.
It's a dissociated pain. The organ is amputated. Someone's leg is amputated. He still feels the leg. The leg still itches. There's still pain in the missing leg.
Isn't this dissociation? Isn't this traveling back in time? Isn't this, in other words, flashback?
Again, I refer you to work by Whalley, Farmer, Brewin himself in 2007.
Frightening delusions and hallucinations such as occur in psychotic disorders or intensive care patients. This is also a form of traumatic re-experiencing.
These people believe that the hallucination is real. When your life flashes in front of you, it's not like you're watching a movie. You feel that you're there. People insisted that they were there.
When people have out-of-body experiences or near-death experiences, as described by Moody and others, they believed when they had returned to their bodies, so to speak, they regained consciousness.
They claim to have been there. It's re-experiencing. It's re-vividness. It's relieving.
These are all forms of flashbacks.
Flashback, therefore, doesn't have to be a real life event. You could flash back to an imaginary event, to a paracosm, to an imaginary kingdom.
For example, narcissists flash back to the period before the false self, but also flash back to elements of the false self. The process of re-experiencing, relieving, is not limited to external objects and the events that involve external objects. You could flash back internally into internal objects and into the dialogue and the interaction between internal objects.
Processes such as introjection, therefore, might involve flashbacks.
Quite a few scholars dealt with the issue of hallucinations and delusions and fantasies as forms of flashback. I refer you to Berry, Ford, Jellicoe-Jones, Haddock, Gracie, Hardy, Fornells-Ambrojo, Wade. They all described hallucinations, delusions, fantasies, and so on as forms of flashback or as processes that at some stage involve flashback.
You can flash back internally, not only externally.
Hallucinations, just to be totally rigorous, this is an academic setting and I would hate to be considered a YouTube personality, so hallucinations do not meet the current DSM-5 criteria for a traumatic event, and the fact that someone had a terrifying experience and developed characteristic symptoms could be enough for PTSD, but not for flashbacks, not for that element, diagnostic element, symptom of PTSD.
So we need to be very careful. Not all hallucinations qualify as flashbacks, but if the hallucination is intrusive, if it has negative emotionality, negative contents such as horror, fear, terror, if it involves vivid, re-vividness, vivid re-experiencing, vivid re-living, and if it induces trauma, I think it can safely qualify.
I think Brewin others think it can safely qualify as a flashback.
Finally, I refer you to additional articles about treatments focused on flashbacks, going from flashbacks to trauma rather than from trauma to flashback.
So article Brief, Mindfulness-Based Intervention for Rapid Release of Ptsd Symptoms and Specific Phobia. It was written by Smith, California Institute of Integral Studies. It's actually a PhD dissertation. It's published this year, 2020, and this is a very good article in military psychology.
Can you believe it? Military psychology, good article.
Resolution of Dissociated Ego States Relieves Flashback-Related Symptoms in Combat-Related PTSD: A Brief Mindfulness Based Intervention, again written by Janine and by Smith and Hartelius. It was published in February this year, February2020, in military psychology.
Okay, let's pull all the strands.
Flashbacks are now a symptom of post-traumatic stress disorder. There are various types of post-traumatic stress disorder depending which classification or taxonomy you wish to adopt.
Flashbacks are connected intimately to trauma and to dissociation. Flashbacks involve relieving the experiences. Flashbacks are authentic, faithful to the original, and in this sense they resemble very much a hypnotic dissociated state.
Hallucinations, psychotic elements, psychotic symptoms, delusions, and some types of fantasies could be construed as dissociated flashbacks. And in this sense, certain types of mental health disorders, many more mental health disorders should involve flashbacks or we should reconceive of flashbacks as elements and symptoms of many more mental health disorders.
The main function of flashbacks seems to be processing of trauma and separating, defending against the memories of trauma by disengaging from the world.
So it's really a dissociative reservoir, dissociative amnesiac mechanism.
So the flashback allows the person to disengage and retreat and withdraw to a familiar situation that he had already survived and he knows he has survived. However difficult flashbacks are, they're safe and very often they're safer than reality or inability to cope with reality.
So flashbacks are a safety valve against being overwhelmed by emotions, overwhelmed by cognitions, overwhelmed by memories, dysregulation, extreme dysregulation leading to the decompensation, disintegration and acting out.
And so we should expect to find flashbacks in borderline personality disorder, narcissistic personality disorder, all the dissociative identity disorders. And we should find flashbacks in all trauma related conditionsincluding CPTSD and PTSD.
Indeed, that's the very reason we are seriously contemplating to merge all these because there's no clear difference between borderline personality disorder and CPTSD. They all involve dissociative mechanisms.
The situation is such that I'm proposing to consider that the human mind, the human brain has three ways of relating to the world, not two, cognitions, emotions and dissociation. Dissociation is a way of coping with the fact that the world constantly traumatizes us. And it is a fact established in numerous studies that even very, very, very young children employing and use dissociation are traumatized and have flashbacks.
So this must be something very, very fundamental, not acquired. We are born with it, as we are born with cognitions, as we are born with emotions.
And so I think there are three languages, three interactive modes, three pathways of relating to the world, to others, objects, and to internal objects. And these pathways are cognitions, emotions, and dissociative processes, including traumatic dissociative processes.
And when we fail to distinguish internal objects from external objects with the management of our internal environment, including all the internal objects and constructs, fails, or when we confuse and conflate external and internal objects, one of the main symptoms is dissociation, dissociative disorders, including flashbacks.
So flashbacks are a symptom, they're an indicator that there is a massive systemic failure of distinguishing between internal and external in projection and projection. All these processes are compromised. There's a problem.
In extremes, this problem results in psychotic disorders.
In the middle ground, this failure to integrate external and internal and separate them with clear cognitive, emotional, and other boundaries. In the middle ground, this creates borderline personality disorder, or borderline narcissistic disorders, as Kernberg had it.
Kernberg claimed the borderline and narcissism and psychosis, they're all first cousins. So this is in the middle.
And in the benign or healthy end of the spectrum, we all experience trauma repeatedly. We all have mini fleeting flashbacks, mini fleeting traumas. And we use dissociation on a regular basis to cope with the world, as we use emotions, as we use cognitions.
Okay, a lot to chew on, and a lot to think about.
Despite what I've said about Pete Walker, I encourage you to try and read his book. It's not a rigorous clinical experience. It wouldn't pass peer review. But he has many, many interesting insights based on experience with clients and others, many interesting insights into the presentation phase of CPTSD. How CPTSD presents in therapy or in clinical settings.
So he's very descriptive. He's not very good in analyzing, he's not very knowledgeable, but his descriptions are worth absolutely getting acquainted with.
Otherwise, please stick to serious scholars, the ones I've enumerated in this presentation.
Assignments, I remind you, please, assignments through the common platform, the SIAS-CIAPS outreach common platform. And to both academic establishments, Southern Federal University and CIAPS, I wish a good and healthy day. Stay safe. We want you all back face to face when this is over. Don't let the virus traumatize you. And don't ever flash back to this period. It's not a pleasant one. Thank you.