Trauma Flashbacks in PTSD, BPD, Psychosis (Conclusion: 1:03:27)

Next, a sizable percentage of patients with dissociative disorders have recurrent or concurrent PTSD.

Post-traumatic stress disorder seems to go hand in hand with dissociative disorders.

The fifth edition of the Diagnostic and Statistical Manual even introduced a dissociative type of PTSD. This is known as PTSD-D.

Now complex PTSD is the consequence of developmental traumatization, usually. Developmental.

It's long, the abuse or the trauma are long, regular, and a salient feature of the environment of the individual.

And this creates complex trauma.

Now, complex CPTSD is actually a new diagnostic category in the ICD 11 but not in the DSM 5.

The dissociative type of PTSD in the DSM5 limits concurrent dissociation to experiences of depersonalization and derealization and coupled with overmodulation of emotions, which is a very narrow and limited view, and also happens to be counterfactual, as any trauma therapist would tell you.

And so the prevailing view nowadays is that flashbacks and other intrusive phenomena are also dissociative experiences.

And I refer you to work by Van der Hart, Nijenhuis, Steele and others.

Okay, so we've established that flashbacks have something to do with dissociation and dissociation has something to do with post-traumatic stress disorder, whether complex or non-complex, but especially non-complex.

Flashbacks in PTSD seem to be memories experienced as if they were happening in the presence.

And the person conceptualizes this situation, this experience, as re-experiencing.

So flashbacks are a form of re-experiencing, including the re-experiencing or reliving of symptoms.

Janine, which I will discuss a bit later, recognize that unlike normal memories, traumatic memories are inflexible, invariable, they do not change with time and cannot be evoked at will.

Van der Kolk, Fisler and others analyze Janine's work brilliantly in the mid-1990s.

So what's the difference between a flashback and a very, very powerful, strong, overwhelming memory? Aren't they the same?

I just explained. They're not the same.

A flashback is when you lose reality testing.

When you're unable to tell what is real and what is not.

When you believe that your memories are actually reality, when you're back in the battlefield, when you're back in the trauma, in the traumatizing situation. Back, really, fully, essentially, totally, back.

If you're back in the battlefield, your bedroom does not exist, your wife does not exist. The supermarket you're in does not exist.

You're back in the battlefield, you're fighting for your life and you're likely to shoot people.

So that's not memory. That's definitely not emotions or the nonsensical emotional flashback.

Now, when we recover memories in therapy, which is a very frowned upon experience, practice, by the way, but when we do, and sometimes we do, the majority of recovered memories, not all, but the majority, resemble flashbacks.

People with post-traumatic stress disorder report recovered memories as if they are re-experiencing or reliving them, as if this is an instance of revividness.

Recovered memories are involuntary. They are fragmented. They are accompanied by intense emotions and they are experienced as a reliving of past events. This has been described in numerous studies.

Andrews, Malmoe, Leidlo, van der Haar, Bald, Van der Kolk, Fisler, you name it. Numerous scholars have described the nature of recovered memories as very flashback-like.

But these are recovered memories, memories. These are not spontaneous memories. These are not memories that are in consciousness but rarely dwelt upon. These are recovered memories, memories that have been repressed so dramatically and so thoroughly that in principle, they were inaccessible.

And it required therapeutic intervention, massive, radical therapeutic intervention to get to them.

And recovered memories are not the unthought known. Bollas's unthought known. This is not the same thing.

Okay. So we're beginning to see three categories.

We see a category of memories and emotions which are very powerful, could be overwhelming, and so on, and create distress. That's one category. These are not flashbacks. This is not the same as a flashback.

We see a second category of flashbacks where you experience the past as if it were the present, you're reliving the past, you're re-experiencing the past. There is revividness of the past.

And if you're under hypnosis, there is a revivification of the past.

That is flashback.

And the third category are memories and emotions, which are very powerful, could be overwhelming and dysregulated, but they're inaccessible to consciousness in any way, shape, or form.

And they have to be provoked or triggered or brought to consciousness. They have to be surfaced by therapeutic intervention.

Freud was the first to describe this, and he suggested that he called the emotional or the affective correlate of the memory. He called it abreaction.

So these are the three categories at this stage.

Compartmentalization and detachment underpin the dissociation of traumatic events.

So a traumatic event, a truly traumatic event, I'm not talking about failing an exam. I'm not talking about break up with your girlfriend. I'm talking about truly traumatic events. I'm talking about war. Talk about accidents. I'm talking about natural disasters. I'm talking about the traumatic death of a loved one, your child. Really traumatic events.

So when these happen, in order to defend our integrity, in order to protect our cohesion, the cohesion of the self, in order not to fragment and break to pieces, disintegrate, to protect and defend against this, against the compensation, what we do is we repress these memories.

Sometimes we reframe them, but we always repress them. We bury them deep, deep and then even deeper.

And this creates detachment. We are detached from the memories. We have compartmentalized the memories.

Now they're in a drawer which we are never likely to open again. We lock the drawer and throw away the key.

And this process is known as dissociation.

Sometimes, dissociation fails for a variety of reasons.

The memories and the emotions could be too strong, and no amount of dissociation does the trick.

Or the dissociation has been implemented wrongly for reasons I will deal with later.

At any rate, sometimes dissociation fails.

And when it does fail, we have flashbacks.

Now, you know that I'm an adherent of the self-state approach to personality.

I don't believe there is such a thing as a personality. I don't believe there's such a thing as a unitary self or an ego or whatever you want to call it.

I believe that there's an ensemble, there's a theater troupe of self-states and that these self-states are reactive to changes in the external and the internal environment.

Self-states, the systems of self-states are organized around memories.

That's why memories, without memories, you cannot have a core identity. Without memories, they are not organizing or hermeneutic principles around which you can direct the theater play that is your life using a variety of actors which are the self-states.

So you need this narrative, you need this thread, connective tissue between everything and everything, between all the self-states.

And so when there is trauma, the trauma and the memories of the trauma, they become the organizing principle.

The trauma makes sense of your life, of the world, what has happened to you.

And so the trauma fulfills an exegetic hermeneutic role, explanatory interpretative role, but the trauma also organizes everything so it's an organizing principle.

And the problem is that trauma cues, also known as triggers, can unpredictably reactivate or activate the trauma.

And this leads to a sudden intrusion of flashbacks.

The flashbacks are usually experienced as incomprehensible intrusions, overlaps, influences, as if some other reality took over.

It's a familiar reality, a battle zone, a trauma, traumatic event, and so on. It's something familiar because it's linked to memories, but it takes over and suspends, even eradicates the real current reality.

And this is accompanied by a period of dissociative amnesia. It prompts egodystonic, dangerous and maladaptive behaviors.

Self-states, systems of self-states may be experienced as removing memories, but self-states can also send in memories, dispatch memories.

And when the self-state introduces or reintroduces memories into the system, if the memory and the attendant emotions are sufficiently powerful or have been repressed with a lot of investment of energy, these memories are likely to generate flashbacks.

And in other situations, they're likely to yield confabulated memories for other states.

But we'll not talk about it right now.

There is a very interesting association between confabulation and flashbacks because confabulation is perceived as real and flashbacks are perceived as real so there's a linkage there and the linkage is the memory management by the self-state system.

We'll talk about it some other time.

Anyhow, even when the person appears to be completely dysregulated, even then there's always a self-state that is in control, the controller self-state, the state that is B, that is in charge, the so state that creates or moderates the chaos, the psychological chaos someone is in, is in charge.

In borderline, the protector state, the psychopathic state, the secondary psychopathic state, is the controller state.

In DID, dissociative identity disorders, there's a host so-called personality, and the host self-state is in charge.

There's always someone in charge. There's no such thing as no one in charge. There's always someone in charge.

In narcissism, the false self is in charge.

And so this controller entity, this self-state that is in charge, they are the regulators of the traffic of memories.

But as I said, sometimes for a reason we are not fully cognizant of or understand, even the controlled self-state can get embroiled or involved in triggering flashbacks.

We think that maybe it's a defense mechanism.

For example, when you find yourself in therapy, your controller self-state may generate flashbacks in order to undermine the therapy, because the therapy is getting too close for comfort. The insights that the therapy provides threaten to destabilize the whole system.

So one of the self-states, usually the controller's self-states, generates a flashback in order to dissociate from the therapy and destroy it, destroy the whole process.

Self-states appear to experience complex post-traumatic states, flashbacks.

And these flashbacks and complex post-traumatic states are divided among the self-states or self-systemsin terms of emotional, somatosensory, cognitive and behavioral aspects of memory.

This total experience of a flashback is actually doled out, distributed and allocated between the variety of self-states because the flashback state, the flashback condition, is experienced as reality.

And exactly as in reality, the flashback condition has many dimensions.

And so these dimensions are distributed among the self-states because each self-state is specialized. Each self-state is better suited, better adopted to cope with specific aspects of reality.

Since the flashback is perceived as reality, the entire system of self-states is put at the disposal of the flashback, is kidnapped or hijacked by the flashback.

And so then you have a self-state that is better at planning, a self-state that is better at emoting, a self-state that is better at analyzing.

And so these self-states are co-opted by the flashback because, again, the individual cannot tell that the flashback is not real, that it is only happening in his mind. The individual thinks the flashback is real, it's reality, and there's a mobilization of all the self-states to cope with this reality.

And some self-states appear in frank flashback, others in states similar to the dissociative subtype of PTSD.

I mentioned Pierre Janet.

PierreJanet was the true giant of psychology in the 19th century and Freud plagiarized a lot from PierreJanet. Freud plagiarized a lot from everyone, but he especially and egregiously plagiarized from Pierre Janet to the point that the normally docile and very pleasant PierreJanet announced publicly that Freud is a plagiarist. And right he was.

PierreJanet postulated that humans maintain a hierarchy of degrees of reality, and they ascribe these degrees of reality to behaviors, thoughts, imagination, and various perceptions of past, present and future.

In 1928, Pierre Janet created a kind of table of these degrees, a hierarchy of reality.

He said that trauma survivors may place their traumatic memories too high in the hierarchy, and these result in flashbacks experienced as occurring in the present.

In contrast, fantasies would, at the adaptive end of the spectrum, not lead to experience of these mental actions taking over present reality and representing it.

He said that fantasy could be healthy as long as you can tell the difference between fantasy and reality, but in a post-traumatic state, people can't tell the difference between fantasy and reality.

Of course, this is the core feature of narcissism, pathological narcissism, which is a post-traumatic state.

And so, when this happens, the traumatic memories and the fantasies, the compensatory fantasies or the defensive fantasies associated with these traumatic memories, they're placed too high in the hierarchy of realities, and then they're mistaken for reality and then we call it a flashback.

There's been a recent meta analysis and it demonstrated a robust link between dissociation and hallucinations distinct from flashbacks. That's a study by Longden and others in 2020.

And so Longden, L.O. Longden.

And so we're beginning, we're entering the second phase of our conversation.

We have established as a connection between dissociation and flashbacks and flashbacks and post-traumatic reactions or syndromes. That's well established.

What about psychosis? What about psychosis and the most salient and typical feature of psychosis, the most relevant feature of psychosis, which is hallucinations.

Can't we say safely that a flashback is some form of hallucination?

And if we agree that a flashback is a hallucination, can't we then continue inexorably to the next conclusion that a flashback is a micro-psychotic state? It's a kind of temporary psychosis.

London says that we cannot. There's a robust link between dissociation and hallucinations. That part is true.

But they're not the same as flashbacks.

To understand why, I recommend that you read the study by London.

Anyhow, flashbacks are the hallmark of post-traumatic stress disorder. They can be understood as dissociative intrusions of sensory perceptual aspects of a previous trauma, intrusions on the present.

The individual may be unaware of the link between these experiences of flashback, of these experiences of intrusion and past events. Nadel and Jacobs demonstrated it in 1996.

It is a common myth and common mistake, even among clinicians and scholars, to say that when the individual experiences flashbacks, he identifies, he's able to identify the traumatic events that gave rise to the flashback.

That is expressly untrue. There are cases where individuals are at a loss. They cannot explain the content of the flashback they are transported back to environments and situations in periods which are utterly unfamiliar to them, alien, and this is very disconcerting and very terrifying.

And this is called de-contextualization. Decontextualization relates to traumatic memories, like in the study of Nadel and Jacobs.

But it also pertains to schizophrenia. Danyan Rizzo Bruand in 1999 demonstrated decontextualization in schizophrenia.

When the sufferer, the patient, the schizophrenic patient experiences a reality, is convinced that it is reality, and yet is unable to trace this reality to anything that preceded it, it has no antecedence, is unable to link the emergent, spontaneous reality to anything that came before it, to any event, to any trauma, to any experience, to any period, to any environment, to any group of people.

It comes out of nowhere, total bubble.

And so we see the decontextualization exists in both flashbacks and schizophrenia, which is essentially a psychotic disorder.

We're exploring now the connection to flashbacks and psychosis to remind you.

And so such delusions, because decontextualization is a delusion, is a delusion because the experience reality or hyper-reality in the flashback and the experience reality or hyper-reality in schizophrenia, these experiences are divorced from anything that preceded them, divorced from any other dimensional aspect of figment or ingredient or component of reality.

So it's a delusion in effect.

And so we can understand these delusions as deriving from sensory and emotional flashbacks that are so dissociated from their spatial temporal context as to be unrecognizable as memories.

In other words, what causes the patients to fail to connect the experience of the flashback or the experience of the psychosis to the past is the intensity of the dissociation and the repression.

When the dissociation is super intense, and the repression is total and like, wow, unbelievable investment, cathexis, unbelievable investment in forgetting the memory, eradicating the memory, obliterating the memory, burying it, trampling on it, destroying it, just never again.

When this kind of investment happens, when the memory resurfaces in the form of a flashback or a psychotic episode, it is perceived as real, but not as connected to anything. It's perceived as real, but disconnected. Real, but not a part of the previous reality. Because indeed the dissociation has severed all connection to episodic memory and autobiographical memory.

And I refer you to work by Hardy, Moskowitz, Nadel, Watts, Jacobs, and many others.

The re-emergence of implicit memories of early disorganized attachment experiences, which cannot be recalled as autobiographical memories, may provide the foundation for a wide range of delusions, including paranoia and grandiosity.

And I refer you to studies by Liotti, Ghamli, Moskowitz, Montirosso, and others.

We're beginning to see that when the dissociation and the repression are super intense, in other words, when the trauma has been unusually egregious, then this gives rise to disorganized attachment on the one hand, and the experience of attachment is also scattered brained and totally diffuse and a disruption in the formation of autobiographical memories and later on identity.

So we have identity disturbance and we have a wide range of cognitive impairments and cognitive distortions, reality testing impairment, and these delusions of paranoia, grandiosity, these delusions are compensatory because they are no real, they are no accessible memories. They've been repressed and buried and dissociated.

There is an attempt to compensate for this dissociative gap, for this memory gap.

In other words, what emerges is very interesting. It says that delusions and cognitive distortions such as paranoia, such as grandiosity, are actually confabulations.

Remind you, confabulation is a feature of psychotic disorders, and especially schizophrenia.

Narcissists confabulate as well, which is a very powerful indication that underlying pathological narcissism, there's essentially a psychotic disorder with hyper reflexivity, which is something that otto kernberg has alluded to many times and that's where the word borderline comes from, the border between psychosis and neurosis.

Traumatic flashbacks, either directly in the form of sensory flashbacks, which are mistaken for hallucinations, or as interpretations of flashbacks, delusions, particularly when the delusions are strongly emotional.

So traumatic flashbacks come in two forms. Direct sensory experiences, which resemble very much hallucinations, and emotionally tinted delusions about oneself, about the world, about relationships between oneself and the world.

The illusions of course are compensatory, whereas the direct sensory experience, the direct sensory experience, the direct sensory hallucination in a way, which is a feature of flashbacks, is actually a disruption or a failure of the dissociative mechanism.

The delusions are compensatory.

It's like, I don't have a self, it's disrupted, it's diffused, I don't have an identity, it's disturbed, I don't have continuous memories because I'm dissociative, I'm falling apart, I'm disjointed, and so and so forth.

But I am godlike, or I am the center of malign, malevolent intent by others. That's conspiracy theories and the paranoid ideation.

So the grandiosity, the paranoia and other types of delusions, they make sense. They are the glue that creates an as-if identity, as-if identity, pseudo-identity.

Because now, with your grandiosity, you can make sense of yourself. You can have a false self. Now with your grandiosity, you can experience an identity.

And what is your identity? Your identity is the target of malign intent. Your identity is the focus of a conspiracy.

So these are compensatory mechanisms.

In the study, and there are various studies that demonstrate this.

And link all this traumatic baggage or traumatic instrumentation, post-traumatic instrumentation, if you wish, link it to attachment problems in early childhood.

And the development of disorganized attachment mainly.

And I'm you to work by Moscovitz, Montirosso and others.

In a study of adult survivors of childhood abuse, negative and positive dissociative symptoms were correlated actually with complex trauma.

Now when I say negative symptoms, these are depersonalization, derealization, to some extent amnesia. Positive symptoms are flashbacks, not because they are positive, not because they're nice, but because they are active.

We have passive symptoms, which are negative and we have active symptoms, flashback is an active symptom.

Anyhow these dissociative symptoms, positive and negative, were correlated actually in adult survivors of childhood abuse. They were correlated with complex trauma and with disturbances in self-organization.

But they were also correlated with symptoms of PTSD and symptoms of borderline personality disorder.

And I'll come to it in the second part of the lecture.

In the meantime, I refer you to studies by Kneffel, Tran, Lueger-Schuster, and others.

Back to flashbacks.

Flashbacks are obviously an unambiguously direct consequence of abuse trauma and it's unrelated to psychological development. Flashbacks are not the outcome of some disruption in psychological development.

There are other psychopathological manifestations of such disruption.

When the formation of the self is disrupted, formation of the ego is disrupted, we have very bad consequences later down the road. For example, pathological narcissism.

But flashbacks have to do with the trauma, and especially the trauma of abuse.

Because until more or less 2011, we believed that flashbacks are unique to post-traumatic stress disorder, the classic variant, not to complex trauma.

Today we know better. Complex trauma can and does induce flashbacks.

These are failures. Flashbacks are failures of defensive exclusion.

Excluding the trauma content, excluding the memory of the trauma, excluding the emotions that were attendant upon the trauma, this prevented re-vividness.

And this was a defensive mechanism, a defensive array.

When these defenses crumble, when they fail, there's a subsequent surfacing of flash bulb memories of significant failures in emotional exchanges.

It could be emotional exchanges with the attachment figure, like a primary caregiver, mother, a father later in life, could be failure in exchanges with other significant figures in one's life, role models, teachers, peers, and so on.

But there is a close connection between complex trauma, attachment failure, failures in emotional exchanges with important figures, significant figures in life, and ultimately failures of defenses against trauma, which lead to intrusions such as flashbacks, which leads me to borderline personality disorder.

People diagnosed with borderline personality disorder with dissociative symptoms, it's about one third of all borderlines, experience strong flashbacks, trans, angry, dissociative ego state, ego states and memory problems.

But ironically, these people, dissociative borderlines experience little frank amnesia, just run-of-the-mill amnesia.

Now borderlines with highly dissociative symptoms which amount to DD-NOS, and you can watch the video I've made about the connection between highly dissociative symptoms which amount to DDNOS.

And you can watch the video I've made about the connection between borderline personality disorder and OSDD, which is a form of dissociative identity disorder.

So borderlines which have an attenuated form of dissociative identity disorder, that's about one seventh, one eighth, one seventh of all borderlines, experienced strong flashbacks, coming to from amnesia, internal voices, and child andor dissociated ego states.

Severe dissociative symptoms and flashbacks may find expression in the form of acute reactive dissociative psychosis.

So this is where psychosis, dissociative identity disorder, and borderline personality disorder come together in flashbacks.

The differential diagnostic criterion, which gives rise to the differential diagnosis, should be flashbacks.

Which flashbacks, the existence of flashbacks.

Flashbacks, the existence of flashbacks, in the borderline personality pathology.

Flashbacks are strongly indicative of dissociative symptoms and dissociative identity disorder in more extreme cases.

Now, even when we discuss PTSD, classic PTSD, even then, criterion B symptoms of PTSD may resemble psychosis, with nightmares, flashbacks, and intrusive thoughts, mimicking many characteristics of the Schneiderian first-rank psychotic symptoms, which are more common among dissociative patients than psychotic clients.

I refer you to the early work by Ross in 1990.

I'm mentioning this because there's an attempt to reconceptualize or recharacterize borderline personality disorder as a mere variant of complex trauma of CPTSD with maybe some extreme form of emotional dysregulation.

Indeed, there is this diagnosis of emotionally unstable personality disorder, which has replaced borderline personality disorder.

But I think it's a mistaken direction because it does not take into account the very important foundation of borderline personality disorder, which is dissociation.

Borderline personality disorder is a post-traumatic condition, exactly like pathological narcissists.

In both cases, there's probably a genetic predisposition to react by developing a personality disorder.

But heredity is the template. The content of the template is abuse and trauma.

Abuse and trauma trigger these children to become later on in life, borderlines and narcissists.

So these are post-traumatic conditions.

And to reduce the post-traumatic condition merely to emotional dysregulation, ignoring psychotic elements, ignoring dissociation or dissociative states, or even dissociative identity disorder, ignoring flashbacks, this is ignoring praxis.

This is ignoring what every clinician who has ever worked with borderline personality disorder can tell you.

It's wrong to reduce borderline to emotional dysregulation. It's wrong, simply wrong. There's so much more to borderline personality disorder.

And so flashbacks actually occur in about one half of patients with borderline personality disorder. Very similar to PTSD.

Inappropriate intense anger could be a hyperactivated emotional part experiencing flashbacks of past mistreatment, for example. That is if we apply the structural dissociation model to borderline personality disorder.

In an analysis of 34 borderline participants conducted by Cosecva and Dell, Dell is the god of dissociative disorders. So Cosecva and Dell in 2010 analyzed 34 patients with borderline personality disorder.

50% or more reported dissociative symptoms that are typical of a severe dissociative disorder. They endorsed at a clinically significant level, trance-like states, hearing voices, depersonalization, amnesia for recent and remote events, large memory gaps, and doing or saying things when angry that they did not remember.

Their flashbacks lasted for days, involved loss of contact with the present, and made them one to inflict pain on themselves or even die.

Importantly, they rated depersonalization as only sometimes stress related. It actually occurred about three times per month and lasted most of the day for no reason at all.

And so I've discussed borderline at length in other videos. There's a borderline personality disorder playlist on this channel and I don't want to stray too far from the topic of today's video.

But flashbacks should be the litmus test and the main diagnostic criterion of dissociative or disorders of dissociative states, dissociative disorders, PTSD, CPTSD, and borderline personality disorder.

The dissociative core of dissociative identity disorder.

In other words, the dissociative symptoms always present regardless of the level of dissociation.

This core reflects the activities of self-state or alter identities, experiences of identity confusion and memory problems.

The dissociative core of borderlines emphasizes flashbacks, experiences of identity confusion and memory problems.

So there's a bit of a difference between the two.

Regression analysis of flashback scores demonstrated that 61% of the variance in borderline personality disorders flashback scores is unexplained.

And so it seems that flashbacks in borderline personality disorder are probably more structural, they're more built in, to quote Ladis, they're more a consequence of their characterological and neurobiological reactivity.

So in PTSD, the flashbacks are a consequence of the trauma, or an artifact, if you're so inclined, of the trauma. The trauma produces the flashbacks.

In borderline personality disorder, the flashbacks are autonomous processes, either because of the genetics of borderline personality disorder, the brain abnormalities, no one knows.

But flashbacks are built into the borderline personality disorder structure and organization. They're an integral part of it, they're not a bug, they're a feature.

They're an integral part of it. Intrusive dissociative phenomena include the experience of traumatic flashbacks. Pieces of dissociated memory, emotion or perception suddenly intrude upon awareness.

We could say that flashbacks are involuntary and intrusive distressing memories via re-experiencing. These are dissociative reactions. There's a loss of grounding, a loss of reality testing.

And when the criterion B in the DSM-5, criterion B of PTSD equates flashbacks with dissociative reactions, involuntary, intrusive nature of a dissociative kind of process, impact on the regulation of consciousness, it's all true.

But it assumes, the DSM assumes that all these features, involuntary nature, intrusive nature, impact on regulation of consciousness, altered state of consciousness, the DSM assumes that all these are pathological features of a pathological process while the pathological process is at work.

The etiology is totally pathologized, totally traced to an or psychopathology.

But that doesn't seem to be the case. Many clinicians, trauma therapists, so on, who work with trauma patients would tell you that even when the PTSD is cured or when there is a total recovery from PTSD, the flashbacks continue.

Flashbacks seem to be divorced from the underlying psychopathological process of PTSD, CPTSD, BPD, whatever.

They are autonomous manifestations of internal cerebral or neuro-cerebral or neurobiological organization.

It's exactly like dreaming. I can compare flashbacks to dreaming.

When you're in a dream, you think you're in reality. And dreaming and flashbacks probably fulfill the same function.

I could even say that flashbacks are dreaming in a wakeful state. They fulfill the same function.

Reorganizing memories, realigning them, making them conform to a core identity, or in the absence of a core identity, generating a confabulated narrative, delusional narrative of a core identity, for example, in narcissism.

So flashbacks are autonomous functions of the brain as it attempts to make sense of reality by organizing memories in a way which would yield a coherent and cohesive narrative, also known as identity.

We have tactile, sensory, motoric, post-traumatic flashbacks. We have olfactory-triggered flashbacks.

Anything can trigger a flashback, and many times nothing triggers the flashback that we know of.

And that's why often we tend to confuse or misdiagnose flashbacks as hallucinations, because flashback experiences give the impression of hallucinations. They give the impression of psychosis.

But it's not true. It's very important to differentiate between the two.

Flashbacks are functional, they fulfill a function, hallucinations don't.

In the theory of structural dissociation in some cases of PTSD and the dissociative PTSD, PTSDthere's a contrast between maintaining some functionality in some areas of life while coping in a depersonalized, derealized manner by experiencing amnesia, this is the ANP, versus episodes of flashback in PTSD, or extreme emotional over-regulation in PTSDD, which is the EPI part of structural dissociation.

The flashback of memories from disparate events indicated impaired binding during the encoding of abuse experiences as well as gist- based distortion.

So the flashback reflects a failure in binding memories, failure in shelving them, a failure in organizing them, appropriately classifying them, cataloging them, a failure in nosology, if you wish.

On the one hand, and on the other hand, it has its own inherent, innate content, the gist of the re-experience, the gist of the re-viviness, the gist of the re- vividness, the gist of the hyper-reality imposed upon real reality.

And so sometimes this leads to suicidality. This phenomenon is known as flashback suicidality.

Flashbacka re-experiencing of suicidal ideation that had occurred had happened in the period recreated in the flashback. So flashback suicidality is derivative, is secondhand. In the flashback, you experience the environment, physical environment, you experience the circumstances, the history, the episodic memory, you experience the, you experience the circumstances, the history, the episodic memory. You experience the people who were involved at the time. You experience the interactions, especially traumatic interactions, and you also, of course, experience the emotions that you had felt at the time.

And typically the emotions that you felt at the time included suicidal ideation. And so it's re-evoked, provoked within the fleshback. It's a form of emotional reliving or emotional re-experiencing. But the body is also deeply and heavily involved in the flashback because the body keeps the score the body is the repository of trauma memories body memories flashbacks or reenactments of the physical discomforts, seemingly associated with traumatic experiences, body memories are very common.

If somebody wakes up with a pain and stiffness in the neck and shoulders, psychiatrically, we would try to figure out, say, whether this is a tactile fleshback. I'm quoting now from the book, or of having struggled against being pinned down and strangled or raped 30 years ago. Or on the other hand, whether, while visiting mother last night, she said something grossly unempathic and demeaning, and the immediate reaction was the impulse to strangle her. So when we have a flashback of being pinned down, it's because we have been pinned down, or because we should have been pinned down. We had an impulse that had to be controlled. And the flashback reflects this. Internal reality, the memory, the suppression of the impulse and so on. I'm going to read this section again. This is very important. If somebody wakes up in pain and stiffness in the neck and shoulders psychiatrically one wants to figure out say whether this is a tactile fleshback of having struggled against being pinned down and strangled or raped 30 years ago or on the other hand, whether while visiting mother last night, she said something grossly unempathic and demeaning and the immediate reaction was the impulse to strangle her.

And so one of a scholar says, I'm quoting, in practice, I accept the classic Freudian concept of repression not only as the repression of a wish that gains somatic expression in a compromise formation conversion proper but also as the expression of a trauma in a given host to alter in the case of dissociative identity disorder. And this repression of trauma gains somatic expression in a partial post-traumatic fleshback, body memory. It is worth noting that this second sort of conversion was Freud's initial idea, which he then largely replaced by the first sort.

Historically, trauma preceded wish, and then wish replaced trauma. And now we have the return of the repressed. Trauma trumps wish, but both survive. More commonly, children show dissociative manifestations without evidence of discrete identity fragmentation. Tehr, T-E-R-R in 1988, described trans-like states in traumatized children, during which they rigidly and compulsively reenact traumatic scenarios. During dissociative episodes, the child may have a look of non-recognition in response to usually familiar people or places. Sometimes during these dissociative states, the children will appear to have a flashback in which they reenact traumatic scenarios with shouts of no and body movements simulating a violent assault. The work, there's a lot of work of this by S Sintron Salome Blair Andrews and Storch. I read to you this segment to demonstrate that the entire armament, the entire array of dissociative tools and instruments and weapons is available early in childhood. Everything has a preceding childhood, including flashbacks, including flashbacks, all dissociative states, dissociation, repression.

The child comes fully equipped with these tools, and it is the abuse and trauma of the child that trigger these tools and they become entrenched, and later on in life, they become habitual.

A child who has had flashbacks as a child would grow up to be an adult who has flashbacks on a regular basis. A child who has had to dissociate horrific experiences of abuse and trauma is unlikely to become a well-composed, well-balanced adult.

The dissociation will continue to work furiously in order to prevent contact with the shameful harrowing experiences.

And when and if it fails, the person experiences internal mortification, dissociates the dissociation, and tries to defend against the intolerable new condition either by developing delusions or in extreme cases psychosis or by experiencing a flashback.

Flashback may be just an attempt to reenact early childhood trauma, abuse and conflict in order to try to resolve them differently.

And it doesn't have to be early childhood trauma.

If you're an army vet in Vietnam, you've experienced trauma, and you're likely to experience flashbacks.

Flashbacks may be attempts to revisit such scenes, periods and environments and circumstances in order to try to resolve them differently.

In other words, flashbacks may be a form of self-administered re-traumatization, self-administered therapy.

Of course, the individual is helpless to make any good therapeutic use of flashbacks.

Because flashbacks do not provide a different narrative or resolution. They are dumb in the sense that they just reenact. It's like watching a movie.

And so it gets an individual nowhere.

The dissociation continues even more furiously than before because now the individual develops anxiety, is afraid of the oncoming flashbacks.

That's why flashbacks are a major issue in therapy, especially trauma therapy.

And they require intervention which is much more subtle than we are providing nowadays.

We need to realize multiple layers of flashbacks and how they interact with a variety of other protective mechanisms, such as dissociation, such as borderline personality organization, such as emotional dysregulation, which is also in many ways a protective mechanism, such as protector or control as self-states, such as pathological narcissism, such as delusions of grandiosity and paranoia, such as the false self in borderline and narcissism.

These are all protective mechanisms, and flashbacks are just one of them.

And treating flashbacks in isolation, or treating flashbacks as nothing more than the re-emergence of suppressed memories and it's going to go away this is wrong, disastrously and catastrophically wrong many times.

Remember, as a traumatized and abused child or traumatized and abused adult, suicide is never far from consciousness. Suicidal ideation is a normal reaction to such unusual conditions, outliers.

And if you treat these conditions as normal, if you trivialize this trauma and abuse, if you invalidate the patient, suicide ideation is likely to recur even within the flashback. It's a risk. No therapist should take.