Abstract
We postulate that the cascade “Freeze-Flight-Fight-Fright-Flag-Faint” is a coherent sequence of six fear responses that escalate as a function of defense possibilities and proximity to danger during life-threat. The actual sequence of trauma-related response dispositions acted out in an extremely dangerous situation therefore depends on the appraisal of the threat by the organism in relation to her/his own power to act (e.g., age and gender) as well as the perceived characteristics of threat and perpetrator. These reaction patterns provide optimal adaption for particular stages of imminence. Subsequent to the traumatic threats, portions of the experience may be replayed. The actual individual cascade of defense stages a survivor has gone through during the traumatic event will repeat itself every time the fear network, which has evolved peritraumatically, is activated again (i.e., through internal or external triggers or, e.g., during exposure therapy).When a parasympathetically dominated ‘‘shut-down’’ was the prominent peri-traumatic response during the traumatic incident, comparable dissociative responses may dominate responding to subsequently experienced threat and may also reappear when the traumatic memory is reactivated. Repeated experience of traumatic stress forms a fear network that can become pathologically detached from contextual cues such as time and location of the danger, a condition which manifests itself as posttraumatic stress disorder (PTSD). Intrusions, for example, can therefore be understood as repetitive displays of fragments of the event, which would then, depending on the dominant physiological response during the threat, elicit a corresponding combination of hyperarousal and dissociation. We suggest that trauma treatment must therefore differentiate between patients on two dimensions: those with peritraumatic sympathetic activation versus those who went down the whole defense cascade, which leads to parasympathetic dominance during the trauma and a corresponding replay of physiological and dissociative responding, when reminded. The differential management of dissociative stages (“fright” and “faint”) has important treatment implications.
References
2009). Is freezing an adaptive reaction to threat? Evidence from heart rate reactivity to emotional pictures in victims of war and torture. Psychophysiology, 9999, 1–8.
(1969). The epidemiology of common fears and phobia. Comprehensive Psychiatry, 10, 151–156.
(1993). Freud’s seduction theory: Incest, trauma, and hysteria. Middelburg, The Netherlands: Stichting Petra.
(2008). The origin of vasovagal syncope: To protect the heart or to escape predation? Clinical Autonomic Research, 18, 170–178.
(2001). Traumatic relationships and serious mental disorders. New York, NY: Wiley.
(2005). A freezing-like posture to pictures of mutilation. Psychophysiology, 42, 255–260.
(2004). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York, NY: Guilford Press.
(1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
(1994). Autonomic space and psychophysiological response. Psychophysiology, 31, 44–61.
(1998). The epidemiology of blood-injection-injury phobia. Psychological Medicine, 28, 1129–1136.
(2003). Abuse and neglect in childhood: Relationship to personality disorder diagnoses. CNS Spectrums, 8, 737–754.
(2003). The predictive power of peritraumatic dissociation and acute stress symptoms for posttraumatic stress symptoms: A three-month prospective study. American Journal of Psychiatry, 160, 1337–1339.
(2009). Vasovagal syncope: State or trait? Current Opinion in Cardiology, 24, 68–73.
(2000). Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior. Psychiatry Research, 95, 251–260.
(1980). A perceptual-defense-recuperative model of fear and pain. Behavioral and Brain Sciences, 3, 291–323.
(1979). The contribution of relaxation and expectancy for fear reduction via graded imaginal exposure to feared stimuli. Behaviour Research and Therapy, 17, 529–540.
(2004). Freeze, flight, fight, fright, faint: Adaptionist perspectives on the acute stress response spectrum. CNS Spectrums, 9, 679–685.
(2004). The STRS (shortness of breath, tremulousness, racing heart, and sweating): A brief checklist for acute distress with panic-like autonomic indicators; development and factor structure. Annals of General Hospital Psychiatry, 3, 8.
(2004). Does “fight or flight” need updating? Psychosomatics, 45, 448–449.
(2001). Emotion and motivation I: Defensive and appetitive reactions in picture processing. Emotion, 1, 276–298.
(2007). Is peritraumatic dissociation a risk factor for PTSD? Journal of Trauma and Dissociation, 8, 53–69.
(1998). Measurement of dissociative states with the Clinician Administered Dissociative States Scale (CADSS). Journal of Traumatic Stress, 11, 125–136.
(1999). Neural correlates of exposure to traumatic pictures and sound in Vietnam combat veterans with and without posttraumatic stress disorder: A positron emission tomography study. Biological Psychiatry, 45, 806–816.
(1895). Studien über Hysterie
([Studies on hysteria] . Leipzig, Germany: Franz Deuticke.2001). A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behaviour Research and Therapy, 39, 373–393.
(2004). Guidelines on management (diagnosis and treatment) of syncope – update 2004. Europace, 6, 467–537.
(2002). Toward an integration of interpersonal and biological processes: Evolutionary psychiatry as an empirically testable framework for psychiatric research. Psychiatry – Interpersonal and Biological Processes, 65, 48–57.
(2007). Does dissociation further our understanding of PTSD? Journal of Anxiety Disorders, 21, 183–191.
(1974). Rape trauma syndrome. American Journal of Psychiatry, 131, 981–986.
(1976). Coping behavior of the rape victim. American Journal of Psychiatry, 133, 413–418.
(1997). Origins of orienting and defense responses: An evolutionary perspective. In , Attention and orienting: Sensory and motivational processes (pp. 41–67). Hillsdale, NJ: Erlbaum.
(1994). The domain of dissociation. In , Dissociation: Theoretical, clinical, and research perspectives (pp. 15–31). New York, NY: Guilford.
(2008). Disgust, fear and the anxiety disorders: A critical review. Clinical Psychology Review, 29, 34–46.
(2006). Water drinking improves orthostatic tolerance in patients with posturally related syncope. Clinical Science, 110, 343–352.
(2000). The construction of autobiographical memories in the self-memory system. Psychological Review, 107, 261–288.
(1982). Fears and phobias in women: A community study. Journal of Abnormal Psychology, 91, 280–286.
(2004). Evidence that disgust evolved to protect from risk of disease. Proceedings of the Royal Society of London. Series B, Biological Sciences, 271, 131–133.
(2001). Dirt, disgust, and disease: Is hygiene in our genes? Perspectives in Biology and Medicine, 44, 17–31.
(1998). The Expression of the Emotions in Man and Animals. New York, NY: Oxford University Press (Original work published 1872).
(2009). Syncope and vertigo from a neurologic point of view. Berlin: Springer.
(1998). Ethological strategies for defence in animals and humans: Their role in some psychiatric disorders. British Journal of Medical Psychology, 71, 417–445.
(1990). Sexual traumatization in childhood long-term consequences of sexual abuse by relatives. Amsterdam, The Netherlands: SUA.
(2009). Journal of Nervous and Mental Disease, 197, 383–390.
(2009). Dialektisch-Behaviorale Therapie zur Behandlung der Posttraumatischen Belastungsstörung mit schweren Störungen der Emotionsregulation
([Dialectical behavioral theraphy in the treatment of PTSD with severe problems in emotion regulation] . Verhaltenstherapie und Psychosoziale Praxis, 41, 283–307.2009). Emotional learning during dissociative states in borderline personality disorder. Journal of Psychiatry & Neuroscience, 34, 214–222.
(2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345.
(2006). The influence of organized violence and terror on brain and mind – A co-constructive perspective. In , Lifespan development and the brain: The perspective of biocultural co-constructivism (pp. 326–349). Cambridge, UK: University Press.
(2002). Psychological trauma: Burnt into memory. Nature, 419, 883.
(in press ). Fascination violence – on mind and brain of man hunters. European Archives of Psychiatry and Clinical Neuroscience.2009). Guidelines for the diagnosis and management of syncope. European Heart Journal, 30, 2631–2671.
. (2006). Postural modulation induced by pictures depicting prosocial or dangerous contexts. Neuroscience Letters, 410, 52–56.
(1988). A functional behavioristic approach to aversively motivated behavior: Predatory imminence as a determinant of the topography of defensive behavior. In , Evolution and learning (pp. 185–212). Hillsdale, NJ: Erlbaum.
(2003). Catatonia: A clinician’s guide to diagnosis and treatment. Cambridge, UK: Cambridge University Press.
(2008). Peritraumatic tonic immobility predicts a poor response to pharmacological treatment in victims of urban violence with PTSD. Journal of Affective Disorders, 107, 193–197.
(1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
(1995). Arousal, numbing, and intrusion: Symptom structure of PTSD following assault. American Journal of Psychiatry, 152, 116–122.
(1995). The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26, 487–499.
(1938). Tonic immobility in the rhesus monkey (Macaca mulatta) induced by manipulation, immobilization and experimental inversion of the visual field. Journal of Comparative Psychology, 26, 515–526.
(2006). Blood pressure and cerebral oxygenation responses to skeletal muscle tension: A comparison of two physical maneuvers to prevent vasovagal reactions. Clinical Physiology and Functional Imaging, 26, 21–25.
(2007). Factor structure of the Tonic Immobility Scale in female sexual assault survivors: An exploratory and confirmatory factor analysis. Journal of Anxiety Disorders, 21, 265–283.
(1980). Evidence for the integrity of central processing during tonic immobility. Physiology and Behavior, 25, 189–194.
(1977). Tonic immobility: Evolutionary underpinnings of human catalepsy and catatonia. In , Psychopathology: Experimental models (pp. 334–357). New York, NY: W. H. Freeman.
(1996). Tonic immobility as a model of extreme stress of behavioral inhibition: Issues of methodology and measurement. In , Motor activity and movement disorders (pp. 57–80). Totowa, NJ: Humana Press.
(2010). Differential cortisol responses in patients with severe PTSD who were raped versus not raped. Journal of Psychiatric Research.
(1976). Tool using. National Geographic Society.
(Educational Series Catalog No. 50331 (film) , 5122776 (video).1979). Distinguishing among orienting, defense, and startle reflexes. In , The orienting reflex in humans (pp. 137–167). Hillsdale, NJ: Erlbaum.
(1987). The psychology of fear and stress. Cambridge, UK: Cambridge University Press.
(1981). Return of fear: The role of inhibition. Behaviour Research and Therapy, 19, 135–143.
(1946). On the nature of fear. Psychological Revue, 53, 250–275.
(2005). Tonic immobility and childhood sexual abuse: A preliminary report evaluating the sequela of rape-induced paralysis. Behaviour Research and Therapy, 43, 1157–1171.
(1980). On the ability of prey to recognize predators. Zeitschrift für Tierpsychologie, 54, 71–84.
(2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review, 25, 1–23.
(1986). Stress-response syndromes: A review of posttraumatic and adjustment disorders. Hospital and Community Psychiatry, 37, 241–249.
(2005). Cognitive-behaviour therapy for depersonalisation disorder: An open study. Behaviour Research and Therapy, 43, 1121–1130.
(1889). L’automatisme psychologique.
([Mental automatism] . Paris, France: Nouvelle Édition.1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66, 185–192.
(2000). An evolutionary approach to psychiatry. Australian & New Zealand Journal of Psychiatry, 34, 8–13.
(1973). In , Catatonia. Baltimore, MA: Johns Hopkins University Press. (Original work published 1874).
(1993). The neurobiology of fear. Scientific American, 268, 94–101.
(1989). Defensive behaviors in infant rhesus monkeys: Environmental cues and neurochemical regulation. Science, 243, 1718–1721.
(1991). Principles of neural science. New York, NY: Elsevier.
(1985). A behavioural formulation of posttraumatic stress disorder in combat veterans. Behaviour Therapist, 8, 9–12.
(1968). The relationship between clinical diagnosis and anxiety, assessed by forearm blood flow and other measurements. British Journal of Psychiatry, 114, 611–626.
(1996). Factorial dimensions and correlates of blood, injection, and related medical fear: Cross validation of the medical fear survey. Behaviour Research and Therapy, 34, 323–331.
(2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. The American Journal of Psychiatry, 160, 1501–1508.
(2007). Structural and functional neuroplasticity in relation to traumatic stress. Current Directions in Psychological Science, 16, 326–329.
(2007). Altered oscillatory brain dynamics after repeated traumatic stress. BMC Psychiatry, 7, 56.
(2009). Dissociation in borderline personality disorder: A detailed look. Journal of Trauma and Dissociation, 10, 346–367.
(1896). Die Schreckneurosen
([The fright neuroses] . In , Ein Lehrbuch für Studierende und Ärzte (Vol. II), Leipzig, Germany: Barth.2002). Management of vasovagal syncope: Controlling or aborting faints by leg crossing and muscle tensing. Circulation, 106, 1684–1689.
(2000). Eating disorders in adolescents and young adults. The Medical Clinics of North America, 84, 1027–1049.
(2006). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report. Recommendations and Reports, 55, 1–48.
(1993). Integration and self healing: Affect trauma, alexithymia. Hillsdale, NJ: Analytic Press.
(1995). Toward a cognitive neuroscience of dissociation and altered memory functions in post-traumatic stress disorder. Neurobiological and clinical consequences of stress. In , Normal adaptions to PTSD (pp. 239–268). New York, NY: Raven Press. [chap. 14].
(1998). The emerging neurobiology of dissociation: Implications for the treatment of posttraumatic stress disorder. In , Trauma, memory, and dissociation (pp. 321–363). Washington, DC: American Psychiatric Press.
(1975). The psychophysiology of mental illness. London, UK: Routledge and Kegan Paul.
(1966). Physiological measures, sedative drugs and morbid anxiety. Maudsley Monographs, No. 14. London, UK: Oxford University Press.
(1979). A bio-informational theory of emotional imagery. Psychophysiology, 16, 495–512.
(1984). Dead souls: Or why the neurobehavioral science of emotion should pay attention to cognitive science. In , Self-regulation of the brain and behavior (pp. 255–272). Berlin, Germany: Springer.
(1998). Emotion, motivation, and anxiety: Brain mechanisms and psychophysiology. Biological Psychiatry, 44, 1248–1263.
(2000). Fear and anxiety: Animal models and human cognitive psychophysiology. Journal of Affective Disorders, 61, 137–159.
(2006). A review of neuroimaging studies in PTSD: Heterogeneity of response to symptom provocation. Journal of Psychiatric Research, 40, 709–729.
(2002). Brain activation during script-driven imagery induced dissociative responses in PTSD: A functional MRI investigation. Biological Psychiatry, 52, 305–311.
(2001). Neural correlates of traumatic memories in posttraumatic stress disorder: A functional MRI investigation. American Journal of Psychiatry, 158, 1920–1922.
(2003). Recall of emotional states in posttraumatic stress disorder: An fMRI investigation. Biological Psychiatry, 53, 204–210.
(1996/1997). Alterations of corticothalamic perfusion ratios during a PTSD flashback. Depression and Anxiety, 4, 146–150.
(1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford.
(2008). Both predator and prey: Emotional arousal in threat and reward. Psychological Science, 19, 865–873.
(2007). Elevated pain thresholds correlate with dissociation and aversive arousal in patients with borderline personality disorder. Psychiatry Research, 149, 291–296.
(2010). Recognizing and treating vasovagal syncope. American Journal of Nursing, 110, 50–53.
(1987). Fears, phobias, and rituals: Panic, anxiety, and their disorders. New York, NY: Oxford University Press.
(1988). Blood-injury phobia: A review. The American Journal of Psychiatry, 45, 1207–1213.
(1998). Peritraumatic dissociation and posttraumatic stress disorder. In , Trauma, memory, and dissociation (pp. 229–252). Washington, DC: American Psychiatric Press.
(1992). Retention of massed vs. distributed response prevention treatments in rats and a revised training procedure. Psychological Reports, 70, 339–355.
(2008). Tonic immobility as an evolved predator defense: Implications for sexual assault survivors. Clinical Psychology: Science and Practice, 15, 74–90.
(2003). Dissecting the components of the central response to stress. Nature Neuroscience, 6, 1011–1012.
(1999). Disgust sensitivity, blood-injection-injury fear, and dental anxiety. Clinical Psychology and Psychotherapy, 6, 279–285.
(2002). Descending control of pain. Progress in Neurobiology, 66, 355–474.
(2004). Is death feigning adaptive? Heritable variation in fitness difference of death-feigning behaviour. Proceedings of the Royal Society of London. Series B, Biological Sciences, 271, 2293–2296.
(1962). Tonic immobility: Differences in susceptibility of experimental and normal sheep and goats. Science, 135, 729–730.
(2004). “Scared stiff”: Catatonia as an evolutionary-based fear response. Psychological Review, 111, 984–1002.
(1999). Proximate and evolutionary studies of anxiety, stress and depression: Synergy at the interface. Neuroscience and Biobehavioral Reviews, 23, 895–903.
(2007). The effect of a 473-ml (16-oz) water drink on vasovagal donor reaction rates in high-school students. Transfusion, 47, 1524–1533.
(1998). Somatoform dissociative symptoms as related to animal defensive reactions to predatory imminence and injury. Journal of Abnormal Psychology, 107, 63–73.
(2001). Peritraumatic somatoform and psychological dissociation in relation to recall of childhood sexual abuse. Journal of Trauma and Dissociation, 2, 49–68.
(2003). Self-injurious behavior in rhesus monkeys: New insights into its etiology, physiology, and treatment. American Journal of Primatology, 59, 3–19.
(2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: W.W. Norton.
(2006). Disgust, anxiety, and fainting symptoms in blood-injection-injury fears: A structural model. Journal of Anxiety Disorders, 20, 23–24.
(1994). Blood-injury phobia. Clinical Psychology Review, 14, 443–461.
(2003). The role of disgust in faintness elicited by blood and injection stimuli. Journal of Anxiety Disorders, 17, 45–58.
(1982). A classification review of mimicry systems. Annual Review of Ecology and Systematics, 13, 169–199.
(1923). The identity of inhibition with sleep and hypnosis. Scientific Monthly, 17, 603–608.
(1927). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. London, UK: Oxford University Press.
(1995). Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain. How “states” become “traits”. Infant Mental Health Journal, 16, 271–291.
(1990). Naloxone reversible stress induced analgesia in post traumatic stress disorder. Archives of General Psychiatry, 47, 541–547.
(2005). Contagious yawning and the brain. Cognitive Brain Research, 23, 448–452.
(2007). The psychophysiology of posttraumatic stress disorder: A meta-analysis. Psychological Bulletin, 133, 725–746.
(1995). Orienting in a defensive world: Mammalian modifications of our evolutionary heritage: A polyvagal theory. Psychophysiology, 32, 301–318.
(1998). A specific role for the thalamus in mediating the interaction of attention and arousal in humans. Journal of Neuroscience, 18, 8979–8989.
(2003). Diagnosis of Eating Disorders in Primary Care. American Family Physician, 67, 311–312.
(1989). Pierre Janet and modern views of dissociation. Journal of Traumatic Stress, 4, 413–429.
(1967). Comparative aspects of hypnosis. In , Handbook of clinical and experimental hypnosis (pp. 550–587). New York, NY: Macmillan.
(2000). Exaggerated amygdala response to masked facial stimuli in posttraumatic stress disorder: A functional MRI study. Biological Psychiatry, 47, 769–776.
(2006). Decoupling neural networks from reality: Dissociative experiences in torture victims are reflected in abnormal brain waves in left frontal cortex. Psychological Science, 17, 825–829.
(1994). Eye movement desensitization: A partial dismantling study. Journal of Behavior Therapy and Experimental Psychiatry, 25, 231–239.
(2004). Fear-induced hypoalgesia in humans: Effects on low intensity thermal stimulation and finger temperature. The Journal of Pain, 5, 458–468.
(2008). Is tonic immobility the core sign among conventional peritraumatic signs and symptoms listed for PTSD? Journal of Affective Disorders, 115, 269–273.
(1987). The pattern and habituation of the orienting response in man and rats. The International Journal of Neuroscience, 37, 169–182.
(1992). Pain perception in self-injurious patients with borderline personality disorder. Biological Psychiatry, 32, 501–511.
(2000). The treatment of war wounds in Graeco-Roman antiquity (studies in ancient medicine). Boston, MA: Brill Academic.
(2008). Psychophysiology of the defence cascade – Implications for the treatment of post-traumatic stress disorder (PTSD) and dissociative disorders, Invited Lecture. Society for Applied Neuroscience, Biennial SAN Conference, Seville, 2008; http://www.applied-neuroscience.org/.
(2005). Narrative exposure therapy (NET). A short-term intervention for traumatic stress disorders after war, terror, or torture. Cambridge, MA: Hogrefe & Huber.
(2009). Prelimbic prefrontal neurons drive fear expression: A clue for extinction-reconsolidation interactions. Journal of Neuroscience, 29, 13432–13434.
(2006). Neural correlates of antinociception in borderline personality disorder. Archives of General Psychiatry, 63, 659–667.
(1990). An ethological model for the study of activation and interaction of pain, memory, and defensive systems in the attacked mouse: Role of endogenous opioids. Neuroscience and Biobehavioral Reviews, 14, 481–490.
(2002). Autonomic response in depersonalization disorder. Archives of General Psychiatry, 59, 833–838.
(2003). Basal norepinephrine in depersonalization disorder. Psychiatry Research, 121, 93–97.
(1985). Regulation of cardiac vulnerability by the cerebral defense system. Journal of the American College of Cardiology, 5/6 (Suppl.), 88–94.
(1988). Brain involvement in cardiovascular disorders. In , Behavioral medicine in cardiovascular disorders (pp. 229–253). Chichester, UK: Wiley.
(1963). In , Perception and the conditioned reflex. New York, NY: Macmillan. Original work published 1958.
(2006). Recent developments in the theory of dissociation. World Psychiatry, 5, 82–86.
(2007). Pathologische Dissoziation – ein sinnvolles Konzept
([Pathological dissociation – A useful concept?] . Trauma & Gewalt, 1, 34–44.1979). Tonic immobility as a response to rape in humans: A theoretical note. Psychological Record, 29, 315–320.
(1999). A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status weight, blood pressure, and pulse. Transfusion, 39, 316–320.
(2004). Trauma-related dissociation: Conceptual clarity lost and found. Australian and New Zealand Journal of Psychiatry, 38, 906–914.
(1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1, 253–265.
(1996). Traumatic stress: The effects of overwhelming experience on mind body, and society. New York, NY: The Guilford Press.
(1989). Endogenous opiods, stress-induced analgesia and post-traumatic stress disorder. Psychopharmacology Bulletin, 25, 108–112.
(2008). Is there any point to vasovagal syncope? Clinical Autonomic Research, 18, 167–169.
(2007). Cardiac defense: From attention to action. International Journal of Psychophysiology, 66, 169–182.
(1992). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47, 373–388.
(1999). Evolutionary versus prototype analyses of the concept of disorder. Journal of Abnormal Psychology, 108, 374–399.
(1992). Conditioned inhibition of analgesia. Animal Learning and Behavior, 20, 339–349.
(2004). The developmental psychopathology of self-injurious behavior: Compensatory regulation in posttraumatic adaptation. Clinical Psychology Review, 24, 35–74.
(