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Neurophenomenology
and Trauma-Related
Altered States of Consciousness

Paul Frewen & Ruth Lanius

The Neuropsychotherapist

issue 20 November 2015

here has been increasing recognition of the causal role of traumatic life events
in the development of dissociative experiences. Indeed a dissociative subtype
of PTSD is now recognized in the DSM-5 (Dalenberg & Carlson, 2012; Lanius,
Brand, Vermetten, Frewen, & Spiegel, 2012; Lanius et al., 2010; Wolf et al., 2012), and
the dissociative disorders are among those most strongly associated with trauma histories (Brand et al., in press; Dalenberg et al., 2012). Trauma-related disorders are among
the most difficult to treat, and collaboration between clinicians and researchers is essential to understanding the complexity of dissociative experiences and improving therapeutic outcomes. Our recent text, Healing the Traumatized Self, is designed to further
the dialogue between clinicians and researchers concerning the neurophenomenology
of trauma-related disorders, focusing on the first-person lived experience of traumatized
persons and its underlying neural correlates.

In Healing the Traumatized Self, we develop

a four-dimensional model (the 4-D model) that
categorizes experiences of posttraumatic stress
into those that characteristically exemplify a
dissociative presentation, termed trauma-related altered states of consciousness (TRASC), as
distinct from those that occur within the range
of experience, which we call normal waking consciousness (NWC). A body of evidence in support
of the 4-D model is emerging in studies of chronically traumatized women (Frewen & Lanius,
2014), women with borderline personality disorder (Frewen, Kliendienst, Lanius, & Schmahl,
2014), acutely traumatized persons (Frewen et
al., 2014), and in community samples assessed
online (Tzannidikis & Frewen, 2015). The four
neurophenomenological dimensions we identify within the 4-D model refer to a persons experience of time, thought, their body, and emotion, as summarized in what follows.

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The Neuropsychotherapist

experience of time are extremely complex, certain brain regions (including the
basal ganglia, cerebellum, and the anterior insula) play a definite role. For example, Craig noted that the anterior insula
supports awareness of the immediate
moment with a coherent representation
of my feelings about that thing (Craig,
2009, p. 65; 2010), and response within
the anterior insula has been correlated
with flashback/reliving experiences during
symptom provocation in individuals with
PTSD (e.g., Hopper, Frewen, van der Kolk,
& Lanius, 2007; Osuch et al., 2001; Whalley
et al., 2013).
What is it that is situated in time, so as
to create our felt impression of existing
within it, of being held or cradled by it?
We would suggest that this is one of the
bases of our sense of selfthat thoughts,
ones body, and emotion move within
Figure 1. FromHealing the Traumatized Self: Consciousness, Neuroscience,
time. Thus strengthening a felt presence
Treatmentby Paul Frewen and Ruth Lanius, 2015, p. 72. Copyright 2015
of oneself across thought, body, and emoby W. W. Norton & Co. Reprinted with permission.
tionfor example, through mindfulnessbased therapiesshould more securely attach ones
experience to the present, thereby providing security
Dimension of Time
Conscious experience occurs within a subjective pre- against disorienting and disabling intrusions from past
sent, or now, partially immersed within the continu- self-states. Rather than only taking persons back to the
ously forming memory of ones immediate past and an- past, as is conducted in traditional trauma-focused or
ticipated future. As such, within NWC, the subjective exposure-based therapies, present-centered therapies
units of timepast, present, and futureare experi- deserve greater recognition in the treatment of trauenced as relatively seamless. Moreover, time is usually ma-related disorders (Frost, Laska, & Wampold, 2014;
experienced as continuously moving forward and has an Markowitz et al., 2015).
expected pace or velocity in its progression; for example, normally, we have a sense of how long one minute
feels like.
In contrast, traumatized individuals often experience
marked alterations in their sense of the passage of time.
Time can seem to rapidly speed up or slow down, particularly during traumatic events: sensory experience
and thoughts can seem to fly by with an extreme sense
of urgency, as if on a hell-bound train; or it can slow
to a crawl, with feelings and thoughts seeming to grasp
and seize unremittingly, seemingly lasting forever. As
well, sensory impressionsaffective and bodily feelingsand thoughts from the past often forcefully revive themselves in the present, such that memories are
relived in the form of flashbacks. During flashbacks, a
traumatized person becomes disoriented and confused.
Unable to discern past from present, they react as if the
past is the present.
Although the neurobiological underpinnings of our

The Neuropsychotherapist

Dimension of Thought
Consciousness is inexorably referential, requiring
both a subject and an object. In other words, consciousness is by nature always about something (Brentano,
1968). Indeed, philosophers have likened the passage
of thought to a narrative, entailing perspective (usually
in first person), plot (i.e., the content of the story), and
an organized structure taking the form of a beginning,
middle, and end.
Psychological trauma not only affects the self-referential content of thought, but also the structure and
narrative perspective of experience. For example, as
opposed to only experiencing thoughts in first-person
perspective, thinking I am bad or I deserve to die in
relation to what happened to me, or what I did, traumatized persons may also experience internal voice hearing, akin to experiencing thoughts in second-person
perspective, for example, experiencing internal voices
issue 20 November 2015

telling them you are bad or you deserve to die (e.g.,

Longden, Madill, & Waterman, 2012; McCarthy-Jones,
2011; Pilton, Varese, Berry, & Bucci, 2015). When a person experiences these internal voices, they are no longer
the only storyteller of their lived experience. Now there
is more than one voice or narrative speaking, possibly
associated with distinctly different goals, motivations,
and affects, and creating for some the impression of
possessing multiple selves.
Although neuroimaging studies are yet to examine
the mechanisms through which voice hearing is linked
to trauma-related disorders, studies of patients with
psychotic disorders suggest that brain regions involved
in speech production and comprehension are also likely
involved in internal voice hearing (auditory hallucination)highly distinct from the midline anterior and
posterior cortices typically associated with internal selfreferential thought. Insofar as internal voice hearing
represents an altered state of consciousness of verbal
thought, therapy for voice hearing in traumatized persons may require interventions somewhat distinct from
the traditional cognitive psychotherapeutic modalities typically adopted in the treatment of first-person
thought. Such may include the two-chair and round ta-

ble techniques of process experiential, emotion-focused

and hypnotherapy.
Dimension of Body
Thoughts, feelings, and actions originate from the
body. As Damasio described, Whatever happens in
your mind happens in time and in space relative to the
instant in time your body is in and to the region of space
occupied by your body (Damasio, 1999, p. 145). This
gives us the impression of being embodied; our experience of selfhood, the felt sense of our identity, is normally undeniably linked to our physical being.
Sorely, however, a common experience of traumatized persons is of being detached or divorced from an
experience of their bodies, and feeling that their own
bodies are themselves unsafe. In the aftermath of trauma, the mind/body connection is often severed, leaving
a person with the sensation that their body does not
belong to them. These experiences form the core of the
construct of depersonalization, which is central to the
recently described dissociative subtype of PTSD.
The neurobiological correlates of depersonalization
are increasingly well studied, and are thought to be as-

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When a person experiences

internal voices, they are no
longer the only storyteller of
their lived experience

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The Neuropsychotherapist

tive awareness and helping diminish detachment from

bodily states (Follette, Briere, Rozelle, Hopper, & Rome,
2014), acknowledging the importance of administering these embodied mindfulness practices in a traumasensitive way. Similarly, somatosensory therapies and
other body-based interventions are frequently effective
in trauma treatment.
Dimension of Emotion
In the aftermath of trauma, traumatized persons
frequently vacillate between states of emotional undermodulation, when they are overwhelmed by painful states of fear, anger, guilt, and shame, and marked
states of emotional overmodulation and suppression,
when all feeling virtually ceases, leaving the individual
emotionally detached, empty, numb, shut-down, and
unable to feel or know what they are feeling. We have
suggested that, in the extreme, the latter numb, detached, and shut-down emotional states of the trauma
survivor are appropriately regarded as an altered state
of affective consciousness. Emotional numbing symp-

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sociated with midline frontal, posterior, and lateral temporoparietal cortex (Blanke et al., 2005; Blanke, Ortigue,
Landis, & Seeck, 2002; Hopper et al., 2007). Recently,
it was demonstrated that states of depersonalization
are associated with an impairment of the encoding of
episodic memory in healthy individuals, during which
encoding within the posterior hippocampus may be
disturbed (Bergouignan, Nyberg, & Ehrsson, 2014), establishing a model whereby depersonalization at the
time of trauma may promote amnesia of traumatic
memories.
Recognizing the disembodied self-state of many
traumatized persons, it is critical that therapy for trauma-related disorders not only employ exclusively cognitive, talk therapy modalities, but also consider direct
body-based forms of treatment. Such modalities provide for a greater balance between the body-versusmind elements of effective mind-body therapies in
trauma recovery. For example, body-scan meditations,
as practiced within mindfulness-based therapies, can
help facilitate awareness and the self-monitoring of
bodily sensations, enhancing the capacity for interocep-

The Neuropsychotherapist

issue 20 November 2015

toms have been associated with decreased response

within the amygdala while viewing happy faces (Felmingham et al., 2014) and decreased response within the
dorsomedial prefrontal cortex during emotional imagery (Frewen et al., 2012). It is highly important, therefore,
that trauma therapy assist trauma survivors not only to
face the sources of their fear, guilt, and shame but also
to shift out of emotionally numb and shut-down states.
Trauma recovery should be regarded as incomplete until the survivor is able to master and embrace the full
range of human emotions, in particular, joy, pleasure,
and triumph (also see Etter, Gauthier, McDade-Montez,
Cloitre, & Carlson, 2013; Frewen, Dean, & Lanius, 2012;
Frewen, Dozois, & Lanius, 2012).
A Case Study: Mya vs. Kaylin
In Healing the Traumatized Self, we open by describing
Kaylin and Mya, two middle-aged women with PTSD related to significant trauma histories occurring throughout childhood, adolescence, and adulthood. Kaylin,
despite having significant PTSD symptoms, at the time
of the assessment did not endorse any symptoms of
TRASC. By comparison, Mya endorsed both symptoms
of PTSD and TRASC. The Figure below differentiates
Myas (red line) from Kaylins (blue line) clinical profile
on the PTSD Checklist for DSM-5 (PCL-5) appended by a
symptom list we developed to measure TRASC.
As one can see, relating to PTSD symptoms classified by the 4-D model as NWC states of distress (in
blue background) and measured by the PCL-5, Kaylin
endorses significant PTSD symptomatology, indeed, in
most cases, just as severely as does Mya, with the only
prominent exception being with reference to avoidance
symptoms (A1A2) and amnesia (N1). In comparison,
however, Kaylin evidences clear drops on the line graph
when it comes to questions about experiences of TRASC
(in red background) and, incidentally, also in the case of
PTSD symptom R3, which refers to flashbacks and is the
equivalent of the TRASC of time experience. In contrast,
Mya clearly endorses experiences of TRASC, indeed at a
level of severity comparable with her PTSD symptoms.
These obviously differing clinical presentations of two
complexly traumatized persons strongly suggest the
importance of distinguishing between non-dissociative
trauma-related symptoms associated with NWC-distress versus dissociative experiences associated with
TRASC. Of utmost clinical significance, treating only
NWC forms of distress may be insufficient to address
the complexity of symptomatology experienced by
persons with trauma-related dissociative experiences
traumatized persons frequently vulnerable to TRASC
may require specific interventions directed at their dissociative experiences and symptoms. A number of therwww.neuropsychotherapist.com

Figure 2. Symptom indicators refer to those for PTSD in

DSM-5, that is, re-experiencing (R1R5), avoidance (A1A2),
negative alterations in cognition and mood (N1N7), and
hyperarousal (H1H6), with background shaded blue. Questions about experiences of TRASC are background shaded
red.

apeutic interventions we have found helpful in our own

clinical-research practices are described in Healing the
Traumatized Self.
Concluding Remarks
In summary, Healing the Traumatized Self calls for
greater recognition and differentiation within the symptomatology of trauma-related disorders, distinguishing
between traumatized persons who are experiencing
distress associated with normal waking consciousness
(NWC) versus those who also experience dissociative
trauma-related altered states of consciousness (TRASC).
We review research from the fields of consciousness
studies, neuroscience, and clinical treatment and conclude that, although many traumatized persons do not
endorse the presence of dissociative experiences, many
will meet criteria for a dissociative subtype of PTSD associated with experiences of TRASC along the four dimensions outlined abovenamely, the neurophenomenology of time, thought, body, and emotion. We hope
that clinicians and researchers will continue to work
together and fully embrace the complexity of the experience of traumatized persons in our studies, assessments, diagnostic practices, and in therapy. Only then
will we find the most helpful ways forward to healing
the traumatized self.

The Neuropsychotherapist

Practice, & Policy, 4, 551559. doi:10.1037/a0027900

Damasio, A. (1999). The feeling of what happens: Body
and emotion in the making of consciousness. New
York, NY: Harcourt Inc.
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