Co-authored by Dr. Ruth Lanius, Lauren Rudolph, and Dr. Breanne Kearney
If we know what is different in the brain in PTSD, can we choose more targeted treatments to improve outcomes?
In people with PTSD, the brain may continue predicting threat because information is not being adequately shared across lower and higher levels of the brain. In our recent post, we discussed the latest study we conducted showing disruptions in the connections between upper parts of the brain (the cortex—the reflective brain) and lower parts of the brain (the brainstem and cerebellum—the survival brain). Vertical integration refers to the connections between upper and lower parts of the brain that allow these levels of the brain to communicate and share information. By sharing information throughout the brain (for example, the sensory information that your surroundings are calm and you feel relaxed here), the brain and body can update to a felt sense of safety.
Why would restoring vertical integration be helpful?
Restoring vertical integration could help improve treatment outcomes because, in order to benefit from treatment, you need to be able to update information based on present-day experience. If the brain can’t update information, you can’t learn from new experiences, so you may relive the past over and over, continually feeling triggered and unable to feel safe in the present. Restoring vertical integration may help the brain update to a felt sense of safety, so the past no longer controls you.
We therefore hypothesize that vertical integration is important for trauma treatments to foster deeper healing. We suspect that using sensory-based therapies to restore vertical integration could potentially make other therapies, including cognitive therapies and emotion-focused therapies, easier to undergo and more effective. We anticipate this could help people who have not experienced sufficient improvement from other therapies.
Being able to update information through vertical integration is also important to improve specific trauma symptoms, such as flashbacks, avoidance, feeling triggered, overly vivid memories, hypervigilance, and other associated symptoms. Better communication and integration between lower and higher brain regions may allow new sensory information to update old threat predictions. This would help the brain register that what was dangerous then (for example, a sudden bang) is not necessarily dangerous now.
How can we restore vertical integration?
To restore vertical integration, we may need to bring safe sensory input into the brainstem (the survival brain). The brainstem is the part of the brain that first registers incoming sensory information. The cortex (the reflective brain) is often not optimally online when someone is dysregulated or experiencing PTSD symptoms, so treatment may need another entry point that is always online: the brainstem. Sensory information provides this entry point.
When you are confronted with unsafe sensory inputs, such as in a traumatic environment, the brain prioritizes activity at the level of the brainstem because the brainstem reacts without thinking; it’s quicker than the cortex. When the brainstem instead receives safe sensory input, it may no longer need to take the driver’s seat.
We hypothesize that when the brainstem experiences safe or enjoyable sensory input, it could help change the brain’s connections, allowing this new information to reach higher levels of the brain. We are hopeful that this could help to improve the connectedness between the lower and upper parts of the brain, thereby restoring vertical integration and helping the person update to a felt sense of safety.
This approach is at the heart of our recently published book, Sensory Pathways to Healing From Trauma. In it, we explore how the eight senses can provide important entry points for trauma treatment in order to address what is happening in the brains of people with PTSD, particularly when words alone may not be enough.
What treatments could help restore vertical integration?
Sensory inputs could include tactile (touch), auditory, visual, proprioceptive (physical), vestibular (movement, balance), interoceptive (internal body), and other forms of safe sensation. The following sensory-based and somatic treatments provide safe sensory inputs that we hypothesize could help restore vertical integration.
Deep Brain Reorienting (DBR) is an emerging treatment that targets brainstem-based responses that are involved in orienting to a threat during the initial impact of trauma. The interim results of our randomized controlled trial showed very significant improvements—about half of participants no longer met the criteria for PTSD after eight sessions of DBR therapy conducted online. We hypothesize that DBR may help restore vertical integration by processing trauma-related bodily sensations associated with shock and intense negative affect, thereby creating greater capacity to access and integrate sensations of safety. We are currently analyzing brain scans to assess how DBR could potentially help restore vertical integration. Stay tuned for these results.
Sensorimotor Arousal Regulation Treatment (SMART) is an embodied treatment that uses sensory-motor engagement to promote connections between the brain and body. Because it involves sensory input through all eight sensory systems (which we discuss in our recent book), we hypothesize that SMART may help improve vertical integration.
Somatic Experiencing and Sensorimotor Psychotherapy are body-based therapies that use bodily sensations as key entry points for processing trauma, rather than the cognitive “story.” Both can help people process incomplete survival responses and reconnect with present-moment safety through bodily sensations. We hypothesize that these approaches may help restore vertical integration by creating opportunities for safe sensory input and motor action while reprocessing traumatic memories. Through this ongoing loop between sensory input and motor action, the brain may update its predictions about threat and safety, helping the person register that the trauma is over.
Eye Movement Desensitization and Reprocessing (EMDR) is widely recognized as an approach that incorporates sensory processing. We hypothesize that the bilateral eye movements used in EMDR may engage vestibular and sensorimotor systems, supporting the integration of sensory information with emotional and cognitive processing, helping people re-establish a felt sense of safety.
Other trauma therapies such as Sensory-Based Expressive Arts Therapy, Multimodal Motion-Assisted Memory Desensitization and Reprocessing, Neurofeedback, and Repetitive Transcranial Magnetic Stimulation (rTMS) can help restore vertical integration.
Research on this hypothesis is ongoing. Research methods are improving, allowing us to assess connections across all levels of the brain, including the survival brain. We look forward to sharing research that we are conducting on the effectiveness of sensory-based treatments in the near future.