1. PTSD: A Phychophysiological Perspective
Carmen V. Russoniello, PhD., LPC, LRT, BCB, BCN
Director, Psychophysiology Lab and Biofeedback Clinic
East Carolina University
russonielloc@ecu.edu

2. Disclosure
In the spirit of full disclosure I acknowledge that I currently serve on
the Scientific Advisory Committee of Biocom Technologies (unpaid)
and own a small percentage of the company stock .

3. https://author.ecu.edu/cs-admin/mktg/basic_retraining_video.cfm

4. Kilo Company 3rd Battalion 26th Marines
Namo Bridge Fall, 1969

11. “It is not the strongest of the species that
survive, nor the most intelligent, but the
one most responsive to change.”
-Charles Darwin

12.  The overall goal of the ECU Wounded Warrior
Program is to increase performance and
promote functional independence.
 The program involves methods to help
Marines learn how to control physical and
emotional reactions to stress (resiliency), as
well as techniques to increase strength,
endurance, cognitive performance, social and
life skills.
 The program involves sessions both at Camp
Lejeune and at the Biofeedback Clinic at East
Carolina University.

13. PTSD
When a person is exposed to extreme
stress such as sexual abuse, war, or even
the extended effects of a natural disaster,
clinically significant symptoms often
emerge.

14. The existence, frequency,
intensity, and duration of these
symptoms are dependent upon
many factors, including, gender,
age, and ethnic background of
the person exposed to the
stressor as well as the person’s
social environment and ability to
employ coping strategies.

15. Specific emotional and behavioral
responses to stress have been
observed and studied by mental
health professionals in multiple
settings, under different
circumstances, over time. These
symptoms have become the clinical
indicators used for identifying the
stress related disorder known as
posttraumatic stress disorder
(PTSD).

16. APA categorizes PTSD symptoms into
three main clusters:
1.A traumatic event that is
persistently re-experienced;
2.A persistent avoidance of stimuli
associated with the trauma and
3. A numbing of general
responsiveness and persistent
symptoms of increased arousal. The
symptoms must last at least one
month and adversely affect normal
functioning.

17. “the development of characteristic and
persistent symptoms along with difficulty
functioning after exposure to a life-
threatening experience”. These persistent,
post trauma symptoms were the basis for
the development of the original PTSD
diagnosis in 1980 and with some
modification still serve as the diagnostic
criteria. While this classification system is a
useful is has some limitations such as the
exclusion of some less common cognitive,
emotional, behavioral and physiological-
somatic symptoms.

18. • Inescapable Shock
• Autonomic Nervous System
• Sympathetic
• Parasympathetic
• Learned Helplessness
• Defense Defeat Model
• Possible bipolar effect with parasympathetic
becoming dominant and then sympathetic rather
than rhythmic

20.  Exposure of rhythmic environments to
chemical or behavioral stressors can
result in increases and decreases in the
response (Antleman (1996, 1997)
 Possible innate biological function
designed to reset the rhythm

21.  Sympathetic Dominance can
produce:
muscle bracing, bruxism, occular
divergence, tachycardia,
diaphoresis, pallor, tremor, startle,
hypervigilance, panic rage and
constipation

23. • Symptoms of palpitations, nausea,
dizziness, indigestion, abdominal cramps,
diarrhea, and incontinence
• Self perpetuating symptoms causing
continued dysregulation “free falling”
“The syndrome of trauma has now
literally taken control of the body”

24.  The ANS plays an important role in the
development and maintenance of a wide
range of somatic and mental diseases
 In general autonomic imbalance and
decreased parasympathetic tone may be the
final common pathway linking negative
affective states and ill health (Thayer &
Brosschot, 2005)

25.  Symptoms of dissociation mimic the bipolar
nature of the defining symptoms of PTSD
(arousal, reexperiencing, avoidance).

26.  Altered perception of time, space,
sense of self and reality.
 Emotional Expressions can range
from panic to numbing and catatonia.
 Altered sensory perceptions may vary
from anesthesia to analgesia to
intolerable pain.
 Motor problems include weakness,
paralysis, and ataxia as well as
tremors, dysarthia, shaking, and
convulsions.

27.  Cognitive Symptoms include confusion,
dysphasia, dyscalculia, and extreme
attentional deficits.
 Perceptual symptoms include ignoral and
neglect
 Memory alterations may appear as
hyperamnesia (Flashbacks), fugue states or
selective traumatic amnesia.

28.  Endogenous opiate reward systems contribute
to the establishment of conditioned procedural
memory in trauma.
 Exposure to war trauma often results in a
sustained period of analgesia (soldiers in
wounded in battle require lower doses of
morphine than in other non-combat related
wounds)
 Stress can induced analgesia in many forms of
trauma

29.  Relates to facts and events
 Plays an important role in conscious
recall of traumatic events)
 Involves the hippocampal and prefrontal
cortical pathways (inaccurate and subject
to decay)

30.  acquisition of new motor skills and habits
to the development of emotional
memories and associations, and to the
storage of conditioned sensorimotor
responses. Unconscious, implicit, and
extremley resistant to decay when linked
to emotional or threat based interventions.
(Scaer, 2001)

32.  Surgical Revolution
 Anesthesia introduced in 1846
 Antibiotic Revolution
 Penicillin introduced in 1941
 Endogenous Factor Revolution
 Personal healing
 Attacking germs and more importantly “Bad Habits”

33. Walter Cannon (1896)
 Coined “flight or fight response” to stress
 developed concepts of mind/body model
 Emphasized the importance of the
parasympathetic system
Selye (1975)
General Adaptation Syndrome
Stages
alarm reaction
resistance
exhaustion

34. The Defense/Defeat Model
 fight or flight
 immune system suppression
Folkow (1993)

36. “environmental demands tax or exceed
the adaptive capacity of an organism,
resulting in psychological or biological
changes that may place persons at risk for
disease.”
Cohen, Kessler & Gordon (1995).
Measuring Stress

37.  “Technically speaking, a stress reaction is a mental
and physical response to an adverse situation that
mobilizes the body’s emergency resources, the
flight or fight mechanism, which floods the body
with hormones that arose to meet the challenge.
Unfortunately modern life continually triggers this
response when we can neither fight or flee, which
can lead to chronic heightening of blood pressure
and muscle tension, irritability, anxiety, and
depression-and a lowering of immune
effectiveness”.
(Daniel Brown, 2003. Stress, Trauma and the Body, p. 89).

38.  Stress enhances susceptibility to
disease
 Both psychosocial & biological
stressors evoke the flight or fight
response
 Stress Disinhibition Theory
 People engage in a broad range of
dysfunctional behaviors as a result of
stress

39.  commonplace stressful
events produce
immunological alterations
 chronic stressors have been
linked to the longer-term
down-regulation of immune
function
 immunological changes have
negative consequences for
health Lonely Person with a Kind Heart

40.  Endocrine system
 facilitates communication between the mind and
body
 acts as an internal intelligence carrying information
that regulates the organism
 receptors for catecholamines (adrenaline) in immune
cells
 nerve fibers go "into virtually every organ of the
immune system and form direct contacts with the
immune system cells“ (Ader, 1993).

41. The Defense/Defeat Model
 fight or flight
 immune system suppression
Folkov (1993)

45.  The central nervous system that regulates the
ANS balance is called the central autonomic
network (CAN). The CAN work with networks to
regulate the following functions:
 Executive
 Social,
 Affective
 Attentional
 Motivational

46. 
When negative
Inhibitory or
circuits are
negative
Autonomic, compromised
processes or
cognitive, and positive circuits
feedback
affective function develop and result
circuits that
assist humans in hypervigalance.
permit
maintaining The symptoms can
behavior and
balance in the face be devastating and
redeploy
of environmental if not ameliorated
resources
challenges can develop into
needed
permanent
elsewhere
conditions

47.  A common subcortico neural system
regulates defensive behavior including
autonomic, emotional and cognition
 When prefrontal cortex is taken “offline” for
whatever reason parasympathetic inhibitory
action is withdrawn and relative sympathetic
dominance associated with defensive occurs
 This can be measured by assessing
parasympathetic contribution to overall HRV

48.  Growing evidence supports the use of
HRV as a predictor of hypervigilance and
inefficient allocation of attentional and
cognitive resources (Thayer & Brosschot,
2005)

49.  “Autonomic Imbalance and Decreased
Parasympathetic Tone in particular may
be the final common pathway linking
negative affective states and
dispositions, including the indirect
effects via poor lifestyles, to numerous
diseases and conditions as well as
increased mortality, and it may also be
implicated in psychopathological
conditions”.

50.  Low HRV is associated with the following
conditions
 cardiac symptoms of panic attack
 Poor attentional control
 Poor emotional regulation
 Behavior inflexibility
 Friedman and Thayer, 1998

51.  Depression (Thayer et al., 1998)
 Generalized anxiety disorders ( Thayer
et al,
 PTSD (Cohen et al., 1999)
 Cardiovascular morbidity and mortality
 Diabetes (Ziegler et al., 2001)

52.  Immune deficiency and inflammation
contributing to:
 Aging
 CVD
 Osteoporosis
 Arthritis
 Alzheimer’s
 Periodontal disease
 Certain types of cancers as well as muscle decline
increased frailty and disability

53.  The overall objective of Heart Rate variability
training is to decrease ANS hyperarousal and
improve its balance.
 Wounded Warriors learn to control ANS
responses to stress producing stimuli such as
thoughts, memories and images associated
with combat.
 Decreasing arousal and maintaining ANS
balance for increasing lengths of time is the
goal of training.

54.  Once it was observed that alpha waves were
dysfunctional in vulnerable populations protocols were
developed to help people learn to train alpha and theta
waves as a method of improving function.
 Peniston and Kulkosky showed increased alpha and
theta brainwave production resulted in normalized
personality measures; and prolonged prevention of
relapse in alcoholics. The protocol has also showed
efficacy as an intervention in drug addiction,
depression and PTSD.

56.  The graded stress exposure training program used in
this study is one month in duration and consist of a pre
assessment, 16 biofeedback sessions (four per week) a
post session evaluation and a 3 month follow up.
 Each week participants will be exposed to increasing
stress producing stimuli: 1. Stroop Color Word Test,
Math Stressor; Talk Stressor/Everyday Events 2. Talk
Stressor/ Combat Experiences; 3. Images and Sounds of
Combat; 4. Virtual Baghdad or Afghanistan (virtual
reality exposure).

57.  Each biofeedback session consists of 5
minutes of baseline followed by 5 minutes of
the weekly stressor, followed by 20 minutes
of HRV and neurofeedback training, followed
by 5 minutes of the stressor; followed by 20
minutes of HRV and neurofeedback and
finally 5 minutes of recovery data.

58.  Preliminary clinical data collected so far indicate
decreases in ANS hyperarousal and increases in
parasympathetic activity. Reports on PHQ-SF 36
indicated positive changes in physical symptoms,
and decreases in depression panic attack and
anxiety.

64.  Heart rate variability training changes
 Neurofeedback
 The Posttraumatic Stress Checklist (PCL)
 Deployment and Resilience
 Patient Health Questionnaire short form (PHQ SF-36)
 Profile of Mood States
 Salivary alpha-amylase (sAA) changes.
 Behavioral questionnaire assessing alcohol, drug,
nicotine use, nutrition habits etc.
 Self satisfaction inventory

65.  Dysfunction in ANS and CNS flexibility and balance
are associated with symptoms of PTSD in combat
veterans.
 Methods that are designed to restore balance in
these systems are needed to ameliorate these
symptoms.
 Biofeedback/Neurofeedback is a safe method to
achieve these goals.

66.  To create an awareness and
understanding of the components of
effective health improvement programs.
 To explore the specific application of
health applications in the treatment of
PTSD, anxiety, and depression.

67.  Define the treatment components of
health improvement programs and their
prescriptive parameters
 Review specific health improvement
protocols for PTSD, Anxiety and/or
Depression

68.  The greatest revolution of our time is the
knowledge that human beings, by
changing the inner attitudes of their
minds, can transform the outer aspects of
their lives.
-William James

73.  Exercise and Body Awareness
 Nutrition
 Stress Management
 Mental Focus
 Relaxation-meditation- and other antidotes to
stress (recreation/physical activity)
The overall focus is on positive behavioral change
and coping.

74. The first requirement necessary for change is that
you want to change!
We are all in different STAGES with respect to
multiple behaviors in our lives.

75. DEFINITIONS:
 Precontemplation
 Someone in this stage probably has no intention of making change or adopting
healthier habits.
 Contemplation
 Someone in this stage realizes the importance of specific changes. They may be
thinking of making some behavioral changes in the next six months.
 Preparation
 Someone in this stage is ready to make some behavioral changes. They may
already engage in some health behaviors some of the time but it is just not
something they do regularly.
 Action
 Someone in this stage has overcome all the obstacles and have integrated
behavioral changes but haven’t been doing it very long . They are doing it! (e.g.,
They are physically active on a regular basis– less than six months).
 Maintenance
 Someone in this stage is has integrated the behaviors on regular basis and has
maintained these for more then six months.

76. Precontemplation
Example: Learn about all the benefits of being
physically active.
Start thinking about what being physically active could
mean for you.
Contemplation
Example: Remind yourself all the benefits you will get
from being active. Picture yourself healthier and more
energetic than ever before. Try to record your progress and
improvements and make sure you have support from family
and friends.

77. Stages of Change
Preparation
 Set a start date.
 Tell everyone you know.
 Establish priorities.
 Make the change a high priority in your life.
 Leave no room for excuses.

78. Action
Example: Participate in activities that are not
effected by the weather- join an exercise class or
indoor sports league.
Make physical activity a priority. Plan physical
activity in your daily schedule.
Make sure your family and friends know how
important physical activity is to you.

79. Stages of Change
Maintenance
Maintain your behaviors. Reinforce yourself.
Examples: Try a new activity or sport.
Vary your walking or cycling path.
Change the music you walk to.
Be active at different times during the day.

80. Each level of the activity pyramid is
important in helping you increase
your physical activity level and
overall health. Each day you should
try to participate in a variety of
physical activities. Remember not to
limit yourself to one type of activity.

82. DEFINITIONS OF ACTIVITY PYRAMID LEVELS
Aerobic Exercise: Aerobic exercise improves cardiovascular fitness
and makes your heart and lungs stronger (3-5X/wk.).
Recreational Activities: Recreational activities may also improve
cardiovascular efficiency or more simply said will make your heart
and lungs strong (2-3X/wk.).
Leisure Activities: Leisure activities are low-level endurance
activities.
Flexibility and Strength: Flexibility activities help to increase and
maintain muscle flexibility. Strength exercises can help improve
muscle strength (2-5X/wk.).
Sedentary: The top level of the pyramid signifies sedentary life. This
is the smallest part of the pyramid and the activities here should take
up the smallest amount of your leisure time.

83.  Identify your personal activity levels based upon
the activity pyramid.
 Estimate the types of activities you do on an
average week.

84.  The purpose of this activity is to demonstrate the
many inherent benefits of a recreational activity
 Think social, emotional, cognitive, physical, and
spiritual.
 Bingo:
 Swimming:
 Gardening:
 Arts & Crafts:
 Scuba Diving:

85.  Goals
 Assist the patient/client create an awareness of
current nutritional patterns.
 Provide information to assist Marines/clients in
identifying healthy and unhealthy nutritional choices.
 Assist Marines/clients in implementing strategies to
change unhealthy nutritional patterns

86. Key Nutrients
Milk and Milk Products
Calcium
Meat and Meat Alternatives
Protein
Iron
Vegetables
Folic Acid
Vitamin A
Vitamin C
Fruits
Folic Acid
Vitamin A
Vitamin C
Breads and Cereals:
Complex Carbohydrates
 Fiber
Servings From The Food Guide Pyramid
Milk, Yogurt, and Cheese: 1 cup of milk or yogurt, 1 1/2 ounces of natural cheese, 2 ounces of process
cheese
Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts: 2-3 ounces of cooked lean meat, poultry, or fish, 1/2 cup
of cooked dry beans, 1 egg, or 2 tablespoons of peanut butter count as 1 ounce of lean meat
Vegetables: 1 cup of raw leafy vegetables, 1/2 cup of other vegetables, cooked or chopped raw, 3/4 cup of
vegetable juice
Fruit: 1 medium apple, banana, orange, 1/2 cup of chopped, cooked, or canned fruit, 3/4 cup of fruit juice
Bread, Cereal, rice, and Pasta: 1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal,
rice, or pasta

87. •Daily Servings and Guidelines
•Food Labels
•Calculating Calories

89. North Carolina State University A&T State University
Cooperative Extension
North Carolina Governor’s Council on Physical Fitness
and Health
Pace University
 Made possible through a grant from Child Nutrition
Services, the State Board Of Education and the
Department of Public Education.

90.  There is a need to identify automatic thoughts
and patterns before intervention begins.
 One effective method is to have the client/patient
record a daily record of automatic thoughts ( A
positive and negative thought diary!).

91.  Can you name any?

92. 1. All-or-nothing thinking
2. Overgeneralization
3. Mental filtering
4. Disqualifying the positive
5. Jumping to conclusions
 Mind Reading
 Fortune telling

93. 6. Magnification and minification
7. Emotional Reasoning
8. Labeling
9. Personalization
10. “Should Statements”

94.  Challenge Automatic Thoughts
 Clarify the Problem and What Can Be Done
 Taking Small Steps
 The Three “Cs” (‘Four)
 Commitment
 Control
 Challenge
 and Closeness

95.  The Relaxation Response
 Mini-Relaxation Response
 The Quieting Response
 Autogenics
 Imagery

96.  Anxiety
 PTSD

97.  Each one to two-hour session includes a
relaxation exercise, stretching and body
awareness exercises, data collection, didactic
presentation, experiential exercises, and self help
assignments to reinforce skill development.
 Theses protocol is applicable to PTSD, Anxiety
disorders and most depressions.
 Contraindications include individuals who are
actively suicidal, psychotic or otherwise unable to
comprehend the presented information and
ormanage their own care.

98.  Each one hour session includes:
 a relaxation exercise,
 stretching and body awareness exercises,
 data collection,
 didactic presentation,
 experiential exercises and
 self help assignments to reinforce skill
development.

99.  The protocol is applicable to:
 generalized anxiety,
 panic attacks or
 specific phobias such as
social phobias

100. Contraindications include individuals who
are:
 actively suicidal,
 psychotic,
 unable to comprehend the presented
information, or
 unable to manage their own care

101. Session I
 The MindBody Connection
 Physiology of Stress
 Changing Behaviors
Session II
 Relaxation Response
 Diaphragmatic Breathing

102. Session III
 Benefits of Distraction
 Developing Mental Focus
Session IV
 Benefits of Exercise
 Movement/body Awareness
 Developing Mindfulness

103. Session V
 Stress Warning Signs
 Automatic Thoughts
Session VI
 Attitudes, Beliefs, and Assumptions
 Stress Hardiness
 Cognitive Restructuring Skills

104. Session VII
 Awareness and Choice
 Moods, Feelings, and Emotions
 Effective Coping & Problem Solving
Session VIII
 Social Support
 Self-Esteem
 Effective Communication

105. Session IX
 Relapse Prevention
 Setting Realistic Goals
Session X
 Review: Stress Hardiness
 Community Resource

106.  Effects of treatment and the disorder may
produce symptoms (anxiety, depression,
physical dysfunction)

107. Designed to help Marines deal with PTSD
symptoms
Designed to teach Marines how to take an
active role in their healthcare
Designed to help Marines become resilient
to stress

108. Session I
 The MindBody Interaction
 Physical, Emotional, and Cognitive Effects of
Stress
 Psychoneuroimmunology and other MindBody
Research
 Introduction to the Relaxation Response
 Use of Recreational Activities
 Characteristics of Long-Term Survivors

109. Session II
 The Importance of Exercise
 Diaphragmatic Breathing
 Yoga/Body Awareness
 Nutrition Information
Session III
 Stress Hardiness
 Control, Commitment, Challenge, Caring
 Short and Long term Goal Setting

110. Session IV
 Cognitive Restructuring
 Recognizing Negative Automatic Thoughts
 Challenging Automatic Thoughts
 Using Positive Affirmations
Session V
 The Immune System
 Using Imagery

111. Session VI
 Recognizing emotions (Journal Writing)
 Dealing with Emotions of Fear, Anger, Depression,
and Guilt
 Family Patterns of Expressing Emotions
Session VIII
 Communication with Family and Health Care
Providers
 How My Diagnosis Affects Others

112. Session IX
 Living with Uncertainty
 Physical Self-Care Habits
 Support Networks
 Attitudes and Beliefs
 Action Skills to Change the
Situation
 Life Experiences That Will Help

113. Session X
 Humor as a Coping Strategy
 (CousinsTribal Rituals)
 Recreational Activities
 Program Debriefing
 Staying Motivated
 Reflections and Thoughts to Remember
 Celebrate Life

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