Rethinking Depression

Depression – A biological response to threat


Published in Counselling Matters, (the magazine of the National Counselling Society) August 2022.

What do we know about depression?  We can list its symptoms such as low mood, low energy, a slowing of thought and movement, loss of concentration, and loss of pleasure and interest in activities.  There is also a disruption of our patterns of appetite and sleep, negative, hopeless, and sometimes suicidal thoughts, and a loss of both the ability and desire to socialise with others. 1     But what exactly is depression?   I am going to argue that it is a normal biological response to threat which has become “stuck”. 

Our human nervous system can respond to danger and life-threat in two key ways.  The first is by going into fight-flight, a state of heightened metabolic arousal. The second is by means of a bodily shut-down brought about by a sudden metabolic collapse. 2     This two-fold “threat response system” can be best understood by looking at the context in which it evolved – one animal’s need to catch and devour another, and the prey animal’s need to stay alive.   

When a predator attacks its prey, the prey goes into a state of highly aroused running or fighting to help it escape.   However, if this fight-flight response fails, an older threat response shuts down the body and the prey collapses, as we can see when a cat catches a mouse.   This collapse, which is the same biological mechanism as a faint3, stops the predator’s attack and can lead to a window of opportunity for escape if, for example, the predator has to fight off competition.  If such an escape route opens up, there is a sudden metabolic switch from collapse back into fight-flight4.   Then, if a place of safety is reached, the prey animal can rest and relax, and the threat response system switches off.

This threat response, which I refer to as our “Fear System”, evolved in the context of relatively brief attacks and chases5, but where the danger lasts too long or there is no place of safety that can be reached afterwards, the fear system becomes dysfunctional and is unable to switch off, and, as a result, fight-flight or shutdown reactions to any level of threat, whether real or imagined, become habitual6.   As humans evolved as intensely social animals, for whom expulsion from the group was a life-threatening danger, this fear system was wired-up to react to social threats, such as rejection, bullying or loss of status, with metabolic arousal or collapse, in the same way as if they were physical attacks7.   

I am proposing that this threat-induced collapse is the biological mechanism underlying depression.   Such a theory could clearly explain the experience of depression.  The metabolic collapse is brought about by a drop in heart rate and blood pressure8 that disables energy production by starving cells in every part of the body of the glucose and oxygen they need to function9.  This means muscle cells stop working, and our limbs feel heavy as lead.  Lack of understanding has stigmatised depression sufferers by treating energy loss as if it was just imagined.  This theory points to the physical (biological) reality of energy loss in depression.   

It would also explain many of the other symptoms of depression, as this shutdown de-energises brain cells, so we can no longer concentrate, or think clearly, and what thinking capacity remains is negative and hopeless.    The same de-energising of brain cells in the cortex deactivates our social engagement system10, so we lose both the desire and the ability to relate socially to others.  Unsurprisingly, we therefore lose all sense of pleasure in life. 

This theory raises the question as to why depression does not normally present as the full physical collapse seen in prey animals when they are caught by the predator.  I think the answer to this lies in our social engagement system which has developed to powerfully control our fear system responses (thus making social life possible).  However, where the fear system has become chronically stuck, and can’t deactivate, the ability of the social engagement system to control fear responses becomes impaired.  I think this impairment is the underlying cause of depression which can be seen as a metabolic collapse that has been partially but ineffectively controlled by the social engagement system11.  Thus, there may be “gradations in reactions to life threat” 12 so that the threat-based shutdown can be experienced not only as a full physical collapse, but also at lower levels of intensity, in the same way as we can experience a full faint, and also various levels of “feeling faint”.

Seeing depression as a stuck form of bodily shutdown would explain why it is so often experienced alongside anxiety, which can be viewed as a stuck form of the fight-flight response.  Where the overall threat system cannot switch off, these are the two most common states in which we are trapped.  Some people are affected predominantly by anxiety, others by depression, but many oscillate between both.

We see from the context of prey and predator that one way out of bodily shutdown is back through fight-flight.   When psychological therapists help people to get in touch with anger that has previously been inaccessible, they are helping them to reconnect with the physical sensations of fight-flight which can trigger a raising of mood. 13

However, the key factor in switching off the overall threat response system is safety14.  This system can only switch off if we can find safe places in which we can relax.  In a world of increasing poverty, zero-hours contracts, over-monitored employees, government-created “hostile environments”, over-tested schoolchildren, collapsing care services and fear-driven and polarised politics, safe places where we can truly relax are disappearing, and unsurprisingly, levels of anxiety and depression are rising.   

As a sense of safety depends on the contexts in which we live and work, this theory suggests that depression is not some sort of “defect” in the individual sufferer but arises from a normal biological response to threat. However, if there is insufficient support to enable us to return to a sense of safety in the aftermath of a threat, or we live in contexts where threats are unrelenting, the threat response cannot deactivate, and will manifest as anxiety and depression.

Michael Guilding                                                                                        

Notes

  1. American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association. p.356
  2. Porges, S. W. (2017) The Pocket Guide to the Polyvagal Theory; The Transformative Power of Feeling Safe, New York, WW Norton & Co Inc., pp. 53-56
  3. Porges, S. W. (2017)  pp.10-11.
  4. Levine, P. (2010).   In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness, Berkeley, North Atlantic Books.  pp. 47-50
  5. Sapolsky, R.M. (2004). Why Zebras don’t get Ulcers (3rd Ed.), New York, Holt Paperbacks.  pp.154-5. (When flight-fight is activated, the immune system increases activity for about 30 minutes then drops back to normal levels by about one hour.  If stress continues beyond this point, the immune system is impaired, compromising the ongoing defence of the body.) 
  6. Levine, P. (2010) p. 19-30, 54
  7. Sapolsky, R.M. (2004).  pp. 355-383
  8. Van der Kolk, B. (2014). The Body Keeps the Score. London, Allen Lane. p. 82
  9. This process is very clearly explained in Myhill, S. (2014).  Diagnosis and Treatment of Chronic Fatigue Syndrome. London, Hammersmith Health Books. pp. 20-24
  10. The biological system involved in sending and receiving signals of safety which enable us to engage with each other without activating defensive responses.  Porges, S. W. (2017)  p.26.
  11. Guilding, M. (2020). What is Complex Trauma?  Perspectives on Trauma. The Journal of the Complex Trauma Institute,Volume 1, Issue 1, pp. 3-18. 
  12. Porges, S. W. (2017)  p.12.
  13. Agazarian, Y.M. (2004). Systems Centered Therapy for Groups, London, Karnac.  p. 203. See also Levine, P. (2010) pp. 73-95. and Ogden, P., Minton, K., Pain, C. (2006)  Trauma and the Body:  A Sensorimotor Approach to Psychotherapy,  New York, WW Norton & Co Inc. pp.186-187
  14. Porges, S. W. (2017) pp.xv-xvi.

For a fuller account of the thinking behind this theory, see the article below:

Rethinking Depression as a Fear System response.  (June 2018)

Part 1:   Depression and Immobility.

What is depression, and what is happening in our bodies and our minds when we feel depressed?   These questions have puzzled me for many years working as a therapist, but over the past few years I have started to think that an answer may lie in understanding our Fear System, which evolved in the age-old struggle between prey and predator. 

My knowledge of the Fear System until a few years ago was confined to the well-known concepts of Fight, Flight and Freeze which are states of activation of the Sympathetic Nervous System.  My understanding was significantly deepened when I read Peter Levine’s book “In an Unspoken Voice” and learned that underlying Fight, Flight and Freeze was an older fear response involving physical collapse or immobility.    This led me to read Stephen Porges’ “Polyvagal Theory”.  Stephen Porges has clarified our understanding that the Parasympathetic Nervous System controls not just the body’s “rest and recovery” system but also its immobility response.   He was the first person to propose that the Vagus nerve, a key element of the Parasympathetic Nervous System, consisted of two separate branches, evolving many millions of years apart.  The old, or Dorsal Vagus, triggers sudden shutdown and collapse of the body, while the newer, or Ventral Vagus, linked directly to the heart’s pacemaker, brings the heart to its resting rate where the body can calm and recover.

The Immobility Response

We all have some acquaintance with the immobility response.   We know for example that when a cat catches a mouse, the mouse collapses as if dead, but if the cat’s attention wanders, the mouse can come back to life and escape at high speed.  I thought this was something strange that mice did!  I had not realized that the same mechanism could activate in me if I was unlucky enough to be attacked by a predatory animal or human.1

The biological mechanism behind this collapse, is the body’s most ancient Fear System response, the immobility response or “tonic immobility” (referring to the fact that muscles lose their tone or tension).   It evolved over 500 million years ago as a reaction to life-threatening danger and operates when all other ways of seeking safety have failed.   When it activates, the whole organism goes into shutdown. Heart rate and blood pressure drop, the major organs of the body slow down, and the brain releases numbing opioids into the bloodstream. The body goes into collapse and appears dead to a predator.  This de-activates the predator’s attack response and creates a possible window of opportunity for revival and escape. This collapse is the same mechanism as the vasovagal syncope more commonly known as fainting,2 though it does not necessarily lead to full loss of consciousness.

When the immobility response is triggered, the body is starved of oxygen and the cell respiration cycle, that generates the energy in each cell, slows down.   As the brain cells in our cortex slow down we lose the ability to think and we also lose the desire and the ability to relate to others, or care for others. As our muscle cells can no longer generate energy, our arms and legs lose their power and start to feel heavy as lead.  The gut can no longer process food (there can be loss of control of the bladder and bowels), and the other major organs start shutting down, as does our immune system.  

What does Immobility feel like?

What does that feel like when it’s happening to you?    Two years ago, I had a bout of food poisoning.  Sitting on the toilet after the dramatic onset of this condition early one morning, I suddenly felt faint and knew I’d fall over if I didn’t do anything.  I threw my dressing gown onto the floor tiles and collapsed onto it.   I then lay there unable to move a muscle.  My eyes were open, and I could see I was lying on the floor, but my mind, (constantly active during normal consciousness), was a complete blank, absolutely nothing happening.  I had no sense of time.  The parts of my bare legs that were on the cold tiles felt slightly different from the parts on my dressing gown, but they didn’t feel chilled.  Then, all of a sudden, something shifted – I just got up and went back to bed – checking my alarm clock I saw that I had been lying on the floor for around 30 minutes.

At the time, I just thought of this as a wave of extreme tiredness, but later I realized it was an immobility response – limbs feeling like lead, thinking process switched off, and a numbing of feeling which meant I could not properly feel the cold of the floor tiles.  I was puzzled at the time as I thought immobility was only triggered by fear, but I later found out that many other factors could trigger it.3

As a fear response, immobility is most often experienced when a sense of terror combines with the experience of being trapped (such as when the predator catches its prey).   This is the reason why rape so often triggers immobility. 4  A client of mine with a history of childhood sexual abuse described episodes when she suddenly felt nauseous, her legs went wobbly, and she feared she was going to faint.  She would collapse onto her bed and lie there for hours.   This terrified her as she thought she was crazy and despised herself for being so weak. She felt that her body was unreliable and lost confidence in being able to work or socialize.

After the food-poisoning incident, I became more sensitized to what immobility felt like.  My next encounter with it was less extreme, and happened in a group I was in, at a conference.  I made an intervention, which elicited an angry response from one of the other group members.  I experienced that response as shaming, a condition I now believe to involve the triggering of the immobility response.  

What I noticed was a slightly sickening “pulling downward” sense in my stomach, a general heaviness and postural collapse, and my head felt fogged and as if I was wading through treacle in my thinking.  After the initial shock of the angry response, I found I was not registering the words that were said to me and afterwards, in a calm state, I could no longer remember them with any clarity. 

A link between Immobility and Depression?

This incident, made me wonder whether an immobility response could be experienced with less intensity than a complete collapse.  The experience of shaming certainly felt to me like an immobility response, but it also felt like a depressive episode, and I started wondering whether depression and immobility were connected.   

I realized I had never been really clear about what depression was.  When I started to wonder if it could be an activation of the immobility response it made complete sense of so many aspects – the energy drain, drop in heart rate, numbing effect of the opioids, and the shutting down of cognition and social engagement.  

I’m jumping ahead here however, because the catalyst to me thinking about depression as an immobility response initially came from a thought I had that Peter Levine’s method of treating chronic trauma-based immobility was closely parallel to a method for working to alleviate depression which I had learned from Yvonne Agazarian.

Peter Levine works towards releasing his clients from trauma-induced immobility by helping them to notice the defensive impulses trapped in the limbs at the moment of collapse and encouraging them to complete these impulses – using imagination, but often physically, for example, placing a cushion on the floor in front of the client and encouraging them to make running movements with their legs. 5  His theory is that the immobility response experienced in trauma has become stuck in some people and needs an activation of the flight-fight impulse to reverse its effects.

Yvonne Agazarian worked with depression by trying to find out exactly when the client had become aware of a drop in mood, and then exploring what had been happening at that time.   Very frequently this would uncover a threat to the self, which involved a surge of the flight-fight reaction, which Yvonne Agazarian referred to as the “retaliatory impulse” – the urge to hit, to attack, to kill.   This had often been the trigger for the sudden drop in mood.  The aim of the therapeutic work was to help the client get in touch with their retaliatory impulses without becoming too alarmed by them, and to process these impulses, acting them out in the imagination.  This often resulted in the depression lifting. 6  

So it seemed to me that the same process was being used to unlock chronic immobility and also to unlock depression. Perhaps depression was an aspect of the immobility response?

Looking at Peter Levine’s account, and also at Stephen Porges’ Polyvagal Theory, on which Peter Levine relies, I found hints in their writing that they seemed to see this connection.    Peter Levine talked about chronically immobilized individuals who “go through the motions of living without really feeling vital and engaged in life” 7(which sounded to me a very good description of depression), and he listed depression as one of the core symptoms of trauma.  Stephen Porges noted that deficits in the regulation of the vagal brake on the heart were related to a variety of psychiatric disorders including depression.8 

Exploring Heart Rate 

Following this train of thought with a growing conviction that depression was an experience of the immobility response, but, at that time, lacking sufficient validation, I thought I’d investigate my own mood changes, so I got myself a Fitbit and a Polar chest heart-rate monitor and started to familiarize myself with my heart rate patterns, focusing on lowered heart rate as a symptom of immobility.

I had one minor result, which supported my hypothesis – lying on my bed with a resting heart rate in the mid 50’s, I experienced a moment of real despondency, and noted that my heart rate had dropped to 47 beats per minute.  However, on the whole, all I was able to notice were patches of mild low mood where I felt drained of energy, and normal daily tasks felt like hard work.   On those occasions I noted that my heart rate was at least 10 beats per minute higher than I would expect to be seeing for the same tasks.

These results, which conflicted with my focus on lowered heart rate, led to me shelving my theory about depression and immobility for some time, but my interest was sparked again some months later.    A client of mine, with whom I had discussed these ideas, noted his heart rate at the start of an episode of depression.  This client had a history of early emotional neglect and depression. A family incident that reminded him of the way he had been treated as a child triggered the sudden onset of low mood and he had to sit down to avoid feeling faint.  Our previous discussion prompted him to check his Fitbit, and he noted his heart rate had dropped to 48 beats per minute.  He reported that his resting heart rate was around 55-60 at the time, and even in sleep it never went below 50 beats per minute.   Perhaps there was a link between depression and the immobility response.

Resolving the problem of lowered and raised heart rates

I was still stuck with the problem of my low moods coinciding with a raised heart rate while other depressive episodes were associated with lowered heart rate.   However, I got some clarification when I started reading Robert Sapolsky’s book on stress “Why Zebras don’t get ulcers”.   Sapolsky discussed the complexity of depression and the contrasting symptoms of its various states, ranging from psychomotor retardation where the person moves and speaks slowly, can’t concentrate, and finds simple tasks exhausting, to a state where low mood and lack of energy go hand in hand with mental agitation, and high levels of stress hormones in the body.9 This matched what I was finding about raised and lowered heart rates in different stages of depressed mood.

At the same time, I had started to get interested in breathing and the way in which each in-breath prompts the sympathetic nervous system to raise the heart rate, and each out-breath prompts the parasympathetic nervous system to lower the heart rate.  A continual balanced process of accelerator and brake is operating on the heart, governed by each breath we take.   In this normal balance, the brake on the heart is provided by the newer ventral vagus.10

I wondered whether, in less severe depression, this normal balance is disrupted by a “mild” triggering of the older dorsal vagus (the immobility response).  If this puts a second brake on the heart, perhaps this prompts a stronger sympathetic nervous system reaction, in other words, the body raises the heart rate to counteract this additional brake.   I imagined that this might be like trying to drive off in your car with the handbrake on, which would mean that you have to accelerate harder than normal to get anywhere. Is this what was happening when I noticed that my mood and energy were both low, but that my heart rate was slightly raised?  

Conclusion

So, to summarize my hypothesis, I am suggesting that the underlying biology of depression may be the activation of tonic immobility.  However, while the immobility response normally reverses itself within a fairly brief timescale once the goal of survival is achieved, sometimes it gets stuck, and I am proposing that it is this prolonged experience of the physical impact of the immobility response that we are referring to when we talk of depression.

I am suggesting that it may be possible to think of different levels or stages of immobility shut-down.  A milder activation of this response may trigger compensatory activity from the sympathetic nervous system which raises heart rate, while a more powerful activation may disable the sympathetic response, lowering the heart rate. 

What are the implications of seeing depression as a manifestation of the body’s immobility response?  The popular stigmatizing misconception of depression sees it as something that is “just in your head” (and therefore can be “snapped out of”).    However, when we see it as a prolonged experience of tonic immobility, the ancient survival response which shuts down our metabolism by depriving all the cells of the body of the oxygen and glucose they need to function, then we understand it as an intensely physical and paralyzing “whole-body-and-mind” event. 

To think more clearly about the implications for how we work to alleviate depression, we need to see how tonic immobility and flight-fight operate together as our overall survival response which I am referring to as the Fear System. We also need to consider why the immobility response can become stuck, resulting in depression and what can be done to reverse this.              

Part 2: Depression and the Fear System which fails to switch off.

Having argued in Part 1 that Depression could be understood as the experience of a prolonged immobility response, I now want to look at the Fear System as a whole, consisting of the interrelation between flight-fight and immobility, so we can think about how these two very different responses work together to achieve the goal of survival, and also how the Fear System deactivates once this goal has been achieved.  I then want to look at what happens when the Fear System fails to deactivate, and how this relates to both anxiety and depression. 

The attack of a predator sends a prey animal into a high state of arousal – the sympathetic nervous system triggers the release of adrenaline and sends the heart rate shooting up.   The HPA axis 11 triggers the production of a series of hormones which release glucose, fatty acids and amino acids from the body’s storage cells into the bloodstream so the whole body has a boost of energy for sustained high levels of speed and strength.   This is the flight-fight response with which most people are familiar.  

How the Fear System switches off. 

If the prey out-runs the predator, it burns off all that energy in the escape, reaches a place of safety and rests. Muscles lose the tension of the chase, breathing deepens, activating the new (ventral) vagus nerve which brings the heart rate down, and receptors in the brain signal that stress hormone levels are now too high for the present state, so the HPA axis switches off.12 This is the Fear System “goal-correcting” – switching off when it is no longer needed so that it is ready to activate just as effectively the next time it is needed.       

If the prey fails to outrun the predator and is finally trapped, the heart rate peaks in terror, the old (dorsal) vagus nerve triggers a sudden drop in heart rate and blood pressure, and the prey collapses as if lifeless. However, the immobility response is a temporary state,13 and if the predator’s attention is diverted, the prey can revive, going straight back into a highly-aroused flight-fight state. If this enables it to escape, it burns off the energy boost, reaches a place of safety, and the Fear System switches off in the same way as if it had not been caught. 

Peter Levine provides a very interesting example of how the Fear System can deactivate after a trauma, writing of his own experience of being hit by a car. 14   In the immediate aftermath of this accident, the following elements were involved in this deactivation: 

First, he was helped to feel safe by a passing doctor who sat down beside him and held his hand.  Her presence calmed him and he felt himself come back into his body. 

Being calmed enabled him to shake and tremble – this is the body’s way of releasing the massive energy burst of the flight-fight response when we can’t burn it off by running or fighting.   

He then took deep spontaneous breaths – a shift from the shallow breathing of flight-fight to the deeper breathing, which stimulates the new vagus nerve to calm the heart. 

He then got in touch with his rage at the driver of the car – a further surge of flight-fight. 

Later he focused on the tension in his arms, which put him in touch with the movements his arms had been making as they had tried to protect him from the impact with the car windscreen and the road. This triggered a memory of the impact, followed by a feeling of relief.  

The whole process describes a move out of immobility and back into flight-fight, followed by a calming, then further waves of flight-fight followed again by relief and calming.  As a result, Peter Levine’s heart rate was close to normal even before the ambulance got him to the hospital. His Fear System had “goal-corrected”. 

What if the Fear System doesn’t switch off? 

If the Fear System fails to switch off, it remains active, responding with flight, fight, freeze 15 or immobility to any trigger or threat, however minor or unreal.  Like a barn door swinging in the wind without a latch to hold it, those with a history of severe trauma can oscillate between uncontrollable rage or panic, and physical collapse or severe depression.  Those, with less traumatic histories can oscillate between anxiety and low mood.  

There is a vivid example of this oscillation between flight-fight arousal and immobility collapse in Jeanette Winterson’s autobiography. She described what happened to her when she had a real setback when trying to trace her biological parents. She received a letter containing a cursory bureaucratic response to her application – “Applicant should fill in the usual form and refer back”.  

“I sat on the back step looking at it over and over again like someone who can’t read. My body was slight-shaking all over in the way that you do if you get caught in an electric fence.   I went into the kitchen, picked up a plate and threw it at the wall …’Applicant…usual form…refer back… It’s not a fucking credit card referral, you asshole.’ 

And what happened next makes me ashamed but I will force myself to write it: I wet myself.   I don’t know why or how. I know that I lost bladder control and that I sat down on the step soiled and wet and I couldn’t get up to clean myself and I cried in the way that you do when there is nothing but crying.” 16

Going back to the metaphor of the barn door swinging without a latch, how can we repair this so that the Fear System can activate in response to real threats, but ignore minor or unreal ones? The metaphor over-simplifies, as the actual process of deactivating the Fear System seems to be a complex multi-system affair, possibly requiring a variety of approaches. 

Why doesn’t the Fear System switch off? 

In the animal kingdom, the flight-fight response has either succeeded or failed within a brief period of time.  If activated for more than around an hour it becomes dysfunctional,17 undermining physical health and creating a huge energy drain that can lead to chronic fatigue.  It is a system of intense physical response to threat, which needs a physical discharge, but in humans it can be activated by thoughts predicting future dangers where no physical discharge is possible.

With Peter Levine’s account of his accident in mind I tried to think of the various inter-related systems that might be involved in switching off the fear response.  Linking this with learning from Robert Sapolsky, and a more recent explanation of Polyvagal Theory by Stephen Porges, the following sequence of ideas occurred to me: 

If there is no safe place to run to, or if the people looking after us following a trauma are themselves in a state of anger or fear, there is no calming.   

If there is no calming, tension in the body does not relax, so there can be no trembling or shaking to release the energy of the flight-fight response.   

If the energy is not released, it gets trapped in the muscles as chronic tension.  

If muscles are chronically tense it is impossible to breathe deeply.  

If we cannot breathe deeply we get into habitual shallow breathing, which keeps the sympathetic nervous system in a continuous state of dominance and prevents the parasympathetic system from lowering the heart rate.    

If the heart rate is not lowered, the stress hormone receptors in the brain will not signal that hormone production should cease.   

If stress hormone production continues for too long the sensitivity of the stress hormone receptors in the brain weakens so the feedback loop which deactivates the HPA axis fails. 18

If the Fear System is chronically on alert, the calming brake on the heart (the ventral vagus) is underused and its activity is chronically dampened.19  Thus the most important element in regulating the Fear System becomes ineffective. 

This has implications for how we might work with trauma, but to understand how such approaches tie in with the traditional therapeutic focus on the relationship with our clients we need to go back to Stephen Porges and his Polyvagal Theory.    The theory explains that we have three systems for defence against threat – Immobility, which evolved 500 million years ago, Flight/Fight (300 million years old) and Social Engagement (80 million years old).

The social engagement system involves a connection in the brainstem between the new (ventral) vagus, which calms the heart rate, and the nervous system controlling the muscles of the face, neck, throat and middle ear.20   When we meet with another human, see their face and hear the tone of their voice, our mirror neurons replicate the same “settings” in us, and link these to our ventral vagus.   If face and voice are friendly, the ventral vagus signals a calming of the heart, and following this the social engagement system in the cortex becomes fully active, and the attachment systems predominate over fear responses.   This is the biology underlying empathic attunement.

If the human face we see is aggressive, the ventral vagus withdraws its brake on the heart. Either flight-fight kicks in and the amygdala inhibits the social engagement system in the cortex, or immobility kicks in, and the cortex is shut down through lack of oxygen. Either way, the fear responses overwhelm the attachment systems.

Working with minor trauma, the friendly voice and face of the counsellor help to bring our clients out of fear and into safety where change becomes possible.  With complex or developmental trauma, the fear system cannot be so easily shut down as the body has “locked” into a hyper-alert setting through such things as chronic muscle tension, habitual shallow breathing, desensitised cortisol receptors and an underactive ventral vagus.   Such clients are beyond the reach of empathic attunement and cognition until their bodies have been helped to relax and unlock.

Many activities outside of counselling, such as regular physical exercise, yoga, meditation, and singing, repeatedly activate and thus strengthen the signal of the ventral vagus, enabling increasing regulation of fear system responses, but in addition to encouraging these activities, there is much we can do as therapists.   I want to pick out just three ways we might focus on the body when dealing with complex trauma and illustrate them with examples from my work with my clients. 

Example 1 – Creating safety in the body 

The client I referred to in Part 1 had a history of childhood sexual abuse and her frequent experiences of immobility, which could physically debilitate her for hours at a time, terrified her and made her feel that her body was weak and unreliable.  

Over the course of a couple of years the counselling room became a safe place for her, but I was unable to reduce her fear of her periodic collapses.   This changed once I understood the biology of the immobility system and was able to explain to her what was happening in her body when she collapsed and how it related to past trauma.  This made sense to her of these frightening symptoms and stopped her thinking she was crazy and that her body was unreliable. She still experiences periodic immobility, but it no longer terrifies her, and she has calmed to the point that we can now consider working directly with the abuse.

Example 2 – Helping to release chronic muscle tension  

My second client, who came to see me with anxiety and depression, had become a premature caregiver to her depressed father and complaining mother.  At the age of 12 years she had an accident where she was hit by a car.  At the roadside, she was attended by the driver of the car who was furious with her, and by a highly distressed teacher who had told her it had been safe to cross. 

She was not long married when she came to see me, and thoughts about possibly having a baby terrified her and made her miserable.    We used a Focusing-Oriented approach which gives slow attention to sensations in the body. I encouraged her to describe these sensations with no attempt to theorize or explain, simply noticing.   

Paying attention in this way to tensions in her calf muscle in the leg which had been injured in the accident, she then became aware of a sensation of tension around her right shoulder blade.  I encouraged her to focus on this sensation and describe it for several minutes. Suddenly there was an audible “crack”, and she reported the tension had gone from her shoulders. 21    Over the next few weeks her level of general anxiety dropped significantly, her mood improved, and she reported becoming able to state her own needs and establish boundaries with her parents.  Shortly afterwards, she became pregnant, and we finished our work just before the baby was due with her feeling positive and able to face becoming a mother.      

Example 3 – Completing the impulses of Flight-Fight 

My third client, with a history of developmental trauma, had been driven from her job by a bully, abandoned by her husband, and had to move to a different area and accept a job at a lower grade.  She wanted to get a job at her original grade, but whenever she applied she failed the interview as she went into collapse, feeling small and weak and simply unable to think.  Her present team at work was dominated by another bully, and she felt powerless to voice her opinions. 

I helped her to get in touch with her retaliatory impulses towards those who had mistreated her in the past. Shortly afterwards, frustrated in a team meeting, she imagined herself slapping the bully across the face.  The next moment she found she had spoken up and challenged the bully, survived the counter-attack and got most of the team on her side.

Further work on the retaliatory impulse helped her to focus on tension in her arms – she wanted to shake the first bully who had driven her out of her job and I encouraged her to imagine herself doing this.    Afterwards she reported she was much calmer and mentioned “shuddering” in bed before falling asleep at night – a discharge of the flight-fight energy.  She then managed two interviews without collapse and got a job at her original grade.  

Conclusion 

Where traumatic events are experienced without calm and empathic support in the immediate aftermath, or where they are unrelenting as in developmental trauma, the Fear System is activated, but is unable to shut down, leaving the person affected subject to the constant triggering of both flight-fight and immobility responses.   We readily understand anxiety as the constant triggering of flight-fight, and I am proposing that we now view depression as the prolonged triggering of the immobility response.   Trauma itself could be defined as a state in which the Fear System is unable to shut down, and the two most common symptoms of trauma, seemingly opposites, but intimately connected, are anxiety and depression. 

Michael Guilding             

Notes                                                                                      

  1. Volchan, E. et al. “Is there tonic immobility in humans? Biological evidence from victims of traumatic stress”,  Biological Psychology 88 (2011)13-19
  2. Gaynor, D and Egan, J. “Vasovagal Syncope (The Common Faint): What Clinicians Need to Know. The Irish Psychologist, May 2011, Volume 37, Issue 7, pp.176-179  (My thanks to Jonathan Egan for responding enthusiastically to my first thoughts on depression and giving me the confidence to pursue this idea).
  3. For example, Canli T. Reconceptualising major depression disorder as an infectious disease. Biology of Mood & Anxiety Disorders 2014; 4(10). DOI10.11.1186/2045-5380-4-10. Discussed by Jackson C.  Therapy Today February 2015 pp.8-9.  This is an interesting example of tonic immobility triggered by infection being interpreted as depression, with the conclusion then being drawn that depression was purely caused by infection and could not have psychological causes.  See also Gaynor and Egan (2011) above for further triggers of immobility.
  4. Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness,Berkeley, North Atlantic Books. pp. 58-59
  5. Levine, P. (2010) p.119
  6. Agazarian, Y.M. (2004). Systems Centered Therapy for Groups, London, Karnac.  p. 203
  7. Levine, P. (2010) p. 67
  8. Porges, S.W. (2011).  The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York, Norton. p. 239.     See also p.292, Fig. 19.1 where Depression is included as one of the outcomes of immobilization along with Shutdown, PTSD, low heart rate and low cortisol levels. More recently in Porges, S.W. (2017). The Pocket Guide to the Polyvagal Theory,New York, Norton. p. 11, depression is specifically linked to the activation of the dorsal vagus.
  9. Sapolsky, R.M. (2004). Why Zebras don’t get Ulcers (3rdEd.), New York, Holt Paperbacks. pp. 275-6
  10. Porges, S.W.(2011) pp. 31-32
  11. The interlinked systems of the hypothalamus, the pituitary gland and the adrenal glands
  12. Sapolsky, R.M. (2004). Why Zebras don’t get Ulcers (3rd Ed.), New York, Holt Paperbacks p.294 
  13. Levine, P. (2010) p.54 
  14. Levine, P. (2010)  Chapter 1 
  15. There has not been space in this paper to examine Freeze.  Levine, (2010) p.48 caused me considerable confusion for some time by equating Freeze with tonic immobility.   However, Le Doux, (Le Doux, J. 1998. The Emotional Brain.  The mysterious underpinnings of emotional life. New York, Touchstone pp.141-142) makes it clear that Freeze is a state of Sympathetic Nervous System arousal alongside Fight and Flight. Muscles in Freeze are tense, ready for mobilisation while in tonic immobility they are flaccid.  
  16. Winterson, J (2011), Why be happy when you could be normal?  London, Jonathan Cape, pp 188-189 
  17. Derived from Sapolsky, R.M. (2004). pp.154-5. When flight-fight is activated, the immune system increases activity for about 30 minutes then drops back to normal levels by about one hour.  If stress continues beyond this point, the immune system slows even further compromising the ongoing defence of the body. 
  18. Sapolsky, R.M. (2004). p.294 
  19. Kolacz, J. & Porges, S.W. “Chronic Diffuse Pain and Functional Gastrointestinal Disorders after Traumatic Stress: Pathophysiology through a Polyvagal Perspective”, Frontiers in Medicine, Vol. 5 (2018) 145 https://www.frontiersin.org/articles/10.3389/fmed.2018.00145 
  20. Porges, S.W. (2011).   pp. 55-56.
  21. The “crack” phenomenon was described by my client as being exactly the same as the crack she was familiar with when being manipulated by an osteopath.    Osteopaths understand this as nitrogen being released from fluid in the joints. It would appear that the focusing technique can result in a similar release of muscular tension.    In my practice so far, the audible crack has only happened twice, but the experience of tension release after focusing is common. As far as nitrogen is concerned, I wondered if this relates to the function of nitric oxide, an unstable molecule involved in signalling the dilation of blood vessels, which causes the sudden loss of blood pressure during tonic immobility.