In his NY Times article “A Drug to Cure Fear,” Richard Friedman noted: “It has been an article of faith in neuroscience and psychiatry that, once formed, emotional memories are permanent.” This has not been a principle of these disciplines, including clinical psychology, for many years. Consolidation-reconsolidation-extinction models have been around for some time now, applied in particular to persons suffering from traumatic memories; e.g., Holocaust survivors, war and genocide survivors, etc. “Extinction” of memories creates room for new memories, that then inhibit overwhelming threat memories.
According to this thinking, retrieval of memories can render them labile and “disruptable,” because order for a memory to persist after retrieval it has to be re-consolidated – a point at which new experiences and information can – and will – be combined with the old memory and made into a new one.
I am currently working with Joe LeDoux, a prominent New York University neuroscientist who studies defensive survival neural circuits in mammals. Joe will quickly point out that he and his colleagues do not study fear or anxiety, since these are more complex emotions, involving autonoetic consciousness and working memory, etc. Joe sees anxiety as “the price humans pay for autonoetic consciousness.” He places conscious experience at the center of the science of anxiety. (Joe and I will be having a dialogue on the neuroscience and subjective phenomenology of severe fear and anxiety and their alleviation through psychotherapeutic approaches on Friday evening March 18th at NYU – if interested, contact me at [email protected] for further details of the meeting.)
Friedman refers to a popular psychotherapeutic approach to alleviating the intensity of trauma memories: exposure, and the problem of relapse upon re-exposure to trauma memories. In fact, in Joe’s lab, some researchers have advanced the efficacy of exposure therapy; e.g., when a researcher accidentally delayed the exposure trials (putting a longer delay between the first and second trial) they discovered an increased resilience to re-exposures.
In terms of avoidance, which many psychotherapists try to reduce so the person has a chance of disconfirming their fears, Joe’s lab actually found therapeutic value in what they termed “proactive avoidance.” This term describes “…behaviors and thoughts that directly engage with anxiety triggers in order to change, through learning, their impact and thereby help the organism exert control…This kind of strategy combines self-exposure to anxiety-provoking situations with strategies for gaining control over the trigger cues” (LeDoux 2015, p. 311).
In regard to Friedman’s reference to propranolol (a general beta-adrenergic blocker which can block the Beta-receptors in the heart, reducing the heart’s contractile force) used to enhance the efficacy of exposure therapy, LeDoux’s lab at NYU back in the 1990s (and at other labs) found that the synaptic plasticity underlying acquisition of the CS-UCS (conditioned stimulus-unconditioned stimulus) association by the amygdala in threat learning depends on a subtype of glutamate receptors, i.e., NMDA receptors. Glutamate is an excitatory amino acid. The most plentiful neurotransmitter in our brains, it involves what’s called the ionotropic signal transduction system and it has a much faster transmission velocity than dopamine, serotonin, etc. (metabotropic systems).
Glutamate is involved with learning, synaptic plasticity, etc., and Joe and his colleagues found that if you antagonized (block) these NMDA receptors in the lateral amygdala, threat conditioning is disrupted. Conversely, the use of a glutamatergic agonist (facilitator of the receptor activity), e.g., d-cycloserine (DCS) increased the intensity of the memory created by threat learning. In brief, DCS can facilitate in humans and mammals the process of extinction and exposure.
Cortisol, a stress hormone released by our adrenal cortex, given prior to exposure therapy, reduced subjective reports of anxiety. Cortisol seems to affect both explicit and implicit processing systems, consistent with the extent of its receptors in the neocortex as well as “limbic” subcortical (emotional brain processes, “under the hood”) structures.
Joe’s lab also found that blocking the neuromodulator orexin disrupted fear conditioning. Orexin in the locus coeruleus (a center for norepinephrine) facilitates the release of norepinephrine in the amygdala. Orexins are involved with anxiety, including panic disorder. Joe’s lab is also investigating other agents which can facilitate the extinction of overwhelming fear.
Friedman cogently notes that the use of stimulants, as is occurring in the military, can actually increase the intensity of the consolidation of trauma memories. He noted that they increase norepinephrine. He left out that these medications can, and do, reverse the action of the dopamine transporter (by activation of protein kinase C and calcium calmodulin kinase II resulting in phosphorylation of the dopamine transporter, DAT-these protein kinases are specifically linked to what are called “second chemical messenger systems” in our brain) leading to an excessive amount of dopamine in the synapse. They also are potent sympathomimetic agents (effects occurring not just in the brain, but in the sympathetic nervous system), similar to cocaine.
The dialogue between whether to use medications and other “biological” treatments or psychotherapy to alleviate severe anxieties has a very long history. Scott Stossel (2013) in his national bestselling book “My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind,” in a chapter entitled “Medication and the Meaning of Anxiety,” gives a very good account of the pros and cons of both approaches. He uses Walker Percy as an example of someone who eschews the use of drugs to treat human anxieties. In speaking of anxiety, Percy noted: “under one frame of reference a symptom to be gotten rid of, under the other, it may be a summons to an authentic existence, to be heeded at any cost” (p. 223, quoted in Stossel’s My Age of Anxiety).
Friedman is aware of the controversy surrounding the use of medications in the treatment of trauma. Do we really want to forget the memories of a genocide or collective trauma like 9/11 for example? Friedman noted that it’s not about erasure of memories, but more about reducing the intensity and overwhelm of trauma memories. From an evolutionary perspective, for example, anxiety as a signal could be life-saving.
Friedman concludes that these (and other objections to the use of medications for existential anxieties, and what Freud called the normal misery of everyday life, as opposed to the concept of “cosmetic psychopharmacology”) are good points, but so is the point of alleviating intense terror, panic and severe anxiety if it makes someone’s life better and reduces intense suffering. The question Joe LeDoux and I will be addressing, among other questions, will be how to increase the efficacy of psychotherapeutic approaches to the alleviation of these painful and overwhelming states of anxiety and panic.
Reconsolidation and extinction of the intensity of traumatic memories can be accomplished without the use of drugs. As previously noted, Joe’s lab found proactive avoidance to be particularly helpful. This can be usefully applied to people not just with PTSD, but also with severe social anxieties, etc. Just as the brain (or what I would say the MindBrain, a term used by neuroscientist Jaak Panksepp) can learn to be anxious, it can learn to reduce panic and anxiety.
Joe and I will be discussing ways of improving psychotherapy to facilitate the reduction of overwhelming fear and anxiety at our March 18th colloquium at NYU. Parenthetically, I think some of what Christopher (Kit) Bollas (2013) mentions in his book “Catch Them Before They Fall: The Psychoanalysis of Breakdown” fits in very nicely with current affective neuroscience and developmental psychobiology research on psychotherapeutic approaches to fear and anxiety.
For those interested in a recent update on what LeDoux’s lab has been discovering about anxiety, see the following youtube video:
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Bolas, Christopher (2013) “Catch Them Before They Fall: The Psychoanalysis of Breakdown. Routledge
Friedman, Richard, “A Drug to Cure Fear,” January 22, 2016; New York Times
Ledoux, Joseph (2015) “Anxious: Using the Brain to Understand and Treat Fear and Anxiety.” Viking
Stossel, Scott (2013) “My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind.” Vintage
Zarmbo, Alan “Pentagon study links prescription stimulants to military PTSD risk.” November 19, 2015, Los Angeles Times
Dear Dr Koehler, thank you for the stimulating Article.
I’m sure everyone’s different. I suffered with ‘High Anxiety’ on neuroleptic withdrawal almost to the point of madness. Solutions for me came from what
we’ve had in the world for the last 2, 000 years i.e. Buddhism (in different forms of basic psychotherapy).
There was no real drama attached to it, I just needed to see how my anxiety operated and then how to do something about it. This was how things were for me regardless of any life experience – my anxiety has now reduced to a reasonable level and remains like this.
“There was no real drama attached to it, I just needed to see how my anxiety operated and then how to do something about it.”
LOVE this statement, Fiachra–taking control of our emotional responses, learning our ‘self’–our own unique process–how we operate and how to self-soothe and come back to center. That is the essence of self-agency and self-healing. Beautiful! 🙂
I agree Fiachra. I find by developing mindfulness practice, it is possible to simply watch anxious thoughts arising and ceasing without proliferating them.
I think scientists do not understand the mind at all. Because brain activity is correlated with mental activity, science simply assumes that the brain should be thoroughly studied and treated. Although in very rare cases studying the brain may have some practical applications, in most cases, social and psychological interventions bring about natural structural changes in the brain (through neroplastic and epigenetic changes mechanisms).
I always like your posts because you make a lot of sense and you’re very reasonable at the same time. I do think that most of the “Psychiatric Problems we suffer from today” could be permanently solved with what’s been available all along.
Thanks Fiachra. I like your posts too.
Exactly! Not being anxious about anxiety (or any other emotion) appears to be the most important key to overcoming intense anxiety or “attacks.” Unfortunately, the current model perpetuates the opposite framing – anxiety is a problem, is THE problem, and STOPPING anxiety (or depression or paranoia) is the goal, rather than learning to observe the mind’s machinations from a safe distance and identifying the cause and the process by which the anxiety manifests and ultimately resolves.
Psychiatry’s labeling process is not only not helpful, it appears to be the exact opposite of what actually helps people come to terms with difficult emotions!
From the LINK below
“……As Chief Psychiatrist for the Eastern Health Board Ivor (Browne) tried to reform our mental health system but faced enormous opposition from those who couldn’t accept his unorthodox methods. He mistrusted traditional psychiatry’s dependence on drugs; “That there’s something wrong with the chemical constitution and you put something in to put it right.that’s gone right through the tradition of psychiatry and terrible damage has been done as a result….”
Thanks for this article. Thinking about the current “drug people into oblivion” policy of most US healthcare brings to mind the movie Equilibrium, which envisions a world in which it is a crime to feel. Here’s a look:
Psychiatrists ought to stop perceiving severe anxiety as a “disorder” and instead understand it as a signaling function, as indicating a deficit of self-soothing capacity which can be remedied by positive human relationships, or even as revealing a traumatic history and environmental situation so challenging that anxiety has lost its signaling function and become chronic terror. Of course, they will not do this because most psychiatrists are poorly trained in how to understand and help people in extreme states, and they are comfortable with profiting from seeing someone for 15 minutes and giving them a pill so that neither they nor the client has to wrestle with difficult emotions.
In his book, “The Infantile Psychotic Self”, Vamik Volkan wrote about how the signaling function of anxiety becomes lost in severe psychotic states of mind including those labeled “schizophrenia”. Following experiences like incest, war trauma, severe prolonged neglect, perception of hatred in one’s caretakers, sexual abuse, etc. a vulnerable person may experience profound “organismic (whole body) terror” to use Volkan’s terminology. This experience fragments the ego into part-selves including an infantile self-representation that constantly experiences overwhelming anxiety. It is truly a horrific state of mind to be trapped in (as I know from personal experience) and is surely one of the reasons why so many terrified psychotic people try to commit suicide.
But such terror is curable or reversible. With time talking to a supportive, containing external person, the terrifying memories can be exposed and seen in context so that they are no longer so overwhelming and scary. This allows a gradual reintegration of the part-selves and a “dissolving” of the infantile psychotic part-self that contains the original terror. From a biological standpoint, the amygdala and other brain structures orient themselves more realistically to the external world so that they no longer continuously generate terrifying emotions (based on terrifying memories) even in the absence of present-day repetitions of those experiences.
From a technical object-relations standpoint, in this healing process, the initially psychotic person is able to modify or mature archaic all-bad part-self/other images into more integrated whole self/other images, or at least to reach a position at which positive images outweigh the negative images (therapeutic symbiosis). At this point, the formerly psychotic or “schizophrenic” person is no longer psychotic, and can become essentially normal psychologically as long as he is able to develop and maintain the positive relationships and associated positive independent functioning.
In my own case I studied how these processes work and, starting from a severely terrified position, took specific steps to allow myself to make this progress in my therapy and my life. As I improved and felt safer, I could begin to internalize love and security from an external person for the first time, which further reduced, but never eliminated the anxiety.
I would add that another function of terror or overwhelming anxiety is to reject internalization of soothing or positive external human influences (new all-good internal objects). This is very important and poorly understood by most psychiatrists. People in chronic terror often cannot be calmed down or soothed by interactions with their fellow human beings, as most of us can. Their terrifying internal images of other people does not permit them to easily trust others; i.e. they expect others in the present to repeat traumas done to them in the past. In other words, they use projection and projective identification to constantly replay and recreate the traumatic world of the past in the present by not learning anything new about how people in the present are different than original caretakers in the past. Viewed from another lens, they constantly reenact an inversion of the normative developmental process – rather than take in good relationships and spit out bad relationships, they cling to bad relationships and reject good relationships.
This process must be interrupted and reversed if real learning is to take place and differentiation to occur in which the person can perceive that others in the present are in fact good and trustworthy. The person can then internalize all-good relationships to cover over the all-bad ones and eventually integrate the two polarities.
Obviously, the understandings I have described above are completely lacking from the minds of most psychiatrists. Their strategy of drugging people backfires because while it may reduce anxiety in the short-term, it does nothing to address the internal object relations situation of the terrified person, and it further communicates to the person that they are “mentally ill” – that their reaction of terror is not a normal reaction to an abnormal situation, but rather something wrong with them. This prevents any productive work or learning from getting done. Also, it often causes the psychiatrist to be viewed as an engulfing or abandoning all-bad figure. Therefore no modification of the closed internal system of the client is possible at all.
This situation is a large part of the reason why we have so many disabled “psychotic” people unable to work or love in America. Because no real effort is made to understand or help them modify their anxiety psychologically; rather, they are turned into zombies and told they are hopeless. Whereas, if the intensive psychotherapeutic strategies I am talking about were effectively applied to terrified and/or psychotic people at scale, most psychotic people could be cured and become functional citizens within several years. How sad that an advanced country like the USA has sunk to this pathetic level of service to its citizens…
“Do we really want to forget the memories of a genocide or collective trauma like 9/11 for example? Friedman noted that it’s not about erasure of memories, but more about reducing the intensity and overwhelm of trauma memories. From an evolutionary perspective, for example, anxiety as a signal could be life-saving.”
As a former New Yorker who was coerced in to taking drugs by an Illinois psychologist and psychiatrists who, according to their medical records, actually believed in 12/2001, that angst at 9/11 is a good rationale to drug a person. I agree with you, anxiety is sometimes appropriate, even life-saving. And I absolutely disagree with the psychiatric practitioners I dealt with, who claim to this day that disgust at 9/11 is “bipolar.”
Although, my psychologist also had an ulterior motive, which was to cover up the bullying, spiritual and sexual abuse of my children, perpetrated at the hands and other body parts of her pastor and friends. Which I didn’t learn until later, after reading her medical records, and after my child’s medical records with the evidence of the abuse were also handed over. I was in denial of the sexual abuse of my child when I was initially gas lighted by a pastor, board members of my children’s school, and doctors.
And since I have found seemingly most psychiatric practitioners today want to profit off of covering up child abuse (http://psychcentral.com/news/2006/06/13/child-abuse-can-cause-schizophrenia/18.html). Rather than actually help a mother or child abuse victim properly deal with such a crime, I’ve done the best I can to help my child heal. And I find this interesting:
“In fact, in Joe’s lab, some researchers have advanced the efficacy of exposure therapy; e.g., when a researcher accidentally delayed the exposure trials (putting a longer delay between the first and second trial) they discovered an increased resilience to re-exposures.
“In terms of avoidance, which many psychotherapists try to reduce so the person has a chance of disconfirming their fears, Joe’s lab actually found therapeutic value in what they termed ‘proactive avoidance.'”
Am I correct in understanding this to mean it is possible that the best way to help a child heal from child abuse is, of course, to stop the child abuse from happening as quickly as possible. Not even approach the subject in depth, in other words, not re-expose him to the feelings of trauma, until the child is more mature and able to mentally cope with such a betrayal. At which point, the ‘proactive avoidance’ should end. And in my family’s case, I recommended a lawyer to my child, who specialized in religious child abuse cover ups, when he was 18.
But found the following psychiatric theology is 100% incorrect, especially when dealing with a child abuse victim, who was 4 years old, at the time of abuse.
“It has been an article of faith in neuroscience and psychiatry that, once formed, emotional memories are permanent.” So today’s psychologists do absolutely know that they can profit off of drugging up a mother, to cover up child abuse for a pastor, and all the men and women working for the ELCA.
And indeed, the child will erase the memory of the abuse from his memory, by the time he is of legal age to sue. “This has not been a principle of these disciplines, including clinical psychology, for many years. Consolidation-reconsolidation-extinction models have been around for some time now, applied in particular to persons suffering from traumatic memories….”
I agree, what my subsequent pastor confessed was “the dirty little secret of the two original educated professions” is a deplorable little hobby of today’s psychiatric practitioners. And the two original educated professions should be ashamed of themselves, especially since it’s now known that 2/3’s of all so called “schizophrenics” today are child abuse or ACEs victims, likely turned into “schizophrenics” for profit, with the neuroleptic and psychiatric drugs.
The good news is love, and keeping my child away from psychiatric practitioners of all sorts, did allow him to heal largely. He went from remedial reading in first grade, to getting 100% on his state standardized tests in 8th grade. Which did shock his school social worker, who was quite persistent in wanting to get her hands on a well behaved and brilliant, young child. Apparently today’s school social workers want to drug all those outside the bell curve, even if in the upper end of the bell curve? Strikes me this is very unwise.
Although, it is a shame my ex-religion’s pastors, bishops and leaders are now nothing but a bunch of unrepentant child molestation cover uppers. Espousing Satan’s theology that “repentance is a work, thus unnecessary.”
Lots of interesting information in this article, thank you, Dr. Koehler.
One thing I discovered as I came off of a plethora of psych drugs after a number of years believing that I’d be dependent on them for life, is the my anxiety decreased tremendously as I allowed myself to actually embody my emotions, to actually be expressive, rather than always talking as though I were walking a tightrope–not too much expression in either direction, or you will tip the balance, so to speak, in the environment. Being myself in my real and authentic emotions was vital for relief in my body, mind, and heart from terrible and disabling anxiety.
It was actually rather a double bind at first, however: if I expressed my emotions authentically, I felt so much better and centered, as though I were being true to myself. Yet, in the mental health system, that was actually grounds for being blatantly stigmatized, if not diagnosed. At the very least, I felt as though some were embarrassed or uncomfortable by my emotions, and perhaps, that I should be, too. This was my experience as I was healing, the emotions that were finally being freed up were actually invalidated. This seemed like a cultural standard to me, got my attention big time.
As an actor, filmmaker, and musician, I can’t even imagine being uncomfortable in my emotions, and they range pretty wide. I found it impossible to be an expressive and spirited human being within the vicinity of the mental health world, without feeling somehow marginalized and ‘othered.’
Fortunately, that was not my dominant community, I’ve always belonged to a variety of communities, but the mental world and its drugging ways of zapping emotions (and creativity) as the means to suppress anxiety is what I really find to be utterly confounding and disheartening. I think there is an awesomely powerful and brilliantly creative world underneath all those drugs. I wish we could tap into it, rather than demean and repress it, for the sake of…I really don’t know what anymore. It’s just a dark age until we turn this around, imo.