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Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype
Open accessAbstract
In this article, the authors present evidence regarding a dissociative subtype of PTSD, with clinical and neurobiological features that can be distinguished from nondissociative PTSD. The dissociative subtype is characterized by overmodulation of affect, while the more common undermodulated type involves the predominance of reexperiencing and hyperarousal symptoms. This article focuses on the neural manifestations of the dissociative subtype in PTSD and compares it to those underlying the reexperiencing/hyperaroused subtype. A model that includes these two types of emotion dysregulation in PTSD is described. In this model, reexperiencing/hyperarousal reactivity is viewed as a form of emotion dysregulation that involves emotional undermodulation, mediated by failure of prefrontal inhibition of limbic regions. In contrast, the dissociative subtype of PTSD is described as a form of emotion dysregulation that involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions. Both types of modulation are involved in a dynamic interplay and lead to alternating symptom profiles in PTSD. These findings have important implications for treatment of PTSD, including the need to assess patients with PTSD for dissociative symptoms and to incorporate the treatment of dissociative symptoms into stage-oriented trauma treatment.
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“Specifically, when the prefrontal cortex is shutdown among individuals with classic PTSD, it can propagate an emotion under-modulation symptom profile, which includes hypervigilance and hyperarousal symptoms.”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“In response to trauma scripts, patients with the reexperiencing/hyperarousal response—as in PTSD—show decreased activation in anterior brain regions implicated in regulating arousal and emotion (ventromedial prefrontal cortex and rostral anterior cingulate cortex), decreased activation in the thalamus and occipital cortices, and increased activity in the amygdala and insula.53–58”
From Fear and the Defense Cascade (2015) · cites this paper as [56]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Building on this seminal work, Lanius et al. (2010) proposed a neurobiological model of PTSD-DS, characterized primarily by symptoms of derealization, depersonalization, and tonic hypoarousal that contrasted with the more typical symptoms of re-experiencing and hyperarousal that feature predominately in the majority of cases of PTSD.”
From A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions (2016) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Ultimately, this undermines the proposed neurobiological basis (e.g. Lanius et al., 2010; Terpou et al., 2019) of the defense cascade model and the dissociative subtype as a whole.”
From Trauma-related dissociation and the autonomic nervous system: a systematic literature review of psychophysiological correlates of dissociative experiencing in PTSD patients (2022) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“In addition to these core cognitive and affective symptoms, individuals with PTSD have shown unique neural signatures that overlap with key brain regions involved in the sensory transmission of incoming interoceptive and exteroceptive sensations, including the brainstem, the insula, and the prefrontal cortex (Lanius et al., 2010; Nicholson et al., 2015, 2017; Daniels et al., 2016; Sierk et al., 2”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measured
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“Moreover, in patients with the PTSD dissociative subtype, the prefrontal cortex is thought to play an inhibitory role on subcortical structures identified in the innate alarm system, including the amygdala and the periaqueductal gray, which contributes to an emotion over-modulation symptom profile, including depersonalization/derealization and emotional detachment behaviors (Lanius et al., 2010; N”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Here, we propose that sensory-based treatments may be an alternative mechanism that can bring online the prefrontal cortex, a key brain region for multisensory integration, emotion regulation and social cognition, which may be offline under certain conditions (Lanius et al., 2010; Aupperle et al., 2013).”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al., 2010
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
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“Lanius and colleagues have proposed a model of heightened prefrontal recruitment with associated dampening of amygdala-based threat responding [64].”
From Trauma, PTSD, and the Developing Brain (2017) · cites this paper as [64]
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“Similarly, greater activity in prefrontal cortex was associated with subjective feelings of dissociation (e.g., depersonalization/derealization) across various emotionally provocative tasks [147–149].”
From Treatment of dissociative identity disorder: leveraging neurobiology to optimize success (2024) · cites this paper as [147]
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“prior work indicates that individuals with the dissociative subtype of PTSD have greater activity in regions associated with “top-down” regulation (e.g., prefrontal cortex) and diminished activity in limbic regions (e.g., amygdala) when presented with emotionally provocative autobiographical trauma-related scripts [147,148].”
From Treatment of dissociative identity disorder: leveraging neurobiology to optimize success (2024) · cites this paper as [147]
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In the citing paper
“Thereby, dissociation can become maladaptive [10] and possibly interfere with treatment [46–50].”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
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“Dissociation can also develop in the aftermath of trauma and generalize across situations”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
The cited source says what the claim attributes to it.
In the citing paper
“Based on more recent neuroimaging findings in PTSD [10], Lanius and colleagues (2010) proposed a neurobiological model that distinguishes between two types of responses to traumatic reminders or other stressors: patients with a dissociative response type (D-PTSD) are thought to “over-modulate” their emotions, as opposed to patients who primarily suffer from re-experiencing symptoms”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
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In the citing paper
“Patients who reported a stronger increase of state dissociation (DSS) showed significantly lower amygdala reactivity to negative distractors [139], in line with aforementioned findings by Hazlett and colleagues [135] and theoretical models [10].”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
The cited source says what the claim attributes to it.
In the citing paper
“Dissociation may be a protective strategy to cope with overwhelming emotions in traumatic/stressful situations [1, 3, 10].”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
The cited source says what the claim attributes to it.
In the citing paper
“Pathological dissociation is a complex and heterogeneous phenomenon [2–4, 153], which has been closely linked to traumatic stress [1, 10].”
From Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder (2017) · cites this paper as [10]
The cited source says what the claim attributes to it.
In the citing paper
“Neurobiological studies of PTSD-DS continue to underscore the observation that depersonalization and derealization represent distinct responses from re-experiencing/hyperarousal reactivity in persons with PTSD (Lanius et al., 2010(Lanius et al., , 2012(Lanius et al., , 2006;;Nicholson et al., 2015).”
From A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions (2016) · cites this paper as Lanius et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“Specifically, whereas reliving responses are thought to be mediated by a failure of prefrontal inhibition or top-down control of limbic regions, depersonalization and derealization responses are thought to be mediated by increased prefrontal inhibition of limbic regions.”
From A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions (2016) · cites this paper as Lanius et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“this pattern of brain activity is similar to that seen in patients with the PTSD-DS during presentation of trauma-related scripts (Lanius et al., 2010(Lanius et al., , 2012(Lanius et al., , 2006)).”
From A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions (2016) · cites this paper as Lanius et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“Evidence of distinct patterns of neural activity (Frewen and Lanius, 2006;Lanius et al., 2010Lanius et al., , 2012) )”
From A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions (2016) · cites this paper as Lanius et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“Lanius et al. (2010) postulated that among individuals with the PTSD dissociative subtype, overactivation in the prefrontal cortex exerts top-down inhibitory effects on the amygdala, which is a key structure for emotion processing.”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al. (2010)
The cited source says what the claim attributes to it.
In the citing paper
“Interestingly, these patterns differ from previous studies conducted by our research group that suggest among individuals with the PTSD dissociative subtype, the prefrontal cortex exerts top-down inhibitory effects on emotional reactivity structures (Lanius et al., 2010; Nicholson et al., 2017).”
From How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD (2021) · cites this paper as Lanius et al., 2010
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“Neurobiological and clinical studies also support that PTSD has two main subtypes, re-experiencing type and dissociative type (Lanius et al. 2010, Swart et al. 2020).”
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What REBT Can Offer in a Trauma-Informed Therapy World
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“Research on dissociative PTSD also indicates that trauma-related dysregulation can involve both affective undermod - ulation and overmodulation (Lanius et al., 2010), processes that cannot be reduced to secondary evaluation alone.”
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Self-citationThe role of endocannabinoid function in posttraumatic stress disorder
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Dissociative Experiences in Psychiatric Inpatients
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“Dissociative subtypes have been proposed for psychiatric disorders such as PTSD [8] and schizophrenia [12,13].”
BackgroundThe relation between skin conductance responses and recovery from symptoms of PTSD
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Peritraumatic Dissociation and PTSD: a Shortcut to Neurodegeneration?
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“Patients in this group would present predominant dissociative manifestations of depersonalization and derealization and would develop poor prognosis characterized by more severe functional impairment and psychiatric comorbidities, greater suicidality and history of early and multiple trauma [10].”
BackgroundImpact van neuropsychologische klachten op de behandeling van de posttraumatische stressstoornis
de Haart, R., Nijdam, M. J., & Vermetten, E. H. G. J. M. (2019) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-2263-3_7 · Cited by 1
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Simple versus Complex Posttraumatic Stress Disorder
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Trauma- und stressorbezogene Störungen: Diagnostische Konzeptualisierung im DSM-5
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“…stress disorder (PTSD) has been conceptualized as a disorder of emotional regulation and includes two maladaptive pathways, the first pathway being overmodulation (i.e., avoidance/numbing) and the second pathway being undermodulation (i.e., reexperiencing, hyperarousal; Lanius et al., 2010).”
BackgroundFreyberger, H. J., & Stieglitz, R.-D. B. (2019) · Elsevier eBooks · doi:10.1016/b978-3-437-22485-0.00016-6 · Cited by 1
Posttraumatische Belastungsstörung
Priebe, K., Schmahl, C. G., & Stiglmayr, C. (2013) · Springer eBooks · doi:10.1007/978-3-642-35066-5_6 · Cited by 1
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A spontaneous dissociative episode during an EEG experiment
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“Early life exposure to trauma is often of an interpersonal nature, includes violation of one ‘s physical integrity and occurs during vulnerable periods of child’s development, often resulting in symptoms of post-traumatic stress disorder (PTSD) such as avoidance or numbing [27–29].”
The Role of Trauma in the Therapeutic Relationship
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“Clinical and neurobiological characteristics that distinguish between PTSD and PTSD-DS were described by Lanius et al. (2010).”
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Ten misconceptions: CBT for depersonalisation and derealisation
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“A review of this subtype (Lanius et al ., 2010) argues that depersonalisation serves as a protective mechanism against the emotional impact of trauma memories, resulting in an altered perception of reality and the self.”
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PTSD, appraisal, and coping among firefighters during a disaster scenario
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Réaction de défense et confrontation péritraumatique : intérêt d’une approche éthologique
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“, 2012; Guidano & Liotti, 1983; Liotti, 2004), pronounced deficits in memory and attention (Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008; Muller & Roberts, 2005), and transdiagnostic characteristics as the hallmark of the psychopathology (Abramowitz, McKay, & Storch, 2017; Dell & O'Neil, 2015; Kadak, Nasiroglu, B…”
Valdez, C. E., & Lilly, M. M. (2019) · Journal of Interpersonal Violence · doi:10.1177/0886260519829273 · Cited by 1
“…studies suggest there may be distinctive prefrontal cortical responses to trauma memories corresponding to different emotional reactions to distress that distinguish individuals with dissociative and nondissociative PTSD responses (Lanius et al., 2010; Lanius, Bluhm, Lanius, & Pain 2006).”
BackgroundTrauma Informed: The Intersection of Fear, Trauma, Aggression, and a Path to Healing
Moreland-Capuia, A. R. (2019) · Springer eBooks · doi:10.1007/978-3-030-19208-2_3 · Cited by 1
Ätiopathogenese und Neurobiologie
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“In dissociative cases, a reduced emotional experience presents as depersonalization and derealization in comparison with non-dissociative patients who exhibit hyperarousal experiences such as flashbacks [5].”
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Metadata
- Authors
- Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D.
- Affiliations
- Western University (CA)
- ORCID
- Venue
- American Journal of Psychiatry
- Published
- 2010-06-01
- Volume
- 167
- Issue
- 6
- Pages
- 640-647
- ISSN
- 0002-953X (ISSN-L)
- 1535-7228
- PMC
- PMC3226703
- OpenAlex
- W2124556602
- Cited by
- 1,123
- References
- 53
- Citations by year
- 2026: 61 · 2025: 74 · 2024: 64 · 2023: 67 · 2022: 69 · 2021: 74 · 2020: 71 · 2019: 61 · 2018: 84 · 2017: 84 · 2016: 71 · 2015: 66 · 2014: 86 · 2013: 57 · 2012: 74
- FWCI
- 8.63
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- AstraZeneca
- H. Lundbeck A/S
- National Institutes of Health (UL1TR000454)
- National Institute on Aging (P01AG018784)
- National Heart, Lung, and Blood Institute (R01HL088726)
- National Institute of Mental Health (R21MH080208, R01MH056120, R01MH047226, K24MH076955, T32MH067547, R01MH060556)
- National Cancer Institute (R01CA118567, R01CA061309, U01CA197282)
- National Center for Research Resources (S10RR016917)
- National Center for Advancing Translational Sciences
- National Center for Complementary and Integrative Health (RC1AT005733, P30AT005886)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- post-traumatic stress disorder, emotional dysregulation, re-experiencing, hyperarousal, limbic regions, dissociation, trauma treatment, symptom profiles
- MeSH terms
- Affect, Amygdala, Cerebral Cortex, Chronic Disease, Dissociative Disorders, Gyrus Cinguli, Humans, Magnetic Resonance Imaging, Memory Disorders, Neural Inhibition, Stress Disorders, Post-Traumatic
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