Anxiety: What Is It And Do You Have It

Anxiety: What Is It And Do You Have it?

What is Anxiety?

There are as many definitions of anxiety as there are potential reasons to be anxious.  One definition of anxiety is that it is “A painful or apprehensive uneasiness of mind usually over an impending or anticipated ill. It is a fearful concern, marked by physiological symptoms, by doubt concerning the nature of the threat and by self-doubt concerning one’s capacity to cope with it.”

Another definition of anxiety is “ that it is a psychological, physiological, and behavioral state induced in animals and humans by a threat to well-being or survival, either actual or potential. It is characterized by increased arousal, expectancy, autonomic and neuroendocrine activation, and specific behavior patterns. The function of these changes is to facilitate coping with an adverse or unexpected situation. Pathological anxiety interferes with the ability to cope successfully with life challenges.”

Some common symptoms associated with anxiety include:

  • panicky feelings
  • racing heart and chest discomfort
  • dizziness or light-headedness
  • feelings of bewilderment and unreality
  • scary, uncontrollable thoughts
  • nausea, upset stomach, diarrhea
  • hot and cold flashes
  • numbness or strange aches and pains,
  • muscle tension
  • feelings of depression and hopelessness

Common worries people with anxiety have include the following:

  • having a heart attack
  • going insane
  • losing control
  • embarrassment
  • death
  • illness
  • hurting themselves or someone else
  • fainting
  • difficulty breathing

The Neurobiology of Anxiety

The following describes what happens in the brain and the body when a person experiences anxiety.  The experience of anxiety primarily arises from the limbic system of the brain (often called the emotional brain). In simple terms, the limbic system is comprised of the thalamus, the hypothalamus, the hippocampus and the amygdala.  Each part of the limbic system plays a role in generating anxiety, but it begins in the thalamus which is a relay station for incoming information about the external world. The thalamus takes information from our senses (sight, sound, touch, taste, and smell) and assesses it for possible danger.  This information then travels through the brain down what is often referred to metaphorically as either the low road or the high road.

The low road refers to circuitry involving the amygdala which is the early warning or alarm station of the brain.  This part of the brain operates unconsciously.  It is an automatic response to what is perceived as immediate danger. The high road circuitry involves another part of the brain referred to as the cortex, the part of the brain that is needed for conscious thought, the formulation of ideas and the attribution of meaning.  The part of the cortex which is significant to anxiety is the prefrontal cortex which processes information, maintains conscious attention, forms behavioral responses and makes meaning of sensory experience.

When danger is perceived by either road, the brain mobilizes its response to the stress.  This response is often described as “fight, flight or freeze”.  It involves the hypothalamus-pituitary-adrenal (HPA) axis which is the brain system that initiates the stress response to prepare the body to respond to a stressor. The hypothalamus initiates the response by releasing a peptide called corticotropin release factor to the pituitary gland.  The pituitary in turn releases adrenocorticotropin to the adrenal gland which releases adrenalin and cortisol.  The HPA axis starts the sympathetic nervous system arousal which results in increased heart rate and respiration and the redirection of blood flow.  This response also uses up neurochemicals such as serotonin, dopamine and norepinephrine.

Thus when the stress response is initiated, it causes changes in neurochemicals, breathing, blood flow and motor responses.  These responses are meant to be short-term reactions to danger in the environment, but they can be initiated not only by actual dangers but also by thoughts of danger and particularly thoughts that have been associated with danger in the past.  When an experience has been associated with danger in the past, even the anticipation or thought of that experience can trigger the stress responses described above.  One of the greatest factors determining whether a stress response will be initiated is the meaning attributed to the potentially threatening experience.  When stressors (be they internal or external) are constant, the stress response described above functions continuously and anxiety results.

An Anxiety Self Test

If you are curious about whether you may be experiencing anxiety, take this quick self test.

1. Are you troubled by the following?

Repeated, unexpected panic attacks during which you suddenly are overcome by intense fear or discomfort for no apparent reason; or the fear of having another panic attack
Yes / No

Persistent, inappropriate thoughts, impulses, or images that you can’t get out of your mind (such as a preoccupation with germs, worry about the order of things, or aggressive or sexual impulses)
Yes \ No

Powerful and ongoing fear of social situations involving unfamiliar people
Yes \ No

Excessive worrying (for at least six months) about events or activities
Yes \ No

Fear of places or situations where getting help or escape might be difficult, such as in a crowd or on a bridge
Yes / No

Shortness of breath or a racing heart for no apparent reason
Yes / No

Persistent and unreasonable fear of an object or situation, such as flying, heights, animals, blood, etc.
Yes No

Inability to travel alone
Yes No

Spending more than one hour a day doing repetitive actions (hand washing, checking, counting, etc.)
Yes / No

Experience or witnessing a traumatic life-threatening or deadly event or serious injury (such as military combat, violent crime, or serious accident)
Yes / No

2. More days than not, do you experience the following?

Feeling restless
Yes / No

Feeling easily tired or distracted
Yes / No

Feeling irritable
Yes / No

Tense muscles or problems sleeping
Yes / No

Your anxiety interfering with your daily life
Yes / No

3. Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Depression and substance abuse are among the conditions that occasionally complicate anxiety disorders.

In the last year have you experienced changes in sleeping or eating habits?
Yes / No

More days than not, do you feel sad or depressed?
Yes / No

More days than not, do you feel disinterested in life?
Yes / No

More days than not, do you feel worthless or guilty?
Yes / No

4. During the last year, has the use of alcohol or drugs…

Resulted in your failure to fulfill responsibilities with work, school, or family?
Yes / No

Placed you in a dangerous situation, such as driving a car under the influence?
Yes / No

Gotten you arrested?
Yes / No

Continued despite causing problems for you or your loved ones?
Yes / No


The more times you answered yes on the anxiety disorder quiz, the more likely it is you may suffer from an anxiety disorder.

Sections one and two of the anxiety disorder test above are designed to indicate an anxiety disorder, while sections three and four screen for conditions that may complicate anxiety disorders – such as depression or substance use.

When Panic Attacks: What To Do About It

When Panic Attacks: What To Do About It

What is a Panic Attack?

A panic attack is a sudden, intense, often mounting, surge of physiological arousal, largely caused by an increase in adrenaline and cortisol, that is initiated sometimes seemingly out of no where or by an internal or external stimulus which in reality is not dangerous or life threatening — though it may feel so to the person experiencing it.  A panic attack usually develops abruptly and reaches a peak within about ten minutes.  Most panic attacks subside within thirty minutes and rarely last more than an hour.

A panic attack is an extremely uncomfortable and overwhelming experience which has physical and psychological symptoms.  Common physical symptoms associated with panic attacks include heart palpitations, shortness of breath, tightening in the chest or throat, hot or cold flashes, dizziness, faintness, nausea, sweating, shaking, and tingling in the hands and feet.  Common psychological symptoms include feelings of unreality, an intense desire to run away, and fears of going crazy, dying or losing control.

It is such an unpleasant experience that a first panic attack often leaves a person with a strong anticipatory sense of anxiety about the possibility of a recurrence.  Sometimes people only experience one such attack in a lifetime, while others develop a chronic condition involving several attacks a week.

How to Manage Panic Attacks

The good news is that panic attacks can be managed.  Lifestyle choices can make a difference.  Living a lifestyle which involves a regular practice of relaxation of some kind (e.g., meditation), having a regular exercise regime that involves increased cardiovascular activity, eliminating stimulants from your diet (e.g., caffeine), and developing habits of thinking that are calmer and more accepting towards yourself and life, all make a difference.

In addition to these lifestyle choices, there are several strategies and techniques which can be employed to help control panic attacks.  One such strategy is to use your mind in the midst of a panic attack to deflate the sense of danger you experience and to soothe yourself with comforting thoughts.  During a panic attack it is really common for a person to think catastrophically, i.e., to add to the physical sensations they are experiencing by thinking scary thoughts such as “I am going to die, or go crazy or faint or lose control somehow”.  The very definition of a panic attack is that it involves fear without real threat or danger.  If you can use your mind to talk yourself through a panic attack by saying things to yourself such as “This is just a panic attack”,  “I am not really in danger or at risk”, “The sensations I am experiencing are unpleasant, but not dangerous”,  “This will pass ” and so on, you will be calming yourself down and you will not be fueling the unpleasant sensations with your thoughts.

A related technique is simply stick with the physical sensations that you are experiencing moment-by-moment.  You do this by giving them a name or a label such as “tightness in chest” or “sweaty palms”, or “upset stomach”.  This technique does two things: it keeps your mind occupied and not catastrophizing, and it reminds you that all an anxiety attack is is a series of highly unpleasant sensations.

Another technique is to accept and not fight against the symptoms you are experiencing.  This involves cultivating an attitude that is tolerant of the sensations and encouraging of yourself.  You don’t tense against the sensations, you simply feel them.  You say to yourself things like “I am okay”, “I can handle this”,  “This is familiar and I have gotten through it before”,  and “This will end soon; it always does”.  The idea is to be a watchful observer of yourself and your physical sensations and a compassionate coach to yourself.

Yet another technique to manage panic attacks is to teach yourself how to identify the very early stages of a anxiety and learn to intervene before it becomes full blown.  This is different from fighting against a panic attack that is already full blown.  It involves knowing and catching your own idiosyncratic early warning signs of anxiety.  If you can identify the early stages of the anxiety response, you may be able to take action to calm yourself down.  Examples of taking action include:

  • using various breathing techniques to stimulate your parasympathetic nervous system (sometimes referred to as the “relax response”),
  • engaging in physical activity to burn off the cortisol and adrenaline,
  • retreating temporarily from the anxiety-inducing circumstances until you feel that your anxiety is under control,
  • confiding in a supportive person that you are feeling anxious,
  • using various grounding techniques to keep yourself oriented to the present, such as using all of your senses to take in your immediate environment,
  • engaging in an activity that is either soothing (like taking a bath) or requires focused attention (like reading a book),
  • seeking something either pleasurable (like good food) or comforting (like a hug),
  • replacing anxious thoughts with supportive, calming thoughts, and
  • practicing muscle relaxation techniques

The Neuro-Physiology of Panic Attacks

The Neuro-Physiology of Panic Attacks

The Brain’s “Alarm Central”

Our brains are organized to ensure our survival.  The human brain is often conceptualized to comprise three parts: the oldest part, the reptilian brain (found in the brain stem), the mid-section, the mammalian brain (limbic system), and the most recently evolved part, the rational or cognitive brain (pre-frontal cortex).

When the brain’s alarm system is turned on, stress chemicals (adrenaline and cortisol) are secreted and the two older sections of the brain (together often referred to as the the emotional brain) take over and shut down parts of the more recently evolved prefrontal cortex.  The body is then compelled to run, hide, fight or freeze in response to the perceived threat.  The job of the emotional brain is to set in motion these pre-programmed escape/safety plans in order to keep you safe.  The muscular and physiological responses associated with these safety plans are automatic.  They do not require any thought or planning on your part.  They just happen.

A key part of the emotional brain is called the amygdala.  It can be thought of as the “alarm central” of the brain.  When threat is perceived by a person, the amygdala sends signals to other parts of the emotional brain to initiate the stress hormone system and the autonomic nervous system (ANS) to orchestrate a whole-body response to what is perceived as a threat to survival.  The stress hormones (adrenaline and cortisol) increase heart rate, blood pressure and rate of breathing to prepare you to respond to the threat.

When someone is having a panic attack all of these responses kick into play.  It doesn’t matter that there may be no “real threat”, a perceived threat is enough to set in motion the neuro-physiology described above.  Part of learning how to manage a panic attack involves developing the capacity to re-engage the pre-frontal cortex to assuage the emotional brain.  This will be discussed in a future post.

Complex Post Traumatic Stress: Working With The Body

Complex Post Traumatic Stress: Working With The Body


Psychological trauma is a biophysical experience, that is, it takes a toll on a person’s body as well as on a person’s mind. For this reason, understanding how a person’s mind and body respond to, remember and relive traumatic psychological experiences is crucial for understanding and treating trauma. Much has been written on the question of how the mind is impacted by psychological trauma. This blog post focuses on how the body is impacted and how to intervene directly at the level of the body.

Memories that are stored in a person’s body are referred to as “somatic memories”.  In order to understand somatic memories it is necessary to first understand a bit about the sensory system and memory in general. All memory begins with sensory input through the senses one uses to perceive one’s internal and external environments. The external environment is perceived through the eyes, ears, tongue, nose and skin. The internal environment is perceived through the nerves that receive and transmit information from the viscera, muscles and connective tissue. The former is referred to as the exteroceptive system and the latter is referred to as the interoceptive system.  Thus, exteroceptors are nerves that receive and transmit information from outside the body, and interoceptors are nerves that receive and transmit information from inside the body.

We use our interoceptors to register an internal sense of the state of the body.  We may note our heart rate, respiration, the presence or absence of pain, internal temperature, visceral sensations and/or muscle tension.  This internal sense helps us to identify and name our emotions.  Each basic emotion has it’s own distinctive set of body sensations.

One of the hallmarks of CPTSD is persistent physiological dysregulation.  Some examples of this include chronic pain, sensory distortions, involuntary movements, numbing, disconnection from one’s body, loss of pain perception and the inability to feel the sensations associated with or to identity emotions in the body.  In addition, CPTSD sufferers often experience chronic, heightened sympathetic nervous system arousal, including rapid heart rate, constricted breathing and muscle tension.  As a result, many are stuck in fight/flight/freeze/fawn mode and thus lack the capacity to access cortical resources (the part of the brain that affords us executive decision making functions and greater self awareness).

Working directly with the body (rather than with the client’s narrative) in the ways described below, can circumvent the need for the client to tell their story which can sometimes be re-traumatizing.  The goals of somatic (bodily) interventions are to assist clients to learn how to regulate sympathetic nervous system arousal, reorganize self protective defenses, (re)activate the social engagement system, distinguish that past experience is in the past and not the present, develop new and more adaptive postures and physical action patterns, discriminate between an actual traumatic event and one that is merely reminiscent of a traumatic event and reorganize rather than relive past experience.

To meet the goals described above using a body oriented approach, the counsellor:

  • Helps the client make connections between particular body postures, internal sensations and accompanying thoughts, beliefs and emotions,
  • Models and teaches skills associated with regulating levels of nervous system arousal,
  • Encourages awareness of the interaction of thoughts, feelings, body sensation, perceptions and movement impulses associated with traumatic experiences,
  • Facilitates the completion of frozen or truncated impulses to act in self defense,
  • Assists the client to orient their awareness to the present rather than the past,
  • Helps clients to stay with and just notice (rather than dissociate from) physical sensations, and
  • Co-attunes to and mirrors postures and physical actions and encourages alternative postures and actions that challenge habitual trauma-related reactions

An Integrated Approach to Complex Post Traumatic Stress Disorder (CPTSD)

An Integrated Attachment Oriented and Cognitive Behavioral Therapy Approach to Complex Post Traumatic Stress Disorder (CPTSD)


This post reviews how an integrated Attachment and Cognitive Behavioral Therapy (CBT) approach can be used to treat common symptoms associated with Complex Post Traumatic Stress Disorder (CPTSD).  (For an overview of complex post traumatic stress disorder, please see my previous post, “An Overview of Complex Post Traumatic Stress Disorder”.  Much of the material in this post involves adaptations to CBT and an Attachment Oriented Approach based on my clinical experience.

CBT focuses on thoughts, behaviors and emotions and seeks to revise them through critical analysis and experiential exploration to be more in keeping with those that have been identified as beneficial by the client.  CBT presumes that with the assistance of a therapist, a person can effect change for the better through careful examination of their thought, feeling and behavioral habits.

An Attachment Oriented Approach involves creating a reparative relationship between the client and the therapist such that secure attachment is encouraged in the client.  The relationship with the therapist is thought to be particularly important in an Attachment Oriented Approach when dealing with CPTSD as the trauma is generally an interpersonal one.  In other words and as explained in my previous post, people suffering from CPTSD have generally been neglected, betrayed, or abused by others who are known to them and who were often in caretaker roles.  An Attachment Oriented Approach seeks to help a person develop a relationship with a therapist in which s/he feel safe, is able to identify, examine and redefine core beliefs and  explore her/himself in the world in new, freer and healthier ways.

When using these methods to treat CPTSD it is critical for the therapist to help clients to understand that symptoms and habits are adaptations and the result of traumatic experiences and not inherent character flaws.  This helps to assuage the sense of shame that is often experienced by people suffering from CPTSD.   This also helps to engender a sense of hope and empowerment that their suffering is neither inevitable nor their fault.

Some other symptoms common to CPTSD include emotional dysregulation, relational difficulties, increased sympathetic nervous system arousal, emotional flashbacks, dissociative tendencies and being harshly self critical.  Emotional dysregulation refers in part to difficulties associated with identifying, expressing, tolerating and soothing negative mood states.  These methods seek to assist clients to learn the skills noted above to regulate affect both on their own and with the help of caring and compassionate other.  Both skills are important and the capacity of a person to regulate affect inter-actively (with the assistance of another) may well be compromised as CPTSD suffers may not have had trustworthy, capable others with whom to learn this skill.

CBT is used to assist clients learn to identify what they are feeling and then to identify the thoughts associated with the feeling.  It is common for people with CPTSD to think that they are “bad” for feeling difficult feelings like sadness, grief and anger as they may not have been permitted to have such feelings by their caregivers.  CPTSD sufferers thus deny these feelings.  This leads to shame and dysregulation.  When feelings can be identified, expressed, tolerated, soothed (both through self-regulation and interpersonal regulation) and not thought of as “bad”, a person becomes more emotionally regulated.

Relational difficulties involve not being able to trust others or trusting too readily, having a hard time setting healthy boundaries, and having a so-called “insecure” attachment style. (For an explanation of insecure attachment styles please see my post on “Attachment Theory and Clinical Counselling Practice”.   Using these two methods, the therapist seeks to explore with the client their assumptions, behaviors, thoughts, feelings and history with respect to trusting others as well as whether and when they were permitted to establish boundaries in their families of origin.

Boundary work is key to healing CPTSD.  This is because sufferers have likely had many experiences of boundary violations and may not have reasonable expectations about how they should be treated.  Historical habits regarding boundary setting as well as the relational results are explored.  This exploration leads to insight and awareness and the possibility of doing things differently in the present.  Moreover, the therapist seeks to be trustworthy and to model healthy boundaries to give the client a felt experience of what it is like to safely be able to count on someone.

Clients with CPTSD have often been chronically over aroused, i.e., their sympathetic nervous systems have been on overdrive as they have had repeated experiences of not being safe.  Sometimes the state of nervous system over arousal, can become so habitual that it becomes a trait.  Therapy for CPTSD thus involves teaching clients to identify and manage nervous system over arousal.  This typically involves breathing exercises to stimulate the para sympathetic branch of the nervous system which is the relax response and can be thought of as the brakes on the sympathetic branch of the nervous system.  In addition, clients with CPTSD often over use certain strategies (to the exclusion of other more adaptive strategies) related to the fight/flight/freeze/fawn response.  It is important to help clients gain insight into these habitual behaviors and to expand their repertoire of strategies related to managing threat.

CPTSD sufferers often experience emotional flashbacks.  This is when something in the present triggers memories from the past such that a person experiences feeling states from the past which may be out of proportion or incongruous to the present.  When in the midst of an emotional flashback a person often feels small, helpless, hopeless worthless and utterly overwhelmed.  (For a thorough explanation of how to soothe emotional flashbacks, please see my post on CPTSD and emotional flashbacks.)  CBT methods help a person use their thoughts to recognize that they are actually in the present and not in the past, that they have far more resources at their disposal than they did when the original trauma(s) occurred and that they are actually lovable despite not having been well treated historically.

When CPTSD sufferers are emotionally over whelmed it is not uncommon for them to dissociate.  This involves “splitting off” and “compartmentalizing” feelings and awareness of the events that precipitated them, as these things are too upsetting to integrate into ordinary consciousness.  Attachment Oriented methods encourage the acceptance, exploration and integration of upsetting feelings and experiences by allowing them to be processed with a skilled other with whom the client feels safe enough to tolerate that which was historically off limits.

Children who are neglected or abused can’t fathom that their caregivers are inadequate, neglectful or abusive.  They are utterly dependent and have no choice but to adapt to their circumstances.  They believe that they must deserve the treatment that they are receiving.  It is common for the children who become adults with CPTSD to try to be perfect to get the love and nurturing that they crave from their caregivers.  As part of this process, they internalize the messages that they get from their caregivers and become harshly critical of themselves.  CBT aims to identify and revise these self criticisms and negative core beliefs through various methods including “thought substitution”.  Attachment Oriented methods encourage the capacity to be loving and compassionate to oneself.

If you believe you may be suffering from CPTSD and would like assistance, please feel free to fill out the contact form below.

An Overview of Complex Post Traumatic Stress Disorder (CPTSD)

An Overview of Complex Post Traumatic Stress Disorder

Complex post traumatic stress disorder (CPTSD), also known as developmental trauma or complex trauma, is a term that has been proposed to capture a constellation of symptoms which result from the stress associated with chronic neglect or abuse during childhood. This neglect/abuse occurs in the context of interpersonal dependence (which childhood is by definition) and particularly during significant periods of emotional and intellectual development. Interpersonal dependence refers to the qualities of being captive (having no viable escape or alternative) and of being reliant upon those who are mistreating you. The phenomenon of CPTSD is well researched but has not yet become an official diagnosis in the Diagnostic and Statistical Manual (DSM).

CPTSD may develop in situations of chronic maltreatment by one’s own parents (or other caregivers e.g., foster parents or other relatives) or other situations wherein children are trapped or incarcerated for prolonged periods of time such as Indian residential schools, concentration camps or some religious cults. As mentioned above, in addition to having no viable escape (and thus having no choice but to adapt to the circumstances), children who become adult sufferers of CPTSD tend to have been exposed to repetitive or prolonged situations involving neglect or abuse (emotional, physical, and/or sexual) which took place during critical periods of emotional and physical development. Moreover, the perpetrators of the neglect/abuse are generally the very people who were supposed to be meeting the child’s practical, emotional and intellectual needs.

Because the roots of CPTSD extend back to developmentally significant periods of time, emotional, intellectual and social development can be truncated or distorted and core aspects of a person’s functioning may be affected (sometimes severely).

Areas of functioning that may be affected include:

1. affect regulation (the ability to control feelings and mood states and to modulate levels of stress)
2. attention
3. memory/consciousness
4. self perception
5. perceptions of the perpetrator(s)
6. interpersonal relationships
7. systems of meaning

There are multiple symptoms associated with each of the areas noted above. The following is a brief description of some of them. Not all CPTSD sufferers experience all of these symptoms or to the same degree.

Difficulties with affect regulation can include persistent or episodic dysphoria (depression), suicidal preoccupation, hyper-arousal, hyper-vigilance, intense or inhibited anger and the inability to be playful or to experience pleasure or joy. Alterations in attention can involve ADD/ADHD like symptoms, chronic busyness, difficulties focusing or concentrating, and preoccupation with the past or the future and difficulty being in the present. Problems with memory/consciousness include dissociation, amnesia, depersonalization/derealization and reliving experiences through flashbacks or ruminative preoccupation.

Difficulties with self-perception include a chronic sense of helplessness or paralysis of initiative, feelings of shame/guilt/self-blame, a sense of fundamental brokenness, defilement or stigma, a feeling of being inherently different from others, a tendency to be harshly self critical and self abandonment (a tendency to neglect ones own feelings and needs). Alterations in perception of the perpetrator include a preoccupation with the relationship, unrealistic attributions of power to the perpetrator, idealization or misplaced gratitude, a belief in a special relationship with the perpetrator, and an acceptance of the belief system of the perpetrator. Problems with relationships with others can include a tendency toward isolation and withdrawal, difficulties forming lasting intimate relationships, a repeated searching for a rescuer, persistent mistrust of others, intense social anxiety and repeated failures of self-protection. Alterations in systems of meaning can involve the loss of a sustaining faith or belief in anything and a sense of hopelessness or despair.

In his book “Complex PTSD: From Surviving to Thriving”, Pete Walker writes that CPTSD is most easily distinguished from PTSD through identification of five of its most common symptoms: emotional flashbacks, toxic shame, self abandonment, a “viscous” inner critic and the experience of social anxiety (p.3.). Each of these is described below.

Emotional flashbacks involve the experience of regressing to the former feeling states of having been an abandoned, neglected or abused child. A flashback is usually triggered by something in the present which is reminiscent of the past that takes a person back to the overwhelming feeling states of the past in which they generally felt helpless and hopeless. During a flashback, a person often feels highly and inexplicably anxious as the fight/flight instincts are aroused via activation of the sympathetic nervous system. The emotional content of flashbacks generally involves overwhelming feelings such as fear, alienation, despair, depression and grief. Flashbacks range in intensity from mild to extreme and range in duration from seconds to weeks. Typically during a flashback a person feels small, fragile, helpless and afraid. It is not uncommon for flashbacks to bring up a feeling of toxic shame. This is the sense that one is not alright, i.e., that they are fatally flawed, inadequate, bad and unlovable.

The sense of toxic shame that can manifest during an emotional flashback (as well as at other times) is thought to derive from a history of having been consistently neglected or rejected and/or from having been severely criticized as a child. Children get their sense of their own goodness by being reflected back positively by those who care for them. When children are ridiculed, criticized, treated with contempt, disdain or generally judged harshly, they cannot fathom that they are being treated unfairly or that their caregivers are somehow inadequate, rather they believe that they deserve the treatment that they are getting and that they are inherently “bad”. In other words, they internalize the belief that there is something wrong with them in response to such treatment and they feel ashamed of themselves.

Similarly, self abandonment stems from the caregiver’s abandonment of their children. When our feelings and needs are not attended to in a loving, nurturing and consistent way including when we have difficult feelings such as sadness, anger, grief and depression, we tend to turn away from ourselves as adults when we experience these things. We lack the capacity for self compassion because we never received compassion and don’t have a felt sense of it. We say to ourselves in effect, I cannot afford to feel, acknowledge or extend compassion to myself when I feel or need the things that my caregivers rejected in me. Instead, we do things like deny, project, self-medicate, act out or redouble our numbing or perfectionist tendencies rather than lovingly attend to and nurture ourselves.

The so-called inner critic that may develop is paradoxically the child’s way of attempting to stay safe. When children are anxious and fearful, they attempt to stay safe by internalizing the caregivers rules in the hopes that they will gain acceptance and approval from them. Children say to themselves “if I do exactly what I am supposed to do and I am perfect in this way or that way (including by denying feeling certain things) then maybe I will get the care that I so desperately need”. In other words, children come to believe that if they hide their needs and vulnerabilities and make themselves outwardly all the things that their parents want from them, then maybe they will win the loving and nurturing that they crave. Each time they fall short of this perfectionistic goal, they become increasing self critical and redouble their efforts such that the inner self critic becomes a perfectionistic drill sargent.

Being neglected or abused leaves a child with a profound sense of not belonging anywhere or to anyone. Children tend to develop a sense that people are dangerous and not to be trusted. In addition, in the absence of attentive and caring parents, the child has no safe base from which to explore the world socially. There is no place of refuge to which to return in order to consolidate or integrate experiences in the world and learn more adaptive strategies or approaches. A child is left feeling fundamentally without backing, insecure, alone and unsure of himself. This leads to intense social anxiety. Moreover, when a child feels shameful, dejected and hopeless it is difficult to be socially engaged, rather the tendency is to want to withdraw and isolate oneself like a wounded animal.

The next post in this series will cover the ways a person can begin to heal from CPTSD. If you think you may be suffering from CPTSD and you would like assistance, please feel free to contact me.

The Complex Post Traumatic Stress Disorder (CPTSD) Test

The Complex Post Traumatic Stress Disorder (CPTSD) Self Test

Complex PTSD: Conditions and Symptoms


The Complex Post Traumatic Stress Disorder (CPTSD) Self Test

The following is a list of common conditions and symptoms associated with CPTSD. It is not exhaustive, nor has everyone with CPTSD experienced all of the conditions or symptoms. It should not be used for diagnostic purposes. However, it may give you a sense of whether what you are struggling with may be related to CPTSD. The more you answer “yes” to the questions, the more likely it is that you may be suffering from CPTSD.

At this time, CPTSD is not an official diagnosis in the Diagnostic and Statistical Manual (DSM).  CPTSD is often misdiagnosed as several other conditions such as borderline personality disorder, dissociative identity disorder, major depressive disorder, attachment disorder, generalized anxiety disorder and attention deficit hyperactivity disorder. If you have been diagnosed with any of these or another disorder and you feel that your diagnosis does not fully capture the breadth of your symptoms (and particularly if you were chronically traumatized as a child) it may be useful for you to take this use this questionnaire.

Many people find relief in recognizing that they are suffering from CPTSD, as it helps to identify the source of their suffering as being related to what they lived through earlier in life and not that there is something inherently wrong with them. Moreover, there is hope: people can recover from CPTSD.

(N.B. The terms caregivers and parents are used interchangeably throughout the questionnaire.)

Past Experiences/Conditions

Do you believe that you were neglected or abused as a child?

Were your caregivers available to soothe and protect you when you had adverse experiences?

Did you experience ongoing traumatic events in your childhood?

Did you have the sense that you wanted to escape from your family home, but lacked the means to do so?

Did you have regular fantasies about being rescued from your life?

Were your experiences and perceptions regularly denied or discounted?

Did you feel that your parents were cruel?

Did you feel that your caregivers were insensitive to your needs

Did you feel that you were essentially invisible to your parents?

Did you lack any of the basic necessities of life?

Did you regularly have the sense that you hated yourself?

Did you find it especially difficult to calm down or soothe your own distress?

Did you use substances (including food) to regulate your emotions?

Did you feel spaced out like your body was there but you were not?

Were you responsible for meeting the needs of or soothing the distress of your own parent(s)?

Did your parents misuse substances?

Did you feel chronically vigilant, like you were on guard all the time for then next bad thing that was going to happen?

Did you have other sources of trauma in your childhood such as being bullied at school?

Were your caregivers themselves traumatized in their childhoods?

Were your parents incarcerated for periods of time during their childhoods (such as in an Indian residential school or a concentration camp?


Did your caregiver(s) suffer from mental illness?

Present Experiences/Conditions

Do you have a difficult time regulating your emotions?

Do you feel chronically on guard as though something bad is just around the corner?

Do you feel spaced out much of the time like you are not really present or inhabiting your body?

Are you harshly critical of yourself inside your own head?


Do you feel sad much of the time?

Are you preoccupied with suicide?

Are you inclined to injure yourself?

Do you have difficulties with anger (either explosive anger or inhibited anger or both)?

Do you believe that your sexuality is either compulsive or extremely inhibited?

Do you have a difficult time remembering certain childhood events or blocks of time?

Do you sometimes feel like your thoughts or feelings or you yourself are unreal somehow?

Do you sometimes feel like your surroundings are not real?

Do you experience flashbacks (i.e., the reliving of past experiences or emotional states)?

Do you feel helpless and/or that you have lost all initiative?

Do you feel a chronic sense of shame, guilt or self-blame?

Do you experience a sense of being defiled or stigmatized?

Do you feel that you are substantially different from other people?

Are you preoccupied with your relationship with a caregiver(s) who neglected or abused you?

Do you sometimes feel that the caregiver(s) who neglected or abused you are all powerful?

Do you feel grateful to or do you idealize the caregiver(s) who neglected or abused you?

Are you convinced that you have a special relationship with the person/people who neglected or abused you?

Have you adopted the belief system or the rationalizations of the person/people who abused or neglected you?

Do you tend to isolate yourself or withdraw from others?

Do you have a difficult time finding or maintaining intimate relationships with others?

Do you have a hope that someone will find and rescue you from your life circumstances?

Do you find yourself consistently mistrustful of others?

Do you have a difficult time protecting yourself from others?

Do you find it difficult to believe in anything in an ongoing way?

Do you feel hopeless or despairing much of the time?

© All Rights Reserved, Sarah Flynn 2016

Keeping the Brain and Body in Mind: Two Simple Techniques to Reduce Anxiety and Panic

Keeping the Brain and Body in Mind: Two Simple Techniques to Reduce Anxiety and Panic

Keeping the Brain in Mind

Keeping the Brain and Body in Mind

This post covers two simple exercises you can do to manage anxiety and panic which are grounded in  an understanding of the neuro-physiology of the brain and the body.  (For an overview of the neuro-physiology of panic, please see my previous post.)  The capacity to regulate fear (anxiety and panic) comes fundamentally from the ability to maintain self awareness and stay in touch with your body.  The more you try to push your awareness away from the internal signals and sensations of distress, the more likely they are to escalate.  It is often said that what we resist, persists.  When you can not tolerate noticing what is going on inside your body, you may develop a fear of the sensations of fear.  This may result in anticipatory anxiety or panic about experiencing panic.

Recent neuro-scientific studies indicate that one of the best way to manage states of over arousal (hyper and hypo arousal) is to activate the part of the cortical brain referred to as the medial prefrontal cortex which gives us the capacity for “interoception”.  This is the ability to look inside our selves and to notice what is going on inside and and to feel what we are feeling.  It is thought that this capacity coupled with the capacity to stay calm by using your breath to stimulate the parasympathetic nervous system is essential for regulating emotion and arousal.  When we engage the prefrontal cortex and pay focused attention to our bodily sensations (while breathing deeply and consciously by paying attention to the sensation of the breath particularly as we exhale), we increase our control over our emotions and our nervous systems.

Another technique is to be mindful of your thoughts, emotions and bodily sensations without judgement.  This involves noticing, labeling (describing), and accepting your moment-to-moment cognitive, emotional and somatic experience.  For example, you may notice that you are scared that you may have a panic attack.  You might label this “fear”.  You simultaneously notice that that this fearful thought runs through your mind repetitively.  You might label this “ruminating”.  You then bring your awareness to your body and notice that there is a tightness in your chest.  You might label this “chest tension”.  Doing this strengthens the part of your cortex which is responsible for self awareness and decreases arousal.  This simple technique has been shown to activate the brain regions associated with emotional regulation and lead to positive changes in the regions involved with body awareness and fear.  Practicing mindfulness techniques regularly has also been shown to decrease the activity of the amagdala, the alarm station of the brain.

What is an Attachment Orientated Counselling Process?

Overview Of An Attachment Oriented Counselling Process

Attachment Oriented Counselling

Attachment Oriented Counselling

Many clients have asked me “how do you use attachment theory in counselling?”. This post provides an overview of what attachment oriented therapy process looks like.

In attachment oriented counselling (AOC) as I practice it, clients tell stories to make sense of their lives. I use the insights of attachment theory to help clients create stories about their “self” and their “self” in relation to others across time. In the process they develop. Developing involves unlearning some things and learning other things in a way that facilitates a shift from one level or quality of understanding and awareness to another.

One of the primary insights of attachment theory is that people develop best when they feel really safe and when they have the assistance of a caring and able person to help them. In AOC I hope to become a caring and able person in relation to the client – a reparative attachment figure of sorts, a safe haven to assist with the risks associated with developing.

For these reasons, the first step in AOC is to create a sense of safety. For the most part a sense of safety is a result of interacting in the very ways that are known to produce a secure attachment. In essence, this means communicating (both verbally and nonverbally) in ways which are engaged, responsive, receptive, attuned and contingent.

My experience has been that when I communicate in these ways well enough and for long enough, clients come to feel safe enough to just be themselves. They reveal themselves. In time as they do so, we begin to see patterns – patterns of behavior, of thought, and of relating. Seeing patterns is part of the art of this method, in part because it is as much about seeing what isn’t there as it is about seeing what is there. Patterns are often to be found in the interactive dynamics between the client and the counsellor, but also by tracking the characters, events, and themes in the client’s story.

Generally speaking the process unfolds more or less as follows. First we talk to get comfortable with each other. Then we talk to understand the “problem(s)” as presently conceived, and the story as known already. Then we look for patterns in the existing story. Then we talk about the patterns that we think we see. Sometimes we even talk about talking about the patterns. Eventually we talk about changing the patterns and developing the story.

One of the ways we do this talking is with words. There is vast healing potential in words. They have the potential to afford us distance from our experiences. When we use words, we are putting experience into symbolic form. Words are symbols. They are things that stand for other things. Symbols offer a degree of separation between an experience itself and the representation of that experience. This bit of separation can give a person distance from the experience to usefully reflect on it. When it comes down to it, a person’s story is essentially the making sense of representations of experiences of self and others across time.

When an experience is represented in symbolic form it can be picked up, looked at from multiple perspectives and put back down again in altered form as needed. Some symbols can be tossed out in favor of other ones, if we decide they don’t do a good enough job of representing the thing they are meant to symbolize. Symbols can be examined and manipulated

As we use words to symbolize experience, we acquire the capacity to reflect on the symbols and, by extension, on the experience. In so doing, we position ourselves to determine how we represent our experiences to ourselves and to others and we actively author ourselves into being.

In AOC one of the primary ways I do this is to increasingly facilitate a mindful and curiously investigative stance toward experience. With these two stances toward experience, the client is afforded experiential breadth and interpretive depth in relation to their experiences. The more we do this over time, the more we become active agents in how we know, experience, and present ourselves and the more we become able to author ourselves into being.

As we talk with words in AOC, we also talk without them. I listen really closely to the client’s body, face and breathing to see if any of the word-talking we are doing about patterns or experiences is overwhelming to the point that the client is becoming hyper-activated or hypo-activated. If this appears to be the case it is often not possible for the client to have a mindful or interpretive stance toward experience because s/he may well be too embedded in or too dissociated from the experience to usefully reflect on it.

When this is the case, we slow right down or even stop discussing content of the experience altogether. We start talking much more without words. What I tend to do in such moments is to use my affect, tone, body, eyes, breath and a likely a few carefully chosen words to say, in effect, “I understand, you’re not alone, we can handle this together, and we’ll get through it; we’ll do what we need to do so you are as safe as possible”.

There is often vast potential for healing and development in these moments, but it has to be handled really carefully to avoid traumatizing or re-traumatizing a person. In my experience it is often critical in moments like these to keep the focus on the present rather than on the overwhelming past or the feared future. Focusing on the present can include discussing current day resources, sources of safety and even just what “is” in that moment as perceived through a persons senses. Often some sort of relaxation or grounding technique can help to bring a person back to a comfortable level of arousal. When we get through rough spots in a person’s story effectively in this way and then later use words to develop understanding of what happened we are helping a person learn to regulate affect, that is, to be aware of and to monitor their level of arousal with more clarity and to influence it more efficiently.

When a person’s level of arousal is back within tolerable limits, we may revisit those parts of the story which had been overwhelming. We may explore a smaller, more manageable part of the story than before, or we may explore it for a shorter time. The goal is to facilitate a different stance in relation to the previously overwhelming experience, to help the person have enough distance to reflect meaningfully on the experience without becoming the experience.

Often I use my understanding of the person’s attachment history and style as we work on developing a coherent self narrative in this way. If a person characteristically tends to become flooded by emotion at the expense of being able to think, I attempt to engage the person’s left hemisphere cortical capacities to work through the difficult parts of the story toward developing new awareness. Over time I hope to help the person be able to think through and make sense of the experience and to incorporate this new understanding into their story.

If, on the other hand, a person characteristically tends to disavow the emotional content of experience and to think at the expense of feeling, I try to engage their right hemisphere cortical capacities to feel, sense and intuit things to work through the difficult parts of the story. In time I hope to help the person be able to tolerate the emotional and somatic dimensions of the experience and to make room for and sense of this in their story.

As time goes on, the client and I continue to develop the story and the capacity to reflect on it meaningfully, in part by adding in new story lines, themes, characters, and details as needed, but perhaps more importantly, by progressing from one level to the next of awareness about the self and the self in relation to others. Along with more developed understanding and awareness also comes a greater capacity to tell the story coherently, and importantly, a greater capacity to experience oneself and to act on the basis of the more developed understanding and awareness.

As this process progresses I keep track of my client’s story with and for them. If I’ve done this well, I have made myself a safe, familiar and helpful co-holder of the story, giving the client a sense of feeling felt and being known across time.

I believe that over time in these ways a client comes to increasingly internalize a felt sense of security. As this felt sense of security increases, so too does a client’s capacity for autonomous exploration, intimate connection, interactive and self-regulation of affect, and meaningful reflection on experience.

Fifty Shades of Grey: A Compulsion to Repeat Trauma

This post looks at the phenomenon of  “trauma repetition”or “repetition compulsion”, i.e., the tendency to recreate past traumas in the present.  I will use the character Christian Grey from the novel “Fifty Shades of Grey” as an example of this phenomenon.  Many people expose themselves, seemingly compulsively, to situations that are reminiscent of past traumas.  A classic example is a woman who was abused as a child by an alcoholic father who then marries an alcoholic man who abuses her.

In the story “Fifty Shades of Grey”, Christian, the protagonist, was born to a crack addict, prostitute mother with whom he lived until he was four when he was adopted.  As of the first movie (I admit I have not read the book), we know he was badly treated as a young child (for example, he has cigarette burns on his chest from this era), but we don’t know the full extent of the abuse or neglect he suffered.  We do, however, know that when he was fifteen he became involved with an older woman (his mother’s friend) in which he was the submissive (the partner that gives control to another in a Bondage Discipline Sado-Masochism (BDSM) sexual relationship).

In this much touted story, Christian, a twenty-seven year-old Dominant (the partner in a BDSM relationship who takes the active or controlling role over that of the submissive partner), pursues the character Anastasia Steele, a twenty-two year-old innocent, to be his submissive.  Christian is an alpha male.  He is highly aggressive and controlling in his pursuit of Anastasia.  Many have claimed that he displays the characteristics and behaviors of a emotional and/or sexual abuser.  Others claim that he is honest and forthright about his intentions and desires all along.  This blog post is not about this controversy.  Rather, it is about why, given his traumatic history, he would be drawn to being a Dominant in a BDSM relationship.

As a child, Christian was betrayed by the women in his life several times over.  He was betrayed by his biological mother who mistreated him and then gave him up for adoption.  He was then betrayed by his adoptive mother who permitted her friend and contemporary to have sex with her fifteen-year-old son.  And, he was betrayed by the friend, an adult who was engaging in sexual relations with him as a minor.  This is sexual abuse.

With this traumatic attachment history with women, it is not surprising that Christian would want all of the power and control in his relationship with Anastasia.  By the same token, it is also not surprising that he would be drawn to the role of the Dominant in a the context of a highly structured BDSM relationship.  Having power and control means less likelihood of being hurt, i.e., re-traumatized.  However, in another sense Christian is re-enacting his abusive past in the way that he has sex with Anastasia (albeit with the roles reversed) by making the sex (and the relationship) all about power and control.  He victimizes her in ways that are reminiscent of how he was once victimized.

Trauma can be repeated on emotional, physiological and behavioral levels, sometimes simultaneously.  Re-enactment of victimization and the power imbalances associated therewith such as through BDSM play wherein someone who has been abused historically plays the role of the victimizer (Dominant) is an example of the repetition of trauma.  It is common for a traumatized person to compulsively seek out the familiarity of unhealthy relationships suffered in their family of origin or with an abuser and to seek to gain mastery over a set of circumstances in the present that resemble past traumatic circumstances.  Christian is nothing if not masterful in his role as the Dominant.  The irony is that for all his mastery he still loses Anastasia because she does not want him to inflict pain on her in the ways that he wants to inflict it.  She wants a “normal” relationship.  He is trapped in the circumscribed and familiar realm of BDSM wherein power relations are negotiated and defined.  She is not.

If Christian was not a fictional character, I would suggest counselling.  Counselling can help with repetition compulsion in several ways.  Firstly, it can give a person insight into their own behavior.  Often people people who are trapped in these cycles are not even aware that they are compulsively drawn to repeat the past.  Secondly, it would give Christian an opportunity to grieve the losses of his past in a safe setting so that he might not be so controlled by them going forward.  Finally, counselling has the potential to be reparative to the extent it provides Christian with a wholesome and secure attachment relationship from which he could take the risk to explore new facets of himself.