Understanding and Managing Flashbacks

How to better manage post-traumatic stress.

Posted Dec 21, 2018

There is relatively little empirical research into the flashback phenomenon.  Nevertheless, flashbacks are a common distressing symptom people experience in the aftermath of surviving a traumatic event.  Traumatic events emotionally overwhelmed the survivor and involve danger of loss of life or limb or witnessing others being harmed.  Indeed, flashbacks, nightmares and sleep disturbance might be considered the trifecta of post-traumatic stress disorder

David J. Morris in his compelling book The Evil Hours: A Biography of Post-Traumatic Stress Disorder describes flashbacks as “memories gone wild.”  There is an involuntary aspect to the memory recall which typically includes elements of emotional flooding and dissociation.  Flashbacks cause a numbing disconnection from self and a distressing sense of loss of control over one’s mind.  

Morris, who was injured in Iraq in an IED Humvee explosion and developed PTSD, told of an incident when he was watching a movie that showed a similar explosion.  This triggered a flashback; he dissociated and found himself in the lobby of the theater where his perplexed girlfriend intervened.  From my clinical experience, trauma-related flashbacks typically involve emotional states of overwhelming anxiety, panic or terror and constitute an emotional crisis.

History of Flashbacks in Literature

I believe  the term “flashback” originally derives from the worlds of literature and film as a technique in which the on-going narrative is disrupted by intrusion of scenes (usually emotionally laden) from an earlier time in the character’s life. 

In earlier wars there were few references to such a phenomenon so some believe the flashback symptom may be culturally determined, as all cultures dictate in broad strokes how emotional distress from trauma is expressed, i.e., culturally prescribed formats for symptom manifestation. 

Hallucinogenic Flashbacks

And then there is use of the word “flashback” from the context of re-experiencing a hallucinogenic drug experience.

A 1983 book by Harvard psychology professor and hallucinogenic drug researcher Timothy Leary entitled Flashbacks described the drug-related phenomenon.  Leary wrote, "The glimpse of a maple tree flaming yellow and red reminded me vividly of the drug state.  The phenomenon was later called a 'flashback'—a brief but intense reliving of a memory, a sudden re-entry into highly charged rooms in the brain.  To me the flashbacks were a positive indication that once new circuits of the brain were accessed by drugs, one could learn to re-activate the experience without drugs.” [pg.38] 

In recent years, interest in hallucinogenic drug therapy as an adjunct to psychotherapy for trauma has resurfaced. The FDA has approved clinical trials of MDMA assisted psychotherapy which have been underway for some time.  MDMA is known to elicit feelings of trust and compassion for many people who ingest the drug.  (Note: MDMA is not the same as the street drug Ecstasy or molly which frequently contain other dangerous additives.)

The Black Hole of Trauma and Speechless Terror

In a book written by Cathy Caruth by the title Listening to Trauma: Conversation with Leaders in the Theory and Treatment of Catastrophic Experience, she documented her interview of Bessel van der Kolk.   In a section labeled “The Black Hole of Trauma,” van der Kolk referenced a fascinating study he conducted in which he induced flashbacks by having victims of trauma read a detailed sensory script of their traumatic experience and then scanned their brains with positron emission tomography (PET). 

Active areas of the brain process glucose at higher rates than inactive ones.  As the survivors of trauma experienced flashbacks, the right side of their brains became highly active and Broca’a area of the brain would become inactive — “goes dark”.  Broca’s area has to do with communicable language, and in flashback states this “turned off” as viewed on PET scan.  The right visual cortex showed heightened activity.  Van der Kolk interpreted these findings as consistent with the speechless terror trauma survivors experience while in flashback states.  The traumatic states are encoded as physical and emotional states rather than “verbally encoded experiences.”  The ability to verbalize these experiences develops if treatment is successful.

Non-Verbal Therapies

Van der Kolk and Caruth discussed how often other forms of therapy that involve physical movement rather than relying only on speech is required to move the trauma survivor out of these involuntary memory systems and to re-orient to the present.  Psychodrama, theater, sandplay, dance, yoga, Pilates, and others physical movement methods can facilitate this transition. 

Dance is rated as one of the most enjoyable of all human activities.  From personal experience with dance, I know it releases mood enhancing neurochemicals and creates a sense of physical and emotional well-being.  Mythologist Michael J. Mead has said that when tribal societies experienced collective trauma, their first line of healing involves community dancing rituals.

Neuroinflammation, Trauma and Flashbacks

I recently talked with Dr. Mark Gordon in a telephone discussion about his revolutionary work treating veterans who have sustained traumatic brain injuries.  I asked if his hormone replenishment protocols are effective in reducing flashbacks and trauma-related nightmares.  He indicated they are.  He stated when normal hormone levels are restored, these symptoms typically melt away.  When proper hormone levels are reached, brain repair is facilitated and symptoms abate.  The time frame for improvement in functioning can be rapid or can take months, but for many, improvement is rapid. 

From my clinical experience, flashbacks generally diminish in frequency and intensity with time.  However, at anniversary times or at times of high stress, flashbacks can return but typically quickly subside.  Psychotherapy can be extremely helpful by way of psychoeducation and support with respect to normalization and expectation.

I first learned about Dr. Gordon from Andrew Marr’s book The Blast Factory.  Marr was a Special Forces Green Beret who had the benefit of Gordon’s hormonal replacement therapy.  Marr’s compromised neurocognitive and neurobehavioral functioning from brain injuries related to combat explosions quickly abated.  I have received many testimony comments from readers of my previous blogs that discussed Gordon and Marr’s work.  The testimonials talk about how Dr. Gordon’s treatment radically turned their lives around and saved them from downward spirals of depression and despair.

As mental health professionals, we need to get up to speed on these important developments in the areas of traumatic brain injuries and chronic stress exposure.   More work needs to be done to learn how trauma can impact the body, particularly the brain, by way of chronic inflammatory responses which disrupt normal emotional and cognitive functioning.  Flashbacks may be the result of a neuroinflammatory response that blocks normal memory processing of the trauma experience.  I will write more about Gordon and Marr’s exciting work in a separate blog.