Allan N. Schore, PhD

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Right Brain Affect Regulation: An Essential Mechanism Of Development, Trauma, Dissociation, And Psychotherapy

Allan N. Schore, PhD
UCLA David Geffen School of Medicine

Right Brain Processes in Psychopathogenesis: the Interpersonal Neurobiology of Attachment Trauma and Dissociation

During the brain growth spurt (last trimester pregnancy through second year) relational trauma-induced arousal dysregulation precludes the forementioned facial-visual, auditory-prosodic, and tactile-gestural attachment communications and alters the development of essential right brain functions.  In contrast to an optimal attachment scenario, in a relational growth-inhibiting early environment the primary caregiver induces traumatic states of enduring negative affect in the child. This caregiver is inaccessible and reacts to her infant's expressions of emotions and stress inappropriately and/or rejectingly, and therefore shows minimal or unpredictable participation in the various types of arousal regulating processes.  Instead of modulating she induces extreme levels of stimulation and arousal, very high in abuse and/or very low in neglect.  And because she provides no interactive repair the infant’s intense negative affective states last for long periods of time.

Interdisciplinary evidence indicates that the infant’s psychobiological reaction to trauma is comprised of two separate response patterns, hyperarousal and dissociation. In the initial hyperarousal stage, the maternal haven of safety suddenly becomes a source of threat, triggering an alarm or startle reaction in the infant’s right hemisphere, the locus of both the attachment system and the fear motivational system. The maternal stressor activates the hypothalamic-pituitary-adrenal (HPA) stress axis, thereby eliciting a sudden increase of the energy-expending sympathetic component of the infant’s autonomic nervous system (ANS), resulting in significantly elevated heart rate, blood pressure, and respiration, the somatic expressions of a dysregulated hypermetabolic psychobiological state of fear-terror.

But a second later forming reaction to relational trauma is dissociation, in which the child disengages from stimuli in the external world - traumatized infants are observed to be “staring off into space with a glazed look.” This parasympathetic dominant state of conservation-withdrawal occurs in helpless and hopeless stressful situations in which the individual becomes inhibited and strives to avoid attention in order to become "unseen" (Schore, 1994, 2001).  The dissociative metabolic shutdown state is a primary regulatory process, used throughout the life span, in which the stressed individual passively disengages in order to conserve energies, foster survival by the risky posture of feigning death, and allow restitution of depleted resources by immobility. In this passive hypometabolic state heart rate, blood pressure, and respiration are decreased, while pain numbing and blunting endogenous opiates are elevated.  It is this energy-conserving parasympathetic (vagal) mechanism that mediates the “profound detachment” of dissociation. 

In fact there are two parasympathetic vagal systems in the brainstem medulla.  The ventral vagal complex rapidly regulates cardiac output to foster fluid engagement and disengagement with the social environment, and exhibits rapid and transitory patterns associated with perceptive pain and unpleasantness, all aspects of a secure attachment bond of emotional communication.  On the other hand, activity of the dorsal vagal complex is associated with intense emotional states and immobilization, and is responsible for the severe hypoarousal and pain blunting of dissociation (see Figure 1). The traumatized infant’s sudden state switch from sympathetic hyperarousal into parasympathetic dissociation is described by Porges as:

…the sudden and rapid transition from an unsuccessful strategy of struggling requiring massive sympathetic activation to the metabolically conservative immobilized state mimicking death associated with the dorsal vagal complex (1997, p. 75).

Automic Nervous System Arousal

Figure 1. Dynamic patterns of regulated and dysregulated autonomic arousal

Porges (1997) describes the involuntary and often prolonged characteristic pattern of vagal outflow from the dorsal vagal nucleus.  This prolonged state of dorsal vagal parasympathetic activation accounts for the extensive duration of “void” states associated with pathological dissociative detachment (Allen, Console, & Lewis, 1998), and for what Bromberg (2006)  calls dissociative “gaps” in subjective reality, “spaces” that surround self-states and thereby disrupt coherence among highly affectively charged states. These “gaps” are also discussed in the developmental psychoanalytic literature. Winnicott (1958) notes that a particular failure of the maternal holding environment causes a discontinuity in the baby’s need for “going-on-being,” and Kestenberg (1985) refers to as “dead spots” in the infant's subjective experience, an operational definition of the restriction of consciousness of dissociation. At all points of the life span dissociation is conceptualized as “a basic part of the psychobiology of the human trauma response: a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma” (Loewenstein, 1996, p. 312).

Dissociation in infants has been studied with the still-face procedure, an experimental paradigm of traumatic neglect. In the still-face, the infant is exposed to a severe relational stressor: the mother maintains eye contact with the infant, but she suddenly totally inhibits all vocalization and suspends all emotionally-expressive facial expressions and gestures. This intense relational stressor triggers an initial increase of interactive behavior and arousal in the infant. According to Tronick (2004), the infant’s confusion and fearfulness at the break in connection is accompanied by the cognition that “this is threatening.” This stress response is then followed by bodily collapse, loss of postural control, withdrawal, gaze aversion, sad facial expression, and self-comforting behavior.

Most interestingly, this behavior is accompanied by a “dissipation of the infant’s state of consciousness” and a diminishment of self-organizing abilities that reflect “disorganization of many of the lower level psychobiological states, such as metabolic systems.” Tronick (2004) suggests that infants who have a history of chronic breaks of connections exhibit an “extremely pathological state” of emotional apathy.  He equates this state with equated with Spitz’s cases of  hospitalism, Harlow’s isolated monkeys, Bowlby’s withdrawn children, and Roumanian orphans who fail to grow and develop. Such infants ultimately adopt a communication style of “stay away, don’t connect.” This defensive stance is a very early-forming, yet already chronic, pathological dissociation that is associated with loss of ventral vagal activation and dominance of dorsal vagal parasympathetic states.

In parallel to still-face studies, ongoing attachment research underscores a link between frightening maternal behavior, dissociation, and disorganized infant attachment (Schuengel, Bakersmans-Kranenburg, & Van IJzendoorn, 1999). Hesse and Main (1999) point out that the disorganization and disorientation of type “D” attachment associated with abuse and neglect phenotypically resembles dissociative states. In recent work, Hesse and Main observe that when the mother enters a dissociative state, a fear alarm state is triggered in the infant. The caregiver’s entrance into the dissociative state is expressed as “parent suddenly completely ‘freezes’ with eyes unmoving, half-lidded, despite nearby movement; parent addresses infant in an ‘altered’ tone with simultaneous voicing and devoicing.” (2006, p. 320).  In describing the mother as she submits to the freeze state, they note:

Here the parent appears to have become completely unresponsive to, or even aware of, the external surround, including the physical and verbal behavior of their infant…[W]e observed one mother who remained seated in an immobilized and uncomfortable position with her hand in the air, blankly staring into space for 50 sec. (p. 321)

In an EEG study of 5-month-old infants looking at a “blank face” Bazhenova et al. (2007) report increases in vagal activity “over the right posterior temporal scalp area and over anterior scalp areas…This observation suggests greater right hemisphere involvement in face processing during blank face” (p. 73).

During these episodes of the intergenerational transmission of attachment trauma the infant is matching the rhythmic structures of the mother’s dysregulated arousal states.  This synchronization is registered in the firing patterns of the stress-sensitive corticolimbic regions of the right brain, dominant for survival (Wittling & Schweiger, 1993). Adamaec, Blundell, and Burton (2003) reported findings that “implicate neuroplasticity in right hemispheric limbic circuitry in mediating long-lasting changes in negative affect following brief but severe stress” (p. 1264). Gadea et al. (2005, p. 136) conclude that an intense experience “might interfere with right hemisphere processing, with eventual damage if some critical point is reached.”  Recall that right cortical areas and their connections with right subcortical structures are in a critical period of growth during the early stages of human development.  The massive ongoing psychobiological stress associated with unregulated attachment trauma sets the stage for the characterological use of right brain pathological dissociation over all subsequent periods of human development.

In the neuropsychoanalytic literature Watt contends, “If children grow up with dominant experiences of separation, distress, fear and rage, then they will go down a bad pathogenic developmental pathway, and it’s not just a bad psychological pathway but a bad neurological pathway” (2003, p. 109).   Neurobiological research on patients with a history of relational trauma also demonstrates continuity over the course of the life span of the expression of this primitive autoregulation defense.  It is commonly accepted that early childhood abuse specifically alters limbic system maturation, producing neurobiological alterations that act as a biological substrate for a variety of psychiatric consequences, including affective instability, inefficient stress tolerance, memory impairment, and dissociative disturbances (Schore, 2001a, 2002b). 

In a transcranial magnetic stimulation study of adults Spitzer et al. report, “In dissociation-prone individuals, a trauma that is perceived and processed by the right hemisphere will lead to a ‘disruption in the usually integrated functions of consciousness’” (2004, p. 168).  And in functional magnetic resonance imaging research Lanius et al. (2005) show predominantly right-hemispheric activation in PTSD patients while they are dissociating, and conclude that patients dissociate in order to escape from the overwhelming emotions associated with the traumatic memory, and that dissociation can be interpreted as representing a nonverbal response to the traumatic memory.

These and other studies are presently exploring the evolution of a developmentally impaired regulatory system over all stages of life, and provide evidence that prefrontal cortical and limbic areas of particularly the right hemisphere are centrally involved in the deficits in mind and body associated with a pathological dissociative response.  This hemisphere, more so than the left, is densely reciprocally interconnected with emotion processing limbic regions, as well as with subcortical areas that generate both the arousal and autonomic (sympathetic and parasympathetic) bodily-based aspect of emotions (see Figure 2).  Sympathetic nervous system activity is manifest in tight engagement with the external environment and high level of energy mobilization and utilization, while the parasympathetic component drives disengagement from the external environment and utilizes low levels of internal energy (Recordati, 2003).  These components of the ANS are uncoupled in traumatic states of pathological dissociation. 

In line with the current shift from cold cognition to the primacy of bodily-based affect, clinical research on dissociation is focusing on “somatoform dissociation.” According to Nijenhuis (2000) somatoform dissociation is an outcome of early onset traumatization, expressed as a lack of integration of sensorimotor experiences, reactions, and functions of the individual and his/her self-representation.  Thus, “dissociatively detached individuals are not only detached from the environment, but also from the self - their body, their own actions, and their sense of identity “ (Allen et al., 1999, p. 165). This observation describes impaired functions of the right hemisphere, the locus of the “emotional” or  “corporeal self.” Crucian et al. describes “a dissociation between the emotional evaluation of an event and the physiological reaction to that event, with the process being dependent on intact right hemisphere function” (2000, p. 643).”

I have offered interdisciplinary evidence which indicates that the implicit self, equated with Freud’s System Ucs, is located in the right brain (Schore, 1994, 2003b, 2005). The lower subcortical levels of the right brain (the deep unconscious) contain all the major motivational systems (including attachment, fear, sexuality, aggression, etc.) and generate the somatic autonomic expressions and arousal intensities of all emotional states. On the other hand, higher orbitofrontal-limbic levels of the right hemisphere generate a conscious emotional state that expresses the affective output of these motivational systems.  This right lateralized hierarchical prefrontal system, the system Pcs. performs an essential adaptive motivational function - the relatively fluid switching of internal bodily-based states in response to changes in the external environment that are nonconsciously appraised to be personally meaningful.

On the other hand, pathological dissociation, an enduring outcome of early relational trauma, is manifest in a maladaptive highly defensive rigid, closed system, one that responds to even low levels of intersubjective stress with parasympathetic dorsal vagal parasympathetic heart rate hypoarousal and deceleration.  This fragile unconscious system is susceptible to mind-body metabolic collapse and thereby a loss of energy-dependent synaptic connectivity within the right brain, expressed in a sudden implosion of the implicit self and a rupture of self-continuity.  This collapse of the implicit self is signaled by the amplification of the parasympathetic affects of shame and disgust, and by the cognitions of hopelessness and helplessness. Because the right hemisphere mediates the communication and regulation of emotional states, the rupture of intersubjectivity is accompanied by an instant dissipation of safety and trust.

Dissociation thus reflects the inability of the vertical axis of the right brain cortical-subcortical implicit self system (see Figure 2) to recognize and process external stimuli (exteroceptive information coming from the relational environment) and on a moment-to-moment basis integrate them with internal stimuli (interoceptive information from the body, somatic markers, the “felt experience”).  This failure of integration of the higher right hemisphere with the lower right brain induces an instant collapse of both subjectivity and intersubjectivity.  Stressful affects, especially those associated with emotional pain are thus not experienced in consciousness (Schore, in press).

Figure 2. Vertical axis of right brain cortical-subcortical limbic-autonomic circuits and subsequent connections into the left brain

Kalsched (2005) describes operations of defensive dissociative processes used by the child during traumatic experience by which “Affect in the body is severed from its corresponding images in the mind and thereby an unbearably painful meaning is obliterated.” There is now agreement that “traumatic stress in childhood could lead to self-modulation of painful affect by directing attention away from internal emotional states” (Lane et al., 1997, p. 840).  The right hemisphere is dominant not only for regulating affects, but also for attention (Raz, 2004), negative affect and pain processing (Symonds et al., 2006), and so the right brain strategy of dissociation represents the ultimate defense for blocking conscious awareness of emotional pain. If early trauma is experienced as “psychic catastrophe,” the auto regulatory strategy of dissociation is expressed as “detachment from an unbearable situation,” “a submission and resignation to the inevitability of overwhelming, even psychically deadening danger,” and “a last resort defensive strategy”  (Schore, in press).  It thus represents a major obstacle to the change process in affectively focused psychotherapy.