PTSD, meditation and the Alexander Technique

There has not been a recent description of the AT for the medical community. I have spent quite a bit of time recently trying to provide this on my sister blog ATANDPAIN. This posting discusses mediation and the AT. It gives, what I believe, is a useful perspective, but does not add much to this blog.

I'm reprinting it here because I see patients suffering from PTSD every day. Medicine has limited tools to help these people. The theory of the BSN provides strong theoretical evidence that the AT is effective at helping those with anxiety and PTSD. I hope that one day soon this educational technique can be used to help the many sufferers of PTSD and anxiety.

For those readers who are not medical providers or suffering from PTSD, this entry might still be of interest as it dissects meditation and contrasts it to the AT.

This essay was inspired by a talk given by Steven Dobscha, MD from Portland Oregon, an expert on PTSD. He spoke recently on the connection between pain and PTSD. He suggested that mindfulness meditation seems to hold the most promise for treating PTSD. This essay is about the intersections of pain, the AT, meditation, the Body Self Neuromatrix and PTSD.

I will try to present in this essay why the AT might be effective in alleviating PTSD. This is very important. If there is no clear theoretical reason suggesting that the AT is effective in PTSD, then only a small pilot study is indicated. It makes sense to be prudent in these days of limited funding. However, if there is a firm theoretical basis explaining why the AT would be effective in the prevention and alleviation of PTSD then more serious, definitive research is indicated.

Pain, PTSD, meditation and the AT all intersect at the startle reflex.

The startle reflex is among the most deeply entrenched and ancient reflexes. Wikipedia refers to it a brainstem reflectory reaction. It does not involve higher brain participation. And yet, the reflex can seem to be influenced. A heightened startle reflex is part of the very definition of PTSD. So significant past trauma has the potential to interfere with the startle reflex. On the opposite side of the spectrum is the meditator. There was an intriguing study that showed that a meditator with 40 yrs experience can alter the startle reflex.

Perhaps if we examine meditation we can gain some insight on how it influences the startle reflex.

In the study above, the meditator was an expert in two forms of meditation: "open presence" and "focused" meditation. Open presence is when the meditator tries to prevent the mind from getting stuck on anything. The goal is not to dwell on any concerns or thought, not get wrapped up in emotions, not to get too curious about sights or smells to the exclusion of other sensory input. In open presence the meditator does not exclude or neglect anything in the realm of awareness. In distinction, focused mediation brings the mind back to an object and, over time, it becomes more and more fixed on it. Of course, one can choose any number of things to bring the mind to: a question or thought, the sensation of breathing, a candle flame, etc. All of which might have different effects on the meditator.


One might think that these meditators are special people with superhuman abilities. Maybe after 40 year of experience they are (I doubt it), but I'm sure they didn't start out like that. We all start out the same: with plenty of doubts, fears, obsessive preoccupations, nagging pains: a huge variety of distractions from either an "open presence" or a "focused" meditation.

In the "focused meditation" what do you do when you've been distracted? It is a three step process.

1. The first is to wake up and realize that, for example, you just spent the last 10 minutes thinking about chocolate chip cookies instead of your object.

2. The next step is to stop the distraction.

3. The third step is redirect the mind to the object.

Those who practice the "open presence" do without the third step, and just rely on the first and second step.


There are countless ancient and modern lectures, books and teachings to navigate these three steps. The huge variety of teachings exist to support and encourage any person in any situation. But all the teaching support the notion that these two forms of meditation are “mind only”. There is no role for the body. Here is the process in a nutshell: The mind wanders off. The mind realizes that the mind has wandered off. The mind stops focusing on the distraction. And, in the “focused meditation” the mind drags itself back to the object.


For the beginner, a long period of time will go by without any 'stopping'. But as time goes on ones skills improve. A good meditator will recognize and stop distractions hundreds of times in an hour. The mind will not wander very far, nor be away for very long. One begins to be extremely good about stopping and shepherding the mind.


How might meditation effect the startle reflex? It would seem reasonable to divide the reflex into two parts. The first is the immediate reflective response to the jarring stimulus. Again, this is by definition reflexive and does not have any higher cortical participation. I believe that is is similar to the reflexes studied by Rudolf Magnus, and would expect this reflex to work quite well in the deceribrate model.

The second part is not the reflex per say, but the fallout. It's the longer term response. It a combination of the lingering response from the reflex plus our cortical participation.

What kind of time frame are we talking about?

According to the scholarly review paper reviewing the startle eye movement "The psychological significance of human startle eye-blink modification: a review by Diane L. Filion, Michael E. Dawson, and Anne M. Schell:

"Based on these observations, we have proposed that within this paradigm startle inhibition at

the 60 ms lead interval represents automatic, pre-attentive processes, whereas startle inhibition at 120 ms represents a combination of automatic and controlled attentional processes."

So the startle reflex is quick, about 60ms. What I am calling the startle response begins to come into play at roughly 120 ms.


As I have said in previous entries, I am a big fan of the body-self neuromatrix theory. If the reader is not familiar with this one might read my blog post on this theory, but it is a much better idea to read this paper by Melzack. One of the many fascinating aspects of this theory is that it illuminates not just the creation of pain, but of PTSD, and anxiety: any loss of homeostasis. I have stated in the past that I believe the utility of the body-self neuromatrix would be enhanced by conceiving of the process not as simply linear, but as cyclical: the outputs from the BSN quickly become inputs in the next cycle of the BSN.


So, how fast is one cycle of the BSN? It would seem somewhere in the range of 0.12 seconds or about 8 cycles/second.



Using the theory of the BSN how is the startle response is influenced? First there is the loud, unexpected sound. There is a reflective brainstem response called the startle reflex which can be seen in the startle eye movement and changes to the head-neck-back relationship. This loud sound also sends a dramatic input to the BSN via the phasic sensory-discriminative pathway. A loss of homeostasis occurs and various outputs are produced. On the next pass of the BSN, there is the input of sensation via the tonic and phasic somatic inputs. These are muscular changes that are the characteristic pattern of fear. In addition, there is influence of the activation of the sympathetic nervous system. There is input to the BSN from the brain: both tonic inputs (such as underlying PTSD) and phasic brain inputs (such as the pre-conditioning provided by researchers). The thoughts and beliefs, the somatic inputs and the changes in the endocrine milieu are potent irritants to the BSN and lower the threshold for loss of homeostasis when presented with a sudden noxious stimulus.


Stimulating the startle reflex is then a sounding blast into the BSN. Geologist sometime set off underground explosions and then observe the reflective seismic repercussion. Thus they can find gas and oil deposits. Just so, the response to a loud sound can be a measure of the stability of the BSN. A robust startle response would suggest instability of the BSN and a predisposition towards PTSD, anxiety, and chronic pain. This explains, in part, the findings of this study of Emotion, attention, and the startle reflex which finds that the "startle response (an aversive reflex) is enhanced during a fear state and is diminished in a pleasant emotional context."


The expected startle reflex will be seen in any neurologically intact person. A healthy subject will have a minimal startle response. That is, they will quickly realize that there is no real danger. The tonic and phasic inputs from the brain will be reassuring on all subsequent cycles of the BSN. In addition, the tonic inputs from the body will be reassuring. The phasic inputs - the contraction characteristic of the startle reflex - will still be irritating to the BSN. The overall response then is basically healthy: it is mostly appropriate to the non threatening environment.


In someone suffering from underlying anxiety, fear or PTSD the startle response triggered in a benign environment will be inappropriate to the surroundings: abnormal and unhealthy. This secondary response is heightened by obsession, perseveration, distraction; and muscular tension, trigger points, deformity, etc. The response is driven more by habit than by conscious reasoning. It is undesirable if we hope to respond appropriately to our environment.


Just the opposite is seen in the meditator. As I have said above, meditators are very, very good at 'stopping'. The meditators are experts in stopping the inappropriate, undesired responses to stimuli - both external stimuli such as loud sounds, and internal stimuli from the sympathetic nervous system. The meditators underlying tonic state of their body/mind might be so non responsive that it would be very difficult for scientist to see after 60ms. Should there be some spill over and the BSN becomes unstable in the next few passes, the meditators phasic abilities to "stop" distractions quickly will interfere with continued habit based responses.


Finally, we can take a look at how the AT student operates during a startle provocation. Like the meditator the AT student is also an expert in 'stopping'.

FM Alexander had no experience in meditation and was unfamiliar with it’s jargon. But his language does capture the essence of contemporary mindfulness meditation. He speaks about stopping the tendency to focus on the endpoint of our efforts. He called focusing on achieving our goal as “end-gaining”. Honestly, although the words he chooses might be a bit refreshing, this first tool does not add anything substantive to mindfulness meditation. Realizing that we are well ahead of ourselves and stopping that distraction is nothing new, but it is vitally important. Alexander called this first tool “inhibition” and the AT technical term is "inhibition of end-gaining" where end-gaining - the grasping after some goal - is more important than the means by which one achieves the goal. This is similar to the meditator who is experienced at stopping the response to a stimulus that threatens to distracts from their object of meditation. The AT student is an expert at stopping the distraction from how one responds to stimuli to achieve an end. For example, if the phone rings during meditation, the meditator will be distracted, realized they are distracted, say no to the distraction and return to the object. The AT student will hear the ring and inhibit the initial impulse to reach across the desk to answer it. Both meditation and the AT are similar up to this point. In modern pop psychological terms, both meditation and the AT radically anchor one's attention in the present.


But there is more. This "inhibition" is only one of the two tools that the AT teaches. This second tool is employed in the "space" created by stopping. With meditation, one realizes that there is distraction, then stops it. The meditator then passively waits until there is another distraction. The AT makes use of this space between stopping and another distraction. It is in this space that the second AT tool is used.


The second tool is unique to the AT. Once we have applied the first tool we can apply the second tool. This tool is to muster energy, or intention, to direct the use of the body in such a way as to oppose the characteristic pattern seen in the startle reflex. As opposed to the first tool, this “direction” tool his highly nuanced and extremely experiential, hence the need for lessons with a skilled teacher.


The use of 'direction' will change the tonic somatic inputs to the BSN. It's a rather bold statement, but the science suggests this is true. This is a nice summary of some of the research that has measured the tone in AT experts and with those with back pain. This improved tonic somatic input leads to greater resilience of the BSN.


So in addition to the influence of meditation on the BSN, the AT provides an improved tonic somatic influence that provides a highly stabilizing influence to the BSN.


Before moving on, there is one more important distinction between the AT and mediation. Meditation is done on a cushion in a quiet room by people who spend quite a bit away from an otherwise productive activities. Apart from time spent in lessons, the AT is practiced while in every day activities.


So the Alexander Technique starts with the same tools used in "open focused" meditation, but then it adds a unique perspective that has a great deal to offer. It should be far more effective than meditation in alleviating PTSD and anxiety. It is ‘body-based mindfulness’ or ‘meditation in activity’.


So we can see how both meditation and the AT will effect the late expression of the startle response. But so what? What has this got to do with PTSD or anxiety or pain? PTSD is at heart an abnormal, irrational, response to stimuli. PTSD is a habit. Both the AT and meditation help to replace unconscious, habitual, irrational, pathologic responses to stimuli with conscious reasoned responses. Both the meditator and the AT student are highly trained at quickly interrupting the response. In addition, the AT student is experienced in directing the use of the self ways from the characteristic pattern seen in the startle reflex and thus with improvement in the tonic state of the body/mind will further stabilize the BSN.

The AT is effective for chronic pain. There is strong scientific evidence for this. If we subscribe to the theory of the BSN, we can also conclude that the AT is also helpful for PTSD and anxiety as well. I have described here the theoretical basis why the AT is effective in chronic pain, and why the AT should be highly effective in PTSD and anxiety as well. With this theoretical understanding we can suggest the AT to patients and justify spending significant resources on testing the hypothesis.