Apr 15, 2020
Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about
taking advantage of the polyvagal theory of anxiety and social
engagement during psychotherapy.
Dr.
Moller is associate professor of nursing at Pacific Lutheran
University in Tacoma, Wash., where she coordinates the psychiatric
mental health nurse practitioner doctorate nursing practice
program. She also is in practice at Northwest Integrated Health.
Dr. Moller has no conflicts of interest.
Later, Renee Kohanski, MD, discusses the sacred relationship
that exists between doctors and patients.
Take-home points
- The polyvagal (PV) theory relates autonomic nervous system
functions to human behavior and response to trauma.
- The PV theory presents the autonomic nervous system as a
combination of the dorsal and ventral vagus nerve, which together
regulate the autonomic state in response to the environment and
influence behavior.
- The unmyelinated dorsal vagus nerve controls the “freeze
response,” while the myelinated ventral vagus nerve modulates
social communication and can inhibit the arousal state.
- This theory is used in psychotherapy to help patients
understand the value of using techniques to accentuate the activity
of the dorsal vagus nerve.
- It’s easier to apply the insights of polyvagal theory in
person, but Dr. Moller suggests specific techniques during
teletherapy. She prioritizes eye contact, which has to be done by
looking at the camera; modulating your tone of voice to be more
soothing; and having the patient use biofeedback techniques, such
as taking their pulse during a session to make note of their
physical response to anxiety.
Summary
- The association between the sympathetic nervous system and
“fight or flight” is well known. The polyvagal theory relates
autonomic nervous system functions to behavior and response to
trauma. The PV theory presents the autonomic nervous system as a
combination of the dorsal and ventral vagus nerve, which regulate
the autonomic state in response to the environment and influence
behavior.
- The unmyelinated dorsal vagus nerve innervates from the
diaphragm down, controlling the “freeze” response. When the dorsal
vagus nerve is activated, physical signs can include bradycardia or
tachycardia, shallow breathing, and a “pit in the stomach” feeling
from slowing down the GI tract.
- The myelinated ventral vagus nerve innervates from the
diaphragm up, and modulates social communication and engagement,
which can inhibit the arousal state. Social engagement is
attunement to the subtle cues occurring during engagement with
another person.
- The PV theory is used in psychotherapy to help patients
understand the value of using techniques to accentuate the activity
of the dorsal vagal nerve.
- In the PV theory, the concept of “neuroception” is likened to
an unconscious threat detector sensed by the vagus nerve before the
threat is registered by the brain.
- Coregulation is using the environment, most commonly the
physical and emotional response of another person, for emotional
regulation. This occurs in the therapeutic dyad when the therapist
is attuned by and not enmeshed with the patient. Think of
coregulation as akin to attachment theory; when the parent is
attuned and present, the child feels safer and is able to
relax.
- Dissociation is the “freeze” mechanism of reacting to traumatic
events in the moment, and again when the memories are triggered by
stimulus in the environment. One way to treat dissociation is
through engaging the ventral vagus nerve using social connection,
such as gentle voice, gentle touch, and deep breathing or other
grounding exercises. The PV theory connects the physical and
emotional responses to trauma.
- It is impossible to physically connect through telehealth, so
Dr. Moller prioritizes eye contact by looking at the camera, though
this means taking one’s eyes off the patient, as well as having the
patient take their own pulse to reinforce the use of biofeedback,
and “breathing together” over the video treatment.
References
Dana DA, Porges SW. The Polyvagal Theory in
Therapy: Engaging the Rhythm of Regulation (New York: W.W.
Norton & Co., 2018).
Porges SW. The polyvagal perspective. Biol
Psychol. 2007;74(2):116-43.
Beauchaine TP et al. Polyvagal theory and developmental
psychopathology: Emotion dysregulation and conduct problems from
preschool to adolescence. Biol
Psychol. 2007 Feb;74(2):174-84.
Show notes by Jacqueline Posada, MD, who is associate producer
of the Psychcast and consultation-liaison psychiatry fellow with
the Inova Fairfax Hospital/George Washington University program in
Falls Church, Va. Dr. Posada has no conflicts of interest.
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