CHAPTER 4 Testing the Ventral Branch of the Vagus Nerve Simple Evaluation from Facial Observation According to Stephen Forges, social engagement requires the ability to both look and listen. When you are talking with someone, you can sense whether or not he is socially engaged by how much he looks at you, how well he listens to you, and how well he can understand what you are saying. You can determine whether the person is looking and listening by reading the muscles of his face. Does the person look at your face and make eye contact with you, at least some of the time? Are his eyes open? Can he hear and understand what you are saying? The muscles of the face are organized around the openings of the eyes, the nostrils, and the mouth. (See "Facial muscles" in the Appendix.) When these flat, round muscles tighten, they close the skin around the openings. Flat, rectangular muscles attach to the round muscles and can pull them more open, allowing more light to enter the eyes, more smells to enter the nose, and more air to enter the mouth. When we react emotionally, our facial expression changes as we open or close these openings. Does the other person have slightly raised eyebrows, and are the eyes relaxed and open? The flat, round muscle that surrounds the eye is called the orbicularis oculi. (Orbicularis designates a muscle around a facial opening; oath means related to the eyes.) By tightening this muscle, we close the opening around the eye, cutting down the amount of light in the same way that a shutter in an old reflex camera reduces the amount of light coming through the lens to the film. We tighten this muscle to squint when we are exposed to bright light, when we wish to cut down on visual input, when there is something 65 EFTA00810067

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY that we do not want to see emotionally, or when we want to withdraw from external sensory stimuli and contemplate our own thoughts. When we tighten this muscle, we move away from current visual stimuli, away from the here and now. We may remember events from the past, visualize future possibilities, or enter into a state of meditation. When the flat, rectangular-shaped muscles above and below the orbi- cularis ocuii are tense, they pull the orbicularis oculi more open, allowing much more light to come in. These muscles tense when we encounter something that is an "eye-opener." Physical tension in these flat rectan- gular muscles is an integral part of the emotional expression of surprise. It improves our sensory intake and helps us be more present to what is happening around us. Strangely enough, when our eyes are more open, we can also hear better—there is a neurological connection between the nerves involved in sight and hearing. At a lecture, some people open their eyes slightly more in order to better hear what is being said. When you make eye contact with another person, look for spontane- ous facial expression in the middle third of her face (between the bottom of her eyes and the top of her mouth). The small movements here are an indication of social engagement (or lack of it) and the flexibility of her emotional responses. There are two kinds of facial expression: those that we put on to show someone else what we feel, and those that occur without our consciously "making a face:' We can categorize the latter into three types, depending on how long they last. The first type of unconscious facial expression is the pattern of chronic tension, which is more or less permanent, etched into our faces with deep wrinkles and indicative of our characteristic emotional state. The second pattern, of emotional tension, is less permanent and expresses our current mood. This pattern of facial tensions remains for a while—as long as a mood lasts, and generally long enough for someone else to get an impression of how we are feeling. In the third kind of emotional expression, the facial muscles located in the band between the eyes and mouth change tension rapidly, up to 66 EFTA00810068

Testing the Ventral Branch of the Vagus Nerve several times a second. We can usually see these spontaneous micro- changes of expression in a baby or child. It is more rare to notice these changes in adults, as we are more locked into our sense of identity or moods. When these rapid changes are seen, they are too fast for us to read cognitively in order to say definitively that the facial expression indicates a certain emotion, but the fact that these spontaneous movements are there gives us a sense nonetheless that the person is open and without fear. We can experience these rapid changes of facial expression when two people who feel safe with each other make eye contact, look at each other, and allow their feelings to flow without censoring or trying to control them. This is a reflection of the ideal state of openness, when our facial emotional expressions change as quickly as our thoughts. It is far differ- ent from a put-on smile, as when posing for a photo, where we almost grimace in an attempt to show positive feelings. Can you see a flow of emotions on someone else's face—slight, rapidly changing, mercurial facial movements showing he feels happy, satisfied, angry, irritated, afraid, anxious, sad, or depressed—or is his face flat and unchanging, stuck in one emotional expression? Does he have melodic changes (prosody) in his vocal expression when he speaks? Or is his voice flat, with words spoken in a monotone? We tend to think of people as unchanging identities. However, their interactions with other people are affected by their mood, which is affected by the state of their autonomic nervous system at that moment. People in a stress state might look at us in a menacing way, and their attitude might be aggressive. They might not listen to what is being said. They can be prone to react to a single word, to fly off the handle and interrupt us in the middle of a sentence. Often we may need to correct them: "But that is not what I said!" People in fear will avoid eye contact with us, or make eye contact for only a split second and then look away. Their breathing might be shallow, lifting only the ribs of their upper chest, and they might hold their breath after the inbreath. People in a depressed state will tip their heads forward or let their heads hang, with an expressionless face. They move slowly, indicating a 67 EFTA00810069

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY lack of energy. They have no enthusiasm, and do not want to engage in conversation. Sometimes, before a depressed person does or says some- thing, she will breathe out or sigh. OTHER TESTS OF VAGAL FUNCTION In my clinic, in addition to observing aspects such as these, I like to start all my treatments by testing for function of the ventral vagus nerve branch. If a client exhibits some of the symptoms that I describe as the "heads of the Hydra" (see list at the beginning of Part One), and if testing her indicates ventral vagal dysfunction, it's often possible to improve the person's condition by using the exercises and techniques described in Part Two. Then, after the client does the Basic Exercise, or after I treat her with my hands, I test again for ventral vagal function to be sure that we have achieved the desired results. This information is useful in a clinical setting; the procedure described below in a later section of this chapter, which makes it possible to evaluate our own ventral vagal function, is also useful for self-diagnosis and self-care as well as helping others. In addition to looking at the back of the throat and having the per- son say "ah-ah-ah," as I describe later, I sometimes use another test that is useful if I am testing a young child, an autistic individual, or others in extenuating circumstances. For example, if I have a class of second graders, it might start them all laughing if they see me looking into a classmate's throat with a little flashlight and asking her to say "ah-ah-ah." This other test is based on the observation by Mayer, Traube, and Hering in the late nineteenth century that the pulse and blood pres- sure should be faster and stronger on the inbreath than on the outbreath (assuming good function of the ventral vagus nerve). As you gain expe- rience treating many people, you can get a sense that one person has a greater difference than someone else. You might also observe that the dif- ference is greater after she has done the Basic Exercise than it was before. 68 EFTA00810070

Testing the Ventral Branch of the Vagus Nerve It is my experience that people who have a greater difference between the pulses during their inbreaths and outbreaths are usually more robust and healthy, both physically and psychologically. However, these tests that I use in my clinic have limitations for pur- poses of scientific research. They are subjectively based on my personal observations, which only show whether or not the ventral branch of the vagus nerve is functional; they do not quantify the level of vagal function, which can be higher in one person than in another. Other options for testing for vagal function are described below. Objectively Evaluating Vagal Function through Heart Rate Variability (HRV) In scientific research on the autonomic nervous system, there is increas- ing awareness of heart rate variability, which may offer us another way to assess vagal nerve function. When our nervous system is functioning optimally and we are socially engaged, there are differences in the length of time between consecutive heartbeats, resulting from the natural rise and fall of the heart rate in response to breathing, blood pressure, hormones, and emotions. Heart rate variability (HRV) is the measurement of these differences. Greater variation in the time intervals is designated as high HRV. HRV can be used as an indicator of general health." It represents one of the most promising evaluative tools to measure autonomic nervous system activity." When the ventral branch of the vagus nerve functions properly, heart rate variability is high. There is a growing amount of research correlating high HRV with health and longevity? On the other hand, when there is a reduced level of function in the ventral vagus, the person's autonomic nervous system reverts to either a stress state or a state of dorsal vagal activity, as described in the previous chapter. In this case, differences in the time intervals between heartbeats are smaller or nonexistent, and this is designated as low HRV. A growing body of scientific studies shows a correlation between low heart rate variability and various psychological/psychiatric problems. 69 EFTA00810071

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY For example, HRV is related to emotional states, and has been found to decrease under conditions of acute time pressure, post-traumatic stress, emotional strain, and elevated state anxiety.26 Individuals reporting a greater frequency and duration of daily worry are found to have a lower HRV."." Low HRV is apparently also related to a lack of ability to concentrate, and to motor inhibition, both of which are symptoms commonly found in children with ADHD.39 There is also a link between post-traumatic stress disorder and low heart rate variability." In terms of physical health, it is hypothesized that low HRV is an indi- cator of less favorable health in general." A range of adverse health con- ditions may be associated with lower HRV: obesity, diabetic neuropathy, activity of the dorsal branch of the vagus nerve, susceptibility to sudden infant death syndrome (SIDS), and poor survival rates in premature babies. People suffering from obesity generally have lower HRV." While we might assume that overweight people eat too much, exercise too little, and lack the motivation to change their behavior, some overweight people go on a diet and almost starve themselves with little improvement in their weight. Some people wanting to lose weight work with a psychologist or hypnotherapist to change their self-image. I cannot help but speculate: what if their program for weight loss included evaluation of their HRV, and improvement of their social engagement nervous system with the Basic Exercise? Many people with sexual dysfunction seek help from their medi- cal doctor or advice from a psychiatrist or psychologist. A recent study sheds some light on women's sexual dysfunction, indicating that it may be closely linked to their heart rate variability." There are studies that draw a similar conclusion regarding erectile dysfunction in men, noting that "general imbalance of the autonomic nervous system is one of the causes of erectile dysfunction."" Studies of HRV have shown that low HRV was found in people with heart damage," and it has been associated with increased risk of coronary heart disease.9° Reduced HRV also appears to be a predictor of mortality after myocardial infarction (heart attack)." 70 EFTA00810072

Testing the Ventral Branch of the Vagus Nerve Low HRV correlates with early death from several causes in addition to heart problems, such as COPD. In the United States in 2014, COPD was the third most common cause of death after heart disease and cancer." Breathing patterns other than normal diaphragmatic breathing indicate lower levels of physical and psychological health, and there is a relationship between diaphragmatic breathing and higher levels of heart rate variability." In my clinic, I have found that clients with a diagnosis of COPD have very little movement in their respiratory diaphragm, and their tests do not show ventral vagal activity. HRV testing, it seems, may yield valuable diagnostic information, and can serve as a rapid screening tool to evaluate altered autonomic nervous system activity. If scientific research confirms that the state of the autonomic ner- vous system is a factor in psychological issues, it may be interesting to explore the possibility of improving heart rate variability and the func- tion of the ventral branch of the vagus nerve as a first step in treating psychological problems, without immediately resorting to traditional psychological interventions or prescription drugs. (See Chapter 6 for more on this topic.) Testing for Vagal Function: Early Experiences Let me emphasize the importance of testing by recollecting my practice in earlier days. When I started my education in craniosacral therapy, the teacher of the course said that if I did the fixed sequence of techniques that he taught, I could help people to get relief from their stress. How- ever, he never taught us to test the physiological states of the body, so I wondered how he knew that these techniques worked—perhaps he had simply heard that from his teacher, and believed it. That was almost thirty years ago, before I studied with Main Gehin, and long before I heard about the Polyvagal Theory. The only model of stress we had at that time was the old understanding of the autonomic nervous system being in a state of either stress or relaxation. 71 EFTA00810073

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Everyone knew that chronic stress was unhealthy, and there were books and courses on stress management, each promising a positive, stress-free outcome. But none of them showed a way of testing stress physiologically. Today I test every patient before and after sessions; I do not put my blind faith in what someone else once told me about what outcome to expect from my treatments. When I did sessions based on that first course, I completed the stan- dard sequence of techniques, and assumed that my work was finished; the client could no longer be stressed, and was relaxed and ready to go home. But I noticed that clients often had a hard time gathering then$elves after treatment, and they would ask if they could remain on the table for a few more minutes. After ten or fifteen minutes, they often still did not want to get up, and I would have to explain that I needed the massage table for my next client. They would be considerate of my needs, get up reluctantly, and put their shoes on. I remember some clients me if I thought that they could drive; I assured them that it was okay. When they came for their next appointment, they sometimes told me that they were so relaxed after their last session that they had to pull off to the side of the road and shut their eyes to nap for a few minutes. Sometimes they even pulled over two or three times. They enthusiastically commented that this was great because they had been "so relaxed?" Even on the next day, they often did not want to get out of bed and go to work. Today, looking back, I realize that my sessions had left them in a dor- sal vagal state. They were not relaxed, but instead were dissociated and exhibiting depressive behavior. Nowadays, I am careful to address ventral vagal function during a session, and test it again afterward, in order to make sure that they can be socially engaged when they depart. I make sure that they leave my office calm but at the same time alert and able to function, in a state of neither stress nor dorsal vagal activity. Testing the state of the autonomic nervous system before and after a session provides a great perspective if you are a body therapist, psychologist, or any other kind of health care provider. 72 EFTA00810074

Testing the Ventral Branch of the Vagus Nerve Discovering the Polyvagal Theory In the early 1980s, I began to notice that many of my clinical clients who had asthma also had vagal dysfunction. When I helped them to improve their vagal function, their symptoms of asthma were reduced or disappeared. I found this interesting—perhaps people with asthma could be helped by hands-on treatment to improve their ventral vagal function rather than relying on prescription medications, which are expensive and often have negative side effects. I hope someday to do a scientific study based on these experiences. At the time, I used a method of testing vagal function that was based on early concepts of heart rate variability: I monitored the pulse and blood pressure of my clients, and correlated these with their breathing. I learned this method from my Rolfing teachers, Michael Salveson and Gad Ohlgren, in 1982-83. My teachers had learned it from Peter Levine,4° a leading teacher and author in the field of trauma therapy. Peter in turn had been inspired by Stephen Porges; Peter and Stephen have a friend- ship that goes back several decades. Michael and Peter were also part of a small study group of Rolfers and other body therapists in Berkeley, California, in the early 1980s that focused on the function of the auto- nomic nervous system. The method I used involved observation of the breath and pulse. If our pulse is faster on the inbreath and slower on the outbreath, this indi- cates good ventral vagal function. The greater the difference, the better the ventral vagal function. I monitored this by putting a finger over an artery in the client's wrist while at the same time observing the pattern of her breathing. The idea behind this method goes back to studies on the autonomic nervous system from the 1890s, with the discovery of variability in blood pressure described as Traube-Hering-Mayer waves. Although this method was useful in my clinic for my own personal evaluation, it left a lot to be desired in terms of scientific research. I had no objective measurement of vagal function—just my subjective impression based on what I felt under my fingers and saw with my eyes. For scientific 73 EFTA00810075

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY purposes, of course, it is preferable to measure more precisely. Today there are many instruments available to measure vagal function!' Back in 2002, I wanted to ask Stephen Porges (whom I had not yet met) to help me develop a research project investigating my successful hands-on treatment for asthma. Several clients had come to me with breathing difficulties and diagnoses of asthma. When I tested these clients before their first session (using a method of diagnosing the function of the vagus nerve that I had learned in my Rolfing class), I noticed that they all had vagal dysfunction. But after my hands-on treatments, they all tested positive for vagal function. At the same time, their symptoms of asthma disappeared, and their breathing normalized. I was hoping that Stephen could assist me in developing a scientifically acceptable method of measuring this. I asked Jim Oschman,42 a scientist friend of mine, if he knew Stephen and could introduce me to him. Luckily, on my next trip to the United States to visit my family in Philadelphia, Stephen Porges was giving a lec- ture in Baltimore for the American Association of Body Psychotherapists. Jim was in Washington, DC, and all three of us were able to meet at the Baltimore conference and have dinner together. I told Stephen about my idea for doing a research project on treating asthma, and I asked if he could help me measure autonomic nervous system function before and after my treatments. Rather than supplying information on where I could get the hardware and software, as I had hoped, he changed the subject and told us about his Polyvagal Theory. It was new to me, but it sounded interesting. The next morning, Jim and I had breakfast with Stephen, and he told us more about the theory. Later that morning, Stephen gave the keynote speech at the confer- ence. His theme was the Polyvagal Theory, this time illustrated with slides. After hearing Stephen describe the theory for the third time in less than twenty-four hours, I began to truly grasp it. He presented video documentaries showing some of the improve- ments in communication and behavior in autistic children who had taken part in his research, which he calls "The Listening Project Protocori 74 EFTA00810076

Testing the Ventral Branch of the Vagus Nerve (further described in Chapter 7). The children had received five daily forty-five-minute treatments for five days, consisting of listening to unique computer-distorted music through special headphones. The result was that more than half of the subjects no longer reported audi- tory hyperacusis, and many started to engage spontaneously in two-way verbal communication, and became more social. The video showed the children's interaction with an adult who tried to engage them in playful activity that fit their age group—the therapist was blowing soap bubbles. Before the music-listening sessions, one child was hyperactive, could not sit still, ran around in circles, and showed no interest in either the adult or the bubbles. Another child was sitting pas- sively, with her chin drooping on her chest. By contrast, she seemed to be collapsed, alone in her own world, and did not appear to notice the bubbles or the adult. After their fifth listening sessions, both children looked engaged and behaved more naturally. The formerly hyperactive child stood in front of the adult, made eye contact, and played with the soap bubbles. The child who had been shut down appeared to wake from her stupor, related playfully to the adult, and started to play with the soap bubbles as well. The children smiled, laughed, had light in their eyes, and were in a play- ful, relaxed, and open state. This is an incredible accomplishment, given the fact that until then no one had developed a scientifically verified procedure for helping autistic people improve their communication skills and become more social. The Listening Project Protocol points to a potential for effectively addressing this symptom of autism. I was not the only one who was amazed. The room was filled with 150 therapists. After seeing the impact of this intervention on the two children, there was not a dry eye in the house. At that time, I had no experience treating children on the autism spec- trum. I thought about patients I had treated over the years. Many had come to my clinic in a state of stress or dorsal vagal withdrawal, and had left smiling, with light in their eyes and apparently at peace with them- selves. This indicated to me that our sessions had been effective. 75 EFTA00810077

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY I believed that I had the means to bring about similar changes in autistic clients with a protocol of techniques from biomechanical cranio- sacral therapy. However, before hearing Stephen Porges's lecture, I did not have a psycho-physiological model to explain the changes. Also, I realized that my previous model of the autonomic nervous system was limited to states of either stress or relaxation. My model did not include the idea of"shutdown," or any state characterized by activity of the dorsal vagal branch; it did not even distinguish between the ventral and dorsal branches of the vagus nerve. I came away from Stephen's lecture inspired, and my interest shifted from doing research on treating asthma with craniosacral therapy to exploring the possibility of treating children on the autism spectrum. I also had a new understanding of how the autonomic nervous system functions. It was no longer a question of improving just vagal function, but improving the function of the four other cranial nerves also essential for social engagement. I have spent the many years since then studying and applying the Polyvagal Theory in my clinical practice and in my teaching. When I went home to Denmark, I could not set up a lab to do the kind of testing that Porges had done, and I did not have access to his process of testing and acoustic stimulation. But I decided to work with certain clients on the autism spectrum using my new knowledge of the Polyvagal Theory and my hands-on skills from biomechanical craniosacral therapy, which include techniques for improving the function of the five cranial nerves necessary for social engagement. My hope was that, by using those techniques and improving the func- tion of those nerves, I could also help some of these people improve their ability to communicate, thus making it possible for them to engage more fully in social behavior. My treatments resulted in better functioning for most of my autistic clients. They did become more communicative and went from states of isolation to becoming more socially responsive. Although I used a dif- ferent therapeutic approach from that of Stephen Porges, I based my treatments on his Polyvagal Theory. 76 EFTA00810078

Testing the Ventral Branch of the Vagus Nerve It took several years to reach a point where I realized the importance of testing everyone, even after hearing about the Polyvagal Theory. At first I measured vagal function only when I had a difficult patient and felt frus- trated with a lack of results; I was slow to incorporate it for all my clients. When I gave a myofascial release treatment but did not get the result I expected, I would hit a wall—these techniques usually worked, so why not this time? So I worked harder, repeating the same technique again and again, and giving my clients extra time for their sessions. Even with that, my efforts still did not give the results that I wanted, and I became more and more frustrated and unsatisfied at the end of a session. Testing for vagal function gave me a chance to realize that my failures were not due to my lack of judgment in choosing that technique, or skill at performing it, but rather to a lack of receptivity in the client's nervous system. In these cases, information about the state of their autonomic nervous system helped me understand why I did not get the results I had attained with most of my other clients who had well-functioning autonomic nervous systems. With this realization, I no longer questioned my ability as a therapist when I had a difficult case; the shortcoming was not in me or my technique, but was due to the unreceptive state of the client's autonomic nervous system. What would happen if I had the information about their autonomic nervous system issues at the start of the session, and addressed that first? I began to do this. Based on my resultant clinical successes, I believe that the importance of testing for the function of the ventral branch of the vagus nerve cannot be overestimated. Whether my clients come for a Rolling session, to get relief from pain in their back, or to regain mobility in a frozen shoul- der—or for any other of the health issues that I call the "heads of the Hydra"—the first thing that I do is test them for function of the ventral branch of their vagus nerve, using the pharyngeal-branch vagal function test described below, since my first goal as a therapist is to improve their vagal function. If I find ventral vagal dysfunction, indicating a state of either stress or withdrawal, I have the client do the Basic Exercise (see Part Two). Then 77 EFTA00810079

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY I test them again. Usually their vagus nerve responds as it should after doing this exercise once or twice. Then I proceed with specific techniques to complete the treatment. I have learned that if there is not adequate ventral vagal function, therapeutic interventions are less likely to stick. However, when vagal function is successfully restored, my clients often experience improve- ments in other areas of their lives—not only in terms of the health issue that they came in with, but also at work, with their families, and in social relationships with others. Testing another person for social engagement can be valuable if you are working as a teacher, body therapist, psychologist, psychiatrist, or coach. If you are a parent about to send a child to college, it might be a good idea to make sure that your child has a well-functioning autonomic nervous system—and if not, it would be a good idea to get it functional, to ensure the best chance that the time and resources you and your child invest in the education will have a positive outcome. If you find that your child is in a state of stress or withdrawal, you might want to address that with the exercises and treatments in this book, for the best possible chance of success. Testing for Vagal Function: Cottingham, Porges, and Lyon If you are a body therapist, or do anything else to help other people with their health and wellness, performance, or interactions with others, you might find that the state of their autonomic nervous system will predict how successful your efforts will be. Stephen Porges, together with John Cottingham and Todd Lyon, both Rolfers, published the results of a 1988 research project in the journal Physical Therapy" They demonstrated that evaluation of the autonomic nervous system can be an accurate predictor of the level of success in a hands-on therapy session. Over the years, I have found that the implica- tions of this study go far beyond body therapy, and are relevant in all interactions. 78 EFTA00810080

Testing the Ventral Branch of the Vagus Nerve The three did a scientific experiment on a group of men in which they tested the state of the autonomic nervous system and how it related to the level of positive results from a myofascial release technique used in Rolfing. John Cottingham administered a Rolfing technique called a "pelvic lift" to each of the study participants. The pelvic lift is used to balance the sacrum at the end of Rolfing sessions, in order to incorporate and bal- ance changes to the connective tissue from various releases that occurred during the session. In the pelvic lift technique, the client lies face-up on a massage table. The Rolfer slides a hand under the client's sacrum and contacts the bone. With the client's weight resting on the palm of their hand, the Rolfer creates a slight, steady, gentle traction toward the client's feet. When the pelvic lift works as intended, the muscles of the back relax, the spine lengthens, and vertebral alignment is improved. The pelvic lift should leave the client with better posture, greater flexibility in the lumbar spine, and an increased sense of well-being. For the purposes of the study, in order to keep the intervention as uniform as possible for all of the subjects, John Cottingham was the only therapist, administering the same technique to all the subjects. John measured the effects of his technique by testing the flexibility of the spine before and after the pelvic lift. The subjects started in a relaxed standing posture, and then curled forward into spinal flexion. John mea- sured how close their fingertips came to touching the floor, both before and afterward, to determine whether the subject was more flexible, the same, or less flexible after the pelvic lift. John asked them how they felt, and what they experienced as a result of receiving the pelvic lift. Even with the same therapist doing the same technique, there was a wide range of responses. From a first glance at the findings, it appeared that the younger men generally had a more positive gain from the technique compared with the older men, showing an increased range of movement when they bent over the second time. They reported that receiving a pelvic lift had been an enjoyable experience, and they were in a better mood after the intervention. 79 EFTA00810081

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY The older group had quite different results. In spite of John's training, skills, and positive intention, his efforts with many of the older men were not especially successful. Many became stiffer and actually lost some of their range of movement; when they curled forward and tried to touch their toes, their fingers were further from the floor than before the treat- ment. Many reported that they did not feel as good after the technique, and their mood had changed for the worse. A few were noticeably grump- ier and more irritable. It would be easy to conclude that Rolfing simply works better for younger men than for older men. But the researchers were interested in relating the results of the technique to a factor other than age. They discovered that the state of the autonomic nervous system was a relevant indicator in predicting the success of the outcome. Before the treatments in the experiment, John measured the subjects' heart rate variability (HRV). He attached sensors to their skin and ran these wires to a vagal-tone monitor stationed in another room. With this setup, he was able to precisely record changes in the beating of their hearts, and to correlate them to individual breaths. John was not able to see the HRV measurements while carrying out the technique. He had no knowledge of which subjects had high levels of heart rate variability and which had low levels, so this knowledge could not prejudice the way that he performed the treatments. Most of the younger subjects, and some of the older men, had reasonably high heart rate variability. By contrast, a higher percentage of the older men and only a few of the younger men had low HRV. When Cottingham, Porges, and Lyon reviewed the data, they saw a closer relationship between high heart rate variability and a desirable outcome from the treatment than there was between age and outcome. In other words, the success of the treatment appeared to be more closely related to the state of the autonomic nervous system than to age. This is a key point, discussed further below. Measuring heart rate variability with a vagal tone monitor can be useful in scientific research where you need a quantifiable measurement. 80 EFTA00810082

Testing the Ventral Branch of the Vagus Nerve However, there are other ways to evaluate vagal function in a clinical setting that do not require special equipment and take less time. For many years, I have used some of these other methods and found them to be sufficient for my own purposes in my clinic. A Simple Test of the Pharyngeal Vagus Branch The ventral vagus nerve has several branches. Below is a test for the function of one of these, called the pharyngeal branch, which inner- vates the part of the throat immediately behind the nasal cavity and the mouth, above the esophagus and larynx. Nerve fibers from the pharyngeal branch of the vagus go to the soft palate and to the pharynx. This nerve is involved with swallowing and making vocal sounds. The Greek physician Claudius Galen was the first extant writer to describe the pharyngeal branch of the vagus nerve, noting that it provided motor nerve function for the muscles in the larynx, which produce the voice. He learned this by examining a gladiator who had been wounded in the neck and had lost his voice; Galen found that the pharyngeal branch of his vagus nerve had been severed on one side of his neck. To test the validity of his observations, he did an experiment on pigs, whose anatomy is quite similar to human beings. He found that cutting the pharyngeal nerve on pigs would stop their squealing. After trying various ways of testing the ventral branch of the vagus nerve, I eventually chose this method focusing on its pharyngeal branch. It has been described in some of the older textbooks on anatomy and physiology, and it is still taught in medical schools in Denmark. Main Gehin also taught this method of testing for vagus function by looking at the back of the throat. It has been a great asset in terms of my own work with craniosacral therapy. This test evaluates the movement of one of the muscles innervated by the pharyngeal branch, called the levator yell palatini muscle. From my experience, I find that the condition of this branch is a good indicator of the function of other branches of the ventral vagus nerve as well. 81 EFTA00810083

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Improving the function of the pharyngeal branch of the vagus nerve improves the function of the respiratory diaphragm. When this test shows a dysfunction of the levator veli palatini muscle, I usually also observe that the client's breathing is irregular, somewhat rapid, and not especially deep. Then, after the client does the Basic Exercise and this branch becomes functional again, I observe that breathing has improved, becoming deeper and slower. I explain to my clients the importance of proper function in the ven- tral branch of their vagus nerve. I show them drawings, and I explain what I am looking for in terms of movement of their soft palate at the back of their throat. Most of my clients like the idea that I test vagal function, treat them, and then test vagal function again; they like the fact that their autonomic nervous system can be evaluated, and if the ventral branch of their vagus nerve has been dysfunctional, that it can be shown to be brought back into proper function. How to Test for Pharyngeal Ventral Branch Function Ask the person to sit comfortably in a chair. Then stand in front of him and ask him to open his mouth so that you can see the back of his throat. You will need to see the uvula (the small bulb-shaped structure that hangs down in the back of the throat) and the soft-tissue arches on either side of it. Sometimes you can see these sufficiently with normal light; otherwise, you will need to use a small flashlight. (The flashlight app on an iPhone is perfect for this.) If the person's tongue is blocking your view of the uvula and arches, ask him to place one of his fingers on the back of his tongue and push it down onto the floor of his mouth. Then you should be able to see the soft palate more easily. (Medical doctors use a tongue depressor for this, but that makes some people gag, and I have never had a client gag using his own finger.) See the Appendix for a series of drawings of the uvula. In "Uvula 2,"the arches of the soft palate are lifted on both sides by properly functioning levator veil palotini muscles. In "Uvula 3; one side is lifted and the other is 82 EFTA00810084

Testing the Ventral Branch of the Vagus Nerve not; this indicates dysfunction of the ventral branch of the vagus nerve on the side that is not lifted. In these drawings, you can see the !evertor veil palatini muscles embed- ded in the soft tissue, one on either side of the uvula. These muscles are innervated by motor fibers of the pharyngeal branch of the vagus nerve. When they contract, they lift the arches of the soft palate. They are also attached to the auditory (Eustachian) tube between the ears and throat, and pull on it during the act of swallowing. This is why the ears sometimes"pop"with swallowing, as air moves into the middle-ear cavity and pressure is equalized. When we swallow, these muscles should contract, elevating the soft palate and allowing food to go into the esophagus en route to the stom- ach, while at the same time preventing food from entering the larynx and lungs. These muscles should also contract when someone makes the sound-all:A well-trained singer will use this muscle to lift the back of the throat before singing the first note of a phrase. In order to test vagal function, I ask the other person to say, "ah-ah- ah-ah-ah" while I observe the arches on either side of the uvula. These sounds should be percussive and staccato—short, distinct bursts of sound in quick succession, and not a long, drawn-out "aaaaaaaaahhhh: which does not create the desired effect. If there is good function in the pharyngeal branch of the ventral vagus nerve on both the right and left sides, these muscles tighten symmetrically with a clear impulse when the person makes the sounds"ah-ah-ah-ah-ah: lifting the arches of the soft palate equally on both sides. If, on the other hand, there is dysfunction of the pharyngeal branch of the ventral branch of the vagus nerve on one side, the nerve impulses do not innervate the levotor veil palotini muscle on that side, and the arch in the soft palate on that side does not lift when the person says "all: This test for ventral vagal function has profound implications. As mentioned, if we are in a state of fear, there is activity in one of these other two circuits of the autonomic nervous system, and we can suffer from any of the conditions I referred to as the "heads of the Hydra:' Stephen 83 EFTA00810085

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Porges introduced the idea of the "vagal brake"—the inhibitory effect of ventral vagus activity on spinal sympathetic and dorsal vagal activity. What if we then came to feel safe? What if we restored activity in our ventral vagal circuit instead of our spinal sympathetic chain or dorsal vagal branch? The exercises and treatments in this book can move someone out of states of stress or shutdown and into a ventral vagal state. After someone does the self-help exercises or receives the hands-on treatments in this book, you should be able to observe improvement when you test again— the soft palate and the uvula should now lift symmetrically on both sides. The "Trap Squeeze Test" is another test that I use to test for the func- tion of the ventral vagus nerve branch. This test and its implications are described in Chapter 5. It is perfect to use with children, or with any- one on the autistic spectrum who might have difficulty following your instructions. Therapists Can Test for Vagal Function without Touching In January 2008, I co-taught a seminar together with Stephen Porges in Santa Fe, New Mexico, for a large group of psychologists and body therapists. Stephen began the seminar, and everyone was inspired by his presentation of the Polyvagal Theory, recognizing its possibilities as a model for understanding the difference between normal and abnormal human behavior. Psychologists interact verbally with their clients and are regulated by laws governing their professional behavior. In most states in the United States, they are not allowed to touch their clients; doing so would be grounds for losing their license. My work with clients, however, is primarily "hands-on," for body therapists who want to learn how to use their hands to treat their client in this way. The night before I lectured to this group, I wondered, "These psy- chologists cannot touch their clients. How can I give them something 84 EFTA00810086

Testing the Ventral Branch of the Vagus Nerve that they can take home and use in their clinical practice?" I slept on the question, and the next morning, when I woke up, I had an answer: they could diagnose the state of the client's autonomic nervous system by looking at the back of the throat while the client makes the sound "ah-ah-ah-ah-ah" (as described in the section above). I provided each of the seminar participants with a small flashlight to enable them to look at the back of someone's throat. In a practice session during the course, they experimented with testing other semi- nar attendees. The point was for them to learn how to tell whether or not their clients were socially engaged, both before and after their ver- bal interventions—such testing might help them to better understand the behavior and emotional state of their client from a Polyvagal per- spective. They could also evaluate whether their clients needed work to improve the function of their autonomic nervous system and, just as importantly, whether their intervention was successful in terms of the Polyvagal Theory. The possibility of testing before and after a session caught their interest. I told them about my work with body therapy, and the research done by Porges, Cottingham, and Lyon described above. I raised the possibility of a psychologist having clients use their own hands to perform a technique that could facilitate a change in their autonomic nervous system, bringing them from a state of chronic spinal sympathetic or dorsal vagal activity into a state of social engagement. If Stephen Porges's vagal brake can be brought into play—if a psy- chologist can get a client's ventral vagal branch to function properly,"put- ting the brake on" sympathetic or dorsal vagal activity and their harmful consequences—what effects might this have on the behavior, emotions, and thoughts of the client? Since the ventral branch of the vagus nerve inhibits dorsal vagal or spinal sympathetic activity, bringing about a ven- tral vagal state may be effective in addressing conditions often diagnosed as stress or depression. Although in my clinic I utilized a hands-on protocol to bring my cli- ents into a state of social engagement, I reasoned that a psychologist who understood the Polyvagal Theory could use its principles to teach clients 85 EFTA00810087

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY to achieve similar results using their own hands. Such an approach would also give clients the possibility of helping themselves in the future, after the session, to regulate their own autonomic nervous system as needed. This was the origin of the Basic Exercise. (See Part Two for instructions for doing this simple exercise.) This was the first time that I had taught this exercise to anyone, and naturally I was curious whether or not it would work. There were about sixty psychologists in the group, and half of them had shown vagal dys- function when tested prior to doing the exercise. (Their partners in the practice session never touched them.) After they used their own hands to treat themselves, they all showed restored ventral vagal function. Bringing about the change in their autonomic nervous systems had taken only a few minutes. After the seminar, I received an email from one of the psychologists, telling me that she now tested every client at the start of their sessions. If they had vagal dysfunction, she told them how to do the exercise. When she tested them again afterward, they showed ventral vagus function. This exercise, it appeared, successfully put her patients into a state of social engagement. Then she did her usual verbal psychological interventions. She wrote that she was thrilled by the improved results that she was now getting with her clients. When I went back to work in my own clinic, I began asking whether patients had physical or psychological problems. I checked them to see if they had ventral vagal function. Then I taught them to do the Basic Exercise. When they had done it a single time, I looked at the back of their throat again, and each and every one of them now had a well-functioning ventral vagus nerve. I would have been satisfied if I had helped 50 percent of my patients to a ventral vagal state, but I found that I was able to help them all. Eighty- five out of the next eighty-five clients I tracked had a positive outcome. That was a good enough result for me to begin to depend on this exercise. Clients, furthermore, usually gave me good feedback not only at the end of the session but also when I saw them again in the following weeks. 86 EFTA00810088

CHAPTER 5 The Polyvagal Theory— A New Paradigm for Health Care? Generally, our Western approach to medical treatment is biochemical or surgical. If we go to a doctor with a health problem, the doctor listens to our description of the problem. After a physical examination and/ or laboratory testing, the doctor generally makes a diagnosis, writes a prescription for medication, and sometimes suggests a surgical procedure. If we have asthma, doctors prescribe asthma medicine. If we have migraines, they prescribe migraine medicine. If we are having a problem with digestion, they prescribe a specific medicine to help a specific part of the digestive tract. There is a different medicine for every nameable condition; a well-stocked pharmacy offers thousands of medicines. In the conventional approach, however, doctors may be overlooking something. Dysfunction of the autonomic nervous system, for instance, may be a common factor in autism, migraines, CORD, and many other health problems. Rather than focusing on one diagnosis or condition that is treated by one medicine, there is a growing awareness of comorbidity. Comor- bidity is the presence of one or more disorders or diseases co-occurring with a primary disease or disorder. The additional disorder(s) might be behavioral or psychological. The autonomic nervous system monitors and regulates the functioning of the visceral organs, and is a major contributing factor in determining our emotional state. However, doctors do not usually test its function; they do not generally consider the autonomic nervous system as a pos- sible contributing factor, nor are they trained to explore the possibility of changing the state of the autonomic nervous system without using prescription medicines. 87 EFTA00810089

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY In my practice, I have consistently found that assisting the ventral branch of the vagus nerve to function properly often eliminates or reduces the severity of many health problems, and therefore the need for prescription drugs. I believe dysfunction of those nerves to be an underlying cause of many life-impairing physiological and behavioral conditions. I invite you to explore this approach in greater depth after reading this book. Whether you are a layperson, health care professional, or body therapist, I trust that you will find the concepts and techniques as effective as I have found them in my own practice. A Polyvagal Approach for Psychological and Physical Conditions Many people focus on the negative consequences of stress and are gener- ally not aware of problems resulting from chronic activation of the dorsal branch of the vagus nerve. Activity of the dorsal vagus is characterized by a lack of physical energy, low blood pressure, fainting, breathing difficulties stemming from constriction of the airways in cases of COPD, and chronic, general muscle and joint pain, often diagnosed as fibromyalgia." As described in Chapter Two, chronic dorsal vagal activity is also a factor in depressive behavior, social isolation, feelings of helplessness and hopelessness, apathy, lack of empathy, sadness, and grief, as well as some cases of post-traumatic stress and many cases of anxiety. Prior to the Polyvagal Theory, we did not have an adequate physiologi- cal model to understand the nature of these common problems. The new understanding of the autonomic nervous system set forth in the Polyvagal Theory provides us with a physiological model for comprehending the neurological factors underlying these dysfunctions. Improving the func- tion of the ventral branch of the vagus nerve opens new possibilities for healing a myriad of health problems arising from chronic sympathetic- system activation or dorsal-vagal dysfunction. Stephen Porges elucidated how our autonomic nervous system affects us mentally, physically, and emotionally. He postulated that physiological 88 EFTA00810090

The Polyvagal Theory—A New Paradigm for Health Care? factors such as the autonomic nervous system and hormonal levels play a role in determining our psychological state and therefore our behavior. If we want to change our psychological state and behavior patterns, or help others change theirs, the solutions might lie in initiating changes in the state of the autonomic nervous system. The implications of Stephen Porges's theory carry the potential to develop and implement many new treatments. Perhaps we will not have to rely as much on antidepressants or other mood enhancers, which are expensive, often do not work as desired, and in some cases have serious negative side effects.° BUILDING ON STEPHEN PORGES'S SUCCESS For fifteen years before I met Stephen Porges, I had been working with biomechanical craniosacral therapy, a form of hands-on manipulation to improve the function of the cranial nerves." The biomechanical approach to craniosacral therapy includes tests for the function of the cranial nerves as well as techniques to remove restrictions in the sutures (bone junctions) of the cranium in order to improve the function of the cranial nerves. After meeting Stephen in 2002,1 developed a craniosacral therapy protocol by choosing several of Alain Gehin's techniques. Together these techniques usually establish proper function of the ventral branch of the vagus and the other four cranial nerves necessary for social engagement. I have taught this protocol to more than five hundred craniosacral thera- pists in Denmark and Norway, and it has proven to be successful in regu- lating their clients' autonomic nervous systems. In many cases, the positive results have been astounding, and there are no negative side effects. I would like nothing more than to be able to pass on this knowledge to all therapists who are interested. However, these techniques are usually communicated in a direct transmission between a teacher and students in small classes. It takes a long time for students to learn and to master the techniques. My first thought when I started to write this book was to introduce the Polyvagal Theory and then present a description of how to do 89 EFTA00810091

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY these techniques. However, there are major challenges in teaching these advanced techniques through a book, especially to people with no prior skills or knowledge of the craniosacral system. So instead I developed some new exercises and hands-on techniques that can achieve the same results. My criteria for choosing the exercises and techniques were that they must be effective for improving the func- tion of the social engagement nervous system for most people; they must be easy to learn; and they must be easy to do. I was blessed with good intuitions—the exercises and hands-on tech- niques that I present in this book actually do work to bring most people into a state of social engagement, and most people can easily learn them from this book. ALMOST EVERYONE CAN BENEFIT FROM THESE EXERCISES This book is mainly written for average people—not necessarily just health care professionals—and for anyone who has failed to find satisfactory solutions to their health needs within existing treatment modalities. The book can also be a resource for psychologists, psychiatrists,ghands-ore body therapists, physicians, and other health care practitioners who are looking for new ways to bring about positive changes in their clients. This approach can be used as an alternative or as complementary to other types of treatments. Many of us have a hard time affording the rising costs of medical treatment, or want to avoid the negative side effects that can come from medicines. The techniques and exercises in this book are a safe and inex- pensive form of self-help. Once you have bought this book, the treatments are free! Warning: If you are taking medicine prescribed by a physician and want to reduce your dosage or stop taking the medicine entirely, please initiate a process of cooperation with your doctor. Do not change your dosage or stop taking your medicine without consulting them. These exercises should in no way replace medical care by a physician, but they will, I hope, help you to become healthier. 90 EFTA00810092

The Polyvagal Theory—A New Paradigm for Health Care? The Healing Power of the Polyvagal Theory A variety of very different health issues are partly caused by vagus nerve dysfunction. Following are case stories of successful treatments that I have given for specific issues, including respiratory difficulties (such as COPD), migraine headaches, and autism-spectrum disorders. These stories give you a sense of the possibilities that the Polyvagal Theory opens up for health care. Later in the book, I will present other cases from a wider range of more general physical and psychological problems, including stress, depression, and various psychiatric diagnoses. These cases, based on my understanding of the Polyvagal Theory, involved the application of hands-on techniques that I used to bring about a state of ventral vagal activity. Rather than encouraging readers to rely on treatment by a therapist, I have developed extremely simple self-help exercises for this book that achieve the same results. A non-trained reader can learn most or all of the self-help exercises by carefully digesting the information in these pages. These methods of treatment are both effective and safe. You can use these exercises and apply these techniques to achieve similar positive results to help yourself and others. If you are a therapist in a clinical setting, you would first test the other person's autonomic nervous system; then you can demonstrate and teach the self-help exercises. Afterward, you should test again to make sure that you have achieved the desired changes. You can suggest that your client use these self-help exercises in the future if necessary. Relieving COPD and Hiatal Hernia Though many people have heard about COPD (chronic obstructive pulmonary disease) only relatively recently, it is one of the world's most common non-communicable health problems. COPD is a disease state characterized by chronically poor airflow, shortness of breath, and coughing. People with this problem cannot exert themselves physically and have increasing difficulty breathing. 91 EFTA00810093

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY It is currently believed that COPD has many causes, including smok- ing and exposure to environmental toxins, in reaction to which the body creates a surplus of fibers that block the airways in the bronchioles and lungs. This blockage of the airways is assumed to be the cause of the individual's breathing difficulties. It is often difficult for those with COPD to remain actively employed and to maintain their previous lifestyles, so they often have difficulty planning ahead in terms of financial commitments. They often also have difficulty maintaining their activity levels outside of work, and therefore have a reduced quality of life." Although steroids and inhalers can temporarily improve breathing, the problems can return as soon as the medicine wears off. And inhalers and steroids often have negative side effects if used over a long period of time, so they are generally recommended for short-term use only. Furthermore, most people around the world with COPD cannot afford inhalers and steroids and therefore do not have access to them. The bottom line is that there is no known cure for their condition, which steadily worsens until they succumb to an early death. COPD typically worsens over time until the respiration is so limited that it cannot sustain life. People with COPD, accordingly, have a reduced life expectancy. Worldwide, COPD affects 329 million people, or nearly 5 percent of the population, although the true prevalence may be higher due to underdiagnosis. In 2012, COPD ranked as the third-leading cause of death (after heart disease and cancer), killing more than three million people.SO How is it possible that, in spite of spending trillions of dollars on medical research every year, we are still unable to successfully treat this widespread illness? Are we looking for answers in the wrong places? As far as I know, until now there has been no known successful treatment for COPD. Perhaps there are solutions that are not based on drugs or surgery. From my success with the following case, among others, I have come to believe that many underlying problems with COPD stem from autonomic nervous system dysfunction, and that COPD is an example of a health 92 EFTA00810094

The Polyvagal Theory—A New Paradigm for Health Care? issue that might be addressed successfully using the insights gained from the Polyvagal Theory. Doctors and hospitals do more elaborate and expensive testing than ever before, but they usually overlook evaluating the function of the autonomic nervous system. This is unfortunate, because patients can be screened quickly and inexpensively for ventral vagus branch function— which affects many other body functions. Restoring the function of the vagus nerve is a key element of my successful treatment of COPD. In my clinic I have been able to help most COPD-diagnosed patients to improve their breathing in spite of the accepted belief in the medical community that no medical treatment can effectively improve a person's mechanical ventilation. By getting the autonomic nervous system to function better, I have been able to help people with a wide variety of chronic problems that have not been helped by other modalities of treatment, whether allopathic or alternative. Although I have worked with many different kinds of health issues, I was especially pleased by my successes in helping COPD-diagnosed clients to improve their breathing capacity. Through a combination of my hands-on treatments and their own practice of self- help exercises, they were able to improve their breathing capacity and thereby increase oxygen uptake into their blood. COPD AND HIATAL HERNIA: A CASE STUDY Although I do not have the facilities to measure vital capacity accurately in my clinic, one of my clients who was diagnosed with COPD had been measured at the hospital before he started with me, and again after seven sessions. His vital capacity (a test for lung function) had improved from 70 percent to 102 percent. (Vital capacity is measured against the aver- age of other people of one's age group, calibrated by body weight. It is possible for a person to be above the average for people in the same age group and calibrated for weight. Therefore it is possible for a person to have a vital capacity of more than 100 percent.) 93 EFTA00810095

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY This client's original lung and bronchial scans showed white areas that the doctors assumed were a concentration of extra fibers, which were supposed to be part of the reason why he was not absorbing sufficient oxygen. My belief was that if we improved the movement of his lungs as he breathed, in time the extra fibers might be absorbed. I saw this client again recently, and his absorption of oxygen had improved by 15 percent. My clinic is in a building in a charming old neighborhood in Copen- hagen. There is no elevator, and my office is one flight up. One day I was expecting a new client, a forty-four-year-old man with difficulty breath- ing. He had told me in an earlier phone conversation that he had a medi- cal diagnosis of COPD. When I heard a knock at the door, I opened it and saw him at the top of the stairs, clutching the railing tightly with one hand, gasping rapidly, and fighting for his next breath. He said that he had had to stop twice to catch his breath on the way up. Before he developed this problem, this man had been in great physical shape. He had actively participated in various sports; his special passion was cross-country skiing. He had just returned from a skiing vacation in the Swiss Alps with his two children, but this time he did not get onto skis; he had to sit on the terrace at the restaurant, wrapped in a blanket, watching them come down the slope without him. He told me about the several large white areas in his lung scan, indi- cating the growth of extra fibers, which the doctors had told him were the cause of his difficulty breathing. I could not deny the fact that there were white areas on the scan, but I did not buy into their explanation that these fibers were the only cause of his breathing difficulties. I looked at his problem as a muscular-skeletal issue: if I could get his ribs and respi- ratory diaphragm to move more normally, I was sure that his breathing would improve, even if scans and x-rays still showed the existence of those extra fibers. From many years of clinical experience, I had come to suspect that when there is a dysfunction in a visceral organ—in this case the lungs— the cause might partly stem from a dysfunction in the autonomic nervous 94 EFTA00810096

The Polyvaga I Theory—A New Paradigm for Health Care? system nerves serving that organ. The ventral and dorsal branches of the vagus nerve, as well as the sympathetic nervous system, innervate the heart and lungs. The dorsal vagus also provides the primary pathways to the subdiaphragmatic vagus nerve branch that extends to the visceral organs below the diaphragm. The dorsal branch of the vagus nerve constricts the bronchioles, reducing airflow. The sympathetic nervous system (associated with stress) dilates the bronchioles, allowing the maximum flow of air. When the ven- tral branch of the vagus nerve functions properly, the bronchioles relax, allowing an adequate flow of air to and from the lungs. Before I started treating this short-of-breath cross-country skier, I asked him where he felt movement when he breathed. He replied that he lifted his upper chest on the inbreath and that it settled back down on the outbreath. I could see what he was describing—he was almost panting, and his breathing was shallow, rapid, and high in his chest. However, this chest movement did not result from lifting of the respi- ratory diaphragm. Rather, it came from the muscles in his neck and should- ers tightening in order to lift his upper ribs. Over time, these tensions had pulled his head into a forward posture (more on this later), which further restricted his breathing. I stood behind him and placed both of my hands lightly on the sides of the lower part of his chest, sensing whether there was any movement in his lowest two ribs. When the respiratory diaphragm functions properly, it tightens on the inbreath, pushing downward and laterally expanding the lower two ribs. The man had only a minimal amount of lateral rib movement on his right side, and no detectable lateral movement on the left side. I like my clients to participate in the evaluation of their own breathing by noticing where there is movement in their chest and belly. Then they can participate by evaluating whether there are any positive changes as a result of my treatment. I showed this client where to feel the movement of different parts of his chest when he breathed in. I asked him what, if any, movement of his ribs he could feel out to the sides. He said that he could not feel any movement. 95 EFTA00810097

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY I tested the function of the ventral branch of his vagus nerve. (I describe how to do this test in Chapter 4.) It took me less than thirty seconds to determine that the ventral branch of his vagus nerve was dysfunctional. Would there be any improvement in his breathing from establishing good function in his ventral vagus with the Basic Exercise? I asked this client to lie down on his back on my massage table, and taught him how to do the Basic Exercise. (You can find instructions for this exercise and others in Part Two.) My cross-country skier had an immediate improvement in his respiration; he was breathing more slowly, more deeply, and without strain. His ribs were expanding out to the sides as he inhaled—he could feel this himself. This represented a major improvement for someone suffering from COPD who had dif- ficulty breathing. I again tested the function of the ventral branch of his vagus nerve, and found that it was now working as it should. Medical doctors and researchers often use a spirometer to test lung capacity. People tend to get nervous, however, when they think that they are being tested, causing them to tense up and restrict their breathing. I prefer to evaluate breathing functionally. I began with the observation that this client had a very difficult time climbing one flight of stairs, indicating how his breathing was impaired when he had to exert himself in a normal, everyday situation. After the treatment, my client looked much more relaxed. When he stood up, I could see that he breathed more deeply and more slowly, and that he had better color in his face. He told me that he felt much better. Not bad for less than six minutes—an examination, one exercise, and a reexamination. My next goal was to further improve the movement of his respiratory diaphragm. The lateral movement of his ribs on the right side had increased, but there was still almost no palpable lateral movement of the lower ribs on his left side. By comparing his right side with his left, I clearly felt that something on his left side was interfering with the movement of his diaphragm. From my experience with many patients, I suspected that this might be caused by a hiatal hernia. 96 EFTA00810098

The Polyvaga I Theory—A New Paradigm for Health Care? What is a hiatal hernia? The stomach is on the left side of the abdo- men, normally below the respiratory diaphragm. The esophagus—the elastic muscular tube that connects the back of the mouth to the top of the stomach—passes through a round opening (hiatus) in the respiratory diaphragm. The ventral branch of the vagus nerve innervates the upper third of the esophagus, allowing its muscle fibers to change their length and lift or lower the stomach, although the typical medical understanding of a hiatal hernia does not consider the role of the vagus nerve. If there is good vagal function, the esophagus can relax and lengthen, letting the stomach move down slightly into the abdomen as the dia- phragm tightens on the inbreath. Ideally, as the diaphragm ascends and descends freely along the esophagus, the contents of the chest remain in the chest (above the diaphragm), and the contents of the abdomen remain in the abdomen (below the diaphragm). However, in cases of vagal dysfunction, the upper third of the esophagus tightens and shortens, pulling the stomach up against the bottom of the respiratory diaphragm. (See "Stomach 2" in the Appendix.) In extreme cases, the esophagus can be so tight and short that it pulls the stomach up against the diaphragm, forcing its opening to enlarge and pulling part of the stomach up into the chest. This is called a hiatal hernia. (The word hiatus means "gap or interruption; and a hernia is a protrusion through an opening in tissue.) In addition to major difficulties breathing, people with hiatal her- nias often have acid reflux. When stomach acid comes up and burns the esophagus or back of the throat, the result is acid reflux, also called GERD (gastroesophageal reflux disease), or heartburn. Other symptoms can include a bloated feeling after eating, and a propensity to eat several small meals rather than three normal meals daily. Normal breathing should involve the di gm moving up and down (see "Diaphragmatic Breathing" on page n cases of breathing dif- ficulties such as asthma and cold lungs (a.k.a. COPD), I have found the shortened esophagus to be a factor that disrupts normal breathing—in fact, I believe it is at the core of many breathing disorders. When the 97 EFTA00810099

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY stomach is pulled up into it, the diaphragm cannot descend freely on the inbreath. When I treat the vagus nerve with the Basic Exercise and then use a technique adapted from visceral osteopathy to lengthen and relax the esophagus, breathing difficulties disappear immediately, and the client breathes deeply without effort. That's often all it takes! Treating a Hiatal Hernia Following is an osteopathic visceral-massage technique for treatment of a hiatal hernia. It works well as a simple self-help exercise. I first instruct clients how to do the Basic Exercise (see Part Two). Then I use a simple osteopathic technique to pull their stomach down and to stretch (lengthen) and relax the esophagus. I usually teach them to do this for themselves. With this protocol, I have helped many patients with diagnoses such as asthma, pulmonary fibrosis, and shortness of breath. The stomach is on the left side of the abdomen, just under the rib cage. Place the fingertips of one hand lightly on the top of where you imagine you can find the stomach. The stomach is soft but palpable. You should be able to feel the stomach if you slowly and gently extend your finger- tips into the abdominal muscles. You only want to feel the top surface of the stomach. Under no circumstances should your move be painful. If the person experiences pain, you should stop immediately. Gently pull it downward toward the feet until you sense the first sign of resistance— usually after pulling it only about one half-inch to one inch (Figure 1). Hold it at that point of slight resistance until the esophagus relaxes. Although you might be tempted to push the stomach down in order to stretch the esophagus, it in not necessary to exert any force. If you have your fingers on the top of the stomach, you will signal the nerves for the esophagus to lengthen, and the stomach will descend in the abdomen, making room for the respiratory diaphragm to descend on the inbreath. A sigh or a swallow usually accompanies this moment of relaxation. At this point, it feels as if the muscular resistance to the stomach's being pulled down melts. And immediately the person is able to breathe moreeasily and deeply. 98 EFTA00810100

The Polyvagal Theory—A New Paradigm for Health Care? Figure 1. Hiatal hernia treatment For this particular client, I guided him in this simple self-help tech- nique so that, by gently pulling his stomach downward, he was able to stretch his esophagus and breathe more freely. With a relaxed esophagus, his stomach was free to move into a better position, lower in his abdomen, an inch or two below his respiratory diaphragm. His diaphragm could then move freely up and down, sliding normally over the outer surface of his esophagus, now that there was mom for it to descend on the inbreath. His lower ribs could also expand laterally to both sides. His breathing was much deeper, and markedly slower. He was exchanging a greater volume of air on every breath. Now came the functional test: The landing at my office door is one flight up from street level, and I asked my client to go up to the top of the stairwell—another four flights up—and then to come back down again. When he returned, he was breathing hard, but his breathing was deeper. Smiling, he said, "I ran the whole way up and the whole way down. I didn't need to stop once:' This was a man who could not walk up one flight of stairs without stopping to catch his breath before our session. 99 EFTA00810101

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY This client continues to take occasional sessions with me. In addition to treating his hiatal hernia, we addressed tensions in other visceral organs that can also hamper breathing. He continued doing the Basic Exercise, the self-help technique for hiatal hernia, and other visceral-massage techniques. I also gave him some movement exercises. After twelve weeks, he was able to ride a bike for several hours with his brother, who had been a national triathlon champion in Denmark. When I last spoke with him, his breathing was continuing to improve, and he was planning a biking trip in the mountains of Switzerland with his brother. This was only six months after he started his sessions with me. When this man was medically scanned again, there were still white areas in his lungs, showing the continued presence of fibers. However, the fibers did not seem to be restricting his breathing. The fibers do reduce the effectiveness of lung tissue in absorbing oxygen. But with a far greater lung capacity, he was now able to perform at a higher level than many athletes. I believe most attempts to treat COPD have been using the wrong map, failing to take into account that part of the problem can be traced to dysfunction of the vagus nerve. I believe that the cause of COPD often involves a lack of activity in the ventral branch of the vagus nerve, leaving the dorsal branch's activity unchecked. The dorsal branch constricts the bronchioles, making it difficult to get enough air into the lungs. This constriction is appropriate for the immobilized state of shutdown, for instance, in a crocodile after it has eaten a big meal and must lie still in order to digest. However, if this constriction is unchecked, it becomes problematic for humans trying to function normally in everyday life. Using the Basic Exercise to activate the function of the ventral branch of the vagus nerve moves people out of the dorsal-branch state of shutdown, so that their bronchioles are no longer constricted. The Basic Exercise, combined with stretching of the esophagus, takes only a few minutes. There is no prescription medicine required, and it is immediately effective, with no negative side effects. To me, this is evidence that the widely accepted explanation of the cause of COPD is not the 100 EFTA00810102

The Polyvagal Theory—A New Paradigm for Health Care? whole story. The man that I treated brought me x-rays and scans showing white areas in his lungs, and had been told that these areas were fibers causing breathing restrictions. If after ten minutes of my treatment he was able to breathe more normally, the idea that his breathing was restricted by the fibers does not hold—or at least we can say that this was not the only explanation. For this man with COPD, improving the function of his ventral vagus nerve, bringing his head back from a forward position, and easing the function of his respiratory diaphragm contributed to improvement in his vital capacity. This was confirmed by hospital tests. Diaphragmatic Breathing Good diaphragmatic breathing is an important element of social engagement. Every person I have observed in my clinic who is in a state of stress or dorsal vagal activity has a disturbed pattern of breathing. Normal breathing should involve up-and-down movement of the diaphragm. In order to evaluate whether this is happening, I place my hands lightly on the sides of the chest at the level of the last two ribs. If there is diaphragmatic breathing, I can detect a lateral movement of the lower two ribs on both sides. However, if there is a hiatal hernia, I can feel lateral movement on the right side but almost none on the left. When we cannot inhale with a normal lowering of their respiratory diaphragm, we find alternative ways to make space for the expanding lungs. One very common way is to lift the shoulders and upper ribs.This is called high costal breathing ("costal" refers to ribs).This breathing pattern is associated with the emotions of fear, anxiety, and panic. Another common pattern in non-diaphragmatic breathing is to inhale using the abdominal muscles. Sometimes, when we are typically short of breath, the belly is distended, soft, and flabby.The belly muscles are too soft, and when they go slack the intestines descend, pulling the lungs down. Sometimes people call this "belly breathing" and interpret it as a good sign because they can see that the breath is going down into the 101 EFTA00810103

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY abdomen. However, it does not actively involve tightening the respiratory diaphragm. People breathing this way often hold their stomach muscles tight on the inbreath. The muscles of their abdomen feel hard. This breathing pattern is associated with anger. Ideally, the abdomen and chest expand and contract rhythmically, at the same time. The lower two ribs (R11 and R12) move to the sides, down, and back with expansion. The next five ribs up (R6-R10) swing out to the sides; this lateral movement is likened to that of a "bucket handle." The next group of ribs above those (R5 to R1) lifts straight upward, along with the sternum, in a movement described as the"pump handle:. If we lose optimal tonus in our diaphragm, we also lose proper tonus in our entire musculoskeletal system. We tend to collapse into our body, and exhibit the breathing of someone who is shut down and manifesting depressive behavior. If, on the other hand, we tighten the diaphragm and push it down onto our gut, we get the body and breathing of someone in a state of anger. The vagus nerve has both sensory and motor fibers that affect and are affected by the movements of respiration. There are four times as many sensory (afferent, or inward-transmitting) nerve fibers in the respiratory branch of the vagus nerve as there are motor (efferent, or outward- transmitting) nerves, and these are constantly monitoring the functioning of the respiratory diaphragm. Proper function of the motor fibers of the ventral vagus is necessary to facilitate relaxed, efficient breathing. When the respiratory diaphragm is not working properly and does not descend on the inbreath, we use muscles activated by either our spinal sympathetic chain or our dorsal vagal circuit, so a breathing pattern that fails to make proper use of the diaphragm will communicate through the sensory nerve fibers that we are threatened or in danger. This is one example of how feedback from sensory branches of cranial nerves influences the state of our autonomic nervous system. 102 EFTA00810104

The Polyvaga I Theory—A New Paradigm for Health Care? Shoulder, Neck, and Head Pain: CN XI, Trapezius, and SCM In addition to being one of the five "social engagement" nerves, cranial nerve XI (the "spinal accessory nerve") has a special muscular function. It innervates the trapezius and the sternodeidomastoid (SCM), two large muscles in the neck and shoulder. (See "Trapezius" and "Sternocleido- mastoid" in the Appendix.) These are the only skeletal muscles below the face and head that are not innervated by spinal nerves. If either of these two muscles is chronically either tense or flaccid, it will respond differently to massage treatment and movement training than any other muscle of the body. Shoulder problems are among the most common forms of musculo- skeletal problems. Dysfunction in CN XI often leads to pain and stiffness in the neck and shoulders, and sometimes simply improving the function of CN X and CN XI with the Basic Exercise is enough to eliminate pain or restricted movement in this area. After doing the exercise, we might want to try other ways to treat other problems stemming from these muscles; for example, see the self-help treatment for migraine headaches described in Part Two. Doing the Basic Exercise seems to also instantaneously improve the function of all five nerves necessary for social engagement for most people. Returning to the trapezius and sternocleidomastoid muscles, we note that dysfunction of CN XI and/or a lack of proper tonus in the trapezius and SCM muscles are involved in many other health issues besides neck and shoulder pain and stiffness. These include migraines, forward head posture, breathing difficulties, chronic spinal sympathetic chain activa- tion, chronic dorsal vagal state, and shortened life expectancy. The trapezius and SCM are also determining factors in the shape and health of the spine. Furthermore, a chronic tension in the sternocleido- mastoid muscles on one side can actually change the shape of the back of the head, leaving it flat on one side because of the constant pull of the muscle on the temporal bones (the skull plates behind the ears). In every child I've treated on the autism spectrum, I have observed this distortion 103 EFTA00810105

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY in the shape of the back of their head?' (See Part Two for a technique to round the back of the head.) Turning the head to either side should be an even, well-coordinated movement, without stops or jerks, and without deviation from a smooth curve. The head should be able to turn ninety degrees, or slightly more. People often complain about reduced range of movement, stiffness, or pain in their neck and shoulders when they rotate their head to one side. If the pain or stiffness is on the side opposite to the direction in which they turn their head, the shoulder problem is most likely either the trapezius or the sternocleidomastoid muscle on the side toward which they are turning. If the pain is on the same side as the turn, the problem is not cranial nerve XI and the trapezius and SCM but is most likely due to the levator scapulae. In Part Two there is a set of exercises called "The Salamander Exercises," which improve the neck's capacity for lateral movement. This exercise can be slightly painful at first, but if we are persistent, we can increase the range of movement, improve the flow of blood to CN XI, and improve the function of our trapezius and sternocleidomastoid muscles. The Levator Scapulae Muscle We can improve the function of the cranial nerves, and improve the rotation of the head to the right and left, with the Basic Exercise and the Salamander Exercises. But these still might not be enough to allow full freedom in the turning of the head, since many other muscles of the neck are involved in head movement, and tension in any of them can restrict head tuming. If we have pain in our neck on the same side our head is turning toward, then the problem is not cranial nerve XI and the trapezius and SCM. It is most likely coming from another muscle, the levator scapulae ("shoulder-blade lifter"). In these cases, working on cranial nerve XI and the trapezius and sternocleidomastoid muscles will probably not remove all of the pain and stiffness. 104 EFTA00810106

The Polyvagal Theory—A New Paradigm for Health Care? Janet Travell, David Simons, and Lois Simons, in their book Myofascial Pain and Dysfunction: The Trigger Point Manual, nicknamed the levator scapulae the'Stiff Neck"muscle." This pair of muscles reaches down from the top vertebrae to the shoulder blade, along either side of the neck. I have found that directly massaging the levator scapulae gives relief, but only temporarily—the muscle dysfunction quickly returns. The problem is probably that the levator scapulae is undertoned. So if you want a more lasting result, Tom Myers suggested massaging the supraspinatus muscle (along the top of the shoulder blade) to improve the tonus of the levator scapulae. (See "Supraspinatus" in the Appendix.) Benjamin Shield suggested another approach. He observed that with a side-bending of the upper cervical vertebrae, you can open the spaces between Cl and C3 to take the pressure off of the spinal nerves that go to the levator scapulae. You might try the upper part (Level 1) of the Salamander Exercises, tipping the head to one side to open the spaces between Cl and C3. THE TRAP EZ IUS AND STERNOCLEIDOMASTOID MUSCLES Problems with the trapezius and sternocleidomastoid muscles are more serious than just the discomforts of pain, stiffness, or migraines. Usually people with dysfunction in either of these two muscles are not socially engaged, and they are prone to all of the problems that I earlier described as the "heads of the Hydra" (see the beginning of Part One). Correcting the function of these two muscles usually improves the function of CN XI and can restore the state of social engagement. Because these two muscles are innervated by a cranial nerve, they are different from the other 660 skeletal muscles in the rest of the body, which are all innervated by spinal nerves. Tension in any of these other muscles can cause pain, reduced range of movement, and stiffness. Dysfunction in the sternocleidomastoid and trapezius muscles, by contrast, is related to a host of serious health issues that we usually do not associate with muscular problems. 105 EFTA00810107

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY The trapezius muscles are a pair of thin, flat, trapezoid-shaped, super- ficial muscles covering a large area of the back of the neck, shoulders, and torso. They originate on the occipital bone, at the base of the back of the skull, and attach to the spinous processes of the shoulder blades and the spinous process of each vertebra of the cervical and thoracic spine (in the neck and torso). The sternocleidomastoid (SCM) muscles attach to the tip of the mastoid process of the temporal bones, along the sides of the skull just behind the ears. Then the muscle splits into two "bellies" that wrap diagonally forward and down, with one part attaching to the top of the sternum (breastbone) and the other part to the medial section of the clavicle (collarbone). Because the two muscles' bellies attach at slightly different places on the skull, they pull the head at slightly differ-ent angles. Also, because the sternal and clavicular bellies of the SCM attach in differ- ent locations on the torso, they also contribute to the rotation of the head. The SCM muscles on both sides muscles can be likened to reins that allow a horseback rider to steer the movement of the horses head. The rider pulls in the reins on one side while letting out slack on the other side. If there is no chronic tension in our SCM on either side, our head would be perfectly balanced on our neck; it would turn just as easily to the right or to the left without restriction or pain. Our head would come to a natural resting position looking straight ahead. However, there is often tightness in one of the bellies of the SCM on one side, resulting in a stiff neck. This makes rotation of the neck easy toward one side, but difficult toward the other. Since the SCM is innervated by the eleventh cranial nerve, this stiffness is often caused by a dysfunction of CN XI and is almost always concurrent with a dysfunction of the vagus nerve. If the bellies of the SCM attaching to the sternum tighten on both sides symmetrically, they will shorten the neck, making it thicker, and pull the head forward. This has been described as a "bull neck." If the bellies of the SCM attaching to the clavicle tighten symmetrically, they pull the head backward, making the neck thinner and longer (a "swan neck"). In her book Rolfing,s3 pioneering body therapist Dr. Ida Rolf calls our attention to the fact that the trapezius and the sternocleidomastoid 106 EFTA00810108

The Polyvaga I Theory—A New Paradigm for Health Care? muscles comprise the outer ring of neck muscles. Inside this outer ring, there are many smaller muscles that help us to make finer movements of the head, to lift the upper ribs when we breathe, and to swallow. The complicated coordination of tension and relaxation of the muscles that turn our head requires precise muscle control. This is programmed into our nervous system in such a way that we do not have to think about the mechanics of it. When something catches our attention, we automati- cally focus our eyes on it. The movement of our head follows the direction of our eyes, and then the movement of our body follows the movement of our head. The eyes focus on an object of interest, and center it in the visual field; then the eleventh cranial nerve innervates the fibers of the trapezius and SCM muscles in order to turn the head in that direction. We were born with this ability to coordinate our eye, head, and body movements. When a baby is lying on its stomach, if an object in front of it suddenly moves or changes its speed, the baby's eyes will focus on the object and follow the movement, first with its eyes and then with its head. We respond to sound in the same way. If there is a sound that catches our attention, we move our head to center the sound between our ears. All of this requires complex coordination of the trapezius, SCM, and other muscles. TRAPEZIUS AND SCM MUSCLES IN ACTION ON THE SERENGETI PLAIN A cheetah is the fastest mammal on Earth, able to run at speeds of up to sixty miles per hour. Running at that incredible speed, the cheetah keeps its eyes fixed on the animal it is chasing. The eleventh cranial nerve enables the cheetah to turn its head and, as its head turns, its body follows. An antelope being chased by the cheetah looks for clear areas where it can get away from the cheetah without bumping into anything. When its eyes find such a space, its head follows the direction of the eyes and then its body follows. Although it is not as fast as the cheetah, the antelope has an advantage: if it ran in a straight line, the cheetah could easily catch it, but with its 107 EFTA00810109

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY light body and thin legs, the antelope can turn faster. So, to avoid being captured by the cheetah, the antelope zigs and zags. The cheetah is unable to do this quite as quickly; because it is so agile, therefore, a healthy adult antelope will usually survive being chased by a cheetah. The antelope also has the endurance to run for a longer period of time and outlast a pursuing cheetah. When a cheetah, lion, tiger, or other predator chases its prey and does not manage to bring it down right away, it becomes exhausted from the intense effort, and it takes several hours to regain the strength to try again. Therefore, before it exerts itself, the cheetah spends time studying the herd of antelopes in order to pick out one that is injured or old, or a newborn hiding in the long grass near its mother. Half of all antelope fawns are lost to predators before reaching adulthood. For both the hunter and the hunted, survival depends in part on turn- ing their heads effortlessly, and the muscles primarily responsible for this are the trapezius and the sternocleidomastoid—both innervated by cranial nerve XI. Because turning the head is a matter of life and death, it is not surprising that the structure of CN XI is highly developed and complex, for precise innervation of the individual fibers of these muscles. USE OF TRAPEZIUS MUSCLES WHEN CRAWLING The trapezius is one of the very first muscles that we humans use as babies. When a baby lies on its stomach, its first movement is to arch its back and lift its head using its trapezius muscles. Then, with its head up, the baby can turn its head and look around using the sternocleidomastoid muscles. (See "Baby on stomach" in the Appendix.) The next step in the baby's development will be to lift its head high enough to bring its arms under its shoulders to support the weight of its upper body. With this, the baby will soon be able to come up on all fours. In this position, tensing the fibers of the upper trapezius extends and arches the neck and lifts the head, and the face looks forward. (See "Baby on all fours" in the Appendix.) In order to do this, the baby tenses all the fibers of the three parts of the trapezius more or less equally. The 108 EFTA00810110

The Polyvaga I Theory—A New Paradigm for Health Care? baby arches its lower back with its lower trapezius, pulls the shoulders together with the middle trapezius, and lifts its head up and tips it back with the upper trapezius. In addition to the trapezius muscle, the head is held up and balanced on the vertebrae of the neck partly due to the action of the setnispinalis capitis, the largest muscle in the posterior neck. Then the sternocleidomastoid muscles can rotate the head quite easily. At this stage in its development, the baby supports its weight on its hands and knees and moves much like other four-legged mammals. After a short while, the baby can begin to crawl forward, moving with first one arm forward and the other one back. This asymmetrical pattern of arm movement when crawling requires using the trapezius muscles asymmetrically. With the body supported on all fours, the arms and thighs are at a ninety-degree angle to the trunk. As the baby pushes down with its arms, there is equal force pushing the arm back up into the socket of the shoulder joint, and the proprioceptive nerves in the shoulder joint can report to the brain that the arms and shoulders feel right and are in balance. CHANGES IN TRAPEZIUS USE WHEN GOING FROM CRAWLING TO STANDING I 'Liman babies support their weight on all fours when they crawl. Human beings have the same physical structure as four-legged animals in terms of the muscles, bones, and nerves involved in this movement. We live in gravity, and gravity is always pulling us down. When we crawled on all fours, we distributed our weight more or less evenly on our four limbs, which held our weight by pushing up into our body. This is a stable structure. When we stood up to balance on our hind legs, we had to use our muscles and bones in a completely new way. Everything changed in the balance of tensions in our muscular and skeletal systems. Instead of a more or less even muscle tonus in the muscle fibers, some muscles became chronically tensed, and others became flaccid. Instead of holding our weight on four supports, we balance our heavy upper body entirely on 109 EFTA00810111

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY the two ball-and-socket joints between the legs and hips when we stand, which is most unstable compared to a four-legged stance. (See "Baby standing" in the Appendix.) Over decades, standing on our back legs can give rise to many prob- lems that four-legged animals do not have. Common to most of us is an increase in our forward head posture (FHP) as we age. (See the following section on FHP and its related health problems.) When we first came up to crawl on all fours, the trapezius muscle held our head up high. The three parts of the trapezius functioned like a single muscle in which all of the fibers had roughly the same tension. Some of the muscle fibers worked to pull the shoulders back and together to support our upper spine, and others fibers pulling in other directions worked to lift the head back and up. But when we stood up, parts of the trapezius muscle lost their integ- rity; they were no longer needed to pull our shoulders together in the back and tilt our head up, as before. Rather than acting as a single muscle, these muscle fibers organized themselves into three functional units—now seen as the upper, middle, and lower trapezius—and these three groups of fibers began to work as separate entities. One part, therefore, might be overly tense while another part is under-tensed. This is reflected in the position of the bones of not only the shoulder but the spine as well. (See "Trapezius" in the Appendix.) The spine of a human being has a much different form than that of a horse, a goat, or a giraffe. A four-legged animal supports part of its weight on its front legs, in contrast to a human being whose arms hang freely from the shoulder joint. There is no longer a pushing of the arms into the shoulder joint. If we have shoulder pain, we often ask ourselves what we did to create the pain—we must have lifted something heavy, or thrown something, such as a baseball, which we were not used to doing. However, an unrec- ognized factor in the creation of imbalances leading to shoulder pain might be changes that have occurred because we are standing upright only on our legs. And there is no telling what a lifetime habit of sitting still on chairs does to our musculoskeletal structure. It is not a surprise 110 EFTA00810112

The Polyvaga I Theory—A New Paradigm for Health Care? that many physical therapists report that the most common problems that they treat are shoulder problems. The human spine has weaknesses that lead to stiff necks, backaches, and shoulder problems. When we stand up, the relationship between the head and the spine changes compared to when we were on all fours. (See "Baby standing" in the Appendix.) In order to balance on our legs, the upper part of the trapezius is no longer positioned to hold the head up and back, and the head tends to slide forward. The middle part of the trapezius muscle no longer pulls the shoulder blades together toward the spine to make a stable base. Instead, for most of us, our shoulder blades glide down our back, forward, and around to our sides. Compared with the deep barrel chest of a four-legged animal, our upper chest caves in, and our belly hangs out. If an actor assumed this pos- ture, it would be to portray a character who had lost a sense of self-esteem. When the lower part of the trapezius does not function as it used to when we were crawling on all fours, our spine shortens, and our head moves into a forward position. These changes are not due to increased muscular tension but rather to a general loss of a balanced tonus in the three parts of the trapezius muscle that used to hold our head up against the constant pull of gravity. To improve the function of the trapezius muscle, therefore, we need to improve the tonus of the muscle fibers in all three parts of the trapezius by stimulating the nerves to the muscle. We can do that with a simple movement that I call the "Twist and Turn Exercise" (see Part Two). Unlike most other exercises, this exercise neither stretches nor strengthens the muscle; by tightening and releasing muscle tension, it simply wakes up the nerves innervating the trapezius muscle. Overly tense areas of the muscle can relax, while muscle tone increases in areas that need it. ASYMMETRY IN TRAPEZIUS MUSCLE TENSION There are always differences in tension among the groups of fibers comprising the upper, middle, and lower trapezius muscles. There is also a 111 EFTA00810113

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY difference between the right and left sides. This asymmetry of the various parts can disrupt the balance in the two shoulders. Because the trapezius attaches to the cervical and thoracic spine, imbalances in tension between the right and left trapezius muscles add to rotations, extensions, flexions, and side-bending of the thoracic vertebrae. This changes the internal space within the chest, which in turn affects the function of the heart and lungs. In some cases this asymmetry can also compress the spinal nerves exiting from these segments, affecting the organs they serve. Some of the spinal nerves (T1—T4) go to the heart, and some (T5—T8) to the lungs. Others (T9 and below) connect to various visceral organs. ASYMMETRY IN STERNOCLEIDOMASTOID TENSION The sternocleidomastoid muscles on both sides are the primary muscles for turning the head left and right, and chronic or acute tension in a sternocleidomastoid muscle results in a stiff neck. A baby with this issue tends to turn its head to one side when lying on its back. As the child gets older, this condition might be diagnosed as torticollis ("twisted neck"). If you examine the back of the head of someone with a stiff neck, you may find it to be flat on one side. If so, the same technique described in the "Technique for Rounding a Flat Back of the Head" on page 178 might not only relax a tight sternodeidomastoid muscle but also to some degree start to round the back of the head, even in an adult. A stiff neck usually accompanies a rotation of the first cervical verte- bra, called the atlas (see "Atlas" in the Appendix), resulting in a reduced blood flow to the brainstem. In adults, a stiff neck may indicate dysfunc- tion of the eleventh cranial nerve which, as noted earlier, is one of the five cranial nerves necessary for social engagement. So releasing SCM tension often makes it easier for us to be socially engaged. This observation is not new; we find references that go back thousands of years. There are surprisingly many references to "stiff-necked" people in the Bible. An example from Nehemiah 9:17 says: `They refused to listen, and did not remember the wonders you performed among them. 112 EFTA00810114

The Polyvaga I Theory—A New Paradigm for Health Care? They became stiff-necked, and in their rebellion they appointed a leader to return to their slavery in Egypt." A NEW PICTURE OF CN XI Turning the head is one of the most important and complex movements of the body. It is one of the first movements that a baby makes, and we are so familiar with this movement that we usually do not even think about it. Control of the trapezius and SCM muscles requires a coordinated tensing and relaxation of their many individual muscle fibers, and this action depends on a well-functioning CN XI. Most anatomical illustrations of CN XI attempt to show all the branches of this nerve in a single drawing, but I have personally found those drawings to be confusing. In order to help you gain a clear under- standing of the complexity of structure of CN XI, I asked my illustrator to make some new drawings in color that show the three parts of this important cranial nerve. (See the "CN XI" series in the Appendix.) One branch of CN XI originates in the brainstem and used to be called the "cranial division." It is now considered to be a part of the vagus nerve— the branch that innervates the pharyngeal muscles discussed in Chapter 4. Another branch, called the "spinal accessory nerve," exits the spinal cord in the neck just below the cranium before going directly to the fibers of the trapezius and sternocleidomastoid muscles. There is yet another branch of the spinal accessory nerve, made of up nerve branches that leave the spinal cord, weave together, extend up into the cranium through the foramen magnum, reach across the floor of the skull, and then exit through the jugular foramen in the base of the skull. In spite of their diverse pathways, all the branches of CN XI function together in a coordinated way to innervate the various parts of the tra- pezius and sternocleidomastoid muscles. CN XI and the ventral vagus (CN X) are closely linked, not only functionally, through their role as two of the five cranial nerves necessary for social engagement, but structurally. In two of the CN XI drawings in the Appendix, a clear connection can be seen between branches of CN XI 113 EFTA00810115

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY and the ventral branch of the vagus nerve after they exit the skull through the jugular foramen: fibers from CN XI intermingle with fibers of the vagus nerve outside the cranium for a few millimeters. In addition to the mixing of their nerve fibers after they exit the jugular foramen, both CN XI and the ventral vagus branch originate in the nucleus ambiguus, a strip of nerve fibers in the brainstem. Therefore, it is not surprising that the function/dysfunction of the vagus nerve is directly mirrored in the function/dysfunction of CN XL The test for CN XI gives the same results in terms of indicating function/ dysfunction as do tests for the ventral branch of CN X. CN XI AND THE VENTRAL VAGUS BRANCH The Trap Squeeze Test for CN XI gives us an indication of the function/ dysfunction of not only CN XI but also the other four nerves necessary for social engagement. All five of these nerves work together; if one is dysfunctional, the others will also be dysfunctional. If we improve the function of one, we also improve the function of the other four. When I started using the Trap Squeeze Test for CN XI and ventral vagus nerve function by asking my patients to open their mouth and say "ah-ah-ah," I began to notice that whenever there was a difference in tension between the trapezius muscles on the two sides, there was always a dysfunction in the ventral vagus as indicated by the uvular lift test. I decided to carry out an informal study in my clinic. I tested the next eighty people who came to me for treatment: first I tested their ventral vagus (with the uvular-lift test for vagal pharyngeal- branch function described in Chapter 4), and then their CN XI (with the Trap Squeeze Test). I found a 100 percent correlation between the results of these two tests. On the basis of that, I felt safe concluding that testing the trapezius muscles is a valid indicator of vagal function/ dysfunction. After clients did the Basic Exercise, I tested them again both ways, and found improvement in both CN XI and the ventral branch of the vagus 114 EFTA00810116

The Polyvaga I Theory—A New Paradigm for Health Care? nerve. The patients agreed with me: "Now, when you squeeze, the two sides feel more like each other?' I asked them to turn their head, and to explore the sensations in their head, neck, and shoulders. In almost all cases, they had better movement and could turn their head further, with less or no pain. The Trap Squeeze Test for Shoulder and Neck Problems Some of the most common complaints among clients of physical therapists and body therapists involve stiffness in the neck and pain in the shoulder. As discussed above, these problems usually include a lack of proper tonus of the trapezius and/or sternocleidomastoid muscles, either of which may be chronically tense or flaccid. Most physical therapists, massage therapists, and body therapists start their treatment by working directly on tight shoulder muscles, without considering the state of the client's autonomic nervous system. When people come to my practice with shoulder problems, I base my approach to this on the research findings of Cottingham, Porges, and Lyon.50 As suggested by their research, in order to achieve positive results with fascial release, myofascial release, or release of muscle tensions in general, it is important to have a well-functioning ventral vagus nerve before attempting any other intervention. So I first test the ventral branch of the vagus nerve, or use the following test for CN XI function. This test often takes less time, and is less intrusive than my test for vagal function, in which clients have to open their mouths and saysah-ah-alf while I use a flashlight to observe uvula-area movement. For this test, we only have to squeeze the muscles on the top of the shoulder. The Trap Squeeze Test takes only a few seconds, and is well suited for use on children and people on the autism spectrum, with whom we might otherwise encounter difficulties in getting their cooperation for the usual technique. To use this form of testing, you first need to practice on several people in order to develop the necessary kinesthetic skills. It is normal to feel 115 EFTA00810117

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY uncertain the first few times that you try testing the trapezius muscles. However, you will likely find that you can get the feel of it after a few attempts. CN XI can be tested by sliding, lifting, and rolling the top of the trapezius muscles (on the tops of the shoulders, halfway to the neck), and comparing them on the left and right sides. Although the trapezius muscle covers a large area, it is very thin. 1. Take hold of the trapezius muscle on each side, squeezing it lightly between your thumb and your first finger (Figure 2). Whereas most novices simply grab the muscle, the lighter you squeeze, the better. 2. If you squeeze lightly and slowly, you should be able to lift the muscle slightly away from the underlying muscles. Figure 2. Trap squeeze test 3. Compare the tonus of the trapezius muscle on one side with the tonus of the trapezius muscle on the other side. Do the two sides feel the same to you, or is one side harder than the other? Ideally, both sides should be soft and elastic. However, one side is often soft and 116 EFTA00810118

The Polyvagal Theory—A New Paradigm for Health Care? elastic, while the other is not. If you squeeze them slowly, with a light pressure, you can feel that the muscle on one side remains relaxed, soft, and pliable if you push deeper into it, while the other side may react to your squeeze by tensing up and feeling hard, even though you are using a very light pressure. 4.1 ask the person who I am testing, "When I squeeze, do the two sides feel the same to you, or do they feel different?" If the person answers that they feel different, I ask,"Which side is more tense?" Here is something that I do not understand, but I encounter it often: more than half the time that I do this test, I disagree with the person I am testing as to which side is more tense, or harderf I do not know why this is so. But I have come to the conclusion that it does not matter in terms of the success of my treatment; the main point is that my client and I agree that there is a difference between the two sides. 5. If we agree that there is a difference, I take this as an indication of dysfunction in CN XI, and I conclude that their autonomic nervous system is not socially engaged, and that they are in a state of either stress or dorsal vagal withdrawal. We can then take the appropriate steps to restore ventral vagal function before proceeding with any further therapeutic techniques. Health Problems Related to Forward Head Posture Serious health problems can stem from kyphosis, or forward head posture (FHP), which is related to dysfunctional trapezius and sternocleidomas- told muscles (Figure 3). A forward head posture is one result of poor posture in general. As we get older, many of us lose the good posture that we enjoyed as children; we may have increased difficulty breathing and be bothered by occasional dizziness. These issues are generally not considered to be medical problems; doctors tend to assume that they are a natural part of growing older and that nothing can be done about them. There is no medicine or operation to help remedy these conditions as such. 117 EFTA00810119

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Figure 3. Forward head position The neck has a tendency to sag when we have FHP, allowing our head to thrust forward. Our upper chest collapses, reducing the space for the heart and lungs. The forward head posture also blocks the action of the muscles responsible for helping to lift the first rib during inhalation, resulting in difficulty breathing. As time goes on and FHP gets worse, we lose an increasing portion of our breathing capacity. FHP is often found in people with breathing problems such as asthma and COPD.66 It is no wonder that they experi- ence general fatigue and low levels of energy. Research published in the Journal of the American Geriatric Society also reports that they also have shorter life expectancy—shorter even than people who smoke a pack of cigarettes a day—and that older patients with FHP have a significantly higher mortality rate." Could restrictions in the function of these nerves also be contributing factors in Alzheimer's disease, dementia, and senility? 118 EFTA00810120

The Polyvaga I Theory—A New Paradigm for Health Care? In addition to reducing breathing capacity, the loss of internal chest space puts pressure on the heart and crowds the blood vessels that go to and from the heart. FHP also compresses the spaces between the vertebrae of the neck and upper thorax, putting pressure on the spinal nerves of the neck and the upper thoracic spine. Furthermore, forward head posture compresses the vertebral arter- ies that carry blood up to the head, diminishing blood supply to the face, parts of the brain, and the brainstem, where the social-engagement cranial nerves V, VII, IX, X, and XI originate. When this occurs, as we might expect, we look pale, lack spontaneous facial expression, and are not socially engaged. If these five cranial nerves do not receive adequate blood circulation, they can fail to function properly, and we are likely to be in a state of chronic stress or dorsal vagal activity. Many aches, pains, and stiffnesses develop over time due to deterio- rating posture. According to a Mayo Clinic newsletter, "Forward head posture leads to long-term muscle strain, herniated discs, arthritis, and pinched nerves."" Neurosurgeon and Nobel Prize recipient Dr. AIf Breig stated,"Loss of the cervical curve stretches the spinal cord 5-7 cm and causes disease.." 8 The characteristic stiffening of the neck in FHP also stiffens the entire spine. According to Dr. Roger Sperry, Nobel Prize recipient for brain research,"Ninety percent of the stimulation and nutrition to the brain is generated by the movement of the spine.'S9 People with kyphosis often have difficulty breathing, mild back pain, and tenderness and stiffness in the spine. Emotionally, they may experi- ence apathy and indifference about what is happening—also symptomatic of dorsal vagal withdrawal. Viewed from the side, our ear should be directly above the midline of our shoulder. However, as we age, many of us succumb to a forward head posture, and you can see that the ear has moved forward in relationship to the center of the shoulder. In this case, we are usually stooped over, our upper chest is collapsed, and our head is no longer balanced on our neck. The neck muscles have to work hard constantly to keep the head from tipping even further forward. 119 EFTA00810121

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY "Every inch of Forward Head Posture ... can increase the weight of the head on the spine by an additional ten pounds," according to A. I. Kapandji in The Physiology of the Joints.° The head itself weighs about twelve pounds, and many of us have our head forward by two or three inches. The man in the forward head posture photograph came to me com- plaining of difficulty breathing and general fatigue. His forward head pos- ture was not the result of muscle tensions, but of flaccid trapezius muscles. As mentioned earlier, FHP often results from a dysfunction in the trapezius and sternocleidomastoid muscles; the trapezius lacks sufficient tonus, while parts of the SCM are in chronic tension. Improving the muscular tonus of these muscles, therefore, brings the head back into better alignment. Many forms of massage and movement work well on muscles of the body generally. However, because these two muscles are innervated by cra- nial nerves, I use a different approach for them. The first step toward nor- malizing tension in either of these two muscles is doing the Basic Exercise (see Part Two). I often see that when a patient does this exercise, even for the first time, it helps bring their head back part of the way. For further improving FHP and bringing the head back to an upright position, I also utilize two other exercises—the "Twist and Turn Exercise" and the "Salamander Exercises." You can find instructions for these exer- cises in Part Two. SCAR TISSUE AS A CONTRIBUTOR TO FHP Scar tissue forms after surgical operations in order to make the body stronger, in case a similar wound occurs at the same place in the future. The patient may know intellectually that this extra scaffolding is not nec- essary, because there is not likely to be another incision at the same exact place, but the connective tissue has no way of knowing this. Although the operation itself might have been necessary or even life- saving, the layers of muscle and fascia contract and thicken as the incision heals, and this tightening in the fascial network spreads beyond the local area of the incision to affect the entire body. Every surgical operation has this negative side effect, which is almost never addressed. 120 EFTA00810122

The Polyvaga I Theory—A New Paradigm for Health Care? Even though there may not be much scar tissue visible on the surface, there can still be extensive buildup of scar tissue in the muscles and connective tissue under the skin, and in the deeper fascia layers. Even if the operation was done with a scope to minimize tissue damage, scars form in the deeper layers. There should be a small amount of thick fluid between adjacent lay- ers of muscle and connective tissue, allowing them to slide freely across one another. During an operation, however, this fluid sometimes dries out when exposed to the air so that, instead of sliding, the layers begin to stick to one another. Also, after a surgical incision or any wound, the connective tissue cells produce extra collagen fibers that can bind one layer of muscle or fascia to an adjacent layer. When two layers have grown together, they no longer slide across each other as they once did. Many surgeons take the extra time and care to ensure that the tissues of each layer are sewn together without involving tissues from other layers. Unfortunately, some surgeons do not understand the importance of this, and might sew layers together haphazardly in an attempt to save time and money. The result is that the muscles and connective tissue are much less flexible in that area. Scar tissue feels thicker and tougher, and it forms not just on the surface but deeper in the body. If it is from a C-section, the scar tissue goes all the way down from the surface of the skin to the uterus. If it is in the chest or abdomen, scar tissue restricts the space available for breathing. Scarring after an operation pulls everything together into a knot; the individual layers dry out and stick together, and movement is restricted. As connective tissue on the front of the body tightens, it shortens the front of the body and pulls the head even more forward and down. Therefore, I recommend that anyone who has had chest or abdomen surgery should find a massage therapist skilled in releasing tensions from scar tissue. The idea behind the treatment of scar tissue is to work on restric- tions in each individual layer of muscle and connective tissue, and then to free the individual layers from each other so that one layer can again slide freely on the adjacent layer. I am regularly amazed by the amount of 121 EFTA00810123

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY improvement that occurs in range of motion in the head and neck, flex- ibility in the spine, and in the posture generally after releasing scar tissue. FHP AND SUBOCCIPITAL MUSCLE TENSION Whereas the sternocleidomastoid and trapezius muscles provide gross rotational movements of the head on the neck, the fine-tuning of these movements comes from the small suboccipital muscles between the occiput and the first two vertebrae of the neck. Three of these muscles define an area called the suboccipital triangle. (See "Suboccipital muscles" in the Appendix.) When these suboccipital muscles are tight, they can put pressure on the suboccipital nerve (see"Suboccipital nerve" in the Appendix) and the nearby vertebral arteries, which are embedded in the connective tissue of the suboccipital triangle. This reduces blood supply to the brainstem as well as to the five cranial nerves whose function is necessary for social engagement. With a forward head posture, the muscles of the suboccipital triangle tighten in order to keep the chin from falling forward onto the chest. If these muscles are kept in a state of constant contraction (over months or years), they contract more and more, which further accentuates the forward head posture, and this can further reduce blood flow to the brainstem. It is not surprising that so many people with FHP complain of head- aches at the back of the neck, just under the base of the cranium, where these suboccipital muscles are located. Pressure on the suboccipital nerves often expresses itself as pain at the back of the neck. It is interesting that some clients with headaches complain that they feel as if they are not getting enough energy (blood circulation) up to their head. I have observed that patients with asthma have poor ventral vagal function. Also, they almost always have a forward head posture. They have a stiff upper thoracic spine, and reduced lateral expansion of their chest when breathing in. Reducing FHP improves their breathing. The Basic Exercise usually releases the tension in the suboccipital muscles. Cl rotates back into place, pressure on the vertebral arteries 122 EFTA00810124

The Polyvaga I Theory—A New Paradigm for Health Care? is reduced, the blood flow to the brainstem increases, and this in turn improves our capacity for social engagement. Relieving Migraine Headaches Unlike "cold lungs" (COPD), migraines do not take years off our life expectancy, but they certainly reduce the quality of our life. There are many affordable medicines for migraines, but these do not work all of the time for everyone. Some medicines are also expensive, and most have possible side effects. So many people would prefer to be free from taking medicine altogether. Of the forty-five million people in the United States who suffer from headaches every year, twenty-eight million suffer from migraines." Aside from affecting quality of life, migraine headaches are one of the most costly health problems in terms of time lost from work. This cost in the United States alone was estimated to be $17 billion a year in 2005.62 Migraine is Greek for "one side of the head." If the pain is not localized on one side of the head, I do not consider it a migraine. Migraine headaches, often called tension headaches, range from moderate to severe, and are usually intense, sometimes throbbing, and typically last from two hours to three days. They often occur with symptoms of autonomic dysfunction. They start suddenly and often disappear just as suddenly; this sets a migraine apart from other headaches that are sometimes described as "dull,""on both sides of the head," or "like a tight helmet; or that come on slowly, increase in intensity, and end gradually. Migraines may be accompanied by other symptoms such as blurred vision, nausea, vomiting, fatigue, and oversensitiviry to light, sound, smell, and being touched. Other accompanying symptoms can include visual distortions (seeing auras) and dizziness. Women might report that their headaches come at a specific point in their monthly cycle. Doctors often classify migraines into different types depending on these accompanying symptoms, and patients usually want to give me detailed information about these symptoms, including how long ago the headaches started and how long they last. Although this information is 123 EFTA00810125

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY important to my client, it does not help me as a therapist to treat them—I know that if I can cure their migraines, the accompanying symptoms will also disappear. To effectively treat a migraine, I need only know on which side of the head the pain appears, and which parts of the two major neck muscles are involved. To establish this, I show clients four drawings of trigger points for the trapezius and sternocleidomastoid muscles. (These drawings are based on the work of Janet Travell, MD, and David Simons, MD, described below.) The red areas in the drawings illustrate the patterns of pain that can come from tensions in these muscles. I ask the migraine sufferer to pick out which drawing best fits the headache, and to show me exactly where she feels pain. Without hesitating, all have been able to identify which of these four drawings best illustrates the pattern of their pain. With this information, I know exactly which muscle is involved. I am primarily interested in the pattern of the pain, which tells me exactly where I should intervene with my hands to bring about lasting relief. In the "Headache" drawings in the Appendix, you can find the different patterns of tension causing these headaches, the different patterns of pain, and where to massage specifically for each pattern. My discovery of this alternative approach to treating migraine headaches did not come all at once in one great epiphany, but in the form of many insights over the years. In my work with Rolfing and other forms of body-oriented therapies, most of my clients came to me because they had pain somewhere in their body. From books by Dr. Janet Graeme Travel ( 1901-1997) 1 learned about using trigger points to successfully bring about relaxation of muscles and to relieve pain. Dr. Travell co-authored the two-volume Myofascial Pain and Dysfunction: The Trigger Point Manual with David G. Simons, MD, and Lois Simons" and served as a physician in the White House, first to John F. Kennedy and then to Lyndon Johnson. President Kennedy had severe back pain stemming from wounds suffered when he served in the Navy in World War II. His fifth and final surgical procedure in September 1957 left him disenchanted with surgical solutions for his back pain. Later, a conservative program, 124 EFTA00810126

The Polyvaga I Theory—A New Paradigm for Health Care? including diluted salt-water injections at trigger points, provided modest relief. He wore a back brace and took hot baths several times a day, often using crutches while walking, except when he was in public view. Janet Travell, however, was able to relieve his severe and chronic back pain. Dr. Travell's research demonstrated that tension in individual muscles generates specific patterns of pain. Most inexperienced massage therapists simply massage where it hurts, but muscle tension often produces pain and other symptoms in other parts of the body. Pain at a distance from the source of tension is called "referred pain?' Dr. Travell found that treat- ing specific points in muscles not only relieves pains near those points but can diminish referred pains as well; she called these "trigger points?' All muscles have trigger points. The therapist will often observe that they feel a little harder compared with other areas on the surface of the muscle; the patient will also feel that those points are painful. Massaging these trigger points relieves the pain in the area locally, and also relieves referred pain occurring at a distance from the tense muscle. Relieving tension in the trapezius and sternocleidomastoid muscles of the neck, by pressing the appropriate trigger points, relieves migraine headaches. I bought two wall posters for my clinic that illustrate the trigger points of many major muscles in an easy-to-use format. Each drawing showed the pattern of pain in a muscle, the muscle involved, and where to massage that muscle in order to release the pain. When people came for pain treatment, I would ask them to point to the drawing in the posters that matched the pattern of pain they felt in their body; then I knew which muscle was involved, and which trigger points, marked with X's, I should massage to bring relief. When I treated the trigger points on the muscles involved in migraines headaches, they disappeared even if they had bothered the clients for twenty or more years. My clients were often amazed at how quickly I figured out where to treat them, and how effectively I could treat pains that other therapists had not been able to handle. I gave photocopies of the drawings of those 125 EFTA00810127

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY muscles to my clients. In case the pain came back, they could treat them- selves, or show it to another therapist treating them. About a third of the people who suffer from migraines can feel when one is about to unleash its fury. This gives them a chance to lie down, take a pill or, better yet, to use the exercises and massage described later in this section. My next important discovery leading to a successful protocol for treating migraines derived from my experiences with biomechanical craniosacral therapy. The twelve cranial nerves exchange information between the brainstem and various parts of the body, primarily to and from regions of the head and neck. One of these nerves, CN XI or the accessory nerve, modulates tension in the sternocleidomastoid and trapezius muscles in the neck, which can cause one of several patterns of pain corresponding to the pains of migraine headaches. Biomechanical craniosacral therapy offers specific techniques to free blockages to the eleventh cranial nerve at the point where it exits the cranium. I get the best results treating migraines when I improve the function of CN XI before releasing tension in the muscles with a light pressure on trigger points. Migraine relief is then faster and longer lasting. Most of my clients are surprised to feel relief on the very first treatment. If the eleventh cranial nerve is not functioning properly, the ventral branch of the vagus nerve and the ninth cranial nerve are usually dys- functional as well. Treating one of the three nerves immediately improves the function of the other two so that, in practice, we do not have to treat each of the three nerves one at a time. The Basic Exercise usually makes all three of these nerves functional. Some writers on the subject of migraines believe that "the underly- ing causes of migraines are unknown'M—and not knowing their cause makes them hard to treat. Other studies show that a number of psycho- logical conditions may be associated with migraines, including activity of the dorsal branch of the vagus nerve, anxiety, and bipolar disorder." I find this of interest from the point of view of the Polyvagal Theory. In Chapter 6, we will look at a few psychological conditions, and note that they have a physiological aspect and are expressions of non-ventral vagal states. 126 EFTA00810128

The Polyvaga I Theory—A New Paradigm for Health Care? Do migraines have a musculoskeletal component? Although some physiotherapists and body therapists are aware of it, the muscular com- ponent underlying migraine headaches is generally not recognized by physicians and medical researchers. Myofascial Pain and Dysfunction: The Trigger Point Manua!shows patterns of pain on one side of the head that are caused by tension in the trapezius and the sternocleidomastoid mus- cles; these are the patterns I show to my clients who complain of migraine headaches, and with these they can easily identify their headache pattern. I have found over the years that improving the function of CN X and XI, followed by releasing tension in these muscles using the appropriate trigger points, usually effectively relieves migraine headaches in a matter of minutes. I have even had success with some people who had migraines their entire life, as far back as they could remember. In my clinic, I like to teach clients how to do the techniques themselves in the event that they are plagued by another migraine headache. Doing the Basic Exercise, they can first establish proper function in their CN X and XI. Then they can find and release the appropriate trigger points. This treatment requires no pharmaceuticals, has no side effects—and no cost. From my successful experience treating migraines, I believe that most migraine sufferers can successfully treat themselves with the Basic Exercise and the self-help massage techniques for migraine described in Part Two, rather than taking painkillers or subjecting themselves to other conventional treatments. In my clinic I occasionally get patients who have had migraines for many years and have tried everything else before coming to me. Perhaps they have treated their migraines with over-the-counter and/or prescrip- tion painkillers, antidepressants, beta-blockers, or drugs developed to treat epilepsy. One of the most common side effects of these drugs is liver damage, which in the worst case can eventually lead to buildup of fluids around the brain. These clients often tell me that they take a lot of medication and would like to cut down. I remember a forty-two-year-old carpenter who was tak- ing fifteen to twenty over-the-counter painkillers a day and was worried about negative side effects, since the directions on the bottle said to take 127 EFTA00810129

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY a maximum of eight tablets a day. My client started taking his first pain- killer in the morning as soon as he opened his eyes, regardless of whether he had a headache or not. He said that he took the pills as a preventive measure so that he did not have to wait for them to take effect in case he got a migraine. He also, however, complained that the painkillers did not always work for him. First I showed him how to treat himself with the Basic Exercise (see Part Two), which is safe, easy to learn, and easy to do. Then I showed him the four drawings of the patterns of pain that are present in most migraine headaches. When he identified the drawing that fit the pattern he was experiencing, I knew which muscles needed to relax, and which trigger points in his neck would relax the tension. His first session with me substantially reduced the number of his head- aches and decreased the intensity of the few that did occur. If the pain returns after I give a treatment, I tell people that they can simply treat themselves as described above. MIGRAINES: A CASE STUDY A woman who had been suffering from migraine headaches for almost ten years came to me for treatments. She was experiencing a migraine at the time she came into my office. On average she had one severe attack every month that usually lasted three to four days. She tried taking painkillers, but they did not help. She tried in general to avoid known migraine triggers such as heavy red wine, strong scents, bright sunshine, etc., but the migraines kept recurring. When she felt a migraine coming on, if she could withdraw and stay in bed, the attack was usually not so bad. This woman is a journalist who wrote articles about beauty for maga- zines. She could schedule around her deadlines if she got a headache because she was working from home; she could take a day or two off, and work when she felt up to it. However, the headaches did keep her from attending many social events and enjoying her weekends off. 128 EFTA00810130

The Polyvaga I Theory—A New Paradigm for Health Care? About a year before she came to me, this woman had started a new career as a TV journalist, which meant that she now had a harder time scheduling around her migraines. She had to show up for work and fol- low the shooting schedule whether or not she had a migraine, so she felt she needed a more effective treatment. First I tested her ventral vagus (see Chapter 4) and noted that it was not functioning as it should. Then I instructed her to do the Basic Exer- cise, and she did this herself; I did not even need to touch her. I tested her again and saw that her ventral vagus nerve was now functioning as it should. Then I showed her the four drawings of migraine pain patterns, and she pointed to the drawing that matched her pattern. I taught her how to use her own hands to treat the trigger points illustrated in that drawing. I certainly could have used my hands for this treatment, but I wanted her to do it herself so that, if she experienced migraines in the future, she could come back to her own muscle memory of how to achieve positive results on her own. Although it is nice when people come back to me because they remember that I helped them in the past, I think it is better for them to help themselves rather than depending on me or any other therapist. I asked this woman to explore the areas in her neck that generally corresponded to the location of the X's in the drawings. She used her fingers to search for areas of the muscles that were hard or painful. If an X area was not hard or painful, she just ignored it. Then I had her rub the hard or painful areas gently until she felt them relax or soften, or until the pain diminished. Although I coached her about what to do and where to put her hands, she treated herself with her own hands. By the end of the session, her migraine had disappeared. She was able to live without migraine headaches for four and a half months. Then, when she did feel a migraine about to start, she again did the Basic Exercise and massaged the trigger points. The symptoms passed quickly and did not develop into a full-blown migraine. 129 EFTA00810131

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CHAPTER 6 Somatopsychological Problems A few decades ago, medical doctors began diagnosing some health prob- lems as "psychosomatic" (meaning that the mind causes problems in the body). However, few psychiatrists and psychologists have investigated the reverse of this: is there such a thing as a somatopsychological problem, where physiology is seen to affect the mind? The word psychology is derived from ancient Greek and means "study of the mind." Today, defining a problem as "psychological" usually means that a psychologist or psychiatrist first looks for the solution in the mind or emotions of their clients, most often using a verbal approach to therapy. In this traditional, older definition, there was no mention of the body. When Freud started psychoanalysis to help people with their psychologi- cal issues, his treatment modality was 100 percent verbal. He let people talk without interruption, and he appeared to be listening. There was no dialogue; he did not even make eye contact or look at his patients face- to-face. People stayed in psychoanalysis for years, often going to sessions several times a week. Before being trained as a psychiatrist, someone must be a medical doc- tor. Then they undergo their own process of psychoanalysis, which may take several years. At one point there were very few trained psychiatrists, and most people could not afford their treatment. Psychologists created a new framework that differed from that of clas- sical psychoanalysis. Clinical psychologists are educated over a period of just a few years in a university program. To help their patients improve their emotional states and change their behaviors, they rely on various models of the human psyche, and they enter into a dialogue with their patients using various verbal approaches. They are generally looking for solutions to specific problems. Although not as expensive as years of 131 EFTA00810133

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY psychoanalysis, psychological treatment is still costly, requiring the time of a trained professional in a one-on-one situation. Some therapists offer group therapy, which is even less expensive, since many patients share the cost of a session. However, that process is more random, since everyone in the group, trained or untrained, gives input into a session. Today we are increasingly moving away from these modalities and relying primarily on prescription drugs to change our behaviors and emotional states. After an initial period of professional consultation to select the medicine and dosage, patients can go for long periods of time just taking their pills without needing to visit a health professional. In spite of the fact that prescription drugs can be expensive, they are cost- efficient when compared to ongoing, one-on-one therapeutic processes with psychologists or psychiatrists. However, because more and more people are taking these medications, this type of treatment means a grow- ing expense for the individual as well as for insurance companies and the national economy. Because psychiatry and psychology started out with an emphasis exclusively on the mind, and because of the current availability and widespread use of prescription medicines, we might be missing out on something else that can help with the health issues that these kinds of treatments intend to address. Perhaps there is something at our fingertips that has no cost or negative side effects. In this chapter, we will look to the body to seek alternative and com- plementary solutions to psychological and mental health issues. We will investigate the possibility of regulating our own nervous systems and our own emotional states and behaviors. We will explore how self-help exercises and hands-on techniques can be perfectly safe and effective in achieving positive changes. Based on my clinical experiences over the last twelve years, I believe that with a working understanding of the Polyvagal Theory many of us can help ourselves by directly treating our own autonomic nervous sys- tems. We may be able to overcome what have been previously considered to be even intractable psychological and psychiatric issues. 132 EFTA00810134

Somatopsychological Problems EMOTIONS AND THE AUTONOMIC NERVOUS SYSTEM Are we open, friendly, communicative, and cooperative? Are we shut down, depressed, or apathetic? Or are we angry, aggressive, anxious, fear- ful, or withdrawn? How do we react to other people when we are in these different states? The way other people respond to us is based on a combination of the state they are in and the state we are in. Our emotions play out in the interaction between the state of our autonomic nervous system and theirs. As mammals, we are social animals, and we need others. We all face challenges and uncertainty from time to time, and in order to improve our chances for survival and fulfillment we are dependent on our interac- tion with others—family, friends, neighbors, workmates, and our social network. How we feel in a given situation or about a specific person is a factor in our behavior. Does someone need our help? Do we enjoy sharing time with her? Is she usually supportive? Are we willing to support her? Do we work well together? Do we feel safe? Is there a chance for coopera- tion, sharing, and friendship? If we are single and dating someone, is there a chance for intimacy and long-term bonding with the other person as a potential partner? If we are married or in an ongoing relationship, do we have enough time together when we are both socially engaged? The more good times we share, the more we have to draw on when the going gets tough. Proper function of the five social-engagement cranial nerves is central to our communication and to bonding with others. These five nerves facilitate our hearing, shape the sounds of our speech, and help us to understand what other people are saying. Can we look at the other per- son calmly and directly, or do we shut them out of our field of vision? If we feel happy and safe, we will generally be able to carry on a normal two-way conversation, listen to what is being said, and look at the other person to exchange meaningful visual cues. I consider the autonomic nervous system and emotional states as two sides of the same coin. If we want to improve our emotional state in order to help ourselves or others, we can accomplish this with physical actions 133 EFTA00810135

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY that improve the state of our autonomic nervous system and move us out of a dorsal vagal or stress state into social engagement. A SELF-REGULATING AUTONOMIC NERVOUS SYSTEM Social interaction with people who are in a state of balance and social engagement is perhaps the most natural and helpful way to achieve self- regulation. If we experience a problem, it is often enough to simply talk about it with a friend. We might sit down and eat a meal, or enjoy a cup of coffee or a beer together. We might sing, dance, or go for a walk together. Another way to self-regulate our autonomic nervous system is to do the exercises in this book. A host of other practices from cultures and traditions around the world have been used for centuries with good effect: meditation, tai chi, and yogic breathing (pranayama), to name a few. When we meditate, we sit still, overcoming any impulse to fight or run. We also learn to keep awake, avoiding the tendency to withdraw and dis- sociate. When we do tai chi, we move slowly, simulating the movements of a very relaxed state. Moving slowly also makes it easier to sense our body and to be present in it. If we can maintain a ventral vagal state, or at least return to it quickly after stress or emotional withdrawal, we can achieve optimal health and well-being. We can open the way to realizing our human potential, enjoy- ing being with other people, and doing what we want with our lives. A FRESH LOOK AT COMMON PSYCHOLOGICAL DIAGNOSES I am neither a psychologist nor a psychiatrist; however, in forty-five years as a body therapist, I have encountered many clients diagnosed by a psy- chologist or psychiatrist. I have also taken many courses in these areas. But I have learned the most from my clients who shared their case stories with me. In this chapter I will present some of these stories. The stories and my commentary are purely anecdotal, based on my own experiences from my practice over the years, seen in the light of my personal and 134 EFTA00810136

Somatopsychological Problems limited understanding of the Polyvagal Theory and its implications. I hope to inspire you—or perhaps provoke you—to take a fresh look at some of these issues, whether you are a trained health care professional, a consumer using health care professionals, or just someone trying to get a better understanding of your own issues in order to help yourself and/or loved ones. I believe that there is an interrelationship between the mind, body, and emotions. Issues as different as post-traumatic stress, anxiety, phobias, and autism spectrum disorders have a somatic component, and almost all cases of so-called psychological problems include a lack of flexibility and resilience in the autonomic nervous system. I have found it both interesting and efficacious to consider the somatic component of what we generally term "psychological issues." A great deal of healing potential becomes available when we consider the possibility of identifying and treating the physical manifestations of the autonomic nervous system at the outset of psychiatric and psychological treatments. If there is indeed a unity of mind-body-emotion, it follows that we might be able to help people with psychological diagnoses by starting their treatment with body-therapy techniques, especially if these can bring them out of a state of chronic stress or dorsal vagal activity and toward greater flexibility of autonomic response. Anxiety and Panic Attacks Since the beginnings of psychiatry at the end of the nineteenth century, there has been a strong focus on anxiety disorders. Occasional anxiety is a normal part of life. We might feel anxious when faced with a problem at work, before taking a test, or when making an important decision. But anxiety disorders involve more than temporary worry or fear. For some of us, anxiety can become excessive, and while we may realize this, we may have difficulty controlling it, so that anxiety may negatively affect our day-to-day living. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time. The feelings can interfere with daily 135 EFTA00810137

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY activities, such as job performance, schoolwork, and relationships. Mod- ern surveys find that some form of anxiety disorder affects as many as 18 percent of people in the United States in a typical twelve-month period; over the course of their lifetimes, 30 percent will experience some anxiety disorder." What we call "fear" is a psychological process involving nervous-system activation in the face of a threatening situation. Fear can immobilize us (via dorsal vagal activity) or mobilize us to fight or flight (from activity of the sympathetic chain). Physical symptoms can include rapid heartbeat (tachycardia), increased respiration, the release of high levels of stress hormones, blushing, difficulty speaking, and sweating in the palms of the hands, soles of the feet, and armpits. Anxiety is similar to fear in terms of its physical manifestations. How- ever, anxiety may not necessarily occur in response to an actual situation. Something can remind us of an event in our past, or we may project our imagination onto something that might happen in the future. In either case, the threat is not happening now. Nonetheless, this emotional state is real, and it exists in the body in present time. When anxious, we find that we cannot get the concerns out of our minds. If another person tells us there is nothing to worry about, it does not quiet our minds; it can sometimes upset us even more. We may respond, "Are you saying my feelings aren't real?" Panic attacks are brief experiences of intense terror and apprehension. They arise abruptly and usually peak in less than ten minutes, although uncomfortable feelings can continue for several hours. Sometimes the specific cause of a panic attack is not apparent. In other cases, we can ascertain that it was triggered by general factors such as stress, fear, or even excessive exercise. People having a panic attack display recognizable signs of fear. Their physical symptoms include trembling, shaking, confusion, dizziness, nau- sea, and difficulty breathing. Their appearance looks strained, their skin is pale, and they have increased sweating in the palms of their hands, soles of their feet, and armpits. Their sweat has a characteristic odor. Dogs and other mammals respond immediately to body smells arising 136 EFTA00810138

Somatopsychological Problems from different emotional states. People also react instinctively to the smell of fear in another person, even though they might not be conscious of it. Many people try to mask olfactory signs of fear and anxiety by using perfumes, deodorants, or foot powders. However, it is difficult to mask a cold, clammy hand and a limp handshake when meeting someone. Sometimes anxiety and panic attacks can be effectively addressed with exercises or hands-on techniques that help bring us out of a state of sym- pathetic nervous system or dorsal vagal activation into a state of social engagement. We sometimes refer to "the drop that made the pitcher overflow!" If an anxious person uses the Basic Exercise regularly, they can minimize the frequency and intensity of panic or anxiety attacks and, in some cases, even prevent attacks. Doing the exercise regularly is like reducing the amount of water in the pitcher, so that it can hold many more drops without overflowing. It is also important to be aware that anxiety can be a side effect of a prescription drug, or indicate a substance-abuse problem, since medica- tions and other drugs alter the state of the autonomic nervous system. CASE STUDY: ANXIETY AND PANIC ATTACKS I had a client who was bothered by anxiety and panic attacks that were keeping her from acting on her desire to have a baby. She also experienced pain in the right side of her abdomen. The anxiety had started fifteen years earlier, when she was eighteen years old and had a surgical operation to remove her ileocecal valve. Problems with the ileocecal valve can be debilitating, and often occur with colitis, abdominal pain, groin pain, bloating, unpleasant body odor, gas, disten- sion of the belly, and breathing problems such as asthma and "cold lunge The ileocecal valve controls the flow of chyme from the small intes- tine into the large intestine. Chyme is the thick, semifluid mass of partly digested food and secretions formed in the stomach and small intestine during digestion. Normally, the ileocecal valve is closed most of the time, only opening for short periods to allow the passage of chyme. When the 137 EFTA00810139

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY chyme reaches the large intestine, excess water is absorbed into the body, and the remaining fiber and other wastes are packed together, formed into feces, and eliminated. Problems arise if the ileocecal valve does not open properly. Problems also occur if it stays open too long, allowing chyme from the small intes- tine to move unrestricted into the large intestine, or to move backwards from the large into the small intestine. In addition to anxiety symptoms, this client had occasional short peri- ods of intense pain on the right side of her abdomen (where the ileocecal valve is located or, in her case, had been located before her surgery). Her doctor took her physical pains quite seriously and wanted to be sure that the operation had gone properly. They did several MRIs and two lapa- roscopic explorations, but found that everything looked all right; they could find nothing to explain her pain. When I asked why she had had the operation in the first place, she said that it was because of pain. But years after the operation, she still had pain in the same area. And despite her psychological pain and suffering, the surgeon expressed no interest in her symptoms of anxiety, even though these had appeared shortly after the operation. Also, no doctor had ever evaluated the function of her autonomic nervous system. The dorsal branch of the vagus nerve innervates most of the organs of digestion, including the small intestine, the ileocecal valve, and the ascending and transverse parts of the large intestine. It receives sensory input from the organs themselves, and exerts motor control over their functions. The first thing that I did in my treatment was to evaluate the state of her nervous system by looking at the back of her throat when she said, "ah-ah-ah." The uvula pulled to one side (indicating dysfunction of the pharyngeal branch of the ventral vagus nerve, described in Chapter 4). I also did the Trap Squeeze Test (see Chapter 5) to check the level of ten- sion in the two sides of her trapezius muscles. There was a dear difference between her right and left sides. My first objective was to help get the woman's autonomic nervous system into a ventral vagal state. I instructed her on how to do the Basic 138 EFTA00810140

Somatopsychological Problems Exercise. One of the great things about this exercise is that clients can do it themselves. It took less than two minutes for me to teach her how to do the Basic Exercise, and less than two minutes for her to do it. After she did the exercise, she felt much better, and she reported that she no longer felt anxious. The muscular tension in her trapezius on the tense side had also relaxed; when I squeezed the trapezius muscles, the muscular tension was similar on both sides. To make doubly sure that there had been a desirable change, I looked at the back of her throat and saw her uvula lifting symmetrical on both sides. I also performed an osteopathic visceral-massage technique to relax tensions in the ileocecal valve, which usually eliminates pain immediately. This client's surgeon assumed that the operation was a success, in terms of its limited objective of removing her ileocecal valve. Until she consulted me, however, no one considered the possibility that her operation had been a traumatic experience that left her autonomic nervous system in a state of dorsal vagal activity. With appropriate treatment, this client made the transition out of a debilitating state of anxiety and into the desirable state of social engage- ment. I emphasized to her that she had made the positive change all by herself, and told her that she could always do the exercise in the future if she ever felt anxiety again. Then I asked her to think about the difficulties triggered by her anxiety in the past. Just thinking about my question was enough to put her into a tailspin, into another state of anxiety. She lost her smile and held her breath, and the skin on her face went pale. So I asked her to repeat the Basic Exercise, and she again told me that she felt better. She looked more relaxed, with good color in her face, and her breathing was deeper. She also told me that she felt the change from anxiety to calm. When I asked her once again to think about the trouble that the anxi- ety had caused her, she was able to remain calm, and said she thought she could manage the anxiety on her own in the future. I tested her auto- nomic nervous system again and found that she was still in a state of ventral vagal activity. She felt no pain. 139 EFTA00810141

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY These improvements came in a single session. The client thought it was a miracle, after all the pain and anxiety that she had suffered before her treatment with me. For me, although I was flattered to hear this, it seemed a shame that the surgeon never examined her autonomic nervous system and did not have a knowledge of visceral massage. A year and a half later, I received an email from this woman. She thanked me for my treatment and wrote that she no longer suffered from anxiety. I suggested that she come for another session with me in order to release any tension that might still remain in the scar tissue, since her long-term improvement depended not only on improving the function of the vagus nerve but on release of the trauma held in scar tissue locally. Pain in the body can cause anxiety. A surgical operation, even though it was consciously chosen, is still an assault on the integrity of the body and, like any trauma, can leave its mark. SOCIAL REGULATION OF ANXIETY STATES Simple, everyday social interactions with supportive family, friends, and colleagues can help regulate our psychological state. We should not underestimate the importance of chatting, small talk, and simple social situations like eating together, having a cup of coffee, or taking a walk with someone. Good social relationships help our nervous systems to self-regulate. Like weeding a garden, if we have been victimized we should eliminate or minimize contact with people who make us feel bad, and maximize the time spent with people who support us and leave us feeling better. When we have been traumatized and then become socially engaged and leave treatment, we will encounter new situations in which we might again feel threatened. At first we may need a therapist's support to be restored to a state of social engagement, but the ideal outcome is having the tools to be able to reach it ourselves. Each time we get back up, we weaken the hold that the traumatic pattern has had on us; we can rest and restore ourselves, making more energy available for us to meet the next challenges in life. 140 EFTA00810142

Somatopsychological Problems If we feel that our social network is inadequate, we may also experience helpful and positive interactions by turning to health professionals such as massage therapists, counselors, coaches, psychologists, or psychiatrists. We may choose to consult a religious or spiritual teacher or leader. We may also find solace in prayer, or read religious and spiritual texts to help put things in perspective. TREATING ANXIETY IN CHILDREN Parents or other adults often tell children, "There is nothing to be afraid of." In many cases, this reassurance from a loving parent or a trusted dose friend is enough to make someone feel safe. It would be even more effective, however, if the adult began by saying, "I understand that you are feeling afraid?' This gives the child assurance that they have been heard, and the knowledge that fear (like other emo- tions) is a normal life experience. The adult can then continue: "There is nothing to be afraid of. It will be all right." Then a little hug helps, so that the child gets positive physical contact and can feel the relaxation of the adult. Phobias Phobias are the single largest category of anxiety disorders, and they can be incapacitating. A phobia is characterized by an experience of extreme fear, with a specific trigger that sets off a state of anxiety or a panic attack. Physiologically, fear arises from a reaction in the sympathetic division of the autonomic nervous system. Between 5 and 12 percent of the world's entire population is esti- mated to suffer from phobic disorders.' Sufferers typically anticipate terrifying consequences from encountering the object of their fear. They want to flee, but they are immobilized. They may understand intellectu- ally that their reaction of fear is irrational and out of proportion to the potential danger, but they are still overwhelmed by their fear." 141 EFTA00810143

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Psychologists and therapists often focus on the object of fear, such as heights (acrophobia), not having enough space (claustrophobia), or spiders (arachnophobia). Their diagnoses focus on the triggers, which may or may not be easily linked to specific biographical events. A pho- bia might be caused by experiences from the past—for example, when someone encountered a threatening person or a life-threatening situation. A phobia can just as easily come from a virtual experience, in which the person suffering the phobia did not actually experience the event—for example, it might have come from someone else telling a story, or from watching a scene in a movie. A list of phobias in Wikipedia—which notes that this list is incomplete and invites re to add to it—included twenty-three entries that begin with the lette alone. This gives us an idea of how wide-ranging this problem is, and gives the impression that almost anything can trigger the same kind of anxiety response. In order to better understand something, we tend to classify it and give it a name. But rather than considering ablutophobia (fear of washing) as basically different from acousticophobia (fear of noise), for example, it may be more useful to move our focus away from the triggers and toward an understanding of the physiological activity in the autonomic nervous system in all cases of phobia. You might be able to assist people with phobias if you can help them return from a state of extreme fear to a state of social engagement using the Basic Exercise (see Part Two). The effect can be similar to what parents do when they help their children by hugging and holding them until the child relaxes and feels safe again. Whereas physical contact is natural between a parent and a child, in a professional psychological intervention there should be no physical contact. Therefore, a therapist needs to find another way to make the cli- ent feel safe again, and directing a client to use the Basic Exercise might be an ideal solution. 142 EFTA00810144

Somatopsychological Problems Antisocial Behavior and Domestic Violence Most people consider normal human behavior as an expression of posi- tive social values. When people are not socially engaged, however, it is often hard for others to understand their behavior. Some people who commit aggressive acts do not have any idea that there is anything wrong with them; they are convinced that the other person caused or justifies their behavior. In other words, aggressive people believe their actions to be a natural response: "He had it coming." They might even consider their action as helping the other person: "It's the only way that she will learn." It may be difficult to understand why seemingly normal people com- mit violent crimes. Observing their actions, we can conclude that they lack empathy, but that does not tell us what is going on inside them. What drives them? Is it territory, power, money, sex, jealousy, or maybe alienation? Or is it just an unpleasant feeling that intensifies and then explodes like a bomb into antisocial behavior? Many violent crimes are not premeditated. I heard an ex-convict in Denmark speak in a radio interview. He had been in prison for most of his adult years for many different offenses, including several bank robberies. After leaving prison, he joined a volun- tary rehabilitation program that included yoga, meditation, and breath- ing exercises, and felt that this program had given him control over his emotions and his actions. When the moderator asked him if he had any remorse about the effects of his actions on his victims, he said no—not when he was committing the crimes. "In a war," he said,"the enemy soldiers have no faces." It wasn't until he had stopped his criminal activities and had been in the rehabilita- tion program that he started to think of the effects on the other people. The perpetrator of a violent crime may or may not have a rational motive that other people can understand, but still somehow they entered a psychophysiological state of fight or flight that drove their actions. 143 EFTA00810145

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY "NICE GUY" COMMITS WAR CRIMES A young man enlisted in the army to serve his country, and was trained to fight. He also learned the rules of conduct expected for soldierly behavior in a war zone, according to the Geneva Convention—not to torture, not to kill civilians, not to rape, not to steal. Almost all soldiers adhere to these rules, but occasionally something else happens. On a routine patrol, this young soldier's best friend was killed by an enemy sniper. Then a few more of his friends were killed or wounded in an ambush by a roadside bomb. Suddenly, the soldier snapped. He ran amok, gathered a few innocent civilians, tied them up, raped one of the women in front of her family, and then massacred them all. He was brought to trial by the army, found guilty, and sentenced to a long prison term. The soldier's parents and friends back home were shocked. They could not believe that he was capable of doing anything like this: "He was such a nice boy, and he came from a good family." "This was so unlike him." "He had always been positive, helpful, and friendly when he was grow- ing up." The term "intermittent explosive disorder" describes the occur- rence of discrete episodes of aggression to other people or to property. The individual may say that the explosive behavior was preceded by a sense of tension or arousal. From the perspective of the autonomic ner- vous system, intermittent explosive behavior is an example of extreme mobilization with fear. Like anxiety, it results in uncontrollable fight or flight behavior. Individual acts of intermittent explosive behavior show up regularly on the evening news—shooting children and teachers at an elementary school, blowing up a church, or suicide bombings. We watch the reports, we are fascinated by the events, and we think to ourselves that we cannot understand how someone could do something like that to other people. The individual's behavior does not seem justified; the violent episodes appear to be grossly out of proportion to any provocation. If you ask the person why they committed the act, they may not be able to give an answer or, if they do, it will not make sense to anyone else. They might 144 EFTA00810146

Somatopsychological Problems say that they felt a (5 of relief are usualk episodes can follow. c of relief immediately afterward. However, feelings d v, hen the level of tension rises again, subsequent CASE STUDY: ONGOING DOMESTIC VIOLENCE Domestic violence is quite different than facing the enemy in a war, or being the victim of random violence in the street. Some people become victims of domestic violence simply when a love relationship goes sour. Let's shift our focus from the perpetrator of violence to the victim. A man and woman are attracted to each other, and they spend more time together; they eventually move in together and start a family. She feels safe with him; she might even feel that he is her protector. Then one day, he suddenly loses his temper and hits her. She is surprised and shocked, and starts to cry. When things settle down, he gives her a hug and says he is sorry. She asks him to promise that he will never do it again, and he promises. After a while, they put the incident behind them. At first she is wary, but he seems to have settled down. Their life together goes on as before—almost. One day, out of the blue, he gets angry and hits her again. She is not only in physical pain, she also feels threatened. When his anger fades, he says he regrets it. Again, they kiss and make up, but as this cycle repeats itself, at some point she moves from feeling safe to living in constant fear. He is physically stronger, so she cannot win in a physical fight. She sometimes fantasizes about hitting him with a frying pan while he sleeps. She considers taking the children and running away. But where would she go? Where would she live? How could she support herself and her children? What would other people say? She feels trapped, and cannot see any viable choices. Reluctantly, she stays. But the joy that she originally felt from being with him at the start of their relationship is dead. He notices that she has cooled to him emotionally, which upsets him even further: "What is wrong with you?" After a few more incidents, she loses any will to fight back or run away. She just endures, and dissociates from her body when she is attacked, as if 145 EFTA00810147

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY she does not care what is happening to her. She may even see herself from a distance when she is being hit. She is just hoping that this will soon be over. But eventually, she even stops hoping. This woman has made a long, unwanted journey from love (social engagement) to mobilization with fear (fighting back and/or running away) to immobilization with fear. She has succumbed to a state that we can describe as "freeze," with the accompanying emotions of apathy, detachment, and hopelessness. Perhaps giving in and being passive when he attacked her helped her to survive; she might have been even more injured if she had fought back, or if she ran away and he came after her. She is too ashamed to tell other people, so she suffers alone. The responses of others may often sound like condemnation: "If it was so terrible, why didn't you run away?""Why didn't you call me? I would have helped you:'"How could you let him continue to do this to you?""If you were so stupid and did not do anything, it's your own fault." These com- ments seem unfair when what she needs is a feeling of being understood, a feeling of safety and support. Other people are unlikely to understand that her nervous system had been hammered down the evolutionary scale from social engagement to stress and finally to withdrawal and apathy. It was her traumatized nervous system that contributed to her behavior. People assumed that she was the same person they knew before—a rational, well-functioning, and socially engaged person. People can be quick to judge without unde- rstanding the instinctive, emotional mechanisms behind such changes. As a first step, a woman who has been abused needs to find a safe environment where she is free from further abuse. The events in the past have already occurred, and we cannot change them, but we can change the way that we react to them emotionally. Is it possible to recover from these abuses and return to a normal life? By the time that the woman I've just described came to me for her first session, she was already out of the relationship. The first thing I did was to test the function of the ventral branch of her vagus nerve. Not surprisingly, I found her in a state of dorsal vagal activity. Near the end of the first treatment, I tested her again and found that she had come 146 EFTA00810148

Somatopsychological Problems up to a state of social engagement. Before ending the session, I did some additional work on her neck and back, and she told me that she felt much better. However, when she returned for her next session two weeks later, she was back in a state of pain, confusion, withdrawal, and apathy. Again she responded positively to the session, and came back up to a level of social engagement. She returned several more times. Each time she left my office, she had come up to social engagement, and the positive effects lasted longer and longer. Over time, my treatments were enough to bring her out of fear, sadness, and despair. Every time that she got back to a state of social engagement, she was less affected by the more difficult emotional states. When a person is socially engaged even some of the time, their interaction with others can be enough to begin to regulate their own nervous system. This client came to me before I had developed and tested the Basic Exercise. After a few sessions, I taught her how to release the tension at the back of her neck with the Neuro-Fascial Release Technique described in Part Two. Rather than needing to come to me for a session each time, she could use the technique to help regulate herself whenever she felt afraid, angry, or powerless. DOMESTIC VIOLENCE: NOT JUST MEN BEATING WIVES Men can be beaten by their wives, children beaten by their parents, and parents beaten by their children. Although individuals seldom talk about having been sexually victimized or physically abused, domestic violence is a more serious problem than many people realize, since most people do not readily admit to being a victim of domestic violence. When I discuss domestic violence in front of a class, although they do not say anything, I can see strong emotional reactions in the faces of many women. They may have experienced violent behavior from a father who hit them to make a point about how they should behave, or a date who had expectations about sex that they did not fulfill, or a husband over a disagreement about the family budget. It might also be that these 147 EFTA00810149

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY women were thinking about a girlfriend, daughter, mother, or someone else close to them who was a victim of domestic violence. How widespread is the problem of domestic violence, interpersonal violence, and stalking? The US government's Centers for Disease Control and Prevention (CDC) conducts an ongoing National Intimate Partner and Sexual Vio- lence Survey.69 They have found interpersonal violence, sexual violence, and stalking to be pervasive in the United States. Intimate partner vio- lence occurs between two people in a close relationship, including cur- rent and former spouses as well as dating partners. The violence tracked included hurting or trying to hurt a partner by hitting, kicking, or other kinds of physical force. The frequency of such violence exists along a continuum from a single episode to ongoing battering. The CDC reports the following in a report titled Intimate Partner Violence in the United States-201e° • Nearly one in five women (18%) and one in seventy-one men (1.4%) have been raped in their lifetime. • One in four women (25%) and one in seven men (14%) have been the victim of "severe" physical violence by an intimate partner. • One in six women (17%) and one in nineteen men (5%) have been stalked during their lifetime. • Women who experienced physical violence by an intimate part- ner, or rape or stalking by any perpetrator, in their lifetimes were more likely than women who did not experience these to have asthma, diabetes, and irritable bowel syndrome. Men and women who experienced these forms of violence were more likely to report frequent headaches, chronic pain, difficulty sleeping, activity limitations, poor physical health, and poor men- tal health than men and women who did not experience them. It should be noted that statistics such as these will always underest{tnate the problem because many victims feel ashamed or threatened, and often 148 EFTA00810150

Somatopsychological Problems they do not report such violence to police or health care practitioners, or even talk about it to friends or family. The majority of this victimization starts early in life. Often intimate- partner violence starts with emotional abuse, and can progress to physi- cal abuse, sexual assault, or a mixture of both. The longer the violence continues, the more serious are the psychological effects. The traumatic experiences have both short-term and long-term con- sequences. Symptoms may include flashbacks, panic attacks, and trouble sleeping. Victims are often left with low self-esteem, can have a hard time trusting others, and experience difficulties being in relationships. The anger, fear, withdrawal, and helplessness that victims feel may lead to eating disorders, symptoms arising from activity of the dorsal circuit of the vagus nerve, and suicidal thoughts. Intimate-partner violence is linked to harmful health behaviors when victims try to cope with their trauma in unhealthy ways such as smoking, drinking, taking drugs, or having risky sex. When a person is being violated, their nervous system is often in a state of shock or shutdown in which they are vulnerable to hypnotic suggestions, i.e., whatever is said to them by their abuser is fully accepted without critical evaluation. Sometimes victims of abuse have also been threatened that "If you ever tell anyone about this, I will kill you:' This can make it difficult or even impossible to get a victim to talk about what happened. A therapist who suspects that this is the case can ask "Just answer me, yes or no—has anyone ever threatened to harm you if you speak about this?" If they say "yes:' the therapist may have unlocked the door, if the patient is no longer under the compulsion to refrain from talking about what happened. BRAIN CHANGES FROM DOMESTIC VIOLENCE With traumatized victims as well as perpetrators, there are actual changes in the structures and function of their brains, especially in the amygdala. The amygdala lies in the temporal lobe, in the midbrain. It is involved in how we respond emotionally to events and information, and contributes 149 EFTA00810151

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY to determining how we behave when faced with potential risks. On scans, the amygdala shows increased activity during negative emotional experi- ences, and when we endure repeated or prolonged periods of stress, our amygdala becomes enlarged. An enlarged amygdala can make it easier to go into a state of stress or shutdown." The hippocampus is in temporal lobes next to the amygdala, and it is where we store our non rel atic memories. As the amygdala enlarges, the hippocampus shrinks from continued exposure to threatening and dangerous experiences." MOVING OUT OF THE PAST AND RECONNECTING TO FUTURE DREAMS If we have suffered a trauma, we will recover more quickly if we can remember our life dreams, mission, and/or goals, which give meaning to our lives. I asked my client who had been domestically abused, "What is the dream that you had for your life, which you have forgotten? What do you want to do?" She said that she wanted to make a good life for herself and her son. In this way she began to look forward to creating her future rather than fixating on what happened in the past. My clinical experience is that the victim of a single traumatic experi- ence can usually return to a normal state quickly. By contrast, the victim of domestic violence may have suffered a series of assaults, both physical and psychological, over a long period of time, and is therefore less likely to bounce back quickly. A successful treatment outcome requires lifting the patient back up to the level of social engagement again and again until they are stable enough to be self-regulating and function normally. Recovering their previous dreams is helpful in this process. 150 EFTA00810152

Somatopsychological Problems Post-Traumatic Stress Disorder (PTSD) Post-traumatic stress disorder (PTSD), sometimes referred to as post- traumatic stress syndrome (PTSS), has become a common diagnosis. With the wars in Iraq and Afghanistan, we have become increasingly aware of the enormous number of veterans afflicted with post-traumatic stress. TRAUMA AND THE AUTONOMIC NERVOUS SYSTEM Ideally, if we have a resilient autonomic nervous system, we rebound to a state of social engagement after a period of time following a traumatic event. Unfortunately, many people do not bounce back. Everyone experiences events that are intense, shocking, and distress- ing, but we react differently to similar events. Some of us are able to get over them quickly, return to a state of balance, equilibrium, and social engagement, and get on with our lives. Others are changed by what hap- pened, and the effects can be long-lasting, draining, and even incapacitatU ing. The negative consequences can even last for the rest of the person's life. If a person is locked into a state of spinal sympathetic activity,"post- traumatic stress" is an accurate description. However, after a trauma, not everyone is left in a state of chronic stress. Many people are actually left in a state of dorsal vagal activity with depres- sive behavior, and describing their condition as "post-traumatic stress" is inaccurate, confusing, and leads to ineffective treatments. It would be more accurate to talk about two different outcomes after a trauma: a chronic, post-traumatic, spinal sympathetic activation state (the fight-or- flight stress response), or a post-traumatic state of chronic dorsal vagal activity (withdrawal or shutdown). Sometimes a person with PTSD/PTSS flip-flops between these two states, both of which prevent a state of social engagement. The problem for many soldiers returning home with a diagnosis of post-traumatic stress is that often the people treating them have not found effective treat- ments. Sadly, many men and women who have served their country in battle therefore wind up socially isolated, and an alarmingly high number of them commit suicide. 151 EFTA00810153

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY I find that simply using the term "PTSD" is not specific enough, is misleading, and often causes confusion. The label "post-traumatic stress" describes an ongoing physical and emotional reaction to an event that happened sometime in the past. It does not indicate the nature of the problems that are currently resulting from that trauma; it just acknowl- edges that something traumatic occurred and that the repercussions are ongoing. Many patients who come to my clinic with a diagnosis of post- traumatic stress are not stressed in their nervous system (via spinal sympathetic chain activation) but are actually in a chronic dorsal vagal state. They are not mobilized into fight or flight but immobilized into fear, apathy, and hopelessness. Trying to treat them as if they are stressed can therefore be confusing and counterproductive. We get a clearer and more useful picture by differentiating between post-traumatic stress and post-traumatic shutdown. Are the patient's behaviors and symptoms a sign of sympathetic nervous system activ- ity, or of dorsal branch activity? Sympathetic chain activity results in what we usually describe as "stressibehaviors, while dorsal vagal activity leaves a person withdrawn and exhibiting depressive behavior. Shutdown to any degree occurs from a surge of activity in the dorsal (old) vagus branch. Mammals share this shutdown reaction with all the other phyla and almost all vertebrates, all the way down the evolutionary ladder to fish without jaws such as lampreys. When treating post-traumatic stress, therapists tend to focus on the trauma itself rather than the psychophysiological fixation that followed the event. Recalling the experience and telling someone else about it is certainly one way to ease post-traumatic stress, but it is not the only way, and it can often backfire, as the person can become re-traumatized by recounting it. In many cases, it is easier and more effective for a therapist to bypass recall of the event, and work with exercises or hands-on trea- tments to restore a state of social engagement. A project in Denmark involved a group of therapists who treated vic- tims of trauma from the wars in Afghanistan and Iraq. The therapists included traditional psychologists, a craniosacral therapist, and body 152 EFTA00810154

Somatopsychological Problems therapists using various modalities. All of the subjects received the same number of sessions, which included both verbal and nonverbal therapies. Some started with craniosacral therapy, followed by other body therapies, and others started with more traditional, verbal forms of therapy. Looking back on the results, the therapists noticed that the subjects who started with the nonverbal craniosacral therapy had better results than the subjects who started by talking about what they had experienced. One of the psychologists in the group, Marc Levin, speculated that when people felt safe and relaxed after the body therapy, they felt more robust and therefore more open when they started to talk about what they had experienced. By contrast, when people talked about their experiences first, it seemed harder for them to let go of it; some of them may have actually restimulated the trauma." When people recall traumatic events in a therapy session, they may go into a hypnotic trance and restimulate the emotional state from that event. If the therapist makes a comment such as, "That was terrible," the remark can be imprinted on top of the person's own experience, so that it is no longer only the client's own belief. Now there is another person—an authority figure—who agrees with the grievance, and this may reinforce its effect. It is thus possible for people to leave their session in worse shape than when they came in. DORSAL BRANCH ACTIVITY AND PTSD The goal of my treatments for people with a diagnosis of PTSD is to lift them out of a state of activity in their spinal sympathetic circuit or dorsal vagal nerve, and to bring them into the state of social engagement. The next challenge is to help them stay socially engaged by repeating this whenever necessary. It's incorrect to assume that activity of the dorsal branch is a purely psy-chological issue to be treated verbally; it is more aptly termed a psy- chophysiological state. Medical doctors often treat mental manifestations of dorsal branch activity biochemically, with antidepressant medications, many of which work as stimulants and create an aroused state in the 153 EFTA00810155

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY nervous system. This helps people to mobilize generally, but it does not bring about desirable social behaviors, or states of happiness or joy. A new understanding of stress and the role of the vagus nerve branches can be a great help in treating many psychiatric and psychological dis- orders. Physiological states driven by activation of visceral organs through the dorsal vagal branch result in a tremendous drain of resources and loss of quality of life—not only for the individuals themselves, their families, and the people around them, but through their economic impact on society in the treatment of these psychological issues. I believe that it is possible to bring a depressed person up to the highest level of autonomic function with the simple and cost-free hands-on techniques and exercises described in this book. RESTORING FUNCTION AFTER A TRAUMATIC EVENT The autonomic nervous system normally has an inherent capacity to self-regulate. If we feel safe in both our environment and our body, then it is natural to be socially engaged—to share and be at ease with others. Similarly, we can be immobilized without fear in order to rest, rebuild the body, and reproduce. Social interaction with other people where we feel safe often restores our ability to return from stress or shutdown to social engagement. However, this does not always happen. The actual situation may be over; we have stopped running or fighting, and we are now free of the threat or danger—but our nervous system can become stuck in the past, and remain in a state of fight, flight, or,7reez41(dissociation). Post-traumatic stress occurs when the survival responses of fight, flight, or freeze have been aroused but not fully discharged. When our nervous system is deregulated, we dissociate. We lose contact with our body, with other people, or with the here and now. We therefore become ineffective and vulnerable. Many commonly used phrases describe this; "out of touch,""not with it,"“beside myself." In terms of the nervous system, we have lost function in the ventral branch of the vagus nerve. This can be observed by the vagal-function testing described in Chapter 4. 154 EFTA00810156

Somatopsychological Problems The trick for restoring self-regulating vagal function is to do some- thing to get ourselves grounded again, to come back to our senses, be in our body, and return to the here and now. Some of us are helped by meditation, some by prayer, others by going fishing or getting away to a quiet place alone to be able to think things through. In Part Two of this book, I present some exercises that help most people to get back in touch with themselves again by restoring ventral vagal function within a few minutes. I also present a hands-on technique called the Neuro-Fascial Release Technique by which one person can help another to restore their vagal function. Some of us might seek the assistance of a therapist, coach, or teacher. The important thing is not what these health care professionals call their method, or what positive results they claim they can deliver, but whether or not their methods actually work for us. If tests showed that the ventral vagus nerve was dysfunctional before the intervention, then the same tests should show that the ventral vagus nerve has become functional after the intervention is applied. If we are trying to restore the regulation of our nervous system with social interaction, we must be sure that the people with whom we choose to interact are themselves well functioning. A simple way of evaluating this is to ask ourselves, "When I am with them, do I feel better afterward?" We have all had experiences of being with people and feeling the worse for it. Once we are balanced and self-regulating again, we should find that we have greater resilience when we are with the same people who brought us down before. Ideally, we will be less affected by them, or at least recover more quickly. Although we can sometimes cut down on the amount of time that we spend with people who upset us, we cannot always avoid them, so it is helpful to be able to respond more resiliently. It is also important to be patient. Helping ourselves successfully even once will make it easier the next time. Being alive entails meeting a con- stant succession of challenges, threats, and dangers, and regulation is an ongoing process of successfully addressing the next difficulty when it arises. We will have an easier time meeting a new challenge if we can 155 EFTA00810157

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY stay grounded, do not become upset, and maintain or quickly recover a well-functioning ventral branch of the vagus nerve. Depression and the Autonomic Nervous System Depression continues to be the leading cause of medical disability in the United States and Canada, accounting for nearly 10 percent of all medical disability." In recent years, medical doctors have been prescribing more and more antidepressants.% In Denmark, where I live, almost 8.3 percent of the population takes antidepressants.'6 The most common form of treatment of depression is antidepressant medications, which are cur- rently ranked third among prescription drugs in the United States, with global sales of more than $9.8 billion in 2013." People with a diagnosis of depression, or people in a depressed state, typically lose interest in activities that once were pleasurable. They experi- ence loss of appetite, overeating, or other digestive problems. They have reduced energy, and become inactive, introverted, apathetic, helpless, and asocial. They can feel sad, anxious, empty, hopeless, worthless, guilty, irri- table, ashamed, or restless. They may experience lethargy, lack of energy, and a lack of goal-oriented activity. They can have problems concentrat- ing, remembering details, or making decisions, and are often plagued by the aches and pains of fibromyalgia. They may contemplate, attempt, or actually commit suicide. These can all be symptoms of activity in the dorsal branch of the vagus nerve. If we consult with a doctor because we are not feeling good, the doctor might ask questions and ascertain from our responses that we are depressed or stressed. Rather than considering the possibility that the condition is transient, the doctor assumes that it is semipermanent, and we are put on medication. Often there is a period of adjusting the dose until we feel better. We may then stay on the medicine for months or even years. Many people who come to me wish to stop taking their medication. Although I support them in this desire, I tell them to only do so in con- sultation with the physician who prescribed it. Also, I recommend looking on the internet to learn about the negative side effects of the medicine, 156 EFTA00810158

Somatopsychological Problems and to find out whatever information is available about withdrawal symp- toms that might occur if they stop taking it. A study published in the Journal of the American Medical Association showed that antidepressant prescriptions work no better than placebos in mild cases of depression." It is well known that these medicines often have negative side effects. Yet antidepressants are still the most commonly consumed class of medication in the U.S., with 270 million prescriptions written for them each year." This raises some obvious questions: Why are doctors prescribing so many antidepressants? Could we benefit by taking a new approach? I believe the underlying problem is a lack of understanding of the nature of the autonomic nervous system, which should normally be flexible, resilient and only temporarily affected by stressors. The Polyvagal Theory may point the way to this new approach. The medical literature has generally focused on the physiology of chronic stress, with less attention given to the physiology underlying depression. When people come to my clink with a diagnosis of depres- sion from a psychologist or psychiatrist, or when they exhibit depressive behavior, I find that that their problem is usually accompanied by a state of activity in the dorsal branch of their vagus nerve. Prior to the Polyvagal Theory, dorsal vagal issues lacked a physiologi- cal model in terms of the nervous system, and perhaps that is why it has been so difficult to find safe, effective medicine-free treatments for condi- tions such as depression. Stephen Porges's Polyvagal Theory focuses on the relationships of the autonomic nervous system, the emotions, and our behavior, and his work has awakened a growing interest in applications of these understandings by psychologists, psychiatrists, and an array of gifted, insightful trauma therapists. Bipolar Disorder Bipolar disorder is a behavioral pattern marked by periods of height- ened activity, elation, and euphoria ("mania"), alternating with periods of depressive behavior. 157 EFTA00810159

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Mania is characterized by abnormally elevated energy levels and an elated, jubilant, euphoric mood. Periods of mania are followed by periods of activity of the dorsal branch of the vagus nerve, experienced as low energy. In some people, these mood swings are separated by periods of "normal" feelings; in other individuals, states of dorsal branch activity and mania alternate with no respite. Such people are often dissociated from sensing their body, and can suffer from psychotic symptoms such as delusions and hallucinations. Bipolar issues affect up to 4 percent of the U.S. population.s° From the perspective of the Polyvagal Theory, the manic phase can be seen as activation of the spinal sympathetic chain. In a manic state, the person expends great amounts of energy and takes many actions without necessarily enjoying or being satisfied by them. In my clinic, many clients tell me that they have been given a diagnosis by a professional psychologist or psychiatrist. I am not trained or qualified to make psychological or psychiatric diagnoses; my observations are anecdotal, based on treatment of these clients. It seems remarkable that the same approach—techniques for establishing social engagement—can help so many people with different psychological or psychiatric diagnoses, including bipolar disorder. CASE STUDY: BIPOLAR DISORDER A few years ago, a woman in her fifties came to me for craniosacral therapy. I asked her what she wanted in terms of positive change. She said that she had heard good reports about our form of craniosacral therapy, and "wanted to relax more." She went on to say that she had a diagnosis of bipolar disorder and had been in and out of the psychiatric hospital regularly over the last twenty years. She said that she experienced periods of lethargy followed by periods of hectic activity. In Denmark some hospitals have a somewhat flexible system of psychi- atric care. After patients are admitted and have been treated for a while, they can ask the psychiatrist to be discharged when they feel that they can 158 EFTA00810160

Somatopsychological Problems cope, and later can be re-admitted when they feel that is needed. This cli- ent told me that when she was not in a depressed state, she felt compelled to action, to the point of being frantic to get everything done. Then, when she collapsed into depression, she would have herself hospitalized. When this woman told me her history, I could read in her body lan- guage that she was dissociated, and this was confirmed by her words. Rather than being grounded and at ease in her body, she said she felt as if she were looking at her life from the outside as it passed in front of her. Many women experience postpartum (after childbirth) depression, and this woman's bipolar states had started shortly after the birth of her son. It's not unusual for postpartum depression to provoke a crisis in a woman's marriage as well as in herself; because of the wife's dorsal branch-induced shutdown/depression, the husband might feel that she is no longer the same woman he fell in love with. This particular couple's life took an unfortunate turn for the worse, as the birth of their baby did not bring them the joy they had dreamed of. Postpartum depression can be exacerbated if the birth was difficult, especially if it resulted in a cesarean section. Even when a C-section is necessary for medical reasons to save the life of the child or mother, it is still a shock for the woman's body, and leaves scar tissue not only in the muscles of the abdomen but also in the uterus. It can take years for a woman to get over postpartum depression and, unfortunately, some women never do. I told this woman that I was not qualified to treat her psychiatric con- dition, but that I would try to help her relax by making her autonomic nervous system more flexible. As a body therapist, I am careful not to imply that I can successfully treat any psychiatric problem. If a patient has a psychiatric diagnosis and I do not feel totally comfortable treating them, I sometimes decide not to. If you are a therapist and you are ever in doubt in such a case, you can always ask the client to consult with their own psychiatrist or psychologist to determine whether there is any reason that you should not treat them. I found that this client's first two cervical vertebrae were rotated, and that she might benefit if we could improve the function of the ventral 159 EFTA00810161

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY branch of her vagus nerve. I showed her how to do the Basic Exercise to improve the position of these vertebrae. Afterwards, when I checked her again, the first two vertebrae of her neck were less rotated, and her ventral vagus nerve was functional. A week later, when the woman came back for her next session, she seemed like another person; she was calm and centered. I checked her vagal function and the position of her first two vertebrae. These were still good; the effects of the first treatment had held. She told me that she now had good energy and was getting things done, but that she did them calmly. She said that she felt confident and ready to get on with her life again. I felt that we had solved the issue in her nervous system. She had been bipolar, moving back and forth between agitated states of stress and collapsed states of dorsal vagal withdrawal, without finding her way into social engagement. Now that she was coming from a state of social engagement, she felt robust, and her nervous system was flexible. She could be stressed or shut down temporarily, and return to social engage- ment when the challenge passed. I told her that she was welcome to come back if she thought that she needed help again. I advised her to go to a good psychologist, and sug- gested that she could use help to manage her relationships in a new way and structure her plans for her future. By now, her son had grown up; he was attending school and living on his own. My client expressed regret over missing much of the experience of being a mother because she had spent so much time in the psychiatric hospital. Over the twenty years since giving birth, she had also missed opportunities for an education, a career, and a meaningful job. She was also living with a man who had fit into her life as long as she was manic- depressive, but their relationship no longer worked for her. She was not sad, however, but quietly optimistic. She was neither manic nor depressed when she assessed her situation; she was calm and spoke in a clear voice as she expressed her determination to make a good, meaningful life for herself. 160 EFTA00810162

Somatopsychological Problems ADHD and Hyperactivity In addition to chronic stimulation of the sympathetic nervous system in children with attention deficit hyperactivity disorder (ADHD), I believe that there may be another physical cause. I had five clients—all boys with ADHD—during the same period of time, and noticed that all five had hiatal hernias,' This led me to speculate that the reason they continually moved from one position to another was to change the level of tension in their respiratory diaphragm. After a few seconds in the new position, that would also become uncomfortable, so they needed to move again. I was able to ease their symptoms with a combination of two tech- niques. The Basic Exercise addressed a dysfunction in the vagus nerve, allowing the upper third of the esophagus to relax. This then allowed the hiatal hernia technique to gently stretch the esophagus so that the stomach could free itself from the respiratory diaphragm and drop to its normal position. Many people are diagnosed by a psychologist or psychiatrist without any consideration that their problems might arise from a dysfunction of their autonomic nervous system. It is my experience that bringing the person into a ventral vagal state often causes their problems to diminish or disappear. 161 EFTA00810163

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CHAPTER 7 Autism Spectrum Disorders The term autism spectrum disorders (ASD) includes autism, Asperger's syndrome, and other conditions. (ADHD is not defined as an autism spec- trum disorder.) ASD encompasses a wide range of symptoms, levels of impairment, and disabilities that can appear in children or adults. These symptoms, assumed to be developmental brain disorders, can cause sig- nificant social, behavioral, and communication challenges. However, there are no neural tests for these disorders. There are many different categories of autism. The disorders affect each person in a unique way, and range from very mild to severe. People with autism spectrum disorders share some of the same symptoms, and seem to handle information in their brain differently than other people do. The exact causes of autism spectrum disorders are unknown. Research suggests that both genes and environment play important roles. The evidence pointing to genes is based in part on the observation that if one identical twin is autistic, there is a good chance that the other twin will be as well. However, despite spending hundreds of millions of dollars, researchers have yet to identify which genes may be defective in cases of autism. Ideally, this will be determined soon, but at present there is no promising cure for autism spectrum disorder based on genetic research. Autism-spectrum diagnoses are based primarily on psychologists' observations of behavior. However, the people doing the testing do not usually consider the physiological signs of the social-engagement portion of the autonomic nervous system. But the autonomic nervous system in part determines the emotional state, and the emotional state is a contrib- uting factor in determining behaviorl believe that if we change a person's emotional state, we can change their behavior. Might some cases of autism spectrum disorder be understood as manifestations of autonomic nervous system disorder? These individuals 163 EFTA00810165

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY are often in a chronic state of either fight-or-flight or dorsal vagal withdrawal. Sometimes, for no apparent reason, they shift suddenly from one of these states to another, catching caretakers off guard. Their behavior is frequently unpredictable and inappropriate for the situation. Based on my clinical experience, I suggest that autism-spectrum tests should include evaluation of the function of their ventral vagus nerve. If it shows dysfunction, further research could tell whether bringing the patient into a state of social engagement by optimizing the function of this nerve brings about positive changes in their behavior. It is my belief that this would be the case. HOW PREVALENT IS AUTISM? The increasing number of individuals diagnosed with autism spectrum disorders makes this the most rapidly growing developmental disability, with a 10- to 17-percent annual increase in the United States. About one in sixty-eight children have been identified with ASD, according to esti- mates from the CDC's Autism and Developmental Disabilities Monitor- ing Network (ADDM)." According to other estimates, autism-spectrum disorders affect one out of ninety children." The economic costs of autism are also enormous, not only for the individual families but also for society as a whole, as demands for autism- related health care and other services skyrocket. The cost of autism over an average lifespan is $2.4 million per individual in the United States," for an annual total of $20 billion." Other estimates of the cost of support- ing children with autism in the U.S. are $61-66 billion a year; for autistic adults, these costs have been estimated at $175-196 billion a year.d6 More importantly, there is also a human loss to our society. Among the personal costs of autism is the heavy emotional toll it exacts on the parents, which cannot be calculated in dollars. Before the child was born, the parents had dreams and hopes of having a family like other families, with well-functioning children; often autistic individu- als cannot hold a job and contribute to the workforce, or can have difficulty in parenting the next generation. Whatever their goals may 164 EFTA00810166