Tackling hyperarousal: an integrative multimodal approach

Introduction: The effectiveness of treatment for PTSD is limited, which is especially true for war veterans, of whom 30-50% do not respond to therapy. Hyperarousal is central to the maintenance of trauma pathology. The mainstream trauma-focused therapies traditionally target the cognitive processing of traumatic experience. In this article, we propose that these therapies may be enhanced by the inclusion of interventions specifically targeting hyperarousal.Method: We review an earlier formulated model of trauma supporting our proposal. This model is based on a theory of trauma that integrates the concept of allostasis with the predictive processing framework. In this view, trauma is considered a maladaptive stress response guided by false inference.Results: The reviewed model is in agreement with the central role of hyperarousal in the maintenance of trauma-induced disorders. It also demonstrates the importance of targeting hyperarousal at the same time as maladaptive cognitions and behaviours associated with trauma. A treatment for PTSD is proposed that combines exposure to trauma-related cues with neurofeedback-mediated regulation of arousal.Conclusions: Our analysis argues for the integration of hyperarousal-targeting interventions into existing therapies. Accordingly, we offer methodological considerations based on the nested hierarchy principle that can guide such integration.