Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about taking advantage of the polyvagal theory of anxiety and social engagement during psychotherapy.

Dr. Moller is associate professor of nursing at Pacific Lutheran University in Tacoma, Wash., where she coordinates the psychiatric mental health nurse practitioner doctorate nursing practice program. She also is in practice at Northwest Integrated Health. Dr. Moller has no conflicts of interest.

Later, Renee Kohanski, MD, discusses the sacred relationship that exists between doctors and patients.

Take-home points

• The polyvagal (PV) theory relates autonomic nervous system functions to human behavior and response to trauma.
• The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which together regulate the autonomic state in response to the environment and influence behavior.
• The unmyelinated dorsal vagus nerve controls the “freeze response,” while the myelinated ventral vagus nerve modulates social communication and can inhibit the arousal state.
• This theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagus nerve.
• It’s easier to apply the insights of polyvagal theory in person, but Dr. Moller suggests specific techniques during teletherapy. She prioritizes eye contact, which has to be done by looking at the camera; modulating your tone of voice to be more soothing; and having the patient use biofeedback techniques, such as taking their pulse during a session to make note of their physical response to anxiety.

Summary

• The association between the sympathetic nervous system and “fight or flight” is well known. The polyvagal theory relates autonomic nervous system functions to behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which regulate the autonomic state in response to the environment and influence behavior.
• The unmyelinated dorsal vagus nerve innervates from the diaphragm down, controlling the “freeze” response. When the dorsal vagus nerve is activated, physical signs can include bradycardia or tachycardia, shallow breathing, and a “pit in the stomach” feeling from slowing down the GI tract.
• The myelinated ventral vagus nerve innervates from the diaphragm up, and modulates social communication and engagement, which can inhibit the arousal state. Social engagement is attunement to the subtle cues occurring during engagement with another person.
• The PV theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagal nerve.
• In the PV theory, the concept of “neuroception” is likened to an unconscious threat detector sensed by the vagus nerve before the threat is registered by the brain.
• Coregulation is using the environment, most commonly the physical and emotional response of another person, for emotional regulation. This occurs in the therapeutic dyad when the therapist is attuned by and not enmeshed with the patient. Think of coregulation as akin to attachment theory; when the parent is attuned and present, the child feels safer and is able to relax.
• Dissociation is the “freeze” mechanism of reacting to traumatic events in the moment, and again when the memories are triggered by stimulus in the environment. One way to treat dissociation is through engaging the ventral vagus nerve using social connection, such as gentle voice, gentle touch, and deep breathing or other grounding exercises. The PV theory connects the physical and emotional responses to trauma.
• It is impossible to physically connect through telehealth, so Dr. Moller prioritizes eye contact by looking at the camera, though this means taking one’s eyes off the patient, as well as having the patient take their own pulse to reinforce the use of biofeedback, and “breathing together” over the video treatment.

References

Dana DA, Porges SW. The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (New York: W.W. Norton & Co., 2018).  

Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116-43.

Beauchaine TP et al. Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biol Psychol. 2007 Feb;74(2):174-84.

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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