Hypervigilance in PTSD and Other Disorders

By Misha Jan, published March 29, 2022

Fact checked by Saul Mcleod, PhD

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Sensory stimulation such as sweaty palms, heart racing, and looking from side to side is activated to keep us safe during times of danger to prepare us for a freeze, fight, or flight response.

In some cases, it is activated in response to a perceived threat that is not present, this is also clinically known as hypervigilance.

What is hypervigilance?

Hypervigilance is an often fearful, self-protective psychological state of constantly assessing your surroundings. It is critical to help you avoid danger.

Someone who is experiencing hypervigilance elicits amplified sensory sensitivity to their environment, and the nervous system is hyper aroused to detect possible threats.

This over-stimulation of the nervous system leads to erratic and exaggerated self-defensive behavior in response to a perceived danger that is more than often actually absent.

When experienced for a long period of time, chronic hypervigilance involves a persistent overreaction to a threat that may not exist.

Hypervigilance has many serious implications on quality of life. It is associated with high levels of anxiety, which can lead to mental exhaustion and difficulty with sleep.

Hypervigilance can produce obsessive patterns due to constantly being hyper-aware of one's surroundings. Moreover, it can lead to impairments in day-to-day functioning, for example at work or in social interactions.

Hypervigilance vs. Paranoia

Hypervigilance and paranoia are symptoms of mental health disorders such as bipolar disorder, anxiety, schizophrenia, and Post Traumatic Stress Disorder (PTSD).

Accordingly, the most prominent symptom of PTSD is hypervigilance, while the most prominent symptom of schizophrenia is paranoia.

Fear is the underlying emotion of both hypervigilance and paranoia. However, paranoia differs from hypervigilance in the fact that it involves irrational thoughts. For example, a paranoid person will have intruding and real thoughts that transcend into delusions. These delusions often have to do with suspicious ideas about other people.

On the other hand, hypervigilance is a state of active threat detection and involves fixated scanning of the environment to watch out for threats.

Individuals who experience hypervigilance have an intense yet disproportionate awareness of their surroundings.

Paranoia is present-focused and involves untrue and specific beliefs about people, while hypervigilance is a future-focused alert state involving fears about impending danger.

Overview of PTSD

Extremely stressful events can leave lasting imprints on an individual's mental health. Post-traumatic stress disorder (PTSD) is a mental health condition that involves frequent psychological disturbances, as a result of a major traumatic event.

A traumatic event is a stressful or threatening experience that is witnessed or experienced. Upon exposure to trauma, PTSD afflicts about 5% to 10% of the population and is higher in women than in men. 

PTSD is characterized by the impairment of optimal daily functioning. Some of the symptoms of PTSD include recurring flashbacks, panic attacks, depression, nightmares, and constant hypervigilance.

Causes of PTSD

PTSD is caused by either witnessing or experiencing a shocking, disturbing, or frightening event. It is commonly seen in post-war veterans, survivors of physical or mental abuse, serious injuries or accidents, and more.

PTSD can result in chronic hypervigilance due to a constant feeling of uncertainty resulting from traumatic experiences. Although it is important and in some cases useful to be vigilant.

For example, while walking alone at night, chronic sufferers of hypervigilance remain in overdrive even in normal conditions, thus overreacting to triggers that are not really a threat.

This is due to a multitude of triggers that send the body into a sustained “fight and flight” mode to protect itself from re-experiencing the trauma.

Common Triggers

A trigger is a signal that revives past memories which can then produce psychological and physiological responses.

In the context of PTSD, some of the common triggers that can stimulate or worsen hypervigilance are:

• Stress

• Sudden loud noises

• Conflict

• Unpredictable environments

• Crowded places

• Exposure to stimuli associated with the traumatic event

• Feeling abandoned

• Feeling stuck

What are The Symptoms of Hypervigilance?

There are various signs that can help detect hypervigilant states. The symptoms fall under 3 distinct categories.

First, the physiological symptoms are the body’s physical reactions while emotional symptoms are observed through mood and temperament responses.

Finally, behavioral symptoms are the actions that are elicited as a result of the condition.

Physiological Symptoms

The sympathetic nervous system is activated causing adrenaline and noradrenaline to be released into the bloodstream in preparation to fight or flight and respond to danger.

This response is evident through the following symptoms:

• Dilated pupils

• Elevated heart rate

• Increased blood pressure

•  Sweating

• Rapid breathing

• Increased sensitivity to pain and emotions

• Increased energy

• Easily startled

• Highly reactive

• Sleep disturbances

• Racing thoughts

Emotional Symptoms

Hypervigilance is an emotionally taxing state. The emotional effects often cause problems in a healthy functioning lifestyle. Some of the most common symptoms are:

• Anxiety

• Flashbacks

• Restlessness

• Constant fear or worry

• Anticipating danger

• Emotional outbursts

• Mood swings

• Anger

In some cases:

• Emotional withdrawal

• Detachment

• Paranoia

Behavioral Symptoms

Behavioral symptoms are defence mechanisms which can fall into either avoidance and escape behaviors or confronting and aggressive behaviors.

Some examples of common symptoms in each category are as follows:

Avoidance & Escape Behaviors

In avoidance, individuals tend to freeze or flee, withdrawing from social settings and isolate themselves.

This can interfere with important pillars of wellness, for example causing relationships to deteriorate.

• Knee-jerk reactions

• Substance use and/or abuse

• Avoiding difficult conversations and confrontation

• Withdrawn in social settings or new situations

• Not listening to others

• Wishful thinking or daydreaming

• Isolating from friends and family

Confronting and Aggressive Behaviors

People with aggressive and confrontational responses have a proclivity towards fighting or attacking for defense.

This can, at times, lead to trouble with the law.

• Defensiveness during conversations

• Overreacting to mundane stimuli

• Frequently and easily angered

• Denying any blame

• Controlling behavior

• Impulsive aggression

• Deflecting blame onto others

• Risk-taking

The Problem with Hypervigilance

Unfortunately, many individuals who experience hypervigilance turn to drugs as a solution to this overstimulation and chronic stress. To be more specific, it is estimated that 46.4% of patients with PTSD also had a substance use issue (McCauley, 2012).

In addition to substance abuse problems, many people report having a hard time falling asleep.   Hypervigilance in inappropriate settings is the main factor in severe anxiety.

Studies show that in hypervigilance, there is consistent, random and potentiated activation of the amygdala, which is a brain region associated with emotion regulation and fear.

The insula is another brain region located in the cerebral cortex that is also responsible for regulating emotions as well as processing bodily sensations.

It was found to be active even during sleep in people experiencing hypervigilance. Both the amygdala and insula’s hyper arousal is attributed with troubling factors such as difficulty falling asleep, the feeling of wakefulness during sleep, and an increased perception of pain.

Hypervigilance Treatment Options

Fortunately, there are many treatment approaches for hypervigilance.

To understand the symptoms more deeply, a doctor can help you determine if it is linked to another mental health condition.

Therapy

Therapy involves communicating with a psychotherapist to help you understand and overcome your mental struggles in a collaborative way. There are many variations of therapy that can be utilized to manage hypervigilance.

A doctor will assess your individual case to see what approach will work best.

Some of the therapeutic approaches to treatment include, Psychoeducation, cognitive behavioral therapy (CBT), exposure therapy, eye movement desensitization and reprocessing (EMDR), and psychoeducation.

Cognitive Behavioral Therapy (CBT)

CBT is a very common type of psychotherapy in which therapists work collaboratively with patients to constructively reframe their thoughts, emotions, and behaviors.

This form of client-centered talk therapy is shown to be highly effective in treating depression, anxiety, addictions, and many more mental health conditions.

Psychoeducation

Psychoeducation is a part of CBT in which a therapist offers knowledge to the patient about their condition, symptoms, or techniques.

Having awareness about one's condition has been shown to help in the management of symptoms.

Exposure Therapy

Many techniques that work for PTSD may be applied to treat hypervigilance, such as exposure therapy which is another form of CBT.

Systematic desensitization is a form of exposure therapy in which the individual is exposed to the triggering stimuli and works with a trained professional to address the emotions that arise in a healthy way.

EDMR

Unlike many forms of therapy, Eye movement desensitization and reprocessing (EDMR) does not require the patient to communicate all the aspects of their trauma.

Rather, EDMR therapy incorporates specific eye movements from left to right while clients focus on the traumatic memories. This is thought to initiate the brain’s natural ability to process trauma.

Medication

Medications can help decrease symptoms in severe cases and are prescribed on a case-by-case basis.

The anxiety that accompanies hypervigilance may be treated with anti-anxiety medication (such as beta-blockers, benzodiazepines, antidepressants).

Benzodiazepines

Benzodiazepines are GABA agonists. GABA inhibits neuronal activity and acts as the body's natural tranquilizer by increasing relaxation and inducing drowsiness.

Benzodiazepines are often prescribed to treat anxiety and panic disorder. Therefore, it can help manage the stress associated hypervigilance. 

Some commonly prescribed benzodiazepines include alprazolam, chlordiazepoxide, diazepam, and lorazepam.

Antipsychotics

If hypervigilance is associated with schizophrenia or bipolar disorder, antipsychotics may be prescribed.

Antipsychotics work by blocking the action of dopamine D2 which helps reduce neural activity. This is thought to help reduce psychotic symptoms and hyperarousal.

Common Antipsychotic medications include quetiapine, aripiprazole, olanzapine, and risperidone.

Antidepressants

Antidepressants are often used to treat depression. However, they can also be used to treat anxiety, pain, and addictions.

The antidepressants widely prescribed for anxiety are selective serotonin reuptake inhibitors (SSRI).

SSRI’s work by inhibiting the reuptake of serotonin thus increasing the availability of serotonin.

This helps alleviate anxiety and anxiety related symptoms such as hypervigilance.

Antidepressants that are frequently prescribed for anxiety include citalopram, escitalopram, fluoxetine, paroxetine, and sertraline.

Beta-blockers

Beta-blockers are commonly prescribed to treat abnormal health rhythms and hypertension but can also help with hypervigilance.

They work by inhibiting the release of adrenaline which is a stress hormone. They allow heart rate to decrease which helps lower blood pressure and reduce anxiety.

Some examples of beta-blockers include acebutolol, atenolol, betaxolol, and bisoprolol/hydrochlorothiazide.

Coping Skills

Coping skills are an integral part of restoring optimal functioning when suffering from hypervigilance and associated mental health concerns.

Prioritizing self-care is the best way to support yourself through this emotionally draining experience and can include daily practices such as:

Mindfulness

Mindfulness exercises can help bring awareness to the emotional state in the present moment. It means being aware of thoughts and emotions without judgment.

A core component of mindfulness exercises is becoming aware of one’s negative thoughts as soon as they surface and instead of following the thought or ruminating on it, it is simply observed and let go.

Breathing

During hypervigilance, the body’s sympathetic nervous system is activated which is responsible for our fight and flight response, and response to potential danger.

Deep breathing is an excellent tool that has been shown to activate the parasympathetic nervous system and stimulate the vagus nerve.

The parasympathetic nervous system is active during relaxation and is often referred to as the rest and digest response. It has the opposite physiological reactions to the sympathetic nervous system.

Exercise

As noted earlier, one of the problems with hypervigilance is that it increases pain sensitivity. To counter this, exercise can be highly effective at mitigating pain.

During exercise, the body releases chemicals known as endorphins. Endorphins bind to opiate receptors and increase positive feelings, similar to morphine. Most importantly, they help reduce pain and stress.

While there is a range of coping skills you can use at home, it can be difficult to address the root cause of hypervigilance on your own.

Therefore, reaching out to an expert could be extremely beneficial and can help you feel safe during recovery.

Hypervigilance is an emotionally draining experience that impacts many areas of your life; from stressful social interactions to difficulty falling asleep.

Overall, seeking treatment can help you identify if it is being caused by another mental health condition along with personal triggers. 

Working to find a treatment plan that is best suited to your needs, also known as an individualized treatment approach, is critical in re-establishing mental and physical well-being, and ultimately to living a happy and healthy life.

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