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Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid\u2010 and opioid\u2010mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower\u2010level midbrain and extended brainstem systems.<\/jats:p>","DOI":"10.1002\/jnr.24447","type":"journal-article","created":{"date-parts":[[2019,6,29]],"date-time":"2019-06-29T03:38:21Z","timestamp":1561779501000},"page":"1110-1140","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":77,"title":["The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray"],"prefix":"10.1002","volume":"97","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6770-2715","authenticated-orcid":false,"given":"Braeden A.","family":"Terpou","sequence":"first","affiliation":[{"name":"Department of Neuroscience Western University London Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sherain","family":"Harricharan","sequence":"additional","affiliation":[{"name":"Department of Neuroscience Western University London Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret C.","family":"McKinnon","sequence":"additional","affiliation":[{"name":"Mood Disorders Program St. Joseph\u2019s Healthcare Hamilton Ontario Canada"},{"name":"Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton Ontario Canada"},{"name":"Homewood Research Institute Guelph Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Frewen","sequence":"additional","affiliation":[{"name":"Department of Psychology Western University London Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rakesh","family":"Jetly","sequence":"additional","affiliation":[{"name":"Canadian Forces, Health Services Ottawa Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth A.","family":"Lanius","sequence":"additional","affiliation":[{"name":"Department of Neuroscience Western University London Ontario Canada"},{"name":"Department of Psychiatry Western University London Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,6,28]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1002\/da.20462"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.bbr.2011.09.009"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.yhbeh.2012.02.012"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1177\/0269881115570081"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/PSY.0000000000000010"},{"key":"e_1_2_11_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10286-008-0479-7"},{"key":"e_1_2_11_8_1","volume-title":"Diagnostic and statistical manual of mental disorders","author":"American Psychiatric Association","year":"1994"},{"key":"e_1_2_11_9_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.books.9780890425596"},{"key":"e_1_2_11_10_1","doi-asserted-by":"publisher","DOI":"10.1037\/0735-7044.110.6.1397"},{"key":"e_1_2_11_11_1","doi-asserted-by":"publisher","DOI":"10.1038\/nrn2648"},{"key":"e_1_2_11_12_1","doi-asserted-by":"publisher","DOI":"10.1037\/bne0000151"},{"key":"e_1_2_11_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1469-8986.2005.00287.x"},{"key":"e_1_2_11_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.neubiorev.2013.06.004"},{"key":"e_1_2_11_15_1","first-page":"175","volume-title":"Plenum Press","author":"Bandler R.","year":"1991"},{"key":"e_1_2_11_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0361-9230(00)00313-0"},{"key":"e_1_2_11_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/0166-2236(94)90047-7"},{"key":"e_1_2_11_18_1","doi-asserted-by":"publisher","DOI":"10.1002\/jclp.22200"},{"key":"e_1_2_11_19_1","doi-asserted-by":"publisher","DOI":"10.1037\/0033-2909.133.1.1"},{"key":"e_1_2_11_20_1","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1097-4679(199712)53:8<859::AID-JCLP11>3.0.CO;2-J"},{"key":"e_1_2_11_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/0306-4522(82)90157-9"},{"key":"e_1_2_11_22_1","doi-asserted-by":"publisher","DOI":"10.1002\/cne.902500408"},{"key":"e_1_2_11_23_1","doi-asserted-by":"publisher","DOI":"10.1212\/01.wnl.0000318225.51122.63"},{"key":"e_1_2_11_24_1","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0b013e31823fcdee"},{"key":"e_1_2_11_25_1","doi-asserted-by":"publisher","DOI":"10.1037\/tra0000057"},{"key":"e_1_2_11_26_1","volume-title":"The epidemiology of blood\u2010injection\u2010injury phobia. 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