Sensory Modulation Challenges: One Missing Piece in the Diagnosis and Treatment of Veterans with PTSD

Abstract

Veterans with and without a post-traumatic stress disorder (PTSD) diagnosis were evaluated for presence of Sensory Modulation Challenges (SMC) using the Adolescent/Adult Sensory Profile and other measures. Those with PTSD showed significant SMC symptoms. Presence of SMC can contribute to explaining the PTSD symptoms of hyperarousal, avoidance/numbing, and Criterion E cited in the American Psychiatric Association Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5-TR). Participants also received a consultation and handout explaining sensory diet, the occupational therapy self-treatment for their issues, especially hyperarousal. Despite the small sample size of the non-PTSD group, findings indicate that veterans with PTSD should be tested and treated for Sensory Modulation Challenges.

Keywords:

• Veterans
• PTSD
• sensory modulation
• hyperarousal
• numbing
• sensory diet

Post-Traumatic Stress Disorder (PTSD) was first described as a mental health disorder in the Diagnostic and Statistical Manual-III (American Psychiatric Association) in 1980, probably due to observations of symptoms seen in Vietnam war veterans (Aupperie, 2018). This was the first time a DSM diagnosis was related to an outside agent (a traumatic event) rather than an individual neurosis. Besides traumatic exposure criteria, the latest revision of the DSM-5 (American Psychiatric Association [APA], 2013) includes “intensive recollections, avoidance/numbing symptoms, and hyperarousal symptoms” as well as that symptoms can cause “significant distress and functional impairment” (PTSD: National Center for PTSD, n.d.). Of major importance to this present study are the PTSD symptoms of avoidance/numbing, hyperarousal and those noted under Criterion E in the DSM-5 (2013).

1. “1. Irritable behavior and angry outbursts…

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance.” (p. 272)

Purpose

The purpose of this study is to describe and differentiate some of the neurologically based behaviors that underlie the DSM-5 (APA, 2013) symptoms of avoidance/numbing, hyperarousal and Criterion E symptoms seen in veterans with PTSD. These symptoms were investigated to ascertain if the presence of Sensory Modulation Challenges (SMC) could explain them. Sensory Modulation Challenges can be treated, even self-treated using our understanding of how to modulate these overarousal and underarousal reactions to common sensations from the environment, thus potentially offering a new paradigm for the understanding and treatment of these aspects of PTSD.

Literature review

Treatment for PTSD has been mainly trauma informed/focused psychological techniques, including CBT (cognitive behavioral therapy), Exposure Therapy, Narrative Exposure Therapy, Cognitive Processing, EMDR (eye movement desensitization and reprocessing), brief eclectic psychotherapy, and prolonged exposure therapy which are all “strongly recommended” by the American Psychological Association, and “suggested” by the Department of Veterans Affairs and the Department of Defense. (Aupperie, 2018, p. 927). Of importance for this study, Aupperie (2018) stated “There are mixed and limited clinical outcomes literature with combat veterans…In studies that have been conducted with veterans using trauma-focused therapies, only 50–70% experience clinically significant improvement and only 30–40% no longer meet diagnostic criteria for PTSD.” (Aupperie, 2018, p. 927). This leaves the question: what is missing from PTSD treatment?

The DSM-5 (APA, 2013) symptoms of avoidance/numbing, hyperarousal and Criterion E symptoms are indicative of changes in neurological functioning. A thorough analysis of how the structure and function of the brain is influenced by trauma was presented by Weiss (2007). She related neurobiological changes to the symptoms experienced after trauma. She discussed research showing changes in cortisol, glutamate, epinephrine, norepinephrine, serotonin, and dopamine, affecting numerous brain centers including the prefrontal cortex, cortex, thalamus, hippocampus, and amygdala, resulting in problems with the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic activation, decreased inhibition, and increased anxiety and hypervigilance (Weiss, 2007).

Besides Weiss (2007), there are numerous studies which directly indicate that those with PTSD show symptoms with a significant sensory modulation component, Sensory Sensitivity (also called hyperarousal and hypervigilance). Clancy et al. (2017) demonstrated a clear neurological basis for hypervigilance, which has been documented as being a significant bothersome symptom by many veterans. Using psychological scales, the PTSD checklist and EEG, they compared participants with PTSD, anxiety disorder and healthy controls. EEG studies were done during fast passive viewing of sensory rich scenes. Within 5 min subjects were shown 921 randomly intermixed, neutral, positive, and negative pictures, in order to simulate “unceasing complex sensory input from the environment” (p. 2043). What was found in participants with PTSD, but not in participants with anxiety or healthy controls, was an “exaggerated intrinsic (resting state) sensory activity as if they were constantly bombarded by busy sensory input….” Also found was that those with PTSD failed to show adaptation as visual input increased, leading to “a rigid, set mode of sensory hypervigilance” and “frequent complaints of sensory hypersensitivity and distress” (p. 2047). Clancy et al. (2017) also found that this hypervigilance over time blunted “sensory registration, resulting in paradoxical problems in sensory numbing in PTSD” (p. 2047).

LaMotte et al. (2015) found that this sensory numbing led to “intimate personal problems” (p. 479). They found that sensory numbing symptoms were the issue most partners felt contributed to their intimacy problems. It is possible that this sensory numbing is a “shut down” response that can occur when the brain restricts reactions to additional sensory input when it has been overloaded in an intense or prolonged way (Engel-Yeger, et al., 2013; Kimball, 1993, 1999a, 1999b, 2021).

Clancy et al. (2017) also stated that the overload of sensation impedes the cortex in its ability to use its executive functioning abilities, “pointing to a sensory hypothesis of PTSD: constant, spontaneous hyperactivity leads to frontal overload and cognitive depletion, which breaks down executive control, fueling and perpetrating PTSD symptoms. This sensory hypothesis of PTSD expands the current affective conceptualization” (p. 2047).

It also appears that cognitive functioning may be influenced by sensory reactivity. Judah et al. (2018) tested 104 veterans with PTSD. Their findings suggested that “hyperarousal, but not other PTSD symptoms, explained the relationship between neurobehavioral symptoms and cognitive functioning” (p. E10). “Features of hyperarousal, such as hypervigilance, may interfere with the efficiency of working memory through preoccupation of cognitive resources” (p. E14). The authors suggest that “beyond PTSD our findings highlight a need for research to investigate hyperarousal as a transdiagnostic source of attention and working memory impairment” (p. E14).

All the above lead this author to observe that these types of problems in veterans with PTSD described in DSM-5 (emotional numbing, hyperarousal, and Criterion E) need to be further investigated. They appear to be the same issues that have been described for years in children and more recently in adults as one type of Sensory Processing Disorder (SPD); Sensory Modulation Challenges. A standardized assessment was published for children in 1999, the Sensory Profile (Dunn, 1999)) and for adults in 2002, the Adolescent/Adult Sensory Profile (Brown and Dunn, 2002). Sensory Modulation Challenges reflect a person’s arousal level in rection to sensations in the environment. We now know that Sensory Modulation Challenges (SMC) can manifest at any age. They may be present at birth and are very often observed after trauma in children and adults. They consist mostly of over or under arousal reactions to normal sensory events in the environment. The person’s reactions and the resulting effect on behavior can significantly interfere with participation in daily activities. Reactions involve the automatic triggering of the sympathetic fight/flight reaction which is not under conscious control. The primary purpose of our brain is to first alert us to danger to “keep us alive.” Problems arise when our nervous system over alerts us to sensory signals that are not actually threatening, keeping us in a hyperaroused state. And sometimes, as stated earlier, if the nervous system reacts to too much sensory input, the system can become overloaded and “shut down” to additional input resulting in a state that appears to be under aroused.

Research on sensory modulation challenges in adults

Research on Sensory Modulation Challenges (SMC) in adults, especially veterans is limited. The Adolescent/Adult Sensory Profile (AASP) (Brown and Dunn, 2002) is a standardized trait measure of sensory processing. It is a self-evaluation of “behavioral responses to everyday sensory experiences” (p. 1). It measures two types of passive sensory responsivity: Sensory Sensitivity and Low Arousal; and two active behavioral responses: Sensation Seeking and Sensation Avoiding. Sensory Sensitivity, referred to in some publications as “sensory defensiveness” is the measure most reflective of hyperarousal. Low Arousal can reflect avoidance to help control sensitivity or a more severe “shut down” type reaction.

The AASP was used in a Yoga study conducted by the Army to find ways to reduce combat stress in deployed soldiers (Stoller et al., 2012). They used the AASP to measure combat stress and designed a “sensory enhanced hatha yoga program for proactive combat stress management” (p. 59). Results supported the use of the program.

Engel-Yeger and Dunn (2011) studied the role Sensory Modulation Challenges play in “pain catastrophizing” which they define as “an exaggerated negative cognitive response to actual or anticipated pain…associated with enhanced pain experience and pain related outcomes” (p. e1). They considered this to be a coping strategy and found that it was positively correlated with AASP Sensory Sensitivity, as well as Sensation Avoiding and Low Registration. Meredith et al. (2015) also found that AASP Sensory Sensitivity and Sensation Avoiding are related to higher levels of pain catastrophizing. This may be interpreted to mean that people with sensory hyperarousal may have a more difficult time taking an active role in coping and dealing with pain.

In a study of women with fibromyalgia, Wilbarger and Cook (2011) report that the women showed sensory hypersensitivity to sensations found in daily life in the areas of smell, audition, taste, and touch.

The AASP was used in Israel to assess a variety of participants (20% veterans) with post-traumatic stress (PTS) symptoms who were involved in a clinic program, compared to healthy controls (Engel-Yeger et al., 2013). They found that on the AASP, 80% of the sample showed Sensory Sensitivity, 83.3% showed Sensation Avoiding, 63% showed Low Registration and 3.3% Sensation Seeking, and concluded that “PTS may be related to hypersensitivity and low registration” (p. 266).

Kimball et al. (2018) studied four women with PTSD from trauma. The women were assessed with the AASP as well as by the unpublished Sensory Inventory (used by permission: Miller & Schoen, 2008a), which included the Sensory Over-Responsivity Scale (SensOR), the Sensory Under-Responsivity Scale (SensUR), and the Sensory Seeking scale (SensS). The women’s Sensory Modulation Challenges were confirmed, and they then were trained to use the Wilbarger Therapressure Protocol™ (Wilbarger & Wilbarger, 2001) as a sensory modulation self-treatment. After carefully following this sensory modulation treatment protocol, the women showed decreased stress, increased concentration, increased participation in their lives, modulation in the stress hormone cortisol, and improvements in their scores on the AASP and the SensOR.

Although more research is needed, it appears that the Wilbarger Therapressure Protocol™ holds promise as a means of helping those exposed to trauma deal with the Sensory Modulation Challenges associated with PTSD. The modulation of cortisol levels after self-treatment with the Wilbarger Therapressure Protocol™ is particularly noteworthy, as previous research (Pacella et al., 2014) had shown that eight weeks of treatment for PTSD using pharmacotherapy (Sertraline) or psychotherapy was successful enough to allow removal of the PTSD label but did not result in changes in total cortisol output. (The Wilbarger Therapressure Protocol™ requires supervision by a specially trained occupational therapist.)

Research question

Do veterans with PTSD have an identifiable Sensory Modulation Challenges profile? If so, what types do they show and could differentiating them expand our understanding of the arousal issues and Criteria E symptoms described in the DSM-5 (2013) and lead to expanded treatment possibilities?

Method

Participants

The use of human participants in this study was approved by the University of New England (UNE) Institutional Review Board in Portland, Maine. All participants signed Informed Consent, and each participant was tested individually by the author. Recruitment was by word of mouth through programs that veterans attended including horse-back riding, organic farming training, exercise programs and university classes. Participants in this study had a diagnosis of PTSD, which they attested to at the time they agreed to participate in the study. They participated in a 3-hour appointment which included approximately 1 ½ hours to complete assessment forms and provide a history. (Some assessments were scored as others were being completed.) Up to another 1.5 hours was used to explain the individual test scores to the participant as well as what the individual could do to self-treat any sensory modulation issues discovered. A seven-page handout was provided and discussed. It included information on SMC and on the self-treatment called “Sensory Diet” (see Table 1: summary of handout on sensory diet). Many participants enrolled in the study specifically because they wanted more information about this aspect of their PTSD and wanted the individual consultation. Although all participants had enrolled attesting that they had been diagnosed with PTSD, it was discovered during discussing their histories after signing the Informed Consent, that a small number did not have an actual “medical” diagnosis of PTSD but had been “told they had PTSD” without any actual testing, creating a dilemma for this author. However, they wanted this new information on SMC. So, it was decided that they would participate in testing and be provided with information, but their scores would be excluded from data analysis. Seven of the 42 participants did not have a formal “medical” diagnosis of PTSD, resulting in a formally diagnosed PTSD group of 35. This decision was later reconsidered. Rather than eliminating valuable data, it offered an opportunity not only to define the parameters of the sensory modulation issues in veterans with diagnosed PTSD, but to compare them with veterans who were not formally diagnosed but thought they had PTSD. Though unintended, this resulted in a comparison group of 7 (see Table 2).

Table 1. Summary of the 7-Page Handout on Sensory Diet Treatment for Sensory Modulation Challenges Discussed with Each Veteran Research Participant.

Topic	Content
What type of sensations alert us to danger post deployment putting us in fight/flight mode?	Many more than before deployment because the first priority of your nervous system is to keep you alive. Since your brain worked overtime for you in combat, it is now having trouble differentiating which sensations to react to as dangerous, so it stays in hyperarousal mode interpreting too many things as dangerous. You might react to “little things” that never bothered you before: light touch, slight sounds, environmental sounds, visual distractions, smells, combined small distractions.
What can you do to reduce hyperarousal (hypervigilance)?	Occupational Therapists (OTs) have contributed to the understanding of how to keep our nervous system out of fight/flight mode and in that “just right place” needed for good daily functioning. One of the key concepts is called “sensory diet” (Wilbarger, 1991, 1995). It is the amount and type of sensory input a person needs to keep their nervous system “modulated” or in the midrange. In stress related reactions, our nervous system spends more time in fight/flight survival mode. OTs have found that providing opportunities for certain types of modulating activities helps the nervous system stay more even, not hyper-aroused and not depressed.
The sensory qualities of modulating activities	What types of activities help you stay in this calm alert centered space? Rhythmic movement of head through space for a sort time, for example running, jumping on a rebounder, jumping jacks, bouncing on a yoga ball, can modulate you for several hours. Heavy work with joints and muscles: any type of resistance activity with joints and muscles can last up to two hours. Firm pressure on the skin (message, weighted blanket). Certain auditory input: classical music, drumming, or light popular music. Be careful as some popular music can be stimulating because of the mastering it goes through to be electronically available. A full range of sound is necessary for modulation. Deep breathing “Mouth” activities: resistive chewing (gum, jerky) and some tastes (sour, spicy, sharp). Portable activities: exercise bands are used for many types of exercise and fit anywhere. Try a chair push up or pull up anywhere (sit in chair and pull yourself into the seat or push ourself off the seat with both hands).
The difference between sensory diet activities and “regular” activities	You need change from your “usual” activities involving one or more of the following: Increased intensity: for example, heavier weights, biking or running faster. Increased frequency: you don’t need long workouts. Several 5-minute sessions spaced through the day works well. It takes at least 5 minutes of the same activity for the brain to register change. Increased duration: if you want to work longer, try a body moving game with others like basketball, tennis, pickleball, Zumba. Rhythm changes are about whether you prefer sameness or novelty in your activities.
It’s individual	Using activities you like to do and modifying them will work well because you might actually do them. Ask a friend to be our “sensory diet” buddy and share activity ideas with each other.
It’s all in the Timing	When do you most need modulating activities? Analyze your days and add modulating activities before stressful events.
Examples	Several pages of examples of sensory diet activities appropriate for veterans and active-duty military listed by type and strength of the activity.

Table 2. Group Characteristics.

Group 1 (with PTSD diagnosis)	Group 2 (without PTSD diagnosis)
Number: 35	7
Females: 7	1
Males: 28	6
Age range: 27–73	32–75
Independent samples t-tests for equality of means between males and females (equal variances not assumed).
Variable	Significance (2-tailed)
Age	.499
Sensory Sensitivity	.460
Low Registration	.366
Sensation Avoiding	.751
Sensation Seeking	.222
Sensory Over Responsivity	.206
Sensory Under Responsivity	.865
Sensation Seeking	.810

Forty-two veterans participated in this study. There were 10 females and 32 males aged 27–74. Multiple t-tests showed that there were no significant male/female differences on any factor tested; therefore, the information was combined for analysis (see Table 2).

Assessments (in order)

1. History

2. Adult/Adolescent Sensory Profile (Brown & Dunn, 2002)

3. The Sensory Over-Responsivity Inventory for Adults, Research Edition (Miller & Schoen, 2008a), the Sensory Under-Responsivity Inventory for Adults, Research Edition (Miller & Schoen, 2008b), and the Sensory Seeking Inventory (SensS), (Unpublished manuscript, by permission)

4. Basic Personality Inventory (Jackson, 1986)

5. Allen Cognitive Assessment (Allen et al., 2007)

6. Sensory Diet Consultation

(See Table 3: reliability and validity of assessments)

Table 3. Reliability and Validity of Assessments Used.

Adolescent/Adult sensory profile (Brown & Dunn, 2002)
AASP reliability	Low registration	Sensory sensitivity	Sensation seeking	Sensation avoiding
Internal consistency	.692	.639	.657	.699
SEM (adults)	3.58	4.10	4.47	4.03
Basic Personality Inventory (Jackson, 1986)
Internal consistency	Test-retest reliability
Adults 19+	Adults 19+
10 groups	2 samples, n = 391
.6–.90	.63–.87

Clinical validity: The clinical validity of the Basic Personality Inventory correlated with the New York State Adult Temperament Questionnaire and nine other temperament scales. Validity: numerous studies.

Allen Cognitive Level Screen (Allen et al., 2007). The Allen is a test of functional cognition, a person’s capacity to learn. The manual as of 2007 reports numerous studies showing evidence of reliability and validity, but no psychometric data.

History included:

1. Qualitative information from participants about their reactions to sensations in the environment.

2. The effect these reactions had on their participation in the occupations in their lives.

3. History in the armed forces.

4. Generally, if they had experienced any traumatic events. They were not asked for specifics due to IRB concerns about possibly needing an additional mental health professional on call, although many participants did disclose this information voluntarily.

5. The origin of their PTSD diagnosis.

Assessment procedures

Participants were assessed for presence and types of Sensory Modulation Challenges (SMC), as well as personality traits, and functional intelligence They were asked to complete two self-rating scales to assess their reactions to common sensations from the environment: the Adolescent/Adult Sensory Profile (AASP) (Brown & Dunn, 2002) and, by permission, the unpublished Sensory Processing Inventory (Miller & Schoen, 2008b) which consists of three scales, the Sensory Over-Responsivity Inventory (SensOR), the Sensory Under-Responsivity Inventory (SensUR) and the Sensory Seeking Inventory (SensS).

Participants also were asked to complete the Basic Personality Inventory (BPI) (Jackson, 1986) to assess their levels of psychological coping. The BPI is a “240 item questionnaire measure of personality and psychopathology…Scales were chosen to span the domain of personality dimensions broadly relevant to adjustment and psychopathology with scale names chosen to avoid directly suggesting psychiatric diagnosis” (Jackson, 1986, p. 1).

To assess their level of functional intelligence, participants were administered the Allen Cognitive Level Assessment (ACL) (Allen et al., 2007). The ACL is a simple leather lacing sample which tests the participant’s ability to follow directions visually and auditorily. There was concern that some participants might have other issues, for example traumatic brain injury, that could have affected their ability to understand the self-rating scales and especially the sensory diet handout and discussion. No problems were found.

As stated earlier, after the assessments were completed, they were scored, and the findings shared and discussed with the individual participant using the 7-page handout “Sensory Diet Activities for the Military.” It contained an explanation of hyperarousal and hypoarousal and an introduction to self-treatment using occupational therapy “sensory diet” concepts (see Table 1: summary of sensory diet handout). Although there was no direct numerical or structured qualitative measurement of the effect of this handout and discussion, there was ample time to discuss it in relation to the veteran’s scores on the assessments and their history and to suggest sensory diet strategies that fit each veteran’s assessment scores and activity preferences.

This time was designed for private consultation with each veteran, so it was not taped. However general qualitative themes emerged (see the following and Discussion). Many participants stated that this information was very valuable for them, especially knowing that hypervigilance was not their fault, and is not primarily a mental health issue. It is the nervous system’s fight/flight response, and its primary purpose is to keep us alive in dangerous situations. After the prolonged or intense experience of trauma the brain is just interpreting too many things as dangerous.

My email was listed for further questions. Several veterans contacted me about their experiences applying the concepts and what they learned about themselves during the discussion. One veteran said it was the first time she was able to discuss with her family the effects that PTSD has on her life. She explained her sensory issues to her son who helped her design some additional sensory diet activities to keep her sensory systems modulated. When her loud, very energetic daughter came to visit and negatively affected all her mother’s sensory strategies, the son very insistently said “You don’t understand! Mom has Sensory Modulation Challenges! Let me explain them to you!!” They have since involved the entire extended family in the discussion and sensory diet activities with much success (Kimball, 2021, pp. 189–193).

Another veteran who was involved in an organic farm training program using draft horses said “After a day at the farm. I am good to go with my family activities for two days!” Which he explained meant that most sensations from the environment did not bother him as much after his day of heavy work on the farm.

Results

Veterans with a medical diagnosis of PTSD had significantly more issues with Sensory Modulation Challenges as compared to veterans who thought they had PTSD but without a confirmed PTSD diagnosis. Table 4 shows the comparison of scores (independent samples t-tests) on all assessments. There were no significant differences between veterans with and without medically diagnosed PTSD in age, the Allen Cognitive Level Screen, Sensory Under-Responsivity (SensUR), and the two assessments of sensation seeking [(AASP Sensation Seeking, and Miller & Schoen Sensation Seeking (SensS)]. Statistically significant differences were found in AASP Sensory Sensitivity (.000), Low Registration (.003), and Sensation Avoiding (.000), as well Miller and Schoen’s Sensory Over Responsivity (SensOR) (.003).

Table 4. Independent Samples t-Tests: Veterans with and without a Medical PTSD Diagnosis.

Factor/test	t-Value	Significance (2-tailed)
Age	−.174	.862
AASP Sensory Sensitivity	5.077	.000**
AASP Low Registration	3.219	.003**
AASP Sensation Avoiding	3.973	.000**
AASP Sensation Seeking	−1.259	.215
Sensory Over Responsivity (SensOR)	3.195	.003**
Sensory Under Responsivity (SensUR)	1.477	.148
Sensation Seeking (SensS)	1.919	.062
Allen Cognitive Level Screen	.043	.966

**p ≤ .01.

Sensory Sensitivity and Sensory Over Responsivity certainly can contribute greatly to explaining the PTSD DSM-5 (20013) symptoms of interest. Avoiding sensation and not seeking sensation when you are hyperaroused also fits the sensory picture

Veterans with PTSD showed statistically significant differences from veterans without a PTSD diagnosis in perception of sensations from the environment as measured by the AASP. To identify how much scores of veterans with PTSD differ from the standardized sample on the AASP, mean comparisons were done using the 18–64 age norms (Brown & Dunn, 2002) as they were the closest to the participant’s age group (25–75) The normative categories for the 18–64 and 65 and above groups were identical for Sensory Sensitivity and only one number different for Sensation Avoiding, the areas of key interest. Since there were limited participants over 65, it was decided to use the 18–64 norm category.

The differences between the study comparison means and standardization means are shown in standard deviations in the last column of Table 5. The scores of the comparison group (without a formal PTSD diagnosis) are within about half a standard deviation of the norms (.17–.58) whereas the means of the study group (with a medical PTSD diagnosis) are between 1.1 and 2.29 standard deviations different from the normative means.

Table 5. Comparison of AASP* Standardization Means with AASP Means of Veterans with and without PTSD Diagnosis (Brown & Dunn, 2002).

Test	Study means	Standardization means (18–64)	Difference	Standardization standard deviations	Difference shown in standard deviations
AASP with PTSD diagnosis
Sensory Sensitivity	48.09	33.71	+14.38	7.63	+1.88
Low Registration	39.29	30.29	+9.00	6.25	+1.38
Sensation Avoiding	51.40	34.57	+16.83	5.34	+2.29
Sensation Seeking	42.66	49.91	−7.5	6.83	–1.10
AASP without PTSD diagnosis
Sensory Sensitivity	31.00	33.71	−2.71	7.63	−0.36
Low Registration	26.66	30.29	−3.63	6.25	−0.58
Sensation Avoiding	35.86	34.57	+1.29	7.34	+0.17
Sensation Seeking	47.14	49.91	−2.77	6.83	−0.41

On the Sensory Over-Responsivity Inventory (Miller & Schoen 2008a), the PTSD group also showed significantly higher scores, but the Sensory Under Responsivity and Sensory Seeking scores were not significantly different as would be expected as very few participants with PTSD showed these issues,

The Sensory Profile of veterans with a medical diagnosis of PTSD is very clear: increased Sensory Sensitivity (both AASP and SensOR), increased Low Registration, increased Sensation Avoiding, and decreased Sensation Seeking. Those veterans without a medical diagnosis of PTSD were within the typical range in all areas (see Table 5 for AASP standard deviation differences from the standardization means).

The scores on the AASP sensory profile and the SensOR of veterans with PTSD in this study are very consistent with the same measurements in the Kimball et al. (2018) study of four women (non-veterans) with PTSD: increased Sensory Sensitivity (both AASP and SensOR), increased Low Registration, increased Sensation Avoiding and decreased Sensation Seeking. The women’s standard deviation differences were very consistent with the veterans’ (Sensory Sensitivity +2.46, Low Registration +1.15, Sensation Avoiding +2.07, and Sensation Seeking −1.04), lending confirming evidence on how PTSD influences sensory processing.

Table 6 shows correlations between the BPI and AASP factors in veterans with diagnosed PTSD. Although it cannot be considered causative, it is interesting to note that the small sample of veterans without a medical diagnosis of PTSD showed no correlations with the BPI.

Table 6. Veterans with PTSD: Correlations Among BPI and AASP Factors.

BPI/AASP	Sensory sensitivity	Low registration	Sensation avoiding	Sensation seeking
Hypochondriasis (B)	.659**		.519**	−.442
Depression (B)	.516**		.584**	−.418*
Denial (F)
Interpersonal problems (A)	.467**		.403*
Alienation (A)			.340*	−.408*
Persecutory ideas (C)	.424*	.370	.427*
Anxiety (B)	.648**	.389*	.561**	−.379
Thinking disorder (C)	.411**	.430*	.398*
Impulse expression (A)	.519**	.536**	.447**
Social introversion(D)	.603**	.350*	.663**	−.371*
Self-depreciation (D)	.376*		.382*	−.384*
Deviation (E)	.583**	.442**	.515**	−.364*

**p ≤ .01, *p ≤ .05. The Basic Personality Inventory (BPI) (Jackson, 1986) shows indications of possible areas of concern (p. 7).

Code: See codes on chart for further information on what is being measured. A: Inadequate or deviant socialization and impulse control. B: Mood and personal/emotional adjustment. C: Cognitive functioning. D: Self-depreciation and sociability. E: Critical deviant behavior. F: Test taking style. (Parts of this chart were published previously in Kimball, 2021, p. 234.)

Kimball et al. (2012) compared the AASP and BPI of 50 typical women. Results showed that AASP Sensation Seeking was not a sensory strategy used by the typical women, while the other three areas (Sensory Sensitivity, Low Arousal, and Sensation Avoiding) were apparent but showed few correlations with the BPI.

Although it is only correlational data, comparing their results with veterans’ results reveals some interesting indications of how much Sensory Modulation Challenges might influence psychological processing. The typical women showed few correlations while the veterans showed many. Note that in Table 6. those areas that correlate with Sensation Seeking are all negative, indicating that as seeking sensation goes up the psychological correlations go down. Also note that the coding under the table helps define the parameters of each BPI area.

Veterans who are hyperaroused by sensory stimuli would be unlikely to seek more input especially since hyperarousal often results in fight/flight responses. And we know that with their profile of increased Sensory Sensitivity, increased Low Registration and increased Sensation Avoiding, overall sensation is not registering normally. Appropriate interaction with, and interpretation of, sensations from the environment help affirm normal psychological functioning for the individual. With this limited normal interaction with sensations, the numerous BPI psychological correlations make sense.

Discussion

What types of responses do veterans show if they have an AASP profile of increased Sensory Sensitivity, increased Low Registration, increased Sensation Avoiding and deceased Sensation Seeking? The increased Sensory Sensitivity is the most problematic as it results in hyperarousal, a survival response which is not under conscious control. It is difficult to live your life feeling danger in most situations. There are eight sensory systems that work together to respond to sensory input: visual, tactile, olfactory, hearing, proprioception (joint and muscle sense), vestibular (movement), mouth (temperature and texture more than taste), and interoception (internal sensations). I have found that veterans are more likely to over respond to visual, tactile, olfaction and hearing sensations.

During the consultation on sensory diet, veterans reported many qualitative examples of the effects of overarousal that they had experienced, as well as some avoidance strategies they used to feel safe,

Qualitative examples of the effects of overarousal (first reported in Kimball, 2021).

1. Always needing to sit with their back to the wall in a restaurant so no one can sneak up on them.

2. Sitting in the last row in the theater so no one can touch them.

3. Needing to locate the nearest exit in all situations.

4. Need to reduce visual clutter because they do not know if something dangerous is hidden in it.

5. Sensitive to noises at night, so sleep can be a problem. One veteran told me he asked his wife never to be quiet if she wanted to enter a room while he was sleeping. He told her to make lots of noise to wake him up. One night she decided not to wake him. He heard her sneaking in and had his gun up ready to shoot when he realized where he was (Kimball, 2021).

6. Sensitivity to light touch can negatively affect intimacy with partners.

7. Sensitivity to light touch can make children’s kisses feel threatening. One veteran told me that after returning from deployment he could no longer tolerate his daughter’s kiss on his cheek as she left for school. When he pulled away, she thought he no longer loved her, and it became a family problem. The explanation was that light touch was alerting him to danger even though there was no danger present. I asked him if he liked heavy bear hugs with a back pat or back rub and he said “Yes.” I told him to tell his daughter that she could hug him anytime, but she needed to alert (ask) him first so as not to surprise him. The family was very pleased with this easy sensory solution (Kimball, 2021, pp. 82–83).

8. Avoids trigger smells like fuel or burning tires (smells alert us very fast as they go directly to the emotional centers of the brain).

9. Many saying they still want to “hit the deck” when fireworks go off.

10. Do not interpret these examples as learned responses. You will find that the person will not have a defensive reaction, or will have a less intense reaction, when their system is modulated, not hyperaroused. And if they are hyperaroused, in my experience, cognitive behavioral strategies commonly used in PTSD treatment usually do not work as quickly as a strong sensory diet activity (Try four or five jumping jacks, or just jumping up and down a few times. Or if you do not want to be observed, try a few chair pull ups: while sitting, put your hands under the seat and pull yourself firmly down into it several times. The heavy work with your muscles and firm pressure on your joints is inhibitory.)

Application

How can this information change the evaluation and treatment for PTSD? Most occupational therapy practitioners are trained in, or aware of, the medical and psychological interpretations of research and treatment for persons who have suffered trauma and remain highly stressed, negatively impacting their physical health and daily functioning. Occupational therapy practitioners have a 20-year history of using the AASP in mental health settings (see Tina Champagne’s seminal work on decreasing seclusion and restraint in inpatient mental health settings using sensory strategies, Champagne & Stromberg, 2004).

Considering Sensory Modulation Challenges as a major contributing factor in PTSD can change understanding and treatment for veterans. The hyperarousal (hypervigilance) seen in veterans with PTSD can be explained by SMC as measured by the AASP (Brown & Dunn, 2002) and Miller & Schoen (2008b) assessments. As stated previously, research indicates that Sensory Modulation Challenges are not a psychological issue but are physical changes in how the brain interprets sensations from the environment after trauma (Weiss, 2007). Differences in sensory modulation scores between veterans with a PTSD diagnosis and those without can be interpreted to mean that Sensory Modulation Challenges can contribute to the DSM-5 (APA, 2013) symptoms of hyperarousal, avoidance/numbing, and the Criterion E symptoms: “irritable behavior and angry outbursts, reckless and destructive behavior, hypervigilance, exaggerated startle response, problems with communication and sleep disturbances” (p. 272), all of which are seen in nonveterans diagnosed with Sensory Modulation Challenges (SMC). We need to add SMC to our understanding of PTSD so that a fuller range of treatment and self-treatment choices may be made available to veterans (For a comprehensive approach see Kimball, 2021).

Limitations and future directions

The small sample size of the comparison group without a medical PTSD diagnosis is the major limitation. The voluntary self-selection of many participants who were already in veterans’ programs with a physical component that had a positive impact on their sensory systems modulation actually might have resulted in under measuring their level of sensory modulation challenges. One veteran who was in the diagnosed PTSD group had figured out for himself how sensory diet activities had decreased his hyperarousal and anxiety. He had built a room in his house for yoga and other exercises (weights, etc.), and participated frequently in many types of physical activities including pickleball, bicycling, swimming, Zumba, etc.

The aim of the study was to define the sensory parameters of the PTSD group, so having a comparison group was not planned and did not affect the sensory parameters of the PTSD group. The comparison group only added an extra dimension to the study. Future research should include a larger sample of veterans with and without diagnosed PTSD to confirm the presence and parameters of Sensory Modulation Challenges (SMC), and a treatment efficacy study comparing sensory diet concepts and cognitive behavioral strategies for treating hyperarousal.

Conclusion

The findings of this research are clear. Our sample of veterans with PTSD showed a distinct AASP Sensory Modulation Challenges Profile. This could help explain the veterans’ DSM-5 (APA, 2013) symptoms of hyperarousal, avoidance/numbing as well as Criterion E symptoms (irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance). A comparison of veterans with and without a medical diagnosis of PTSD showed those with PTSD had increases in measurements related to hyperarousal and hypoarousal: increased Sensory Sensitivity, increased Low Registration, increased Sensation Avoiding, and decreased Sensation Seeking on the Adolescent/Adult Sensory Profile (AASP) (Brown & Dunn, 2002), and increased Sensory Over Responsivity on the Sensory Over-Responsivity Inventory for Adults (SensOR) (Miller & Schoen, 2008b). The veterans who participated in this study reacted very positively to the information and occupational therapy consultation on using a Sensory Diet to address some of their symptoms, especially hyperarousal (see Table 1). These results indicate that veterans with a medical diagnosis of PTSD should be tested for Sensory Modulation Challenges, and given guidance in getting treatment, including self-treatment for it.