Cold Water Immersion (CWI) Therapy for PTSD
- Thomas P Seager, PhD
- Jan 31
- 12 min read
Updated: Feb 24
How can cold stress resolve traumatic injury?
Summary
Post-traumatic stress disorder (PTSD) is an unresolved traumatic injury, held within the nervous system, that can causes obsessive, catastrophic ruminations. It typically results from experiences in which a subject immobilized and made to feel helpless during stress.
Chronically low cortisol and other irregularities in levels of stress hormones and neurotransmitters are associated with PTSD.
In several documented cases studies, ice baths have resulted in resolution of PTSD. Three mechanisms might explain this success:
Modulation of stress hormone and neurotransmitter levels,
Discharge of trapped sympathetic nervous system energy via shivering or trembling, and
Strengthening of parasympathetic nervous system response -- i.e., vagal tone.
For psychological benefits from ice baths, plunge the whole body at a temperature that is cold enough to initiate the gasp reflex, and stay immersed in cold water for 2-4 minutes -- long enough for the dive reflex to take over. Encourage shivering.
Post-Traumatic Stress Disorder (PTSD)
The late comedian George Carlin did a stand-up bit in which he explained the phrase "post-traumatic stress disorder" was invented during the Vietnam War to distance society from the severity of the psychological injuries suffered by American soldiers.
There's a condition in combat... it's when a fighting person's nervous system has been stretched to its absolute maximum. It's either snapped, or it's about to snap. In the first World War, that condition was called 'shell shock.' - George Carlin (1937-2008).
One account of PTSD and its resolution is described by author and historian William Manchester (1922–2004), who wrote a memoir chronicling his experiences as a young Marine soldier fighting in the Pacific theater during World War 2 (Goodbye, Darkness: A Memoir of the Pacific War, Manchester 1980). For decades after his discharge from the Marines, Manchester suffered from recurring nightmares in which he relives his combat experiences at Guadalcanal, Tarawa, Saipan, and Okinawa. It wasn't until he returned to the old battlefields in the 1970's, to revisit his traumatic experiences from a position of control that his trauma was resolved.,
Since the 1970's, we've learned a great deal more about trauma, including the fact that PTSD doesn't just happen to soldiers. It can happen to anyone who experiences an extreme, unresolved stress event. In his book In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness (2010) renowned psychologist Peter Levine, PhD reframes PTSD as neither a disease nor a disorder. He describes PTSD as an injury -- a description that may encourage trauma survivors to pursue healing of their wounds.
The question is, "How?"
The Origins of PTSD: Sympathetic Overload
PTSD can occur when stress overwhelms the capacity to respond. Children are especially vulnerable, because their capacity to respond is lower. Therefore, what might be a nothing but a nuisance for an older child could be unresolved trauma in a younger child -- not every extreme stress situation results in traumatic injury.
Levine sought to identify patterns that might predict when stress will be successfully resolved, and when it might lead to longer-term trauma-related disorders. He discovered two factors that greatly increased the odds of traumatic injury under stress, both of which were present in Manchester's experiences of combat:
powerlessness, and
immobilization.
Powerlessness frustrates the hormonal and vascular changes that are preparing the human body to fight when attacked. Immobilization frustrates the instinct to flee. Author Gavin de Becker (The Gift of Fear, De Becker 1996) writes that victims who fight back or flee are less likely to experience PTSD-related symptoms after assault. In the fighting or the fleeing, the victims are exercising agency that gives their somatic, adrenal response an outlet, and it seems to offer some psychological protection. Stripping the victim of the choices their bodies are biologically preparing them for creates a discordance between the sympathetic nervous system activation and the reality of their experience.
Hence, their unresolved stress can manifest as trauma.
While de Becker's explanation is sensible and satisfying, Levine goes even deeper. In his foreword to An Unspoken Voice, he describes his own experience of being run over by a car. Although he remained conscious, he had no motor control of his injured body. He was immobilized, but because he could still speak, Levine was not powerless.
When an off-duty paramedic who witnessed the crash rushed to the scene, Levine found that the aggressive tone in the paramedic's voice created confusion and contributed to Levine's fears of powerlessness.
He told the paramedic "Please back off," and the man did.
Levine lay on the asphalt, trembling, trying to make sense of what had happened, until he heard the ambulance arrive.
I see the emergency team slip a collar onto my neck and then they cautiously slide me on to a board... . The ambulance paramedic takes my blood pressure and records my EKG... . She fiddles with the equipment and then indicates that it might be a false reading... . My heart rate is 74 and my blood pressure is 127/70. "Thank you," I say. "Thank God I won't be getting PTSD." - Peter Levine, PhD
How does Levine know he won't be suffering long-lasting ill-effects from unresolved trauma?
Because he allowed his body to tremble in response to his trauma, and as a consequence, his pulse and his blood pressure returned to normal levels. The trembling released his body from the fight or flight mode of being attacked by the car.
Although Levine could not run, or fight, the autonomic shaking of his limbs allowed his body to express its natural adrenal response and release the stress that otherwise would have nowhere to go.
When he explained that to his ambulance nurse, she asked him:
"I've noticed that they often purposely stop people from shaking when we get them to the hospital. Sometimes they strap them down tight and give them a shot of Valium. Maybe that's not so good?" "No, it's not," I answered. "It may give them temporary relief, but it just keeps them frozen and stuck." She asked, "You were, it seemed to me, just shaking. Is that what brought your heart rate and blood pressure down?" "Yes," - Peter Levine, PhD
Somatic routes to recovery
In my article Should I Shiver? I wrote about how trembling, shaking, tremoring, and shivering are all phenomena that help release energy trapped in the sympathetic nervous system during fight or flight activation. That is, trembling a viable way to avoid the immobilization that will increase risk of PTSD.
The same phenomenon is often found in patients recovering from surgery. "Perioperative shivering" was once thought to be a thermoregulatory response in patients who entered a hypothermic state during or after surgery. However, there were irreconcilable problems with that hypothesis (De Witte & Sessler 2002). For example, patients undergoing brain surgery will often experience a post-operative trembling or shivering -- even when kept warm. In this case, their shivering is unrelated to thermogenesis. Rather, it is a natural response to the trauma of the surgery called post-traumatic tremors.
In one case, a 48-year-old Australian man experienced PTSD resulting from a 2009 car crash that resulted in a six-day coma and required facial reconstructive surgery. Doctors trained the patient to self-administer a trembling intervention that "involved learning to activate spontaneous movements, including shakes and tremors in a safe, controlled and self-regulated way through guided group practice twice daily" (Heath & Beattie 2019).
The trembling therapy resulted in extraordinary improvements in the patient's self-reported pain, anxiety, negative thoughts, and ability to cope. The study authors concluded that "the suppression of spontaneous movements including shakes and tremors may be inadvertently increasing the risk of PTSD."
Resolving PTSD in Play
The post-traumatic stress response is characterized by spontaneous and often unpredictable flashbacks to the moment or circumstances of the trauma. Although victims often suffer from the shame of being unable to control their own thoughts, what most people don't realize is that human beings are biologically hard-wired to relive unresolved trauma seeking a position of control. This biological imprinting is so strong, it can even be coded into the expression of our genome and passed down to our children (Seager 2020).
Despite our suffering, there are important evolutionary advantages to being encoded for this compulsion to repeat. Repetition of the experience in our imagination might provide two adaptive advantages that contribute to our survival:
It allows us to experiment in our minds with new resolutions or stress responses resulting from “What if… ?” creative problem-solving, and
It may reinforce fear-based behavioral adaptations that strengthen automatic threat-avoidance reactions.
Imaginative re-experiencing as a way of exploring alternate outcomes sometimes takes place in therapeutic settings. The risk in any re-experiencing is re-traumatization without resolution -- reinforcing disordered patterns. Nonetheless, according to exposure therapy theory, a gradual re-experiencing of the traumatic event from a position of control, either in talk therapy, through journaling, or even virtual reality, can eventually desensitize the sufferer to memories and improve their emotional processing skills (e.g., Powers et al. 2010, Lely et al. 2018).
In human children and in animals, we're more likely to see imaginative re-experiencing of trauma in play than in therapy. Levine describes this phenomena in his book Trauma and Memory (2015), in which he includes this description of three cheetah cubs who survived a lion attack:
In Levine's example, exploring different options and responses in play allows the cubs to resolve the life-threatening trauma of the attack by gaining control of the experience. Empowered by their new self-defense skills, they no longer fear a repetition of the traumatic attack.
Although the cubs will retain the memory of the attack, they will have released the negative emotions associated with that memory, because in the successful reliving of the trauma they will have gained confidence that they can handle the threat.
In this respect, human children work in the same way that cheetah cubs do. For example, in Playful Parenting (Cohen 2002) Lawrence Cohen, PhD describes how a toddler might respond to the trauma of a visit to the doctor’s office for shots.
A three-year-old gets a shot at the doctor’s office. She comes home, and what game does she want to play? Doctor, of course. And who does she want to be? The doctor or nurse—definitely not the patient. And who does she want to to give (the shot) to? Well, her first choice is a parent or another adult. If no one is available, she might use a stuffed animal or doll. And how does she want the game to go? She wants you to pretend to howl and say, “No, no, no please don’t give me a shot. I hate shots! No, no, no,” and act as if you are in agony of pain and terror. This response lets the child be in the more powerful position. It is a simple game of role reversal, but it is very satisfactory… . The play shot might be pretend, but the need for emotional recovery is real. The child chooses this fantasy game because she wants a hand with her genuine feelings about the actual shot. This isn’t just play for fun… . The purpose is to go through the incident again, but this time letting the scary feelings out. That’s why a child likes to play this kind of game over and over and over. - Lawrence Cohen, PhD
Reliving the experience in play rearranges the meaning of the story and builds confidence in capacity for stress handling. Those rearrangements have profound consequences. They change our emotions, our identities, our capabilities, and our prospects. They change our self-perceptions, self-beliefs, sense of self-efficacy, and consequently they change the biochemistry of our bodies.
After rehearsing resolution of the stress or conflict in imaginative play, what used to feel overwhelming now feels more manageable. In other words, rehearsing responses to stress improves stress response.
Parasympathetic Practice for PTSD
The counter-intuitive realization of exposure therapy, and related techniques like stress inoculation training (Meichebaum 2017), is that the key to resolving PTSD is titration of trauma by incremental, additional, and repeated resolution of stressful events. One of the characteristic features of PTSD is hyperactivity in the sympathetic division of the central nervous system, known as "fight or flight." Arousal of the sympathetic response is healthy when faced with imminent danger. It spikes cortisol and epinephrine, boosts blood glucose, and increases heart rate so that the body is prepared for action.
The problem is that immobilization and powerlessness during sympathetic activation means that all the energy and resources mobilized in response have nowhere to go. Without a release, they become stuck in the nervous system without resolution. Ordinarily, the sympathetic division is balanced by the parasympathetic, which is also called the "rest and digest" division. In PTSD, the sympathetic is under constant activation and the parasympathetic is typically underactive.
Cold water immersion (CWI) therapy is a physiological stimulus that pendulates between sympathetic and parasympathetic activation. That is, when you first enter the cold water and experience the gasp reflex, you sympathetic division is in control of our physiological and psychological response. However, after 15 to 30 seconds of structured breathing, the dive reflex takes over. The heart rate slows. Brain waves drop into a meditative state Blood glucose drops, and a sense of calm comes over the body.
A US-military veteran diagnosed with PTSD recently completed a doctoral dissertation in CWI for mental health. As a graduate student at Liberty University, Marcus A. Jean-Franco interviewed several subjects at his home in Malaysia, and summarized their experiences using CWI. They described their initial experiences as "overwhelming" that was characterized by resistance, anger, frustration and shock. However, the subjects reported that these feelings were displaced by rapid improvements in mood, mental clarity, empowerment, and even "euphoria" (Jean-Franco 20204).
Mindy Pelz, DC recently talked about her personal experiences using cold water therapy to resolve her own PTSD. She explained that after surviving the wildfires that leveled Los Angeles homes, she was diagnosed with acute PSTD characterized by "hypervigilant" obsessive thoughts.
Plunging in cold water silenced those thoughts for her, replacing anxiety with optimism.
How is that possible?
Famous American Psychologist Marsha Linehan, PhD explains in her book DBT Skills Training Manual, 2nd ed. (Linehan 2015).
The dive reflex is the tendency in humans (and other mammals) for the heart to slow down to below resting heart rate when the person in immersed in very cold water without oxygen. This effect is due to increased activation of the parasympathetic nervous system, which is the body's physiological system for decreasing arousal. States of emotional overarousal occur when the sympathetic nervous system becomes overactive and the parasympathetic is underactive. - Marsha M Linehan, PhD (2015)
Linehan's recommendation to use CWI therapy to interrupt the cascade of catastrophic thoughts characteristic of PTSD is based on the fact that a cold plunge will activate the dive reflex, strengthen parasympathetic tone, and build psychological resilience in the subject that can be generalized to other stressful events. In other words, without having to talk about or relive the unresolved trauma, an ice bath still benefits the subject by silencing the sympathetic and strengthening the parasympathetic.
Linehan cautions that the effects are temporary, which explains why Pelz and others make a practice of doing CWI every day. Nevertheless, if PTSD is an injury, as Levine claims, then it makes sense to treat it with the tools known to support injury recovery. An ice bath may be one of those tools, both because of the psychological activation of both the sympathetic and parasympathetic keeps them in better balance.
References
Cohen LJ. Playful parenting: An exciting new approach to raising children that will help you nurture close connections, solve behavior problems, and encourage confidence. Ballantine books; 2008 Nov 19.
De Becker G. The gift of fear. New York: Dell Publishing; 1997.
De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anesthesiology. 2002 Feb ;96(2):467-84.
Heath R, Beattie J. Case report of a former soldier using TRE (tension/trauma releasing exercises) for post-traumatic stress disorder self-care. Journal of Military and Veterans Health. 2019 Jul 1;27(3):35-40.
Jean-Francois M. The Impact of Cold-Water Immersion on Mental Health: A Qualitative Study. A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy. Liberty University, Lynchburg, VA. 2024
Lely JC, Smid GE, Jongedijk RA, W. Knipscheer J, Kleber RJ. The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. European journal of psychotraumatology. 2019 Dec 31;10(1):1550344.
Levine PA. Trauma and memory: Brain and body in a search for the living past: A practical guide for understanding and working with traumatic memory. North Atlantic Books; 2015 Oct 27.
Levine PA. In an unspoken voice: How the body releases trauma and restores goodness. North Atlantic Books; 2010 Sep 28.
Linehan MM. DBT skills training manual, 2nd ed.. Guilford Publications; 2015.
Manchester W. Goodbye, darkness: A memoir of the Pacific war. Hachette+ ORM; 1980.
Meichenbaum D. Stress inoculation training: A preventative and treatment approach. InThe evolution of cognitive behavior therapy 2017 Feb 17 (pp. 101-124). Routledge.
Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical psychology review. 2010 Aug 1;30(6):635-41.
About the Author
Thomas P Seager, PhD is an Associate Professor in the School of Sustainable Engineering at Arizona State University and CEO of the Morozko Forge ice bath company. He is an expert in the use of ice baths for building metabolic and psychological resilience, and author of Uncommon Cold: The Science & Experience of Cold Plunge Therapy.
The inducing tremor approach is a form of “somatic healing”.
there is another less talked about somatic approach that may be more powerful long term.
somatic educating.
the following article describes the difference between the two.
https://somatics.org/library/htl-somatichealed