resilience & trauma

resilience & trauma

personal background work through a small charity whose aims are: • to help people with psychological difficulties or pain (especially when effective help is not readily available elsewhere) • to try to provide & encourage a whole person approach using what’s best in conventional, comp-lementary, & self-help methods of health care for more details & a downloadable copy of this talk go to the ‘good knowledge’ section of www.goodmedicine.org.uk click on ‘lectures and leaflets’ and look under ‘emotional expression’ in ‘past lectures’

key points of this talk • trauma memories are very common in depression and anxiety as well as in ptsd • elicit these memories and ‘images’ gently and carefully • disorder onset, severity and persistence seem contributed to by memories and ‘images’ • lessons from ptsd treatment may well improve treatment of depression and anxiety

involuntary memories are normal • involuntary memories of personal life events are reported at least 5 or 6 times daily by “normals” • typically these memories are cued by identifiable aspects of one’s current situation • memories often take their emotional tone from one’s current mood - typically happiness or sadness - and then reinforce this mood • memories are often of recent or of unusual events • intrusive thoughts are even more common and when negative tend to be characterised by fear Berntsen D Involuntary autobiographical memories Appl Cog Psychol 1996;10:435-54 Brewin CR et al Intrusive thoughts and intrusive memories in a nonclinical sample Cognition & Emotion 1996;10:107-12

vicious circle of mood & memory upsetting emotional state depression, social anxiety, agoraphobia, ocd, posttraumatic stress disorder, etc current life experiences trigger memories (felt- sense, visual and shared meaning) old beliefs linked to the memories aggravate the situation further upsetting memories not yet worked through from earlier life experiences facilitated access to memories of similar negative emotional tone disorganized nature of partly repressed emotional memories means that they have no clear ‘date-time’ stamp on them

posttraumatic stress disorder A. exposure - past exposure to a severely traumatic event and response involving intense fear, helplessness or horror B. reexperiencing - the traumatic event is persistently reexperienced in any of a number of ways - recollections, dreams, flashbacks, intense emotional or physical reactions to reminders C. avoidance/numbing - persistent avoidance of reminders and/or numbing of general responsiveness D. excessive arousal - for example insomnia, irritability, poor concentration, etc. E.. duration - for over a month F. significant disturbance - causes significant distress or impairment in functioning American Psychiatric Association Diagnostic & statistical manual of mental disorders (4th ed) Washington DC: American Psychiatric Press, 1994

prevalence of ptsd • 7.8% estimated to suffer from posttraumatic stress disorder at some stage in their lives • 10.4% of women and 5.0% of men • more than a third do not fully recover even many years after the trauma 10.4% women 5.0% men

depression & imagery research • Kuyken W & Brewin CR Intrusive memories of childhood abuse during depressive episodes Behav Res Ther 1994;32:525-8 • Kuyken W & Brewin CR Autobiographical memory functioning in depression and reports of early abuse J Abnorm Psychol 1995;104:585-91 • Andrews B Bodily shame as a mediator between abusive experiences and depression J Abnorm Psychol 1995;104:277-85 • Brewin CR Cognitive processing of adverse experiences Int Rev Psychiat 1996;8:333-9 • Brewin CR, Reynolds M, et al. Autobiographical memory processes and the course of depression. J Abnorm Psychol 1999; 108(3): 511-7.

trauma memories & depression 1 • 31 sufferers from current depression were asked about deaths of family or friends & about other major life events • questioned too about events they felt might have triggered the current episode of depression & about childhood - for example harsh discipline or unwanted sexual experiences • asked too about related memories – these were defined as spontaneous visual images of specific scenes that had actually taken place • 87% of these current depression sufferers said yes - they had experienced 1-5 different intrusive images (av’ge 2.6) Brewin CR, Hunter E, Carroll F & Tata P Intrusive memories in depression: an index of schema activation? Psychol Med 1996:26:1271-6

trauma memories & depression 2 • 55% of these intrusive memory images involved illness or death; 21% involved relationship or family problems; 18% involved abuse and assault • memories were usually associated with mixed feelings of sadness, guilt, anger and helplessness, and to a lesser extent anxiety and shame • scoring these depressive memories using the IES showed that they had similar scores to memories found in PTSD • memories of past abuse and of assault tended to be associated with higher IES scores and with severer levels of depression

% becoming well & staying well % who became well & stayed well over 12 - 24 month follow-up CBT: 30% IPT: 26% PD-IPT: 29% BT: 25% Shea MT, Elkin I, Imber SD et al Course of depressive symptoms over follow-up: findings from the NIMH treatment … program Arch Gen Psychiatry 1992;49:782-7 Shapiro DA et al Effects of treatment … following cognitive behavioral & psychodynamic interpersonal psychotherapy J Consult Clin Psychol 1995:63:378-87 Gortner ET, Gollan JK, Dobson KS & Jacobson NS Cognitive-behavioral treatment for depression: relapse prevention J Consult Clin Psychol 1998;66:377-84

clinical implications 1 • it’s common for depression sufferers to be troubled by significant trauma memories • high levels of intrusion & associated avoidance of trauma memories (high IES scores) are associated with more prolonged depression even when allowing for the initial severity of psychiatric symptoms • it seems likely that asking about trauma memories & using emotional processing methods that lower IES scores may well speed recovery and possibly may even reduce relapse

socialanxiety&imageryresearch • Hackmann A, Surawy C, et al. Seeing yourself through others' eyes: A study of spontaneously occurring images in social phobia.Behavioural and Cognitive Psychotherapy 1998; 26: 3-12 • Wells A. & Papageorgiou C. The observer perspective: biased imagery in social phobia, agoraphobia, and blood/injury phobia. Behav Res Ther 1999; 37(7): 653-8. • Hackmann A, Clark DM, et al. Recurrent images & early memories in social phobia.Behav Res Ther 2000; 38(6): 601-10. • Hernández-Guzmán L, González S, et al. Effect of guided imagery on children's social performance.Behavioural and Cognitive Psychotherapy 2002; 30: 471-483. • Hirsch C, and Mathews A. Anticipatory imagery and the develop-ment of social anxiety.BABCP Annual Conference Abstracts : pp 11-12. York, 2003. • Hirsch CR, Meynen T, et al. Negative self-imagery in social anxiety contaminates social interactions.Memory 2004; 12(4): 496-506

traumamemories&socialanxiety • intrusive ‘images’ are very commonly associated with anxiety provoking situations for people with social anxiety disorder. • these images are often visual but may also occur as an internal felt-sense or via other (often multiple) sensory channels. • intrusive visual images of social situations are typically from an ‘observer’ rather than from a ‘first person’ perspective. • the majority of subjects can link intrusive images to early memories when typically the social anxiety disorder first became particularly troublesome. • holding the intrusive negative image (instead of a neutral or positive image) aggravates symptoms (feelings, attentional biases & mis-estimations) and performance – as judged by the subject, others involved socially, & by external observers • non socially anxious subjects also have their performance disrupted if trained to hold negative rather than neutral images of their performance

clinical implications 2 • educate socially anxious subjects about the frequency, type, importance, origins, effects, and management of images. • emotional processing of associated early memories is likely to be helpful in its own right and may guide the nature of subsequent coping image work. • consider training social anxiety sufferers to hold coping rather than negative images before and during social challenges. • it is reasonable to encourage these coping ‘images’ to involve a variety of sensory channels for example visual, felt-sense & auditory. • coping visual images should be from a ‘first person’ rather than an ‘observer’ perspective. • try training preparatory coping images (guided or self-directed) as a sequence involving experiencing initial difficulties, but progressively mastering the social interaction with eventual successful outcome.

trauma memories & agoraphobia • when questioned, all of a group of 20 agoraphobics – but none of a group of 20 matched controls – reported having distinct recurrent intrusive ‘images’ in agoraphobic situations. • most intrusive ‘images’ involved several sensory modalities such as vision, internal ‘felt-sense’, sound, touch, smell & taste (note vision wasn’t always present as a component). • on discussion, all subjects linked an aversive memory to the intrusive ‘image’, but only 15% (3/20) reported having thought about the content of the memory prior to the interview. • the mean age at the time of the memory was 14.3 years. • 75% (15/20) of the subjects believed the memory affected their anxiety in agoraphobic situations. • common themes with both intrusive images and associated memories were of catastrophic danger and of a negative view of self (such as the self intimidated, humiliated and misunderstood). Day SJ, Holmes EA & Hackmann, A. Occurrence of imagery and its link with early memories in agoraphobia. Memory 2004; 12(4): 416-27

clinical implications 3 • when asking about intrusive ‘images’ in agoraphobia (or other psychological disorders) it may be worth getting the sufferer to imagine (or actually revisit) an upsetting episode • note that recurrent intrusive images can come visually or as a internal felt-sense or via other (often multiple) sensory channels • although on questioning the majority of subjects can link this intrusive image to an early memory, they may well not have made this link before • subjects often recognize quite readily that the image tends to aggravate their symptoms • exploring the meaning and beliefs around the image and memory may well make good sense

trauma memories & OCD • of 34 inpatients with OCD, 71% (24/34) reported that they had intrusive visual images when their OCD was really bad. • for patients with visual images, 33% (8/24) recognized their images as memories of actual aspects of earlier traumas. • when the remaining 16 patients with visual images were asked about their earliest recollection of having had similar sensations and feelings, 94% (15/16) could identify a particular traumatic experience that was linked to the visual image. • the perceived similarity between the visual image & the memory of the traumatic experience was very high, both in terms of sensory characteristics and in terms of interpersonal meanings. • it seems likely that many of the 29% (10/34), who did not report intrusive visual images, might have reported ‘images’ if questioned about felt-sense and other sensory channels. Speckens A, Ehlers A, et al Imagery and early traumatic memories in obsessive compulsive disorder. BABCP Annual Conference Abstracts: p.44. York, 2003

traumamemories&otherdisorders • Hinrichson H, Morrison T, et al. Triggers of vomiting in bulimic disorders: the roles of core beliefs and imagery.BABCP Annual Conference Abstracts: page 8. York, 2003. • Cooper M, and Turner H. The effect of using imagery to modify core beliefs in bulimia nervosa: an experimental pilot study. BABCP Annual Conference Abstracts: pp 8-9. York, 2003. • Osman S, Cooper M, et al. Spontaneously occurring images and early memories in people with body dysmorphic disorder. Memory 2004; 12(4): 428-36 • Brewin CR, Watson M, et al. Memory processes & course of anxiety and depression in cancer patients.Psychol Med 1998; 28: 219-24. • Finkenauer C, and Rimé B. Keeping emotional memories secret: health and subjective well-being when emotions are not shared. Journal of Health Psychology 1998; 3(1): 47-58. • Morrison A. Trauma and psychosis: cause, consequence, common processes and clinical implications.BABCP Annual Conference Abstracts: p 21. York, 2003.

NICE guideline on PTSD psychological treatments that are specific for PTSD are: • trauma-focused cognitive behavioural therapy • eye movement desensitisation and reprocessing march ’05: http://www.nice.org.uk

trauma characteristics/beliefs prior experiences/coping subsequent events thinking processes during trauma arrows indicate the following relationships leads to prevents change in influences nature of trauma memory negative assessments of trauma/subsequent events persistent ptsd persistent ptsd matching triggers Ehlers A, Clark D A cognitive model of posttraumatic stress disorder Behav Res Therapy 2000; 38: 319-45 current threat arousal symptoms intrusions, strong emotions strategies intended to control threat/symptoms

nature of trauma memory negative assessments of trauma/subsequent events matching triggers arrows indicate the following relationships current threat arousal symptoms intrusions, strong emotions leads to prevents change in influences strategies intended to control threat/symptoms disorganized fragmented, partial no date/time stamp ‘distorted’ beliefs: fear, anger, shame guilt, helplessness avoidance (outer & inner), numbing safety behaviours drugs & alcohol

handtrauma,beliefs&outcomes1 • Mervin Smucker reported on 3 research studies done at the Medical College of Wisconsin with PTSD sufferers following traumatic hand injuries. • study 1 involved 630 adult accident victims with PTSD. Prolonged exposure treatment produced 90% positive response when fear was the main PTSD emotion, but only 15% positive response when anger shame, guilt, or mental defeat was the main emotion. Smucker MR. How does theory inform practice in the treatment of intrusive memories? EABCT Annual Conference. Manchester, 2004

handtrauma,beliefs&outcomes2 • study 2 involved 55 adolescents with PTSD following hand injuries. PE resulted in 89% response when fear main emotion, but only 18-19% when guilt/self-blame or anger was main emotion • study 3 involved 23 adults with PTSD after hand injuries who had failed to respond to 6-15 sessions of prolonged exposure (PE). 78% (18/23) showed significant improve- ment with a further 1-3 sessions of imagery rescript-ing with gains well maintained at 6 month follow-up

nature of trauma memory negative assessments of trauma/subsequent events matching triggers arrows indicate the following relationships current threat arousal symptoms intrusions, strong emotions leads to prevents change in influences strategies intended to control threat/symptoms reconstructing the story: telling, tapes, writing & discussion imagery rescripting, behavioural experiments, understanding & compassion tackling substance abuse, education, desensitization, behavioural experiments

cutting edge cbt resources • Brewin C. Posttraumatic stress disorder: malady or myth? Yale University Press, 2003 • Smucker M. et al. Posttraumatic stress disorder. in R. Leahy (ed) Roadblocks in cognitive-behavioral therapy: transforming challenges into opportunities for change. Guilford Press, 2003. • Mueller M, Hackmann A, & Croft A. Post-traumatic stress disorder. in J. Bennett-Levy, et al. (eds) Oxford guide to behavioural experiments in cognitive therapy. OUP, 2004. • Gilbert P. Compassion : conceptualizations, research & use in psychotherapy. Brunner-Routledge, 2005.

to download a copy of this talk for more details and a down-loadable copy of this talk go to the “good knowledge” section of www.goodmedicine.org.uk , click on “lectures and leaflets” and look under “emotional expression” in “past lectures”

resilience & trauma