Considerations, frameworks and challenges in the treatment - PowerPoint Presentation

Slide1

Considerations, frameworks and challenges in the treatment of simple and complex trauma

Martin Dorahy

Department of Psychology

University of Canterbury

martin.dorahy@canterbury.ac.nz

Slide2

Outline

For PTSD trauma-focused interventions central for treatment (NICE, 2005). For complex PTSD trauma-focused interventions may be harmful if not regulated.

PTSD,

Diss

PTSD, CPTSD

Trauma representation in memory (PTSD)

Elaboration & integration

When to be trauma-focused?Slide3

Human beings are resilient!

But there are limits and thresholds that if reached will overcome coping and lead to problems.Slide4

From interpersonal relationship to molecules

Trauma impacts on relational, psychological, physical and molecular systems.

Isolation, relationship separation

PTSD, depression, anxiety, dissociative disorders Physical health problems, cancer (Lanius et al., 2010) DNA breakage (Morath et al., 2013)Slide5

Therapy

Medication not particularly helpful for PTSD (

Hoskin

et al., 2015)SSRIs reduce PTSD symptoms, but the effect is small: “some drugs have small positive impact on PTSD symptoms (e.g., Fluoxetine, paroxetine & venlafaxine” (Hoskin et al., p. 93).Psychological therapy is a better option (NICE, 2005).Psychological therapy has been found to promote repair of DNA breakage (Morath et al., 2013)Slide6

First decision point: What are we dealing with ?Slide7

Accurate assessment essential Slower than able Prolong suffering

Faster than able Increase suffering

But not always easy!Slide8

PTSD & dissociative PTSD

P

T

SD

Re-experiencing

Avoidance

Arousal

Acute

Chronic

Neg. Alt.

Aff&Cog

Depers

/

dereal

Diss. PTSDSlide9

PTSD – DSM-5

‘Simple’ PTSD

Dissociative PTSD

A: Trauma exposure, experience, witnessed, heard✔✔B: Re-experiencing✔✔C: Avoidance✔✔D: Neg.

Alterations in cognition and affect✔✔

E: Arousal✔

✔F: Duration (>1m)

✔

✔G: Functional Significance

✔

✔

H: Exclusions (drugs,

alc

, medication)

✔

✔

Depersonalisation

/

derealisation

✗

✔

Conceptual fuzziness, clinical/therapeutic improvement

(Dorahy & Van der Hart, 2015

)Slide10

Modulation: Over or under Type

of PTSD

2 types of PTSD as found in neuroimaging

Arousal/reliving (undermodulated)Dissociative (overmodulated)Lanius et al., 2010Slide11

Prevalence of Dissociative PTSD (in PTSD samples)

Veterans (Wolf et al, 2012a, 2012b)

15% male sample

30% female sample12% mixed sampleCivilian PTSD sample (Steuwe et al., 2012)26% primarily femaleThose in dissociative group had higher:Comorbidity (e.g., dep, anxiety, PTSD Sx)Axis II (especially in female samples-BPD, APD)Trauma exposureChild abuse and neglectSlide12

PTSD, dissociative PTSD

& Complex PTSD

P

TSD

C

O

M

P

LE

XP

T

S

D

Re-experiencing

Avoidance

Arousal

Alterations in:

Affect regulation

Attention/conscious.

(Dissociation)

Self perception

Relationships

Somatic functioning

Systems of meaning

Acute

Chronic

Neg. Alt.

Aff&Cog

Depers

/

dereal

Diss. PTSDSlide13

PTSD, dissociative PTSD

& Complex PTSD

P

TSD

C

O

M

P

LE

XP

T

S

D

Re-experiencing

Avoidance

Arousal

Alterations in:

Affect regulation

Attention/conscious.

(Dissociation)

Self perception

Relationships

Somatic functioning

Systems of meaning

Acute

Chronic

Neg. Alt.

Aff&Cog

Depers

/

dereal

Diss. PTSDSlide14

Complex trauma

Typically associated with specific types of repetitive, relational trauma involving coercive control over victim that produces a quite specific complex symptom profile.

Events:

Incestuous/abusive familiesChronic CA&N Sexual traffickingPolitical torture Destructive cultsConcentration/labor campsGenocidal traumaLoewenstein et al., Psychiatric Times, 2014Slide15

Complex trauma

Symptoms (individual differences evident) e.g.,

Affective

dysregulation/impulse dyscontrolDissociationAlterations in sense of selfSomatisationLoewenstein et al., Psychiatric Times, 2014Slide16

Complex PTSD symptoms clusters

Loewenstein

et al, 2014Slide17

PTSD: Event or memory?According to DSM-5 PTSD is the result of an event that has the following characteristics:

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as

follows

Direct exposure.Witnessing, in person. Indirectly, by learning that a close relative or close friend was exposed to traumaRepeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties But we know PTSD isn’t result of event, but rather is the result of an internal representation of that event (i.e., memory).Thus, PTSD is a disorder of memoryBrewin (2011, 2014); Rubin et al. (2008)Slide18

Central memory paradox

PTSD

characterised

by vivid involuntarily intrusions with detailed imagery and emotion (enhanced perceptual memory)ANDImpaired voluntary recall/recognition of the same event (fragmented, confused, disorganised, amnestic memory)(impaired episodic memory)Thus: poor intentional recall but vivid unintentional reexperiencing with ‘here and now’ quality.Slide19

Trauma

vs

non-trauma memory

Trauma memories fundamentally different to other autobiographical memories. Autobiographical memoriesOrganisedContextualisedCharacterised by “autonoetic awareness” (Tulving, 2002)Trauma memories Poorly elaborated and incorporated into the autobiographical memory storePerceptually detailedNot given a complete context in time and place (promotes a sense of ‘nowness’). Slide20

Trauma Vs non-trauma memory

Trauma

memory

Non-trauma memoryOccur spontaneouslyOccur less spontaneouslyOften triggered by external & internal eventsAdaptable to social contextOccurrence usually cannot be controlledOccurrence can usually be controlledInvolve subjective distortions in time No subjective distortion in timeExperienced as though event was happening againExperienced as an event in the pastExperienced as fragments of the sensory component of the eventExperienced as integrated memory

Less changing over timeMore altered by repeated recall

Primarily imaged-basedUsually recalled as a narrativeReduced

self referenceSelf referenceSlide21

2nd decision point: What sort of AM are we dealing with ?Slide22

Self referential perspective

First person perspective (this event happened to me)

Self/perspective

Experience/objectsSelfperspectiveExperience/objectsEgocentric/fieldAllocentric/observer

Third person perspective

Self as detached (non-personified) object – “it’s happened to someone else”Slide23

Trauma and cognitive processing

“Acute trauma may simultaneously diminish neural activity in anatomical structures serving conscious processing and enhance activity in structures serving perception” (

Brewin

, 2014, p. 70)But how do we understand this psychologically?Slide24

Dual Representation Theory (Brewin,

Dalgleish and Joseph, 1996; Brewin, 2001,

2010, 2014) - I1. Situationally accessible memory (SAM) system (perceptual) Information derived from lower level processing, including sensory features. Includes sensory, motor & physiological aspects of memory.Stored in a form that “enables the original experience to be recreated” Responsible for symptoms such as flashbacks. Emotions restricted to primary emotions experienced peri-traumatically AmygdalaTrauma memory represented in two separate systemsSlide25

Dual Representation Theory (Brewin, Dalgleish and Joseph, 1996; Brewin, 2001,

2010, 2014)

-

II2. Verbally accessible memory (VAM) system (conceptual, epidosic)Narrative memories of the traumaIntegrated with rest of the autobiographical memory Deliberately recalled Memory can be “deliberately & progressively edited”Subject to the limitations of conscious attention processes – e.g., gapsInclude cognitive appraisals before, during, or after the traumatic event leading to secondary emotionsHippocampusSlide26

What do you see (perceive) & understand (conceive)?Slide27

A MEMORY

Sensory

Perceptual

V

A

Tac

O

G

A

C

Limbic system, PFC

Personif-

ication

Noetic

- unrelated to self

Autonoetic -

self as part

of experience

Conceptual

Cog/meanSlide28

When Trauma occursSlide29

Perceptual memory

Sensory memory

Short term memory

Long term memory* Rapidly decaying*Rel. unp-rocessed*Emot. Stim. more processing

Visual STM

*High res.

*Actively maintained*Resource demanding*Limited

*More abstraction/processing

*More processing (gist)*But still perceptual

Pecept-ual

, SAM

(

perc

.

mem

)

Narrative, conceptual, VAM (

epis.mem

ABM

Sensory

Percept-

ual

Concep

-

tua

l

Personif

-

iedSlide30

Dual Representation Theory (Brewin, Dalgleish and Joseph, 1996; Brewin, 2001) - III

Successful adjustment requires emotional processing (

Rachman

, 1980) via both VAM (episodic) and SAM (perceptual) systems. Successful emotional processing requires repeated SAM activation, which may occur automatically, or as part of exposure therapy. As SAM system is activated, information only coded within the SAMs may also become represented within the VAMs. Eventually, detailed memories in SAMs that signal danger are matched by VAM representations that place the danger in the past. Consequently, VAMs may enjoy retrieval advantage over the SAMs thereby preventing activation of primary emotions It’s often helpful to do VAMs work first to address secondary emotions (anger, shame), then do exposure to address SAMs emotions (e.g., fear).Bailey, 2010; Brewin et al., 1996, 2010Slide31

Poor elaboration

Memorys

’ normally elaborated in time and context, which allows an integration with other memories (conceptual processing, stops nuisance retrieval).

Trauma memories lack adequate elaboration/conceptual processing (they are more perceptual so the aspects of the event are not well elaborated and the memory itself is not well integrated with autobiographical memory. Slide32

Influences on memory

Dissociation assoc with more

perc

. and less self reference (e.g., Lyttle, Dorahy, Hanna, & Huntjens, 2010 ; Van der Hart et al., 2006)Slide33

How does increased perceptual and reduced conceptual come about?

Peritraumatic

dissociation

PTSDe.g., Breh & Seidler, 2007; Lensvelt-Mulders et al., 2008; Ozer, Best, Lipsey, & Weiss, 2003; Shalev et al., 1996, 1997; Weiss, Marmar, Metzler, & Ronfeldt, 1995 This may have something to do with how experience is represented in memorySlide34

Peritraumatic

dissociation

Reduced self-referential

processing

Increased perceptual processing

Fragmented

memory

-

incoherence

-

disorganisation

Hampered post-event conceptual processing

- elaboration

- contextualisation

Persistent

dissociation

Posttraumatic

symptoms

Huntjens

,

Dorahy

, & Van

Wees

, in press

Specific event

General events

Lifetime knowledge

Autobiographical memory

(Conway &

Pleydell

-Pearce, 2000)

e.g.,

Kindt

et al.,2005;

Kleim

et al., 2008;

Lyttle

, Dorahy et al., 2010; Michael & Ehlers, 2005;

Pacella et al., 2011

e.g.,

Briere

et al., 2005; Murray et al., 2002

AvoidanceSlide35

Putting everything

togetherSlide36

Perceptual & Conceptual processing & memory

Conceptually ‘top-down’ Processed Memory

Perceptually ‘bottom-up’ Processed Memory

Increased integrative linkage and elaboration

processing

(Brown &

Kulik

, 1977; Conway &

Pleydell

-Pearce, 2000)

Elaborated specific event

General events

Lifetime knowledge

Dorahy, 2011Slide37

2 principles of intervention

Elaboration of memory

Integration of memory

In that order, integration (connecting memory with other memories, autobiographical history and sense of self) will be unsuccessful if memory unelaboratedBut when do we engage in elaboration (trauma-focused) work?Slide38

Assessment (memory)

Characterise

nature of trauma memory and spontaneous intrusions.

Detailed (crisp) percep. reps. Rel. unchanged over timeActivate strong negative feelingsGaps in memoryWhere in sequence events are muddled, confused.Extent to which memories have ‘here and now’ quality, and strong sensory & motor components.Memory has field/egocentric perspectiveSlide39

It would be lovely if our story ended here

Wishful thinking!Slide40

3rd decision point: Is chronic (usually relational) trauma present but

lower perceptual

symptoms?Slide41

Memory work

Identify hot spots

Challenge appraisals that thinking about T is unsafe, dangerous.

Facilitates elaboration and contextualisation of trauma memorySlide42

Memory work

Imaginal

reliving: reliving experience in presence of therapist and putting into words

Relive experience in minds eye (images, thoughts, feelings, narrativePresent tense‘What do you see, hear, feel’, ‘where do you feel that’, ‘what’s going through your mind’After whole event narrated, further reliving of ‘hot spots’ or problematic aspects of memorySlide43

Memory work

With progressive reliving, narrative becomes more coherent, and sensory (e.g., smells, tastes) and motor (e.g., involuntary movements) components become elaborated and less pure (thereby fading)Slide44

Memory work

In vivo exposure can be used with therapist or as homework

Make sure past and present are differentiated

Imagery techniques to re-script trauma memory or facilitate grievingSlide45

When more complex symptoms, characterological issues and relational dynamics prevail. What then?Slide46

Move fromTrauma focused to phase-oriented therapySlide47

Phase-oriented treatment

Janet (1919/1925); Herman (1992); Van

der

Hart, Nijenhuis & Steele (2005; 2006)Establishing Safety (Stabilisation & symptom reduction)Remembrance and Mourning (memory/trauma work)Reconnection (rehabilitation & reintegration)NB: Not linear progression; like ‘a spiral’Phase 1 Phase 2 Phase 3Slide48

Fear of therapeutic attachment:

The therapist as threat object

A longed-for sense of interpersonal connection and increased intimacy – particularly in the therapeutic relationship – causes heightened anxiety rather than being soothing. Even if a therapist is able to get through the interpersonal defences of a patient and to be seen as kind or helpful, the patient is thrown into more internal conflict, trying to juggle the fragile sense of therapist as benevolent with the uncertainty that the therapist will become hostile, exploitive, or abandoning.

Chu, 1998, 120Slide49

Issues for assessment

Assessment should include:

Symptoms Attachment/process/character

Anxiety: Form of anxiety dischargeRelational style/primary attachment modelAffective basis (e.g., fear vs shame)Modulation: Over or under‘Animal’ defenses: Forms ofThis will determine to what degree trauma-focused versus phase-oriented therapy is required Slide50

Anxiety: Forms of anxiety discharge

Striated muscle

Muscle tension

sighingSmooth muscleUpset stomachMigrainesdiarrheaCognitive perceptual disruptionVaguenessDepersonalisationDerealisationProjectionDavanloo, 1990; Della Selva, 1996; Gottwik et al., 2001Slide51

Relational style

Thoughts

about self (self-esteem)Thoughts about others(sociability)PositiveNegativePositiveSecureAnxious-preoccupiedNegativeDismissive-AvoidantFearful-avoidant(unresolved)Bartholomew & Horowitz, 1991, Miller & Perlman, 2009

Abandonment anxiety

Lo

Hi

Intimacy avoidance

Lo

HiSlide52

Relational style

Anaclitic/other oriented: Dependency, displacement of responsibility

Introjective

/self-directed: (Shame) independency, competitiveness, over-identify as responsible.Blatt, 2008; Dorahy, 2012; Dorahy & Hanna, 2012Slide53

Affective basisPrimary and secondary Emotions

Primary emotions

Secondary (self conscious) emotions

JoyDistressAnger

Fear

Disgust

Surprise

Shame

Guilt

Pride

Embarrassment

Lewis, 1992; Tracy & Robins, 2007Slide54

Factors That Impede Emotional Processing

Lee,

Scragg

and Turner (2001) Shame Guilt Humiliation Slide55

Compass of shame (Nathanson, 1992)

Attack

self Avoid Withdraw Attack other Slide56

Dissociation and modulation4-D model of PTSD (Frewin &

Lanius

, in press a, b, c)

4 dimensions that differentiate more straight-forward PTSD from more complex, dissociative PTSDThey break symptoms into those classed as distress associated with ‘Normal Waking Consciousness’ (NWC) and distress associated with ‘Trauma-Related Altered States of Consciousness’ (TRASC).Slide57

4-D model of PTSD (Frewin & Lanius, in press a, b, c)

4 dimensions and NWC

vs

TRASC symptomsBodyDisembodied experiences of depersonalisation (TRASC) vs Embodied experiences of distress (NWC; e.g., panic)EmotionEmotional numbing/affective shut-down (TRASC) vs non-dissoc. Negative emotionality (NWC) e.g, fear, shame, guilt)Time-memoryFlashbacks (TRASC) vs intrusive recall/distress reminders (NWC)ThoughtVoice hearing (TRASC; e.g., ‘you’re useless’-second person) Vs negative self-ref. thinking/internal verbal cognition (NWC; e.g., ‘I’m useless’ – first person).Slide58

Animal defensive responsesBlanchard et al., 2001; Fanselow

, 1994;

Pansepp

, 2005; Rau & Fanselow, 2007 Preferred activity patternPre-encounter defensePost-encounter defenseCirca-strike defensePoint of no return

Recuperative behaviour

No predatory potential-Avoidance

Increased predatory imminence

Predatory potential-

Stretched approach-Risk assessment-meal pattern reorganisation

Predator detected-Flight if possible-Freeze if not

Predator makes contact

-upright posturing

-vocalisation

-’jump attack’

-escape

-submit

Predator makes the killSlide59

Dissociation of animal defenses

Secondary

structural dissociation

Dividedness amongst dissociative self-aware systems TraumaEmotional part of the personality (EP): e.g.,Apparently normal part of the personality (ANP)

Driven by psychobiological systems of daily functioning Attachment • Play Seeking •self definition

Van

der

Hart et al., 2006;

Nijenhuis, Van der Hart & Steele, 2002

Fight

flight

Freeze

SubmitSlide60

Boon et al 2011 stabilisation work, eg.,

I

nitial

coping skills (reflection), Improving daily life (sleep; a healthy daily structure; free time and relaxation), Coping with traumatic triggers and memories, Understanding emotions and cognitions (core beliefs, cognitive errors), Advanced coping skills (anger, fear, shame and guilt, needs of inner child parts, self-harm, inner cooperation), Improving relationships (isolation, loneliness, learning to be assertive, and setting healthy personal boundaries).Slide61

Martin.dorahy@canterbury.ac.nzSlide62

DSM-5PTSD

Non-dissociative

ReexperiencingAvoidanceNegative alterations in affect and cognitionArousalDissociativeAs above but with prominent dissociation symptoms (derealisation/depersonalisation)Slide63

Neurobiological studies

≈ 70% in scanner (e.g.,

fMRI

) have arousal/reliving response to script driven imageryHR increases, therefore SNS activationLow activation of medial anterior brain regions (e.g., medial prefrontal cortex, anterior cingulate cortex), this reduced arousal modulation and emotion regulationThis is associated with increased limbic activity (especially amygdala) (without functional “hardware” to downregulate impulse and emotion, “software” options are required (to help ‘switch off’).“Emotional undermodulation in response to trauma memories” (p. 2) created by a failure of prefrontal regions to inhibit limbic activity.Lanius et al., 2010Slide64

Neurobiological studies

≈ 30% have “dissociative” response (e.g.,

depersonalisation

, derealisation)HR remains stable, ? PNS activationHigh activation of medial anterior brain regions (e.g., medial prefrontal cortex, anterior cingulate cortex), this increases arousal modulation and emotion regulation. This is associated with reduced (hyperinhibition of) limbic activity (especially amygdala) (without functional “hardware” to upregulate emotion, “software” options are required (to help ‘switch on’).“Emotional overmodulation in response to exposure to trauma memories” (p. 2) created by midline prefrontal inhibition of limbic region.Lanius et al., 2010Slide65

Neurobiological studies

≈ 70% in scanner (e.g., fMRI) have arousal/reliving response to script driven imagery

HR increases, therefore SNS

activation (without functional “hardware” to downregulate impulse and emotion, “software” options are required (to help ‘switch off’).“Emotional undermodulation in response to trauma memories” (p. 2) created by a failure of prefrontal regions to inhibit limbic activity.Lanius et al., 2010Slide66

Neurobiological studies

≈ 30% have “dissociative” response (e.g.,

depersonalisation

, derealisation)HR remains stable, ? PNS activation (without functional “hardware” to upregulate emotion, “software” options are required (to help ‘switch on’).“Emotional overmodulation in response to exposure to trauma memories” (p. 2) created by midline prefrontal inhibition of limbic region.Lanius et al., 2010Slide67

Why SAM and not VAM under stress

“The capture of sensory images by the SAM system is seen as a functional response to the down-regulation of the episodic memory [VAM] system under extreme stress, allowing a large quantity of survival-related information to be encoded and stored for long periods even though conscious attention may be more narrowly focused on the source of threat”

Brewin

, 2014, p. 76Slide68

Perceptual memory

Sensory memory

Short term memory

Long term memory* Rapidly decaying*Rel. unp-rocessed*Emot. Stim. more processing

Visual STM

*High res.

*Actively maintained*Resource demanding*Limited

*More abstraction/processing

*More processing (gist)*But still perceptualSlide69

What do you see and experience?Slide70

A MEMORY

Sensory

Perceptual

V

A

Tac

O

G

A

C

Limbic system, PFC

Personif-

ication

Noetic

- unrelated to self

Autonoetic

-

self as part

of experience

Conceptual

Cog/meanSlide71

Sensory

Perceptual

V

A

Tac

O

G

A

C

Limbic system, PFC

Personif-

ication

Noetic

- unrelated to self

Autonoetic

-

self as part

of experience

Conceptual

Cog/mean

VAMS

SAMS

ABMSlide72

Memory differentiation:

Cognitive Model of PTSD (2000)

Model

distinguishes between data-driven and conceptual processing. If peri-traumatic processing is predominately data-driven then:Trauma memory may be difficult to retrieveStrong perceptual priming for similar stimuliStimulus discrimination may be impaired. Slide73

Division of memory

Human memory

Working Memory

Perc.Rep. SystemSemantic memoryEpisodic memory

Verbal based memory

Based on words/narrative

Perceptual based memoryBased on images (for visual)Slide74

Ehlers and Clark’s Cognitive Model of PTSD (2000

)

PTSD becomes persistent when processing of the event and/or its

sequelae leads to a sense of serious, current threat. Sense of threat may be due to appraisals of the traumatic event and its sequelae, and the nature of the trauma memory. Slide75

Ehlers and Clark’s Cognitive Model of PTSD (2000) - Appraisals

Fact that trauma happened - ``Nowhere is safe''

Trauma happened to me - ``Others can see that I am a victim''

Behaviour/emotions during trauma - ``I cannot cope with stress''Initial PTSD symptomsIrritability, anger outbursts - ``I can't trust myself''Emotional numbing ``I'm dead inside'',Flashbacks, intrusions and nightmares - ``I'm going mad'',Difficulty concentrating ``My brain has been damaged'‘ Other people's reactions after traumaPositive responses ``They think I am too weak to cope'‘Negative responses ``Nobody is there for me''Physical consequences ``My body is ruined'‘Perceived permanent change, mental defeat and alienation seem to be particularly pathogenic appraisals (Dunmore et al., 1999, 2001)Slide76

Cognitive Model of PTSD (Ehlers & Clark, 2000)

Nature of Trauma Memory

Negative Appraisal of Trauma and/or its

SequelaeCurrent ThreatIntrusionsArousal SymptomsStrong EmotionsStrategies Intended to Control Threat/SymptomsMatching Triggers

Cognitive processing during traumatic event

Characteristics of trauma/

sequelae

/ state of individual/ prior experiences/ coping/beliefs

Influences

Leads to

Prevents

change inSlide77

arrows indicate the following relationships

leads to

prevents

change ininfluences

matching

triggers

negative assessments of

trauma/subsequent events

nature of trauma

memory

strategies intended to control threat/symptoms

current threat

arousal symptoms

intrusions, strong emotions

reconstruct the

fragmented trauma

memory

& anchor it in the past through discussion, tapes & writing

change toxic beliefs with education, understanding,

imagery

rescripting

,

behavioural experiments,

& compassion

understand & reduce avoidance, encourage desensitization, tackle

dissociation,substance

abuse

DiscriminateSlide78

Natural progression from SAM to VAM

“Flashbacks initially reflect an adaptive response that is part of the recovery process; when automatically triggered by trauma reminders such as sensory cues, the allocation of conscious attention to the content of these images allows detailed perceptual information to be recoded into episodic memory where it can be made verbally accessible and assigned a temporal and spatial context. Once provided with this context, sensory cues no longer signal a current source of danger, and as a result flashbacks become

progessively

weaker and less frequent”Brewin, 2014, p. 76Slide79

What stops SAM become VAM?

“Involuntary retrieval and reliving of threat-related images is more likely under two conditions:

When encoding of the event into the SAM system is unimpeded or enhanced

When encoding or reencoding into the VAM system is in some way degraded or reducedPTSD results when individuals cannot tolerate reexperiencing of the traumatic image, such that reencoding into episodic memory is never achieved and flashbacks remain intense and persistent” Brewin (2014, p. 76)Slide80

Pathological encoding of trauma (Brewin et al., 2010)

b

Sensory inputs

Early sensory cortical &subcortical areasExteroceptive S-repsPrecuneus: Visual imagerySensory association areas: C-reps, allocentric sensory info.

Insula: InteroceptiveS-reps

Amygdala: Affective valence

Hippocampus:C-reps, allocentric locations

Parahippocampus:C-reps,

allocentric scene info.

Temporal lobe: semantic knowledge

Retrosplenial

& posterior parietal:

Allocentric

-egocentric translation

Papez

circuit:

Viewpoint orientation

Dorsal stream

Ventral streamSlide81

Problem and possibilities

Conceptual error: many other PTSD symptoms dissociative (e.g., amnesia, numbing, flashbacks), but are classed as non-dissociative

(Van

der Hart & Dorahy, under review).But allows dissociation to be considered, identified and treated, given it has significant repercussions for assessment and treatment (Lanius et al., 2010; Van der Hart & Dorahy, under review). Slide82

Cognitive Model of PTSD (Ehlers & Clark, 2000)

Conceptual

Nature of Trauma Memory

Negative Appraisal of Trauma and/or its SequelaeCurrent ThreatIntrusionsArousal SymptomsStrong Emotions

Strategies Intended to Control Threat/SymptomsMatching Triggers

Cognitive processing during traumatic event

Characteristics of trauma/

sequelae

/ state of individual/ prior experiences/ coping/beliefs

Influences

Leads to

Prevents

change in

Perceptua

lSlide83

Is this relevant or important4m-post: N=600; 10m-post: N=412Slide84

Results: Lo & Hi Dissociation

Variable

Low

DissHigh DissFpTime1Depression3.15 (3.3)7.90 (5.2)11.16.001Anxiety3.59 (3.6)7.65 (4.5)2.56.111Time 2 (with intrusions, avoidance and arousal at T1 as covariates)

Dissociation6.09 (1.6)7.35 (2.9)

12.44.000Intrusions6.77 (2.1)8.13 (2.7)

4.28.039Avoidance

5.55 (2.3)6.91 (2.7)7.83.005

Arousal8.36 (2.8)11.08 (4.5)12.45

.000Depression2.44 (3.9)

4.83 (5.0)

8.69

.003

Anxiety

2.21 (3.1)

4.31 (4.1)

7.79

.006

Neg

Emots

.

7.00 (2.3)

8.9 (2.8)

4.60

.033