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Treating simple and complex trauma: What to do and when Treating simple and complex trauma: What to do and when

Treating simple and complex trauma: What to do and when - PowerPoint Presentation

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Treating simple and complex trauma: What to do and when - PPT Presentation

Martin Dorahy Department of Psychology University of Canterbury Outline For PTSD traumafocused interventions central for treatment NICE 2005 Representation in memory Trauma representation in memory PTSD ID: 261197

amp memory ptsd trauma memory amp trauma ptsd processing event perceptual memories 2010 conceptual brewin dorahy exposure experience emotions

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Slide1

Treating simple and complex trauma: What to do and when

Martin Dorahy

Department of Psychology

University of CanterburySlide2

Outline

For PTSD trauma-focused interventions central for treatment (NICE, 2005)

Representation in memory

Trauma representation in memory (PTSD)

Elaboration & integration

When to be trauma-focused?Slide3

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, in press

)Slide4

Modulation: Over or under

Type of PTSD

2 types of PTSD as found in neuroimaging

Arousal/reliving (

undermodulated)Dissociative (overmodulated)Slide5

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 regulation

This 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., 2010Slide6

Neurobiological studies

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

depersonalisation

, derealisation)HR remains stable, ? PNS activation

High 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., 2010Slide7

Lanius

et al., 2010Slide8

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 neglectSlide9

PTSD & Complex PTSD

P

T

S

D

C

O

M

P

L

E

X

PTSDRe-experiencing

Avoidance

Arousal

Alterations in:

Affect regulation

Attention/conscious.

(Dissociation)

Self perception

Relationships

Somatic functioning

Systems of meaning

Acute

Chronic

Neg. Alt.

Aff&CogSlide10

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

followsDirect 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)Slide11

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

, effortful, amnestic memory)(impaired episodic memory)Thus: poor intentional recall but vivid unintentional reexperiencing with ‘here and now’ quality.Slide12

Trauma

vs

non-trauma memory

Trauma memories fundamentally different to other autobiographical memories.

Autobiographical memoriesOrganised

ContextualisedCharacterised 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’). Slide13

Trauma Vs non-trauma memory

Trauma

memory

Non-trauma memory

Occur spontaneously

Occur less spontaneouslyOften triggered by external & internal events

Adaptable to social contextOccurrence usually cannot be controlledOccurrence can usually be controlled

Involve subjective distortions in time No subjective distortion in time

Experienced as though event was happening againExperienced as an event in the past

Experienced as fragments of the sensory component of the eventExperienced as integrated memory

Less changing over time

More altered by repeated recall

Primarily imaged-basedUsually recalled as a narrativeReduced self referenceSelf referenceSlide14

Self referential perspective

First person perspective (this event happened to me)

Self/perspective

Experience/objects

Self

perspective

Experience/objects

Egocentric/field

Allocentric

/observer

Third person perspective

Self as detached (non-personified) object – “it’s happened to someone else”Slide15

“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?Slide16

Dual Representation Theory (Brewin,

Dalgleish and Joseph, 1996; Brewin, 2001, 2010) - I

1.

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 Amygdala

Trauma memory represented in two separate systemsSlide17

Dual Representation Theory (Brewin, Dalgleish and Joseph, 1996; Brewin, 2001, 2010) -

II

2. 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., gaps

Include cognitive appraisals before, during, or after the traumatic event leading to secondary emotions

HippocampusSlide18

What do you see (perceive) & understand (conceive)?Slide19

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/meanSlide20

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 perceptualPecept-ual, SAM(perc. mem)Narrative, conceptual, VAM (epis.mem

ABM

Sensory

Percept-

ual

Concep

-

tua

l

Personif

-

iedSlide21

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, 2010Slide22

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. Slide23

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)Slide24

How does increased perceptual and reduced conceptual come about?

Peritraumatic

dissociation

PTSD

e.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 memorySlide25

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

AvoidanceSlide26

Putting

everything

togetherSlide27

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, 2011Slide28

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?Slide29

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 perspectiveSlide30

Memory work

Identify hot spots

Challenge appraisals that thinking about T is unsafe, dangerous.

Facilitates elaboration and contextualisation of trauma memorySlide31

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 memorySlide32

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)Slide33

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 grievingSlide34

When more complex symptoms, characterological

issues and relational dynamics prevail. What then?Slide35

Move from

Trauma focused to phase-oriented therapySlide36

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 3Slide37

Issues for assessment

Assessment should include:

Symptoms Attachment/process/character

Anxiety: Form of anxiety discharge

Relational style/primary attachment modelAffective basis (e.g., fear vs shame)

Modulation: Over or under‘Animal’ defenses: Forms of

This will determine to what degree trauma-focused versus phase-oriented therapy is required Slide38

Anxiety:

Forms of anxiety discharge

Striated muscle

Muscle tensionsighingSmooth muscle

Upset stomachMigrainesdiarrheaCognitive perceptual disruptionVaguenessDepersonalisation

DerealisationProjectionDavanloo, 1990; Della Selva

, 1996; Gottwik et al., 2001Slide39

Relational style

Thoughts

about

self (self-esteem)

Thoughts about others(sociability)

PositiveNegativePositive

SecureAnxious-preoccupied

NegativeDismissive-AvoidantFearful-avoidant(unresolved)

Bartholomew & Horowitz, 1991, Miller & Perlman, 2009

Abandonment anxiety

Lo

HiIntimacy avoidanceLoHiSlide40

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, 2012Slide41

Affective basis

Primary

and secondary Emotions

Primary emotions

Secondary (self conscious) emotions

Joy

Distress

Anger

Fear

Disgust

Surprise

Shame

GuiltPrideEmbarrassment

Lewis, 1992; Tracy & Robins, 2007Slide42

Factors That Impede Emotional Processing

Lee,

Scragg

and Turner (2001) Shame Guilt

Humiliation Slide43

Compass of shame (

Nathanson

, 1992)

Attack self

Avoid Withdraw

Attack other Slide44

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, 120Slide45

Animal defensive responses

Blanchard et al., 2001;

Fanselow

, 1994; Pansepp, 2005; Rau & Fanselow, 2007

Preferred activity pattern

Pre-encounter defense

Post-encounter defense

Circa-strike defensePoint of no return

Recuperative behaviour

No predatory potential

-

Avoidance

Increased predatory imminencePredatory potential-Stretched approach-Risk assessment-meal pattern reorganisationPredator detected-Flight if possible-Freeze if notPredator makes contact-upright posturing-vocalisation-’jump attack’-escape-submitPredator makes the killSlide46

Dissociation of animal defenses

Secondary

structural dissociation

Dividedness amongst dissociative self-aware systems

Trauma

Emotional 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, 2002Fight flightFreezeSubmitSlide47

Martin.dorahy@canterbury.ac.nz