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
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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