Transcript "Trauma memories in anxiety & depression"

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, complementary, & 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
old beliefs linked to
the memories
aggravate the
situation further
upsetting emotional state
current life experiences
depression, social anxiety,
trigger memories (feltagoraphobia, ocd, posttraumatic stress
sense, visual and
disorder, etc
shared meaning)
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..
F.
duration - for over a month
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
10.4% women
 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
5.0% men
fully recover even many
years after the trauma
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
CBT: 30%
PD-IPT: 29%
% who became
well & stayed
well over 12 - 24
month follow-up
IPT: 26%
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
social anxiety & imagery research
 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 development 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
trauma memories & social anxiety
 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.
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
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
trauma memories & other disorders
 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.
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
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
nature of trauma
memory
matching
triggers
current threat
arousal symptoms
intrusions, strong emotions
strategies intended to
control threat/symptoms
persistent ptsd
Behav Res Therapy
2000; 38: 319-45
persistent ptsd
Ehlers A, Clark D
A cognitive model
of posttraumatic
stress disorder
negative assessments of
trauma/subsequent events
arrows indicate
the following
relationships
leads to
prevents
change in
influences
nature of trauma
memory
disorganized
fragmented, partial
no date/time stamp
negative assessments of
trauma/subsequent events
arrows indicate
the following
relationships
matching
triggers
current threat
leads to
arousal symptoms
intrusions, strong emotions
‘distorted’ beliefs:
fear, anger, shame
guilt, helplessness
avoidance (outer &
inner), numbing
safety behaviours
drugs & alcohol
strategies intended to
control threat/symptoms
prevents
change in
influences
hand trauma, beliefs & outcomes 1
 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
hand trauma, beliefs & outcomes 2
 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 improvement with a further 1-3 sessions of imagery rescripting with gains well maintained at 6 month follow-up
nature of trauma
memory
reconstructing the
story: telling, tapes,
writing & discussion
negative assessments of
trauma/subsequent events
arrows indicate
the following
relationships
matching
triggers
current threat
arousal symptoms
intrusions, strong emotions
imagery rescripting,
behavioural experiments,
understanding & compassion
tackling substance
abuse, education,
desensitization, behavioural experiments
strategies intended to
control threat/symptoms
leads to
prevents
change in
influences
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. Posttraumatic 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. BrunnerRoutledge, 2005.
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
to download a copy of this talk
for more details and 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”