resilience

1
resilience trauma
2
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 whats 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
3
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

4
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 ones current situation
• memories often take their emotional tone from
  ones 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 199610435-54 Brewin CR et al
Intrusive thoughts and intrusive memories in a
nonclinical sample Cognition Emotion
199610107-12
5
vicious circle of mood memory
upsetting emotional state depression, social
anxiety, agoraphobia, ocd, posttraumatic stress
disorder, etc
old beliefs linked to the memories aggravate the
situation further
current life experiences trigger memories
(felt- sense, visual and shared
meaning)
facilitated access to memories of similar
negative emotional tone
upsetting memories not yet worked through from
earlier life experiences
disorganized nature of partly repressed emotional
memories means that they have no clear
date-time stamp on them
6
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
7
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
8
depression imagery research

• Kuyken W Brewin CR Intrusive memories of
  child- hood abuse during depressive episodes
  Behav Res Ther 199432525-8
• Kuyken W Brewin CR Autobiographical memory
  functioning in depression and reports of early
  abuse J Abnorm Psychol 1995104585-91
• Andrews B Bodily shame as a mediator between
  abusive experiences and depression J Abnorm
  Psychol 1995104277-85
• Brewin CR Cognitive processing of adverse
  experiences Int Rev Psychiat 19968333-9
• Brewin CR, Reynolds M, et al. Autobiographical
  memory processes and the course of depression.
  J Abnorm Psychol 1999 108(3) 511-7.

9
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 (avge 2.6)

Brewin CR, Hunter E, Carroll F Tata P
Intrusive memories in depression an index of
schema activation? Psychol Med 1996261271-6
10
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

11
becoming well staying well
who became well stayed well over 12 - 24
month follow-up
CBT 30
IPT 26
BT 25
PD-IPT 29
Shea MT, Elkin I, Imber SD et al Course of
depressive symptoms over follow-up findings from
the NIMH treatment program Arch Gen Psychiatry
199249782-7 Shapiro DA et al Effects of
treatment following cognitive behavioral
psychodynamic interpersonal psychotherapy J
Consult Clin Psychol 199563378-87 Gortner ET,
Gollan JK, Dobson KS Jacobson NS
Cognitive-behavioral treatment for depression
relapse prevention J Consult Clin Psychol
199866377-84
12
clinical implications 1

• its 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

13
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 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

14
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

15
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.

16
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

17
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 wasnt
  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
18
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

19
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
20
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.

21
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

22
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
23
nature of trauma memory
negative assessments of trauma/subsequent events
persistent ptsd
matching triggers
persistent ptsd
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
24
disorganized fragmented, partial no date/time
stamp
distorted beliefs fear, anger, shame guilt,
helplessness
avoidance (outer inner), numbing safety
behaviours drugs alcohol
25
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
26
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 improve- ment with a further
  1-3 sessions of imagery rescript-ing with gains
  well maintained at 6 month follow-up

27
reconstructing the story telling, tapes, writing
discussion
imagery rescripting, behavioural
experiments, understanding compassion
tackling substance abuse, education, desensitizati
on, behav- ioural experiments
28
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.

29
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

30
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