personal background to help people with psychological difficulties or pain (especially when effective help is not readily available elsewhere) to

personal backgroundpersonal background

to help people with psychological difficulties or to help people with psychological difficulties or pain (especially when effective help is not pain (especially when effective help is not readily available elsewhere) readily available elsewhere)

to try to provide & encourage a whole person to try to provide & encourage a whole person approach using what’s best in conventional, approach using what’s best in conventional, comp-lementary, & self-help methods of health comp-lementary, & self-help methods of health carecare

work through a small charity whose aims are:

for more details & a downloadable copy of this talk go to the ‘goodknowledge’ section of www.goodmedicine.org.uk click on ‘lecturesand leaflets’ and look under ‘emotional expression’ in ‘past lectures’

key points of this key points of this talktalk trauma memories are very trauma memories are very

common in depression and common in depression and anxiety as well as in ptsdanxiety as well as in ptsd

elicit these memories and elicit these memories and ‘images’ gently and carefully‘images’ gently and carefully

disorder onset, severity and disorder onset, severity and persistence seem persistence seem contributed to by memories contributed to by memories and ‘images’and ‘images’

lessons from ptsd treatment lessons from ptsd treatment may well improve treatment may well improve treatment of depression and anxietyof depression and anxiety

involuntary memories are involuntary memories are normalnormal

involuntary memories of personal life events are involuntary memories of personal life events are reported at least 5 or 6 times daily by “normals”reported at least 5 or 6 times daily by “normals”

typically these memories are cued by typically these memories are cued by identifiable aspects of one’s current situationidentifiable aspects of one’s current situation

memories often take their emotional tone from memories often take their emotional tone from one’s current mood - typically happiness or one’s current mood - typically happiness or sadness - and then reinforce this moodsadness - and then reinforce this mood

memories are often of recent or of unusual memories are often of recent or of unusual eventsevents

intrusive thoughts are even more common and intrusive thoughts are even more common and when negative tend to be characterised by fearwhen 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 & vicious circle of mood & memorymemory

upsetting emotional state depression, social anxiety,

agoraphobia, ocd, posttraumatic stress disorder,

etc facilitated access to memories of similar negative emotional tone

upsetting memories not yet worked through from earlier life

experiences

old beliefs linked to the memories aggravate the situation further

disorganized nature of partly repressed emotional memories means

that they have no clear ‘date-time’ stamp on them

current life experiences trigger memories (felt- sense, visual and shared meaning)

posttraumatic stress posttraumatic stress disorderdisorder

A.A. exposureexposure - past exposure to a severely traumatic event and response - past exposure to a severely traumatic event and response involving intense fear, helplessness or horrorinvolving intense fear, helplessness or horror

B.B. reexperiencingreexperiencing - the traumatic event is persistently reexperienced in - the traumatic event is persistently reexperienced in any of a number of ways - recollections, dreams, flashbacks, intense any of a number of ways - recollections, dreams, flashbacks, intense emotional or physical reactions to remindersemotional or physical reactions to reminders

C.C. avoidance/numbingavoidance/numbing - persistent avoidance of reminders and/or - persistent avoidance of reminders and/or numbing of general responsivenessnumbing of general responsiveness

D.D. excessive arousalexcessive arousal - for example insomnia, irritability, poor - for example insomnia, irritability, poor concentration, etc.concentration, etc.

E..E.. durationduration - for over a month - for over a month

F. F. significant disturbancesignificant disturbance - causes significant distress or impairment in - causes significant distress or impairment in functioningfunctioning

American Psychiatric Association Diagnostic & statistical manual of mentaldisorders (4th ed) Washington DC: American Psychiatric Press, 1994

prevalence of prevalence of ptsdptsd7.8% 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

5.0% men

10.4% women

depression & imagery depression & imagery research research

Kuyken W & Brewin CR Kuyken W & Brewin CR Intrusive memories of Intrusive memories of childhood abuse during depressive episodes childhood abuse during depressive episodes Behav Res Ther 1994;32:525-8 Behav Res Ther 1994;32:525-8

Kuyken W & Brewin CR Kuyken W & Brewin CR Autobiographical Autobiographical memory functioning in depression and reports of memory functioning in depression and reports of early abuseearly abuse J Abnorm Psychol 1995;104:585- J Abnorm Psychol 1995;104:585-91 91

Andrews B Andrews B Bodily shame as a mediator between Bodily shame as a mediator between abusive experiences and depression abusive experiences and depression J J Abnorm Psychol 1995;104:277-85Abnorm Psychol 1995;104:277-85

Brewin CR Brewin CR Cognitive processing of adverse Cognitive processing of adverse experiences experiences Int Rev Psychiat 1996;8:333-9Int Rev Psychiat 1996;8:333-9

Brewin CR, Reynolds M, et al. Brewin CR, Reynolds M, et al. Autobiographical memory processes and the course of depression. J Abnorm Psychol 1999; J Abnorm Psychol 1999; 108(3): 511-7.(3): 511-7.

trauma memories & trauma memories & depression 1depression 1

31 sufferers from current depression were asked about 31 sufferers from current depression were asked about deaths of family or friends & about other major life eventsdeaths of family or friends & about other major life events

questioned too about events they felt might have questioned too about events they felt might have triggered the current episode of depression & about triggered the current episode of depression & about childhood - for example harsh discipline or unwanted childhood - for example harsh discipline or unwanted sexual experiences sexual experiences

asked too about related memories – these were defined asked too about related memories – these were defined as spontaneous visual images of specific scenes that had as spontaneous visual images of specific scenes that had actually taken placeactually taken place

87% of these current depression sufferers said yes - they 87% of these current depression sufferers said yes - they had experienced 1-5 different intrusive images (av’ge 2.6) 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 & trauma memories & depression 2depression 2

55% of these intrusive memory images involved illness 55% of these intrusive memory images involved illness or death; 21% involved relationship or family or death; 21% involved relationship or family problems; 18% involved abuse and assaultproblems; 18% involved abuse and assault

memories were usually associated with mixed feelings memories were usually associated with mixed feelings of sadness, guilt, anger and helplessness, and to a of sadness, guilt, anger and helplessness, and to a lesser extent anxiety and shamelesser extent anxiety and shame

scoring these depressive memories using the IES scoring these depressive memories using the IES showed that they had similar scores to memories showed that they had similar scores to memories found in PTSDfound in PTSD

memories of past abuse and of assault tended to be memories of past abuse and of assault tended to be associated with higher IES scores and with severer associated with higher IES scores and with severer levels of depression levels of depression

% becoming well & % becoming well & staying wellstaying well

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 & psychodynamicinterpersonal 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

CBT: 30% IPT: 26%

BT: 25%PD-IPT: 29%

% who becamewell & stayed

well over 12 - 24 month follow-up

clinical clinical implicationsimplications 1 1 it’s common for depression sufferers to be it’s common for depression sufferers to be

troubled by significant trauma memoriestroubled by significant trauma memories high levels of intrusion & associated avoidance high levels of intrusion & associated avoidance

of trauma memories (high IES scores) of trauma memories (high IES scores) are associated with more prolonged are associated with more prolonged depression even when allowing for the depression even when allowing for the initial severity of psychiatric symptomsinitial severity of psychiatric symptoms

it seems likely that asking about trauma it seems likely that asking about trauma memories & using emotional processing memories & using emotional processing methods that lower IES scores may well speed methods that lower IES scores may well speed recovery and possibly may even reduce relapserecovery and possibly may even reduce relapse

socialsocial anxietyanxiety && imageryimagery

research research Hackmann A, Surawy C, et al. Hackmann A, Surawy C, et al. Seeing yourself through others' Seeing yourself through others'

eyes: A study of spontaneously occurring images in social eyes: A study of spontaneously occurring images in social phobia.phobia. Behavioural and Cognitive Psychotherapy 1998; 26: 3-12 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. Hackmann A, Clark DM, et al. Recurrent images & early memories in social phobia. Behav Res Ther 2000; 2000; 38(6): 601-10.(6): 601-10.

Hernández-Guzmán L, González S, et al. Hernández-Guzmán L, González S, et al. Effect of guided imagery on children's social performance. Behavioural and Cognitive Psychotherapy 2002; 2002; 30: 471-483.: 471-483.

Hirsch C, and Mathews A. Hirsch C, and Mathews A. Anticipatory imagery and the develop-ment of social anxiety. BABCP Annual Conference Abstracts : pp 11-12. York, . York, 2003..

Hirsch CR, Meynen T, et al. Hirsch CR, Meynen T, et al. Negative self-imagery in social anxiety contaminates social interactions. Memory 2004; 2004; 12(4): (4): 496-506 496-506

traumatrauma memoriesmemories && socialsocial

anxietyanxiety intrusive ‘images’ are very commonly associated with intrusive ‘images’ are very commonly associated with

anxiety provoking situations for people with social anxiety anxiety provoking situations for people with social anxiety disorder. disorder.

these images are often visual but may also occur as an these images are often visual but may also occur as an internal felt-sense or via other (often multiple) sensory internal felt-sense or via other (often multiple) sensory channels.channels.

intrusive visual images of social situations are typically from intrusive visual images of social situations are typically from an ‘observer’ rather than from a ‘first person’ perspective. an ‘observer’ rather than from a ‘first person’ perspective.

the majority of subjects can link intrusive images to early the majority of subjects can link intrusive images to early memories when typically the social anxiety disorder first memories when typically the social anxiety disorder first became particularly troublesome.became particularly troublesome.

holding the intrusive negative image (instead of a neutral or holding the intrusive negative image (instead of a neutral or positive image) aggravates symptoms (feelings, attentional positive image) aggravates symptoms (feelings, attentional biases & mis-estimations) and performance – as judged by biases & mis-estimations) and performance – as judged by the subject, others involved socially, & by external observers the subject, others involved socially, & by external observers

non socially anxious subjects also have their performance non socially anxious subjects also have their performance disrupted if trained to hold negative rather than neutral disrupted if trained to hold negative rather than neutral images of their performanceimages of their performance

clinical implications 2clinical implications 2 educate socially anxious subjects about the frequency, educate socially anxious subjects about the frequency,

type, importance, origins, effects, and management of type, importance, origins, effects, and management of images. images.

emotional processing of associated early memories is emotional processing of associated early memories is likely to be helpful in its own right and may guide the likely to be helpful in its own right and may guide the nature of subsequent coping image work.nature of subsequent coping image work.

consider training social anxiety sufferers to hold consider training social anxiety sufferers to hold coping rather than negative images before and coping rather than negative images before and during social challenges. during social challenges.

it is reasonable to encourage these coping it is reasonable to encourage these coping ‘images’ to involve a variety of sensory channels ‘images’ to involve a variety of sensory channels for example visual, felt-sense & auditory. for example visual, felt-sense & auditory.

coping visual images should be from a ‘first coping visual images should be from a ‘first person’ rather than an ‘observer’ perspective.person’ rather than an ‘observer’ perspective.

try training preparatory coping images (guided or self-try training preparatory coping images (guided or self-directed) as a sequence involving experiencing initial directed) as a sequence involving experiencing initial difficulties, but progressively mastering the social difficulties, but progressively mastering the social interaction with eventual successful outcome. interaction with eventual successful outcome.






trauma memories & trauma memories & agoraphobiaagoraphobia

when questioned, all of a group of 20 agoraphobics – but when questioned, all of a group of 20 agoraphobics – but none of a group of 20 matched controls – reported having none of a group of 20 matched controls – reported having distinct recurrent intrusive ‘images’ in agoraphobic situations.distinct recurrent intrusive ‘images’ in agoraphobic situations.

most intrusive ‘images’ involved several sensory modalities most intrusive ‘images’ involved several sensory modalities such as vision, internal ‘felt-sense’, sound, touch, smell & such as vision, internal ‘felt-sense’, sound, touch, smell & taste (note vision wasn’t always present as a component). taste (note vision wasn’t always present as a component).

on discussion, all subjects linked an aversive memory to the on discussion, all subjects linked an aversive memory to the intrusive ‘image’, but only 15% (3/20) reported having intrusive ‘image’, but only 15% (3/20) reported having thought about the content of the memory prior to the thought about the content of the memory prior to the interview. interview.

the mean age at the time of the memory was 14.3 years.the mean age at the time of the memory was 14.3 years. 75% (15/20) of the subjects believed the memory affected 75% (15/20) of the subjects believed the memory affected

their anxiety in agoraphobic situations.their anxiety in agoraphobic situations. common themes with both intrusive images and associated common themes with both intrusive images and associated

memories were of catastrophic danger and of a negative view memories were of catastrophic danger and of a negative view of self (such as the self intimidated, humiliated and of self (such as the self intimidated, humiliated and misunderstood). 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 clinical implicationsimplications 3 3 when asking about intrusive ‘images’ in agoraphobia when asking about intrusive ‘images’ in agoraphobia

(or other psychological disorders) it may be worth (or other psychological disorders) it may be worth getting the sufferer to imagine (or actually revisit) an getting the sufferer to imagine (or actually revisit) an upsetting episodeupsetting episode

note that recurrent intrusive images can come note that recurrent intrusive images can come visually or as a internal felt-sense or via other visually or as a internal felt-sense or via other (often multiple) sensory channels (often multiple) sensory channels

although on questioning the majority of subjects although on questioning the majority of subjects can link this intrusive image to an early memory, can link this intrusive image to an early memory, they may well not have made this link before they may well not have made this link before

subjects often recognize quite readily that the subjects often recognize quite readily that the image tends to aggravate their symptoms image tends to aggravate their symptoms

exploring the meaning and beliefs around the image exploring the meaning and beliefs around the image and memory may well make good senseand memory may well make good sense

trauma memories & OCDtrauma memories & OCD of 34 inpatients with OCD, 71% (24/34) reported that they of 34 inpatients with OCD, 71% (24/34) reported that they

had intrusive visual images when their OCD was really bad.had intrusive visual images when their OCD was really bad. for patients with visual images, 33% (8/24) recognized their for patients with visual images, 33% (8/24) recognized their

images as memories of actual aspects of earlier traumas. images as memories of actual aspects of earlier traumas. when the remaining 16 patients with visual images when the remaining 16 patients with visual images

were asked about their earliest recollection of having were asked about their earliest recollection of having had similar sensations and feelings, 94% (15/16) had similar sensations and feelings, 94% (15/16) could identify a particular traumatic experience that could identify a particular traumatic experience that was linked to the visual image. was linked to the visual image.

the perceived similarity between the visual image & the the perceived similarity between the visual image & the memory of the traumatic experience was very high, both in memory of the traumatic experience was very high, both in terms of sensory characteristics and in terms of interpersonal terms of sensory characteristics and in terms of interpersonal meanings. meanings.

it seems likely that many of the 29% (10/34), who did not it seems likely that many of the 29% (10/34), who did not report intrusive visual images, might have reported ‘images’ report intrusive visual images, might have reported ‘images’ if questioned about felt-sense and other sensory channels. 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

traumatrauma memoriesmemories && otherother

disorders disorders Hinrichson H, Morrison T, et al. Hinrichson H, Morrison T, et al. Triggers of vomiting in bulimic Triggers of vomiting in bulimic disorders: the roles of core beliefs and imagery.disorders: the roles of core beliefs and imagery. BABCP Annual Conference Abstracts: page 8. York, 2003. . 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. Osman S, Cooper M, et al. Spontaneously occurring images and Spontaneously occurring images and early memories in people with body dysmorphic disorder.early memories in people with body dysmorphic disorder. Memory 2004; 12(4): 428-36Memory 2004; 12(4): 428-36

Brewin CR, Watson M, et al. Brewin CR, Watson M, et al. Memory processes & course of anxiety and depression in cancer patients. Psychol Med 1998; 1998; 28: 219-24.: 219-24.

Finkenauer C, and Rimé B. 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.Journal of Health Psychology 1998; 3(1): 47-58.

Morrison A. Morrison A. Trauma and psychosis: cause, consequence, common processes and clinical implications. BABCP Annual Conference Abstracts: p 21. York, 2003. . York, 2003.






NICE guideline on PTSDNICE guideline on PTSD

trauma-focused cognitive trauma-focused cognitive behavioural therapybehavioural therapy

eye movement eye movement desensitisation and desensitisation and reprocessingreprocessing

psychological treatments psychological treatments that that

are specific for PTSD are:are specific for PTSD are:

march ’05: http://www.nice.org.uk

matchingtriggers

negative assessments of

trauma/subsequent events

nature of traumamemory

current threatarousal symptomsintrusions, strong

emotions

strategies intended to control

threat/symptoms

persiste

nt p

tsdp

ers

iste

nt

pts

d

trauma characteristics/beliefs

prior experiences/coping subsequent events

thinking processes

during trauma

Ehlers A, Clark DA cognitive modelof posttraumaticstress disorder

Behav Res Therapy2000; 38: 319-45

arrows indicate the following

relationships

leads to

preventschange in

influences


relationships

leads to

preventschange in

influences

matchingtriggers





threat/symptoms


emotions

disorganizeddisorganizedfragmented, partialfragmented, partialno date/time stampno date/time stamp

‘‘distorted’ beliefs:distorted’ beliefs:fear, anger, shamefear, anger, shameguilt, helplessnessguilt, helplessness

avoidance (outer & avoidance (outer & inner), numbinginner), numbing

safety behaviourssafety behavioursdrugs & alcoholdrugs & alcohol

handhand trauma,trauma, beliefsbeliefs &&

outcomesoutcomes 11 Mervin Smucker reported on 3 research studies Mervin Smucker reported on 3 research studies

done at the Medical College of Wisconsin with done at the Medical College of Wisconsin with PTSD sufferers following traumatic hand injuries.PTSD sufferers following traumatic hand injuries.

study 1 involved 630 adult accident study 1 involved 630 adult accident victims with PTSD. Prolonged exposure victims with PTSD. Prolonged exposure treatment produced 90% positive response treatment produced 90% positive response when fear was the main PTSD emotion, when fear was the main PTSD emotion, but only 15% positive response when anger but only 15% positive response when anger shame, guilt, or mental defeat was the main shame, guilt, or mental defeat was the main emotion. emotion.

Smucker MR. How does theory inform practice in the treatment of intrusive memories? EABCT Annual Conference. Manchester, 2004

handhand trauma,trauma, beliefsbeliefs &&

outcomesoutcomes 22 study 2 involved 55 adolescents with PTSD study 2 involved 55 adolescents with PTSD

following hand injuries. PE resulted in 89% following hand injuries. PE resulted in 89% response when fear main emotion, but only 18-19% response when fear main emotion, but only 18-19% when guilt/self-blame or anger was main emotionwhen guilt/self-blame or anger was main emotion

study 3 involved 23 adults with PTSD after study 3 involved 23 adults with PTSD after hand injuries who had failed to respond to hand injuries who had failed to respond to 6-15 sessions of prolonged exposure (PE). 6-15 sessions of prolonged exposure (PE). 78% (18/23) showed significant improve- 78% (18/23) showed significant improve- ment with a further 1-3 sessions of imagery ment with a further 1-3 sessions of imagery rescript-ing with gains well maintained at 6 month rescript-ing with gains well maintained at 6 month follow-upfollow-up


relationships

leads to

preventschange in

influences

matchingtriggers





threat/symptoms


emotions

reconstructing thereconstructing thestory: telling, tapes, story: telling, tapes, writing & discussionwriting & discussion

imagery rescripting,imagery rescripting,behavioural experiments,behavioural experiments,

understanding & compassionunderstanding & compassion

tackling substancetackling substanceabuse, education,abuse, education,

desensitization, behav-desensitization, behav-ioural experimentsioural experiments

cutting edge cbt cutting edge cbt resourcesresources

Brewin C. Brewin C. Posttraumatic stress disorder: Posttraumatic stress disorder: malady or myth?malady or myth? Yale University Press, Yale University Press, 20032003

Smucker M. et al. Smucker M. et al. Posttraumatic stress Posttraumatic stress disorder.disorder. in R. Leahy (ed) in R. Leahy (ed) Roadblocks in Roadblocks in cognitive-behavioral therapy: transforming cognitive-behavioral therapy: transforming challenges into opportunities for change.challenges into opportunities for change. Guilford Press, 2003.Guilford Press, 2003.

Mueller M, Hackmann A, & Croft A. Mueller M, Hackmann A, & Croft A. Post-Post-traumatic stress disorder.traumatic stress disorder. in J. Bennett- in J. Bennett-Levy, et al. (eds) Levy, et al. (eds) Oxford guide to Oxford guide to behavioural experiments in cognitive behavioural experiments in cognitive therapy.therapy. OUP, 2004. OUP, 2004.

Gilbert P. Gilbert P. Compassion : Compassion : conceptualizations, research & use in conceptualizations, research & use in psychotherapy.psychotherapy. Brunner-Routledge, 2005. Brunner-Routledge, 2005.






to download a copy of this to download a copy of this talk 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”

Documents

personal background to help people with psychological difficulties or pain (especially when effective help is not readily available elsewhere) to