Martin Dorahy
Department of Psychology
University of Canterbury


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?

‘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 )

Modulation: Over or under
Type of PTSD

2 types of PTSD as found in neuroimaging

Arousal/reliving (undermodulated)

Dissociative (overmodulated)


≈ 70% in scanner (e.g., fMRI) have arousal/reliving response to script driven imagery




HR increases, therefore SNS activation
Low 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 under modulation in response to trauma memories” (p. 2) created by a failure of prefrontal regions to inhibit limbic activity.
Lanius et al., 2010


≈ 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 over modulation in response to exposure to trauma memories” (p. 2) created by midline prefrontal inhibition of limbic region.
Lanius et al., 2010


Veterans (Wolf et al, 2012a, 2012b)

15% male sample


30% female sample
12% mixed sample

Civilian PTSD sample (Steuwe et al., 2012)

26% primarily female

Those in dissociative group had higher:




Comorbidity (e.g., dep, anxiety, PTSD Sx)
Axis II (especially in female samples-BPD, APD)
Trauma exposure
Child abuse and neglect

P
T
S
D
Affect regulation
Re-experiencing
Attention/conscious.
(Dissociation)
Avoidance
Self perception
Alterations in:
Neg. Alt. Aff&Cog
Relationships
• Acute
• Chronic
Arousal
Somatic functioning
Systems of meaning
L
E
M
P
X
C
O
P
T
S
D


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 follows




Direct exposure.
Witnessing, in person.
Indirectly, by learning that a close relative or close friend was exposed to trauma
Repeated 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 memory
• Brewin (2011, 2014); Rubin et al. (2008)


PTSD characterised by vivid involuntarily intrusions with detailed imagery and emotion (enhanced perceptual memory)

AND

Impaired 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.

Trauma vs non-trauma memory

Trauma memories fundamentally different to other autobiographical memories.

Autobiographical memories



Organised
Contextualised
Characterised by “autonoetic awareness” (Tulving,
2002)

Trauma memories



Poorly elaborated and incorporated into the autobiographical memory store
Perceptually detailed
Not given a complete context in time and place
(promotes a sense of ‘nowness’).

Trauma memory
Occur spontaneously
Often triggered by external & internal events
Occurrence usually cannot be controlled
Involve subjective distortions in time
Non-trauma memory
Occur less spontaneously
Adaptable to social context
Occurrence can usually be controlled
No subjective distortion in time
Experienced as an event in the past Experienced as though event was happening again
Experienced as fragments of the sensory component of the event
Less changing over time
Primarily imaged-based
Reduced self reference
Experienced as integrated memory
More altered by repeated recall
Usually recalled as a narrative
Self reference

First person perspective (this event happened to me)
Self
Allocentric/observer
Experience/objects perspective
Egocentric/field
Self/perspective Experience/objects
Third person perspective
Self as detached (non-personified) object – “it’s happened to someone else”


“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?

Dual Representation Theory (Brewin, Dalgleish and
Joseph, 1996; Brewin, 2001, 2010) - I
Trauma memory represented in two separate systems
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

Dual Representation Theory (Brewin, Dalgleish and Joseph, 1996; Brewin, 2001, 2010) - II
2. Verbally accessible memory (VAM) system (conceptual, epidosic)
 Narrative memories of the trauma


Integrated 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
Hippocampus

V
A
O
G
Tac
A
C
Noetic - unrelated to self
Cog/mean
Autonoetic self as part of experience
Sensory
Perceptual Conceptual Personification
Limbic system, PFC
A MEMORY

Sensory
Perceptual
*High res.
*Actively maintained
*Resource demanding
*Limited
*More abstraction/ processing
Sensory memory
Visual
STM
Short term memory Conceptua l
* Rapidly decaying
*Rel. unprocessed
*Emot.
Stim. more processing
*More processing
(gist)
*But still perceptual
Long term memory
Peceptual, SAM
(perc. mem)
Narrative, concept ual, VAM
(epis.me
m
ABM
Personified

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, 2010


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.


Dissociation assoc with more perc. and less self reference
(e.g., Lyttle, Dorahy, Hanna, & Huntjens, 2010 ; Van der Hart et al., 2006)

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 memory

Autobiographical memory (Conway
& Pleydell-Pearce,
2000)
Specific event
General events
Lifetime knowledge
Avoidance
Peritraumatic dissociation e.g., Kindt et al.,2005;
Kleim et al., 2008; Lyttle,
Dorahy et al., 2010; Michael
& Ehlers, 2005; Pacella et al., 2011
Reduced selfreferential processing
Increased perceptual processing
Fragmented memory
- incoherence
- disorganisation
Hampered postevent conceptual processing
- elaboration
- contextualisation
Posttraumatic symptoms
Persistent dissociation e.g., Briere et al.,
2005; Murray et al.,
2002
Huntjens, Dorahy, & Van Wees, in press

Elaborated specific event
PERCEPTUAL & CONCEPTUAL
PROCESSING & MEMORY
Conceptually ‘top-down’ Processed
Memory
General events
Lifetime knowledge
(Brown & Kulik, 1977; Conway & Pleydell-Pearce, 2000)
Perceptually ‘bottom-up’ Processed
Memory
Dorahy, 2011


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 unelaborated

But when do we engage in elaboration
(trauma-focused) work?


Characterise nature of trauma memory and spontaneous intrusions.

Detailed (crisp) percep. reps.






Rel. unchanged over time
Activate strong negative feelings
Gaps in memory
Where in sequence events are muddled, confused.
Extent to which memories have ‘here and now’ quality, and strong sensory & motor components.
Memory has field/egocentric perspective


Identify hot spots

Challenge appraisals that thinking about T is unsafe, dangerous.

Facilitates elaboration and contextualisation of trauma memory


Imaginal reliving: reliving experience in presence of therapist and putting into words


Relive experience in minds eye (images, thoughts, feelings, narrative
Present 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 memory


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)


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 grieving


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 3


Assessment should include:

Symptoms Attachment/process/character





A nxiety: Form of anxiety discharge
R elational style/primary attachment model
A ffective basis (e.g., fear vs shame)
M odulation: Over or under
‘ A nimal’ defenses: Forms of

This will determine to what degree traumafocused versus phase-oriented therapy is required


Striated muscle

Muscle tension
 sighing

Smooth muscle

Upset stomach


Migraines diarrhea

Cognitive perceptual disruption



Vagueness
Depersonalisation
Derealisation

Projection
• Davanloo, 1990; Della Selva, 1996; Gottwik et al., 2001

Thoughts about self (self-esteem)
Thoughts about others
(sociability)
Positive
Abandonment anxiety
Positive
Secure
Lo
Negative Dismissive-
Avoidant
Intimacy avoidance
Lo
Anxiouspreoccupied
Hi
Negative
Fearful-avoidant
(unresolved)
Hi
Bartholomew & Horowitz, 1991, Miller & Perlman, 2009




Blatt, 2008; Dorahy, 2012; Dorahy & Hanna, 2012

Primary emotions
Affective basis
Primary and secondary Emotions
Joy
Distress
Anger
Fear
Disgust
Surprise
Shame
Guilt
Pride
Embarrassment
Secondary (self conscious) emotions
Lewis, 1992; Tracy & Robins, 2007

Factors That Impede Emotional Processing

Lee, Scragg and Turner (2001)

Shame


Guilt
Humiliation

Avoid
(Nathanson, 1992)
Attack self
Withdraw
Attack other

 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, 120

Blanchard et al., 2001; Fanselow, 1994; Pansepp, 2005; Rau & Fanselow, 2007
Preferred activity pattern
Pre-encounter defense
Postencounter defense
Circastrike defense
Point of no return
No predatory potential
Avoidance
Recuperative behaviour
Predatory potential
Stretched approach
-Risk assessment
-meal pattern reorganisation
Predator detected
-Flight if possible
-Freeze if not
Increased predatory imminence
Predator makes contact
-upright posturing
-vocalisation
-’jump attack’
-escape
-submit
Predat or makes the kill

Secondary structural dissociation
Dividedness amongst dissociative self-aware systems
Trauma
Emotional part of the personality (EP): e.g.,
Submit
Fight flight
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, 2002