Considerations, frameworks and challenges in the treatment of simple and complex trauma Martin Dorahy Department of Psychology University of Canterbury martin.dorahy@canterbury.ac.nz Outline For PTSD trauma-focused interventions central for treatment (NICE, 2005). For complex PTSD trauma-focused interventions may be harmful if not regulated. PTSD, Diss PTSD, CPTSD Trauma representation in memory (PTSD) Elaboration & integration Human beings are resilient! But there are limits and thresholds that if reached will overcome coping and lead to problems. From interpersonal relationship to molecules Trauma impacts on relational, psychological, physical and molecular systems. Isolation, relationship separation PTSD, depression, anxiety, dissociative disorders Physical health problems, cancer (Lanius et al., 2010) DNA breakage (Morath et al., 2013) Medication not particularly helpful for PTSD (Hoskin et al., 2015) SSRIs reduce PTSD symptoms, but the effect is small: “some drugs have small positive impact on PTSD symptoms (e.g., Fluoxetine, paroxetine & venlafaxine” (Hoskin et al., p. 93). Psychological therapy is a better option (NICE, 2005). Psychological therapy has been found to promote repair of DNA breakage (Morath et al., 2013) Therapy First decision point: What are we dealing with ? Accurate assessment essential Slower than able Prolong suffering Faster than able Increase suffering But not always easy! PTSD & dissociative PTSD Depers/dereal Re-experiencing P Avoidance T S D Neg. Alt. Aff&Cog Arousal • Acute • Chronic 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, 2015) Modulation: Over or under Type of PTSD 2 types of PTSD as found in neuroimaging Arousal/reliving (undermodulated) Dissociative (overmodulated) Lanius et al., 2010 Prevalence of Dissociative PTSD (in PTSD samples) 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 PTSD, dissociative PTSD & Complex PTSD Depers/dereal Affect regulation C O Re-experiencing Attention/conscious. M (Dissociation) P P Avoidance T L Self perception S D Alterations in: Neg. Alt. Aff&Cog X Relationships Arousal • Acute • Chronic E Somatic functioning P T S Systems of meaning D Complex trauma Typically associated with specific types of repetitive, relational trauma involving coercive control over victim that produces a quite specific complex symptom profile. Events: Incestuous/abusive families Chronic CA&N Sexual trafficking Political torture Destructive cults Concentration/labor camps Genocidal trauma Loewenstein et al., Psychiatric Times, 2014 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 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) Central memory paradox 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, 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 Vs non-trauma memory Trauma memory Non-trauma memory Occur spontaneously Occur less spontaneously Often triggered by external & internal events Adaptable to social context Occurrence usually cannot be controlled Occurrence can usually be controlled Involve subjective distortions in time No subjective distortion in time Experienced as though event was happening again Experienced as an event in the past Experienced as fragments of the sensory component of the event Experienced as integrated memory Less changing over time More altered by repeated recall Primarily imaged-based Usually recalled as a narrative Reduced self reference Self reference 2nd decision point: What sort of AM are we dealing with ? Self referential perspective First person perspective (this event happened to me) Allocentric/observer Self Experience/objects perspective Egocentric/field Self/perspective Experience/objects Third person perspective Self as detached (non-personified) object – “it’s happened to someone else” Trauma and cognitive processing “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, 2014) - 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, 2014) - 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 What do you see (perceive) & understand (conceive)? O A A G V C Tac Noetic - unrelated to self Cog/mean Perceptual Conceptual Sensory Limbic system, PFC A MEMORY Autonoetic self as part of experience Personification When Trauma occurs Perceptual memory Sensory Perceptual *High res. Sensory memory * Rapidly decaying *Rel. unprocessed *Emot. Stim. more processing Visual STM *Actively maintained *Resource demanding *Limited *More abstraction/ processing Short term memory Conceptual Personified *More processing (gist) *But still perceptual Long term memory Peceptual, SAM (perc. mem) Narrative, concept ual, VAM (epis.me m ABM 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 Putting everything together Elaborated specific event PERCEPTUAL & CONCEPTUAL PROCESSING & MEMORY Conceptually ‘top-down’ Processed Memory Lifetime knowledge (Brown & Kulik, 1977; Conway & Pleydell-Pearce, 2000) Increased integrative linkage and elaboration processing General events Perceptually ‘bottom-up’ Processed Memory Dorahy, 2011 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 unelaborated But when do we engage in elaboration (trauma-focused) work? Assessment (memory) 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 It would be lovely if our story ended here Wishful thinking! 3rd decision point: Is chronic (usually relational) trauma present but lower perceptual symptoms? When more complex symptoms, characterological issues and relational dynamics prevail. What then? Move from Trauma focused to phase-oriented therapy 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 3 Issues for assessment Assessment should include: Symptoms Attachment/process/character Anxiety: Form of anxiety discharge Relational style/primary attachment model Affective 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 Anxiety: Forms of anxiety discharge 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 Relational style Thoughts about self (self-esteem) Thoughts about others Positive (sociability) Positive Negative Intimacy avoidance Secure Abandonment anxiety Lo Lo Negative DismissiveAvoidant Hi Anxiouspreoccupied Hi Fearful-avoidant (unresolved) Bartholomew & Horowitz, 1991, Miller & Perlman, 2009 Affective basis Primary and secondary Emotions Joy Distress Primary emotions Anger Fear Disgust Shame Guilt Pride Secondary (self conscious) emotions Embarrassment Surprise Lewis, 1992; Tracy & Robins, 2007 Factors That Impede Emotional Processing Lee, Scragg and Turner (2001) Shame Guilt Humiliation Compass of shame (Nathanson, 1992) Attack self Avoid Withdraw Attack other Dissociation and modulation 4-D model of PTSD (Frewin & Lanius, in press a, b, c) 4 dimensions that differentiate more straight- forward PTSD from more complex, dissociative PTSD They break symptoms into those classed as distress associated with ‘Normal Waking Consciousness’ (NWC) and distress associated with ‘Trauma-Related Altered States of Consciousness’ (TRASC). 4-D model of PTSD (Frewin & Lanius, in press a, b, c) 4 dimensions and NWC vs TRASC symptoms Body Disembodied experiences of depersonalisation (TRASC) vs Embodied experiences of distress (NWC; e.g., panic) Emotion Emotional numbing/affective shut-down (TRASC) vs non-dissoc. Negative emotionality (NWC) e.g, fear, shame, guilt) Time-memory Flashbacks (TRASC) vs intrusive recall/distress reminders (NWC) Thought Voice hearing (TRASC; e.g., ‘you’re useless’-second person) Vs negative self-ref. thinking/internal verbal cognition (NWC; e.g., ‘I’m useless’ – first person). Animal defensive responses 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 Recuperative behaviour No predatory potential -Avoidance 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 Dissociation of animal defenses Secondary structural dissociation Dividedness amongst dissociative self-aware systems Trauma Emotional part of the personality (EP): e.g., Fight Submit Freeze 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 Boon et al 2011 stabilisation work, eg., Initial coping skills (reflection), Improving daily life (sleep; a healthy daily structure; free time and relaxation), Coping with traumatic triggers and memories, Understanding emotions and cognitions (core beliefs, cognitive errors), Advanced coping skills (anger, fear, shame and guilt, needs of inner child parts, self-harm, inner cooperation), Improving relationships (isolation, loneliness, learning to be assertive, and setting healthy personal boundaries). Martin.dorahy@canterbury.ac.nz