personal background work through a small charity that focuses on

trying to help people in persistent pain or with stress related disorders - especially when effective help is not easily available elsewhere

lecture and run seminars widely - usually for health professionals - aiming to integrate what is most useful in complementary, conventional and self-help methods of health care

juggle with the notion that the effectiveness of what I do is crucially affected by my inner state

we’ll look at two major areas

do traumatic memories that are not worked through damage our health?

is it helpful to express these memories through writing, talking or other media?

the first area do traumatic memories

that are not worked through damage our health?

1.) involuntary memories are a normal everyday process for all of us2.) they become particularly trouble

some in posttraumatic stress disorder3.) problematic memories also occur in

depression and other disorders as well

involuntary cognitions 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 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

upsetting emotional state posttraumatic stress disorder,

depression, etc

facilitated access to memories of similar negative emotional

tone

many upsetting memories available due to life history

numerous possible triggers for emotional upset

current life experiences may trigger upsetting

memories

the psychiatric illness iceberg

psychiatric inpatients 0.6%mental illness services 2.4%conspicuous psychiatric

morbidity 10.2% recognised morbidity

amongst GP attenders 23%whole community 26 - 31.5%

psychiatric morbidity rates per year in the UK:

Shah A The burden of psychiatric disorder in primary careInternational Review of Psychiatry 1992;4:243-50

posttraumatic stress disorderA. 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 mentaldisorders (4th ed) Washington DC: American Psychiatric Press, 1994

trauma survey of 5,877 US adults

Kessler RC et al. Posttraumatic stress disorder in the National Comorbidity Survey Arch Gen Psychiatry 1995;52:1048-60

direct combat experience women: 0% men 6.4% involved in life-threatening accident 13.8 25.0 involved in fire, flood, or natural disaster 15.218.9 witnessed someone being badly injured or killed 14.535.6 raped (sexual intercourse against your will) 9.2 0.7 sexually molested (unwanted genital touch) 12.3 2.8 serious physical attack or assault 6.9 11.1 physically abused as a child 4.8 3.2 seriously neglected as a child 3.4 2.1 threatened with weapon, held captive, kidnapped 6.8 19.0 other unusual terrible experience 2.7 2.2 great shock when above happened to someone close 12.4

11.4

trauma frequency & chance of ptsd overall 60.7% of men and 51.2% of women had

experienced a severe traumatic event different types of event had different chances of

producing PTSD - e.g. rape, childhood physical abuse and combat exposure had worse outcome

women were both more likely to experience “worse” events and then to develop PTSD

8.2% of men exposed to severe trauma developed PTSD in contrast to 20.4% of women

ptsd prevalence

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

5.0% men

10.4% women

assessment

on _______ you experienced ________________ (date) (life event)below is a list of comments made by peopleafter stressful life events. please check each itemindicating how frequently these comments weretrue for you during the past seven days.if they did not occur during that time, pleasemark the "not at all" column

frequency

not at all rarely sometimes often 0 1 3 5

a. I thought about it when I didn't mean to

b. I avoided letting myself get upset when Ithought about it or was reminded of it

c. I tried to remove it from memory

d. I had trouble falling asleep or staying asleep,because of pictures or thoughts about it thatcame into my mind

e. I had waves of strong feelings about it

f. I had dreams about it

g. I stayed away from reminders of it

h. I felt as if it hadn't happened or it wasn't real

i. I tried not to talk about it

j. pictures about it popped into my mind

k. other things kept making me think about it

l. I was aware that I still had a lot of feelingsabout it, but I didn't deal with them

m. I tried not to think about it

n. any reminder brought back feelings about it

o. my feelings about it were kind of numb

for each question score 0 for "not at all", 1 for "rarely", 3 for "sometimes" and 5 for "often"

intrusion total comes from adding the scores for questions a, d, e, f, j, k, n; avoidance total from adding scores for questions b, c, g, h, i, l, m, o. add intrusion

and avoidance for the full total

Horowitz M et al Impact of event scale: a measure of subjective

stress Psychosomatic Medicine

1979;41:209-18

typical total IES scores for ptsd

sufferers range from 30 to 60; a score of

10 or more for either subscale suggests at least moderate ptsd, while a score in the

20’s for either subscale suggests

high ptsd

depression too is very common

Survey of 8,098 US adults: Blazer DG et al. The prevalence

& distribution of major depression in a national

community sample: the National Comorbidity Survey Am J

Psychiat 1994;151:979-86

17.1% estimated suffer from major

depression at some stage in their lives women:21.3%,men:12.7%4.9% current prevalenceprobably 2 to 3 times this number suffer from sub- syndromal depression

recent depressive memories research Kuyken W & Brewin CR Intrusive memories of

child- hood 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 Memory, depression, and PTSD presentation at BABCP Conference, Canterbury, UK 8-12 July 1997

depression & intrusive memories

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

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

asked too about related memories - 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 to 5 different intrusive images (average 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

depression & intrusive memories 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 assault tended to be associated with higher IES scores and with severer levels of depression

the first area do traumatic memories

that are not worked through damage our health?

1.) involuntary memories are a normal everyday process for all of us2.) they become particularly troublesome in posttraumatic stress disorder3.) problematic memories also occur in

depression and other disorders as well

we’ll look at two major areas

do traumatic memories that are not worked through damage our health?

is it helpful to express these memories through writing, talking or other media?

the second area is it helpful to express these

memories through writing, talking or other media?

1.) some comments about functional and dysfunctional emotions2.) ptsd & other disorders are usually complex and treatments may need to be multifaceted3.) what place has writing in all this?

emotions are often adaptive

“in the wilderness in which the human racedeveloped its current genetic characteristics,

individuals who had the capacity to respond todangerous or otherwise significant circumstances

with an adequate set of emotions, and actedaccordingly, had a better chance to survive, to

have children, and to raise them than individualswho were deficient in that respect”

Gut E Productive & unproductive depressionLondon: Routledge, 1989

emotions as helpful action tendencies:

event

action

appraisal

arousal

examples of emotional functions

anxiety can serve an individual by making them hypervigilant - ready to run or freezeand it also alerts others to possible danger

anger can help an individual act rapidly to defend themselves when their territory is invaded & it serves to frighten others away

depression can occur when our attachmentto a major goal/value is blocked - it causes us to pause, re-evaluate and change direction

Well, it’s a delicate situation , sir ... sophisticated firing system, hair-trigger mechanisms, and Bob’s wife just left him last night, so you know his mind’s not into this.

Gary Larson

emotionscan be

dysfunctional!

why troubled by intrusive memories?

memories formed during times of intense emotion are “seared” into the brain biochemically - this stops us forgetting information that may be crucial for survival

until powerful experiences are worked through and integrated into an updated sense of the world, the experiences will keep coming back into consciousness

some possible explanations:

normal cycles of learning

1,3... immersion in experiences

2,4... reflecting & learning from those experiences

the second area is it helpful to express these

memories through writing, talking or other media?

1.) some comments about functional and dysfunctional emotions2.) ptsd & other disorders are usually complex and treatments may need to be multifaceted3.) what place has writing in all this?

ptsd & other disorders are complex

genetic vulnerabilities early life experiences significant life events coping skills & resources

pre-existing vulnerability to ptsd, both long & short term

factors intrinsic to the precipitating ptsd trauma

coping style and resources affect extent of ptsd damage

damage may itself affect memory & involve several diagnostic categories

to be uncertain is to be uncomfortable; to be certain is to be merely ridiculous

Goethe multiple factors affect both

the onset and the courseof psychological disorders

diagnostic categories of damage

mood disturbancespost-traumatic stress reactionssexual difficultiesself-damaging behaviourinterpersonal problems

common psychosocial problems among abuse survivors who seek therapy:

Jehu D Post-traumatic stress reactions among adults molested as children Sexual and Marital Therapy 1991;6:227-43

maintaining factors - for anxiety states

appraisal of threat

probability x awfulnesscoping + rescue

physiological &biological changes

potential threatssituations, sensations, thoughts

safety seeking behavioursavoidance, escape, within-situation,

neutralisation, checking, reassurance

selective attention

maintenance

of arousal

failure to disconfirm

Salkovskis PM Anxiety, beliefs,

& safety-seeking behaviour in:

Frontiers of cognitivetherapy New York:

Guilford Press, 1996

treatment: multifaceted & still evolving

it is often best to combine biological, psychological & psychosocial treatments

the most realistic & helpful aim may be to optimise life quality rather than work for complete “cure”

In God’s kitchen

with severe, chronic PTSD:

Shalev AY et al Treatment of PTSD: a reviewPsychosom Med 1996:58:165-82

what place has writing in all this?

memories formed during times of intense emotion are “seared” into the brain biochemically - this stops us forgetting information that may be crucial for survival

until powerful experiences are worked through and integrated into an updated sense of the world, the experiences will keep coming back into consciousness

writing can address

these & other needs:

work by james pennebaker Pennebaker J W & O'Heeron Confiding in others & illness rate

among spouses of suicide and accidental-death victims J Abnorm Psychol 1984; 93:473-6

Pennebaker JW & Klihr Beall S Confronting a traumatic event: toward a understanding of inhibition & disease J Abnorm Psychol 1986;95:274-81

Pennebaker JW, Kiecolt-Glaser JK & Glaser R Disclosure of traumas and immune function: health implications for psychotherapy J Consult Clin Psychol 1988;56:239-45

Pennebaker JW, Colder M & Sharp LK Accelerating the coping process J Personal Soc Psychol 1990;58:528-37

Petrie KJ, Pennebaker JW et al Disclosure of trauma & immune response to a hepatitis B vaccination program J Consult Clin Psychol 1995;63:787-92

Pennebaker JW Opening up: the healing power of expressing emotions New York: Guilford Press, 1990/1997

emotions are gut stuff

general - outlet to emotion afforded by drama etc.

medical - purgation psychological -

abreaction: free expression & release of previously repressed emotion

greek: kathairo=cleanse

concise oxford dictionary

catharsis

emotions are gut stuff

strong exposure involved

Visualise all the details of your surroundings, the sights, sounds and smells. Get into the fantasy as much as possible. Now I want you to look deeply inside yourself and to really experience as intensely as possible the full extent of your feelings associated with this event. Now, for the next 30 minutes, I want you to explore the full extent of your feelings associated with this traumatic experience by writing them down on the piece of paper in front of you. Describe as vividly and fully as possible all of the thoughts and feelings that you have when you imagine this experience. As you write, sink into your feelings more and more. Do not write about your emotions in general, but rather about how you responded emotionally to this particular eventGreenberg MA et al Emotional expression and physical health: revising traumatic memories or fostering self-regulation? Jl Personal Soc Psychol 1996;71:588-602

mechanisms and effects stops the cumulative stress

& vulnerability produced by constant work of inhibition

recovery & exploration of suppressed emotional reactions results in cognit-ive reappraisal of memories

increased tolerance for & capacity to work with intense emotions

sense of more resilient self

reduction in intrusive memories and thoughts

improved psychological well being

improvements in immune function & physical health

reduced dependence on health professionals and other helping agencies

How birds see the world

Gary Larson

working through held emotions helps

us see & feel differently

If a pickpocket meetsa saint, all he sees are

his pockets

For the man who wears shoes, the

whole world is covered with leather

we have looked at two major areas

do traumatic memories that are not worked through damage our health?

is it helpful to express these memories through writing, talking or other media?