Transcript Psychological Trauma: Human Cognitions & Affects

Psychological Trauma:
Human Cognitions & Affects
Tim Dunne
Consultant / Chartered Clinical Psychologist
Delivered at Webster University, Geneva
February 2008 ©
Outline
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Historical overview of Trauma
Definition of Trauma
Risk Factors for PTSD
Cognitions & PTSD
Affects & PTSD
Individual & Organisational factors affecting
development of PTSD
Vicarious Trauma
Future Directions
Trauma: Historical Overview
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Galen, father of Greek
medicine, described trauma
symptoms among soldiers in
the Peloponnesian wars
1862 American Civil War =
“Soldier’s heart”
1891 Boer War =
“Disordered action of the
heart” (DAH)
WW1 = “Shell shock”
WW2 = “Battle fatigue” or
“Lack of moral fibre” LMF
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1950 Korean War = “Old
Sergeant syndrome”
1972 “Buffalo Creek
syndrome” in USA
1979 Vietnam War = PTSD
1982 Falklands/ Malvinas
War = “Battleshock”
1993 = “Gulf War
syndrome”
1993 ICD-10 WHO defined
clinical criteria for diagnosis
of PTSD
Trauma: Definition
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2 main Definitions –
ICD-10 (1993) WHO, &
DSM-IV-TR (2000,
American Psychiatric
Association)
6 Criteria
Person is exposed to
traumatic event or events that
involve actual or threatened
death or serious injury.
Response involves intense
fear, helplessness or horror
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Intrusion - event is relived by
the person
Avoidance - stimuli
associated with the event are
avoided
Physical - persistent physical
symptoms of arousal or
hypervigilance
Social – disruption in social,
occupational or other areas
of functioning
Time – above symptoms last
longer than 1 month
Trauma
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“There is an interval…..of suspended
animation, a kind of psychological shock or
paralysis. It is caused by a traumatic or subtraumatic experience which explodes, as it
were, the world that is familiar to the person as
well as his image of himself (sic) within that
world.”
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Source: CIA Counter Intelligence Interrogation
manual www.gwu.edu/~nsarchiv
PTSD Risk Factors
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Not everyone is affected
No two people react in the same way to the same event
“One in Ten” rule is a good rule of thumb in assessing
reactions to large scale events
1.5% of the general population suffering from PTSD at
any one time
Previous life experience, life stage, mood & individual
perceptions of the event all play a part in how the
person responds to a traumatic event
High Risk Groups %
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Shipwreck survivors
Bombing/Terrorist
survivors
Rape victims
Combat veterans
Victims of bullying
Emergency Rescuers
Car crash survivors
General Population
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75
50
50
40
35
30
20
1.5
Cognitions & Trauma
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Cognitions refers to any conscious thought,
belief, value, idea, image, attitude in the person’s
mind
Hindsight Bias (Brewin, 2003)
Assumptive World Views (Janoff-Bulman1989)
Key Thoughts at moment of danger
Attribution Theory (Heider,1958)
Heuristic Biases (Kahneman & Tversky,1974)
Hindsight Bias (Brewin, 2003)
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The tendency for someone to assume, once something is known
to have happened, that it could and should have been anticipated
So pervasive that not only onlookers but also victims often
blame themselves for not acting differently
HB also relates to the tendency to blame victims for their
misfortunes = Maintains Psychological Distance from the
trauma in other people
Victims of trauma arouse discomfort in others by their mere
presence, particularly when the victim does not make a speedy
recovery
Victims of trauma shatter our illusions of invulnerability
Assumptive World View (JanoffBulman, 1989)
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Awareness of our own mortality carries with it a potential for
high levels of anxiety
As a protection against this awareness, people hold cultural
worldviews that provide explanations for existence, standards for
what is valuable and a promise of immortality to those who live
up to these standards
When confronted with reminders of our own mortality, people
either exaggerate their own invulnerability or deliberately
suppress thoughts of death
When reminders of death become more salient, people undergo
subtle changes of which they may be unaware such as increased
liking for those who hold similar worldviews and hostility
towards those with alternative worldviews
Assumptive World View (JanoffBulman, 1989)
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In the presence of victims, people feel ill at ease
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Even people who are actively trying to support trauma victims
are prone to switch the topic of conversation to something more
neutral, press their own perspective on the victim or avoid them
altogether
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Fundamental human difficulty in comprehending and
acknowledging our own vulnerability
Historically, the influence of psychoanalytic theories that were
rooted in internal fantasies rather than external realities, have,
paradoxically, supported these attitudes to victims
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Assumptive World View (JanoffBulman, 1989)
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The World is Benevolent – positive events are believed
to happen frequently & negative events are thought to
be rare & people are viewed as generally good
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The World is Meaningful – Events make sense and bad
outcomes are believed to be justly distributed
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The Self is Worthy – If we see ourselves as good, we
assume we are protected from negative events. After all,
if one is good, then only good things should happen!
Key Cognitions
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Thoughts which the person has at the moment
of danger have been demonstrated to play an
important role in the genesis of PTSD
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Thoughts such as “I’m going to die”, “I won’t
make it”, “I’ll never see my children again” or
“I’m tumbling into the next life”
Attribution Theory (Heider, 1989)
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AT seeks to understand how people explain to
themselves how events in the world happen
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People use ad hoc biases, categorization
processes and other moderating influences to
explain, or explain away, events
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6 Attribution Errors
Attribution Theory (Heider, 1989)
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Fundamental Attribution Error – Observers
underestimate the importance of situation factors and
overestimate that of dispositional factors. In other
words, people are seen as causes too often and
situations are seen as causes too rarely
This locates the problem within the individual and
relieves the rest of us and organizations etc of any
responsibility for the event
EG= widespread use of medication in psychiatry even
though there may be little evidence for its effectiveness
in specific situations or conditions
Attribution Theory (Heider, 1989)
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Actor/Observer Divergence – People attribute
their own actions to the situation but attribute
the same actions by someone else to that
person’s disposition
Let ourselves off the hook with this attribution
really & blame the other person who might do
the same thing as ourselves
Attribution Theory (Heider, 1989)
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Hedonic Relevance – We see actions which have
more affective consequences for ourselves as
being more dispositional than other actions
(EG) – car rolling down a hill when the owner
forgot to put the handbrake on. If it crashes
into my car, I will tend to see this as deliberately
caused. If its not my car which is struck, then it
is just an “accident”
Attribution Theory (Heider, 1989)
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People are perceived as more responsible for
acts with serious consequences as opposed to
actions with trivial consequences
Attributions follow affective relationships –thus
“good” actions by liked people are attributed to
the person and “bad” actions by liked people to
the situation. “Good” actions by disliked people
are attributed to the situation and “bad” actions
by disliked people are attributed to the person
Heuristic Biases (Kahneman &
Tversky, 1974)
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Judgement under Uncertainty
People pay little attention to base rate probability (ie) airplane
crashes
People tend to end their search for a causal explanation of
events at the first reason which provides a plausible explanation
(eg) power of labels such as mental illness or “satisficing” in orgs
Data which conflicts with my worldview is likely to be
discredited while supporting data is unquestioningly accepted
(eg) effects of environmental tobacco smoke
Ref: Enstrom,J & Kabat, G (2003) “Environmental Tobacco
smoke and tobacco related mortality in a prospective study of
Californians 1960 -98”, The Lancet, bmjjournals.com
Hierarchy of Negative
Cognitions/Beliefs in PTSD
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Responsibility - “It was my fault, I should have done something”
– victims of CSA often present with this NC
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Safety - “I am in danger/ I cannot protect myself/ I cannot trust
my judgement/ I can’t trust anyone” – resulting in
hypervigilance and often following Rape/RTA/ War
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Choice & Control – “I’m powerless”/ “I’m not in control”
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Self-Defectiveness – “I am a failure/ I am permanently damaged
/ I’m a bad person /I’m a disappointment / I am shameful/ I’m
good enough”
Affects & PTSD
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Strong emotions/feelings experienced
by people with PTSD
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Right Hemisphere of Brain foremost
in PTSD
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Strong physical sensations (eg) heart
rate can predict PTSD
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Strong sensory elements associated
with PTSD (eg) intrusive images of the
event or flashbacks, auditory sensations
such as ambulance sirens, smell of
petrol/burning fuel
Alan Schore (2007) & Van der Kolk
(2007) both maintain that
“mobilization for action” is an
automated response to threat in
humans and all animals (eg) flight/fight
response
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“Emotional” Brain centrally activated
in PTSD (eg) Limbic system,
Amygdala, HAP system
(Hypothalamus, Adrenal & Pituitary)
Left hemisphere involved in executive
functions, attention, working memory,
self-observation, reflection, morals &
values, reason
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High Arousal impairs Pre-Frontal
Cortex Functions
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Affects & PTSD
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Neuromodulators such as catecholamines are released into the
CNS and Peripheral NS
These chemicals “turn on” heart and muscles and “turn off ”
stomach
In the Brain, these chemicals “turn off ” the pre-frontal cortex –
we cannot deliberately direct our attention, hold values or goals
in mind, think logically, or imagine alternatives
“Primitive” sub-cortical structures control behaviour and
implement “hard wired” responses
Evolutionary origins = “Stop to think and you're lunch”
Affects & PTSD
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The result is that traumatic, angry experiences are “burned in” –
this is why the bad experiences from our childhood are often
more vivid than the good experiences about growing up
Defensive responses inconsistent with our values and ideal self
are reinforced (eg) irritability and anger
Feelings of Regret, Shame, Guilt, fervent resolutions about the
“next time” all have little effect on the Brain’s conditioning,
including vulnerability to losing executive functions in similar
situations in the future
“Primacy of Affect” – Alan Schore (2007) – “the locus of the
emotional brain represents the biological substrata of the
Unconscious as described by Freud”
“The Body keeps the Score” – van der Kolk (2007)
Affects & PTSD
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RH = location of “corporeal self ” and is centrally involved in
bodily-based emotional processes, empathy, processing of nonconscious self images, threat detection, regulation of
endocrinological and physiological functions, the human stress
response and survival
Emotions represent reactions to fundamental relational
meanings that have adaptive significance (Lazarus, 1991)
From an evolutionary perspective, emotions function to signal
safety or imminent danger & motivate the person for either
approach or avoidance behaviour
Affect amplifies and extends the duration and impact of
whatever activates it
Affects & PTSD
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In summary, emotions are dominant in trauma
reactions, not reason
RH is dominant in all forms of affect stimulation
Historically, psychotherapy has relied on LH, verbal,
rational executive Brain
Psychotherapy is not the “talking cure” anymore but
the “affect regulating cure”
All therapies of whatever school, are now beginning to
focus on affect regulation as the primary goal of
psychotherapy in treating PTSD
Individual Factors in PTSD
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Individual factors –
Life Stage Development of the person at time
of Trauma
3 key phases – Early Adulthood (18 - 25yrs
“Who will I be?”), Mid-Life (35 - 50 yrs “Who
am I?”), Late Adulthood (60+ “Who was I?”)
At each Life phase, individual is particularly
vulnerable to stress/trauma
Individual Factors in PTSD
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Previous exposure to trauma experiences over the life
cycle (eg) CSA, RTA, Assault, Losses, Neglect/
Abandonment
Witnessing trauma to others
Personality – introverted personality appears to be
more vulnerable to PSD. “Hardy” personality less so
Cumulative effects of prolonged exposure to stressful
and traumatic experiences (eg) police/rescue workers
“Emotional Intelligence” – those with good EI are
thought to be more resilient to developing trauma
reactions
Organizational Factors & PTSD
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Orgl Culture – macho culture, bullying style of Mgt/ Peers, Long
working day, Lack of supportive atmosphere, Crisis & Fire
Fighting as normal working day, Tyranny of the Urgent V the
Important in work, Excess of Critical Incidents at work,
Micromanagement from Senior figures
Orgl “Defensive Routines” (eg) Denial of problems, Reactions
to Whistleblowers,
Persecutory Leadership/Mgt style
Emotions are “contagious” hence importance of social
processes in development of anxiety
Management V Leadership
Breaking of the “Psychological Contract”
Secondary Trauma
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Recently recognized phenomena among workers
exposed to others’ trauma (eg) therapists/lawyers/aid
workers
These professionals can experience range of symptoms
secondary to their exposure to clients’ trauma
Historically, seen as “burn-out” or “countertransference”
ST provides more complex and sophisticated
explanation of professionals’ reactions
Secondary Trauma
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ST can involve profound changes in the profl’s
self including:
Disruptions in cognitive schemas
Memory functioning
Team working
Interpersonal relationships
Concerns for safety
Intrusive images
Secondary Trauma
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ST is hypothesized to be rooted in the profls’
“empathic engagement” with the client’s
traumatic story
Therapist treating torture victims
Lawyer listening to client’s story of rape
Aid worker interviewing refugees
Similarities between Burn-out & ST
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Both involve physical reactions (eg) digestive problems,
headaches, increased heart rate
Both involve emotional reactions (eg) anxiety, withdrawal,
feelings of helplessness or hopelessness
Both involve behavioural reactions (eg) sleep disturbance,
increased use of drugs or alcohol
Both involve work related issues (eg) team working difficulties,
conflicts
Both involve interpersonal relations (eg) arguments, irritability
with others
Both can result in decreased concern for clients/org and lead to
decline in performance at work
Differences between Burn-out & ST
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Burn-out more associated with stress in
the workplace in general
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ST = traumatic reaction to specific client
presented information
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Burn-out can happen in any workplace
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ST only occurs in those who work with
trauma survivors
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ST related to specific client trauma
experiences
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ST often has sudden onset of symptoms
not detectable at an early stage
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At personal level, ST leads to feelings of
hypervigilance, trust issues, feelings of being
out of control, intimacy issues, esteem
needs, safety concerns and intrusive imagery
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Burn-out relates to feelings of overload
secondary to work related issues &
complexity
Burn-out progresses gradually as a
result of emotional exhaustion
Burn-out does not result in similar
feelings as ST
Conclusion & Future Directions
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“The Body never lies” – van der Kolk
(2007)
Psychotherapy for PTSD will become
more Body focused & oriented because
that is where the trauma is remembered
and felt
Treatments with major focus on the
Body likely to become the “treatment
of choice” in PTSD such as EMDR
(Shapiro, 1989) & possibly SensoryMotor therapy (Ogden, 2006)
More growth experiences from PTSD
recorded & researched
Affect Regulation likely to become the
goal of Psychotherapy treatment in
PTSD and related disorders such as
Anxiety/ Panic/ Phobic Disorders
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EMDR = well validated in the
literature. Already accepted as the
“treatment of choice” by Govt bodies
in USA, NICE (UK), France, Sweden,
Holland
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Positive Psychology (Seligman, 2000
address to APA) likely to be major
influence (eg) “Broaden & Build”
approach of Frederickson (2003)
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Macro-environment likely to be more
competitive following disasters (ie) forprofit orgs such as Bechtel &
Blackwater now in the market for
provision of relief & reconstruction
following disasters
References
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“Post Traumatic Stress Disorder – Malady or Myth?”
Chris Brewin (2003)
London: Yale UP
“A Guide to Psychological Debriefing: Managing
Emotional Decompression & PTSD” David Kinchin
(2007)
London: Jessica Kingsley Pubs
“A Randomized Clinical Trial of EMDR, Fluoxetine
and Pill Placebo in the treatment of PTSD: Treatment
Effects and Long Term Maintenance” (2007) van der
Kolk, B. et al., Journal of Clinical Psychiatry,
Vol. 68, No.1, pp 37-46
“The Shock Doctrine: The Rise of Disaster Capitalism”
Naomi Klein (2007)
London: Penguin books