Taak 6 Imagery, Imagery Treatments and PTSD
Leerdoelen
1. Wat zijn de criteria van een trauma?
2. PTSD → diagnostische criteria DSM-V
3. Risicofactoren
4. Behandelingen
Taxing the working memory = belasten van het werkgeheugen
Bron: Arntz, Tiesema, Kindt
Introduction
● Exposure therapy most extensively studied
○ Imaginal exposure
■ To the memories of traumatic stimuli
■ Patients asked to recall deatils of traumatic event, while focussing their
attention on any occurring sensory feelings, thoughts, and emotions
■ Result: reduction of fear and avoidance
■ Underlying mechanism: loosening of association between US and CS
○ Exposure in vivo
○ Wait-list
○ Stress inoculation training
○ Eye movement desensitization
○ Reproccessing
● Information processing theory
○ Offers a model of the process by which stimulus information, resposne
information and meanings of these stimuli and responses, are stored in fear
networks
■ Are viewed as programs that stimulate avoidance of trauma-related
stimuli propose that two conditons are necessary for the accomplishment
of fear reduction
■ Fear memory must be activated
■ New info that is incompatible with the current fear structure must be
provided
● Imagery rescripting (IR)
○ Developed as a method not only to activate the traumatic memory and to provide
corrective information to a wide range of issues, but also to provide the patient
with an opportunity to discover and express any trauma-related inhibited
emotional responses
○ Alleviates PTSD symptomatology as well as it changes trauma-related beliefs
and schemas
○ Method: changing the traumatic imagery to correct the situation in fantasy &
produce a more favorable outcome
, ■ Imagening having control over the situation and being able to act
according the one’s needs, to express one’s feelings and action
tendencies
Results
● Treatment is superior to WL in reducing overall PTSD severity
● IE + IR was not superior to IE in reducing PTST symptomatolgy
○ Addition of IR did not enhance the effectiveness of IE treatment in this study
○ But: significant difference in dropout rates between treatment conditions
■ Addition of IR was associated with a significantly and considerably lower
rate of drop-outs
● Without making the treatments less effective in terms of symptom
reduction
● IE + IR would be superior to IE in reducing a broader spectrum of PTSD-related
variables such as anger, anger control, guilt, and shame
○ Completers and Intention-to-Treat analyses yielded generally the same
differences between conditions
■ IE + IR was superior in both analyses with respect to anger control,
externalization of anger, hostility, and guilt
■ Despite high drop-out rates → results seem fairly robust
■ Results less clear with respect to inernalization of anger and shame
● Completers and ITT analyses diverged
● Adverse effect of IR (loss of anger control and increasein aggressive
behavior) → not observed in this study
○ Addition of IR to IE led to a larger increase in anger control and less experienced
anger
● Therapists tended to prefer IE + IR
○ Although, at least as effective as IE alone → but: experiencing less
distress and helplessness
○ Drop out is related to this:
■ Patients feel less use of the treatments because they feel like they can do
it on their own, so why should they be with a therapist??
Wie is er fout?
Anger in:
Internaliseren van woede
Anger out:
Externaliseren van woede
Bron: Ehlers & Clark
Memory for the traumatic event
● Patients have often difficulty in intentionally retrieving a complete memory of the
traumatic event
○ Intentional recall is fragmented and poorly organized
, ○ Details may be missing
○ Difficult recalling the exact temporal order of events
● Patients report high frequency of involuntarily triggered intrusive memoreis involving
reexperiencing aspects of the event in a very vivid and emotional way
○ Characteristics of reexperiencing
■ Mainly consists of sensory impressions rather than thoughts
■ Sensory impressions experienced as if they were happening right now
rahter than being memories from the past and the emotions
accompanying them are the same as those experienced at the time
● Lack of awareness of remembering that usually characterises
autobiographical memories
■ Original emotions and sensory impressions are reexperienced even if the
individual later acquired new information that contradicted the original
impression or he/she knows that these impressions did not turn out to be
true
■ “Affect without recollection”
● Sometimes reexperience physiological sensations or emtions that
were associated with the traumatic event without a recollection of
the event
○ Lack of source information
■ Involuntary reexperiencing of the traumatic event is triggered by a wide
range of stimuli and situations
● Many are cues that do not have a strong semantic relationship to
the traumatic event, but instead are simply cues that were
temporally associated with the event
● Poor elaboration and incorporation into autobiographical memory base
○ Two routes to the retrieval of autobiographical information
■ High-order meaning-based retrieval strategies
● E.g. remembering the first day at school
■ Direct triggering stimuli that were associated with the event
● E.g. particular smells or a piece of music
○ Autobiographical events are usually incorporated into an autobiographical
memory knowledge base that is organized by themes and personal time periods
■ Enhances first retrieval route and inhibits the second one
○ PTSD: trauma memory is poorly elaborated and inadequately integrated into its
context in time, place, subsequent and previous information and other
autobiographical memories
● Strong S-S and S-R associatons
○ These associations make triggering of memories of the event and/or emtional
respones by associated stimuli even more likely
○ S-S: 2 stimuli occurred almost at the same time, before traumatic event
○ S-R: stimulus and response
○ 2 aspects of interest in PTSD
Leerdoelen
1. Wat zijn de criteria van een trauma?
2. PTSD → diagnostische criteria DSM-V
3. Risicofactoren
4. Behandelingen
Taxing the working memory = belasten van het werkgeheugen
Bron: Arntz, Tiesema, Kindt
Introduction
● Exposure therapy most extensively studied
○ Imaginal exposure
■ To the memories of traumatic stimuli
■ Patients asked to recall deatils of traumatic event, while focussing their
attention on any occurring sensory feelings, thoughts, and emotions
■ Result: reduction of fear and avoidance
■ Underlying mechanism: loosening of association between US and CS
○ Exposure in vivo
○ Wait-list
○ Stress inoculation training
○ Eye movement desensitization
○ Reproccessing
● Information processing theory
○ Offers a model of the process by which stimulus information, resposne
information and meanings of these stimuli and responses, are stored in fear
networks
■ Are viewed as programs that stimulate avoidance of trauma-related
stimuli propose that two conditons are necessary for the accomplishment
of fear reduction
■ Fear memory must be activated
■ New info that is incompatible with the current fear structure must be
provided
● Imagery rescripting (IR)
○ Developed as a method not only to activate the traumatic memory and to provide
corrective information to a wide range of issues, but also to provide the patient
with an opportunity to discover and express any trauma-related inhibited
emotional responses
○ Alleviates PTSD symptomatology as well as it changes trauma-related beliefs
and schemas
○ Method: changing the traumatic imagery to correct the situation in fantasy &
produce a more favorable outcome
, ■ Imagening having control over the situation and being able to act
according the one’s needs, to express one’s feelings and action
tendencies
Results
● Treatment is superior to WL in reducing overall PTSD severity
● IE + IR was not superior to IE in reducing PTST symptomatolgy
○ Addition of IR did not enhance the effectiveness of IE treatment in this study
○ But: significant difference in dropout rates between treatment conditions
■ Addition of IR was associated with a significantly and considerably lower
rate of drop-outs
● Without making the treatments less effective in terms of symptom
reduction
● IE + IR would be superior to IE in reducing a broader spectrum of PTSD-related
variables such as anger, anger control, guilt, and shame
○ Completers and Intention-to-Treat analyses yielded generally the same
differences between conditions
■ IE + IR was superior in both analyses with respect to anger control,
externalization of anger, hostility, and guilt
■ Despite high drop-out rates → results seem fairly robust
■ Results less clear with respect to inernalization of anger and shame
● Completers and ITT analyses diverged
● Adverse effect of IR (loss of anger control and increasein aggressive
behavior) → not observed in this study
○ Addition of IR to IE led to a larger increase in anger control and less experienced
anger
● Therapists tended to prefer IE + IR
○ Although, at least as effective as IE alone → but: experiencing less
distress and helplessness
○ Drop out is related to this:
■ Patients feel less use of the treatments because they feel like they can do
it on their own, so why should they be with a therapist??
Wie is er fout?
Anger in:
Internaliseren van woede
Anger out:
Externaliseren van woede
Bron: Ehlers & Clark
Memory for the traumatic event
● Patients have often difficulty in intentionally retrieving a complete memory of the
traumatic event
○ Intentional recall is fragmented and poorly organized
, ○ Details may be missing
○ Difficult recalling the exact temporal order of events
● Patients report high frequency of involuntarily triggered intrusive memoreis involving
reexperiencing aspects of the event in a very vivid and emotional way
○ Characteristics of reexperiencing
■ Mainly consists of sensory impressions rather than thoughts
■ Sensory impressions experienced as if they were happening right now
rahter than being memories from the past and the emotions
accompanying them are the same as those experienced at the time
● Lack of awareness of remembering that usually characterises
autobiographical memories
■ Original emotions and sensory impressions are reexperienced even if the
individual later acquired new information that contradicted the original
impression or he/she knows that these impressions did not turn out to be
true
■ “Affect without recollection”
● Sometimes reexperience physiological sensations or emtions that
were associated with the traumatic event without a recollection of
the event
○ Lack of source information
■ Involuntary reexperiencing of the traumatic event is triggered by a wide
range of stimuli and situations
● Many are cues that do not have a strong semantic relationship to
the traumatic event, but instead are simply cues that were
temporally associated with the event
● Poor elaboration and incorporation into autobiographical memory base
○ Two routes to the retrieval of autobiographical information
■ High-order meaning-based retrieval strategies
● E.g. remembering the first day at school
■ Direct triggering stimuli that were associated with the event
● E.g. particular smells or a piece of music
○ Autobiographical events are usually incorporated into an autobiographical
memory knowledge base that is organized by themes and personal time periods
■ Enhances first retrieval route and inhibits the second one
○ PTSD: trauma memory is poorly elaborated and inadequately integrated into its
context in time, place, subsequent and previous information and other
autobiographical memories
● Strong S-S and S-R associatons
○ These associations make triggering of memories of the event and/or emtional
respones by associated stimuli even more likely
○ S-S: 2 stimuli occurred almost at the same time, before traumatic event
○ S-R: stimulus and response
○ 2 aspects of interest in PTSD
