In this blog post you can read a research article about PTSD,therapy, dissociation and memory.
The article is called:
The research article was published in 2010 by Cheryl Malmo PhDa* & Toni Suzuki Laidlaw PhDb
It has been placed online free by the international Society for the Study of Trauma and Dissociation ( ISSTD ) because April is sexual abuse awareness month.
The researchers compared two groups of people who started therapy. Both groups of peole had PTSD symptoms but one group of people had memories of childhood abuse and the other group did not.
Both groups recovered memories of abuse during therapy and both groups also experienced a reduction of dissociative symptoms during therapy.
There was little difference between the two groups once they had started therapy.
We examined posttraumatic stress symptoms and the memory retrieval process in 2 groups of adult survivors of childhood sexual abuse: 29 participants who reported having memories of their abuse prior to entering therapy (PM) and 13 who reported no memories of abuse prior to therapy (NPM). Participants were asked to indicate on checklists symptoms of constriction, hyperarousal, and intrusion experienced (a) prior to entering therapy and (b) during the surfacing of a memory while in therapy. Overall, the findings indicate that for both groups the same cluster of posttraumatic stress symptoms occurred prior to therapy and during therapy and that there was a continuity of symptoms over time. Participants were also asked to fully describe details of their traumatic memories as these details emerged prior to and/or during therapy. We determined that (a) there were striking similarities in the detailed recall of trauma memories for both groups; (b) memories of abuse emerged in substantial perceptual, somatic, and emotional detail over time before developing into a narrative; (c) the amount of detail remembered increased in the PM group during therapy; (d) members of the NPM group were more kinesthetic than visual in their orientation to the world and may not have had access to the visual information that would associate their symptoms to their abuse; and (e) triggers of traumatic memories were largely the result of internal rather than external stimuli, and these triggers happened primarily outside of therapy sessions.
To study the consequence of childhood sexual abuse (CSA) and the process of retrieving traumatic memories, we developed a survey, “Symptoms of Trauma and the Memory Retrieval Process,” designed for adult survivors in therapy. Given that retrieved traumatic memory has generated controversy in the scientific community, we chose to compare results between two groups: individuals who reported having memories of sexual abuse prior to entering therapy (PM) and those who reported having no memories of abuse prior to therapy (NPM). This article describes our findings.The effects of CSA in adult survivors are reflected in symptoms of posttraumatic stress disorder (PTSD). The Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994) outlines the criteria for PTSD as follows: (a) a traumatizing event, usually involving bodily injury or threat to life; (b) intrusive reexperiencing of symptoms; (c) generalized numbing of responsiveness; and (d) physiological reactivity. Herman (1992) identified three types of complex PTSD symptoms: hyperarousal (the persistent expectation of danger), constriction (the numbing response of surrender), andintrusion (the indelible imprint of the traumatic moment). She detailed numerous ways in which each type of symptom can manifest in cases resulting from continuous and repeated abuse. Explaining that after a traumatic incident, the physiological arousal system of self-preservation goes into permanent alert, Herman cited Kardiner, who used the term physioneurosis to describe the psychosomatic complaints that, like other hyperarousal behaviors, result from chronic arousal of the autonomic nervous system. When people find themselves completely helpless, the self-preservation system shuts down entirely—constricts. Escape is experienced by a change in consciousness, the most severe aspect of which is dissociation, considered to be a reliable predictor of chronic PTSD (D. Brown, Scheflin, & Hammond, 1998). Intrusion is experienced when constriction fails and aspects of the traumatic memory leak into consciousness.Unlike the DSM–IV, which focuses on single-incident trauma, Herman (1992) differentiated two types of PTSD: simple (resulting from single-incident trauma) and complex (resulting from continuous and repeated abuse, such as often occurs in childhood). With complex PTSD, symptoms can be chronic and persistent and can involve severe memory disturbance, both hypermnesic and amnesic (Horowitz & Reidbord, 1992). D. Brown et al. (1998) outlined research documenting the existence of functional amnesia in survivors of CSA, including studies by Cameron (1996), Draijer (1990), Ensink (1992), Herman and Schatzow (1987), and Roe and Schwartz (1996). Terr (1991) divided childhood trauma into two basic types: Type I includes full, detailed memories, “omens,” and misperceptions; and Type II includes denial and numbing, self-hypnosis, dissociation, and rage.Freyd (1996) proposed a two-dimensional model of trauma in which terror results in the hyperarousal aspects of PTSD symptoms, and betrayal by a parent or trusted caregiver results in the amnesia aspect of constriction symptoms.Critics of the concept of traumatic amnesia have held therapists responsible for implanting memories of abuse in unsuspecting clients. However, Williams’s (1994) prospective study on memory in survivors of CSA determined that even in cases when abuse had been documented in medical records, women had amnesia for their abuse. She concluded, “Having no memory for childhood sexual abuse is a common occurrence” (p. 1173). Freyd’s investigation and reanalysis of Williams’s and others’ papers determined that amnesia rates were higher for survivors who had been abused by a family member (Sivers, Schooler, & Freyd, 2002). Fergusson, Horwood, and Woodward (2000) determined that the unreliability of the reporting of child abuse is due not to false reports by people who were not abused but to people who were abused often providing false-negative reports.Although there has been considerable debate regarding amnesia for CSA, trauma experts agree that memory disturbance resulting from extreme trauma is best described as dissociation, a concept first used by Janet (1904). Putnam (1989) defineddissociation as “a normal process that is initially used defensively by an individual to handle traumatic experiences and evolves over time into a maladaptive or pathological process” (p. 9). The DSM–IV (American Psychiatric Association, 1994) definesdissociative amnesia as “episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness” (p. 481). Phillips and Frederick (1995) conjectured that at the extreme end of the dissociation continuum traumatic memory is not simply forgotten, it does not even register in the conscious mind because it is stored in a different part of the brain and is assigned to different aspects of the personality—ego-states.Current research has explored the different functions of dissociation (R. J. Brown, 2006; Sar & Ozturk, 2007) and provides new perspectives with implications for trauma treatment. We have discussed elsewhere how the natural ability to dissociate, in addition to being a coping strategy, can be used for healing in psychotherapy, for example when one imagines a safe place in the mind (Malmo & Laidlaw, 1996). Van der Hart and Nijenhuis (as cited in D. Brown et al., 1998) identified several types of secondary dissociation to account for partial amnesia for trauma and for the way in which traumatic memory can be divided into BASK components (behavior, affect, somatosensory, kinesthetic). Van der Hart (as cited in Van der Kolk, 1996) also described tertiary dissociation, which allows people to maintain a sense of self while separate states of mind process the traumatic event. Nijenhuis, Van der Hart, and Steele (2004) theorized that structural dissociation is the phenomenon at the basis of alter personalities in dissociative identity disorder. It is generally agreed that traumatic dissociation is an unconscious and automatic process that disconnects the conscious mind from a traumatic experience when a person’s cognitions and feelings are overwhelmed, thereby protecting the individual by causing amnesia. Only when amnestic persons are safe enough or when a circumstance reminiscent of the trauma triggers the memory does dissociation begin to break down and memory begin to return (Grassian & Holtzen, 1996, as cited in D. Brown et al., 1998).
Sivers et al. (2002) defined recovered memory as “the recollection of a memory that is perceived to have been unavailable for some period of time” (p. 169). Rossi (1986) proposed that traumatic memory, when dissociated from consciousness, is state dependent (the origin of symptoms is embedded in emotional and somatic states), is centralized in the limbic–hypothalmic system (the link between mind and body), and therefore is often only retrievable when the person is in the same emotional state as he or she was when traumatized. Consistent with this theory, Van der Kolk (1996) argued that traumatic memory is organized differently from ordinary memory as implicit and perceptual rather than explicit and narrative. D. Brown et al. (1998) outlined numerous studies (Cameron, 1996; Davies & Frawley, 1994; Kristiansen, Felton, Hovdestad, & Allard, 1995;Roe & Schwartz, 1996; Van der Kolk & Fisler, 1995) that have reported the return of traumatic memory as sensory (flashbacks, somatic experiences, images, dreams, sudden and intense feelings, fragments, reenactments, avoidant behaviors) rather than narrative. According to Van der Kolk and Fisler, narrative memory emerges over time for most people only after the emergence and gradual integration of sensory memory.
Brewin, Dalgleish, and Joseph (1996) and Brewin (2001) proposed a dual representation theory of PTSD that involves two separate processing systems for trauma: (a) verbally accessible memory, which allows for deliberate and conscious recall of limited aspects of trauma; and (b) situationally accessible memory, which involves visual, sensory, physiological, and motor reenactment of trauma memory. Situationally accessible memory is accessed spontaneously or unconsciously via external or internal stimuli and involves far more detailed and extensive memories, with emotions being reexperienced at their original intensity. Not only do these two systems result in qualitatively different memories, but situationally accessible memories are more voracious and remain intact because of hormonal effects experienced with acute trauma that diminish neural activity in conscious processing while enhancing nonconscious perceptual and memory processing.
The qualitative component provided for an in-depth examination of the emergence of participants’ traumatic memories. We categorized responses according to the kind of sensory material that was reported:
Context—aspects of the environment in which the abuse occurred.
Images—visual pictures in the mind.
Sensations—all sensory information other than images or sounds.
Feelings—emotional state of the survivor and perpetrator.
Behaviors—actions, words, or sounds of the survivor and perpetrator.
Cognitions—recollections of thoughts, meanings, intentions, intuitions.
Narratives—descriptions of what happened over time, including events preceding the abusive incident, the abusive experience itself, and events following the abusive incident.
Complex Posttraumatic Stress Symptoms
Large numbers of participants in both groups indicated that they experienced constriction symptoms prior to as well as after entering therapy (see Figure 1). The most obvious difference between the groups was that all members of the NPM group reported total amnesia before therapy, whereas almost two thirds of the PM group reported partial amnesia for details related to sexual abuse and for associated feelings. In the NPM group, total amnesia completely disappeared during therapy; in the PM group, amnesia for memory details dropped dramatically (from 62% to 2%), but amnesia for feelings remained relatively high (41%). Approximately half of participants in both groups reported generalized amnesia for childhood prior to therapy that decreased during therapy. Experiences related to dissociation were consistently reported in greater numbers by the NPM group before therapy. An altered sense of time was reported in greater numbers by both groups during therapy compared to prior to therapy, and this increase was most dramatic for the NPM group. Although there was a decrease in the reporting of emotional constriction for both groups, the decrease was greater for the PM group.
Large numbers of participants in both groups reported many hyperarousal symptoms—including anxiety, hyperalertness, startle responses, extreme reactivity, medical/physical symptoms, sleep problems, panic attacks, phobias, and explosive anger—both before entering therapy and during the surfacing of traumatic memories in therapy (see Figure 2). Anxiety was consistently reported by a greater percentage of participants in the PM group than in the NPM group at both time periods—83% compared to 62% prior to therapy and 86% compared to 69% during therapy, respectively. Medical/physical symptoms included a variety of gastrointestinal problems (nausea, gagging, choking, stomach pains, rectal bleeding) as well as psychogenic, muscular, neurological, gynecological, respiratory, and cardiovascular problems. Changes in medical/physical symptoms during therapy were noteworthy: Symptoms decreased in the PM group (from 72% to 59%) but doubled in the NPM group (from 46% to 92%). Another noteworthy change was the reduced reporting of phobias by the PM group during therapy compared to prior to therapy.
Large numbers of participants in both groups for both time periods indicated numerous symptoms of intrusion, including overwhelming feelings of sadness or pain, fear or terror, guilt or shame, and anger or rage; visual intrusions—flashbacks, dreams, nightmares; intrusive thoughts and words; kinesthetic intrusions—body sensations and intrusive smells, tastes, and sounds; and compulsive urges, compulsive reenacting, and risk-taking behaviors (see Figure 3). A notable difference was the decreased reporting of overwhelming sadness or pain in the NPM group after entering therapy (from 62% to 38%) and the increased reporting of overwhelming fear or terror (from 46% to 85%). The number of participants in the PM group who reported these symptoms remained constant at about 66%. A notable increase for both groups was the increased reporting during the surfacing of memories in therapy of intrusive images (NPM: from 23% to 69%; PM: from 45% to 76%) and intrusive body sensations (NPM: from 15% to 69%; PM: from 38% to 66%). A somewhat decreased reporting of compulsive urges and behaviors was seen for both groups during therapy.
The place or environment in which the abuse occurred was the aspect of context most often recalled (by more than four fifths of both groups during therapy), followed by the time of day or year, clothing of self and of the perpetrator, awareness of others, voices of others, and sounds from the environment (see Figure 4).
The majority of participants reported seeing images of themselves, followed by images of the perpetrator, body parts, the perpetrator’s facial expression, themselves naked, the perpetrator naked, and symbolic images (such as a snake representing a penis; see Figure 5).
Relational position (such as whether the perpetrator was approaching from the left or right side or was experienced as being above or beside) was consistently reported by about three fourths of participants across groups. However, there was a striking difference in the reporting of kinesthetic memory. For the PM group, reporting of kinesthetic memory doubled from 38% prior to therapy to 76% during therapy, whereas 100% of the NPM group reported kinesthetic memory. The reporting of sense of size of self and smell followed a similar pattern of increased reporting. Only a small number of the PM group reported remembering taste and only during therapy (see Figure 6).
The behavior of the perpetrator was consistently reported by more than three fourths of participants in all cases, and the voice of the perpetrator was consistently reported by more than half in all cases. The most notable differences were in the PM group’s increased reporting of their own behavior, dissociation, resistance, and vocalizations during therapy compared to prior to therapy and the NPM group’s even greater reporting of their own resistance and verbalizations/vocalizations (seeFigure 7).
More than four fifths of the NPM group and the PM group before therapy reported the identity of the perpetrator. There was a slight drop in awareness of the abuser’s identity for the PM group after entering therapy, reflecting the awareness of additional perpetrators. Their own age at the time of the abusive incident was reported by two thirds or more of the participants in all cases. Other aspects of cognitions reported in similar numbers were beliefs, intentions, intuitions, an awareness of power difference, and threats and intimidation by perpetrators (see Figure 8).
Posttraumatic Stress Symptoms
Almost three quarters of the PM group reported medical/physical symptoms prior to entering therapy, and this number decreased a little after groups entered therapy, whereas in the NPM group the numbers doubled from 46% to 92%. The high reporting of medical/physical symptoms highlights the prevalence of somatization, which has long been understood to be an indicator of posttraumatic stress. Van der Kolk, McFarlane, and Weisaeth (1996) identified numerous studies that have linked somatization to childhood sexual or physical abuse, dissociation, and PTSD. They concluded,
Traumatic Memory Retrieval
1. Traumatic flashbacks involve emotional and sensory aspects of the traumatic experience, including visual images and auditory, olfactory, and kinesthetic sensations.
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