BABCP spring meeting: Nick Grey on memory-focused approaches in CBT for adults with PTSD - other applications (5th post)
Last updated on 26th June 2012
Last month I wrote a series of four blog posts about a CBT workshop on memory-focused for adults with PTSD (and a couple of posts about a personal experience of trauma). The third of these posts discussed how this kind of memory-focused approach could also be helpful for other types of "non-PTSD" trauma such as experiences of grief & loss. In today's post I want to explore this extended application even further - looking at the use of memory-focused therapy for anxiety & depression, personality disorders, and complex type II trauma.
So a further type of therapeutic situation where I might want to use an adaptation of trauma-focused cognitive therapy is with the surprisingly common finding that other Axis I disorders (for example social anxiety, panic disorder, depressive disorder, etc) may have been triggered initially by "traumatic" life experiences. Often there is some kind of underlying vulnerability, but this might never have sprouted into a full blown disorder without the specific event trigger. There's more detail in a talk I gave a few years ago - "Trauma memories in anxiety & depression" - a 30 slide Powerpoint presentation highlighting the commoness and probable therapeutic importance of trauma memories in many other conditions besides formal PTSD. Examples mentioned in the talk include depression, social anxiety disorder, agoraphobia & panic disorder, psychosis, OCD & BDD, and eating disorders. More recent research has extended the associations found between traumatic experiences and subsequent disorders to both other psychological diagnoses and also to physical health problems as well - e.g. "The association of traumatic experiences and posttraumatic stress disorder with physical morbidity in old age" with the authors' comment that their study " ... underscores the importance of traumatic experiences and PTSD not only for mental health but also for physical health as a long-term consequence." Thoughtful research highlights that the links between genetic vulnerability, traumatic life events and illness are complex - see for example "Dependent stressful life events and prior depressive episodes in the prediction of major depression: The problem of causal inference in psychiatric epidemiology" and "A longitudinal etiologic model for symptoms of anxiety and depression in women". The latter paper's abstract reads "In a prospective three-wave study of 2395 female twins from the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (VATSPSUD), we examined, using structural equation modeling, how genes, childhood and past-year environmental stressors, personality and episodes of major depression (MD) and generalized anxiety disorder (GAD) influence SxAnxDep (symptoms of anxiety & depression). Results: The best-fit model, which explained 68-74% of the variance in SxAnxDep, revealed two etiologic pathways. Stable levels of SxAnxDep resulted largely from neuroticism, which in turn was influenced by genetic and early environment risk factors. Occasion-specific influences resulted from stressful events mediated through episodes of MD or GAD. These two pathways, which had approximately equal influences on levels of SxAnxDep, were substantially correlated because the genetic, early environmental and personality factors that impacted on stable symptom levels also predisposed to event exposure and disorder onset. No significant interaction was seen between the two pathways. Conclusions: SxAnxDep in women in the general population arise from two inter-related causal pathways. The first, the ‘trait-like' pathway, reflects genetic and early environmental risk factors, and is mediated largely through personality. The second pathway is mediated through episodes of MD and GAD, and is the result of both recent environmental adversities and trait-like factors that influence event exposure and the probability of disorder onset." A crunch question for me is "Does using therapy time to treat trauma memories in anxiety & depression disorders (rather than using the therapy time for other interventions) yield better outcomes?" and despite papers like last year's "Imagery rescripting of early traumatic memories in social phobia" by Wild & Clark, my reading of the literature is that the jury is somewhat irritatingly still out on this one. I remain hopeful!
A third therapeutic situation where I might want to use adaptations of trauma-focused cognitive therapy is in treating personality disorder. The blog post "Handouts & questionnaires for emotions, schema & personality" opens this territory up quite well. Excitingly there are a stream of interesting new publications emerging in this area. For example, see Arntz et al's new book - "Schema therapy in practice: An introductory guide to the schema mode approach" - due out in July with it's description stating "While schema therapy was originally developed for clients with borderline personality disorder, this book takes a much broader approach and shows how it can be applied across different personality disorders as well as to chronic Axis I disorders." And linked with this use of trauma/memory-focused therapy for personality disorders, there is also clear applicability in a fourth therapeutic situation - the treatment of more complex multiple traumas such as child abuse or torture. As Nick Grey highlighted in this day workshop, Professor Marylene Cloitre's research is particularly relevant in these latter situations - see the series of three blog posts beginning with "Improving treatments for complex PTSD and for survivors of child abuse (first post)".
For the next post in this series about Nick Grey's PTSD workshop, see "BABCP spring meeting ... imagined reliving (6th post)".