trauma memories & social anxiety

1. trauma memories & social anxiety • intrusive ‘images’ are very commonly associated with anxiety provoking situations for people with social anxiety disorder. • these images are often visual but may also occur as an internal felt-sense or via other (often multiple) sensory channels. • intrusive visual images of social situations are typically from an ‘observer’ rather than from a ‘first person’ perspective. • the majority of subjects can link intrusive images to early memories when typically the social anxiety disorder first became particularly troublesome. • holding the intrusive negative image (instead of a neutral or positive image) aggravates symptoms (feelings, attentional biases & mis-estimations) and performance – as judged by the subject, others involved socially, & by external observers • non socially anxious subjects also have their performance disrupted if trained to hold negative rather than neutral images of their performance

2. clinical implications 2 • educate socially anxious subjects about the frequency, type, importance, origins, effects, and management of images. • emotional processing of associated early memories is likely to be helpful in its own right and may guide the nature of subsequent coping image work. • consider training social anxiety sufferers to hold coping rather than negative images before and during social challenges. • it is reasonable to encourage these coping ‘images’ to involve a variety of sensory channels for example visual, felt-sense & auditory. • coping visual images should be from a ‘first person’ rather than an ‘observer’ perspective. • try training preparatory coping images (guided or self-directed) as a sequence involving experiencing initial difficulties, but progressively mastering the social interaction with eventual successful outcome.

3. trauma memories & agoraphobia • when questioned, all of a group of 20 agoraphobics – but none of a group of 20 matched controls – reported having distinct recurrent intrusive ‘images’ in agoraphobic situations. • most intrusive ‘images’ involved several sensory modalities such as vision, internal ‘felt-sense’, sound, touch, smell & taste (note vision wasn’t always present as a component). • on discussion, all subjects linked an aversive memory to the intrusive ‘image’, but only 15% (3/20) reported having thought about the content of the memory prior to the interview. • the mean age at the time of the memory was 14.3 years. • 75% (15/20) of the subjects believed the memory affected their anxiety in agoraphobic situations. • common themes with both intrusive images and associated memories were of catastrophic danger and of a negative view of self (such as the self intimidated, humiliated and misunderstood). Day SJ, Holmes EA & Hackmann, A. Occurrence of imagery and its link with early memories in agoraphobia. Memory 2004; 12(4): 416-27

4. clinical implications 3 • when asking about intrusive ‘images’ in agoraphobia (or other psychological disorders) it may be worth getting the sufferer to imagine (or actually revisit) an upsetting episode • note that recurrent intrusive images can come visually or as a internal felt-sense or via other (often multiple) sensory channels • although on questioning the majority of subjects can link this intrusive image to an early memory, they may well not have made this link before • subjects often recognize quite readily that the image tends to aggravate their symptoms • exploring the meaning and beliefs around the image and memory may well make good sense

5. trauma memories & OCD • of 34 inpatients with OCD, 71% (24/34) reported that they had intrusive visual images when their OCD was really bad. • for patients with visual images, 33% (8/24) recognized their images as memories of actual aspects of earlier traumas. • when the remaining 16 patients with visual images were asked about their earliest recollection of having had similar sensations and feelings, 94% (15/16) could identify a particular traumatic experience that was linked to the visual image. • the perceived similarity between the visual image & the memory of the traumatic experience was very high, both in terms of sensory characteristics and in terms of interpersonal meanings. • it seems likely that many of the 29% (10/34), who did not report intrusive visual images, might have reported ‘images’ if questioned about felt-sense and other sensory channels. Speckens A, Ehlers A, et al Imagery and early traumatic memories in obsessive compulsive disorder. BABCP Annual Conference Abstracts: p.44. York, 2003

6. traumamemories&otherdisorders • Hinrichson H, Morrison T, et al. Triggers of vomiting in bulimic disorders: the roles of core beliefs and imagery.BABCP Annual Conference Abstracts: page 8. York, 2003. • Cooper M, and Turner H. The effect of using imagery to modify core beliefs in bulimia nervosa: an experimental pilot study. BABCP Annual Conference Abstracts: pp 8-9. York, 2003. • Osman S, Cooper M, et al. Spontaneously occurring images and early memories in people with body dysmorphic disorder. Memory 2004; 12(4): 428-36 • Brewin CR, Watson M, et al. Memory processes & course of anxiety and depression in cancer patients.Psychol Med 1998; 28: 219-24. • Finkenauer C, and Rimé B. Keeping emotional memories secret: health and subjective well-being when emotions are not shared. Journal of Health Psychology 1998; 3(1): 47-58. • Morrison A. Trauma and psychosis: cause, consequence, common processes and clinical implications.BABCP Annual Conference Abstracts: p 21. York, 2003.