Memory and Personal Identity:The Minds/Body Problem

1. Memory and Personal Identity: The Minds/Body Problem
David Spiegel, M.D.
Willson Professor &
Associate Chair
Psychiatry & Behavioral Sciences
Director, Center on Stress and Health
Stanford University School of Medicine
September 26, 2014

2. Memory and Personal Identity: The Minds/Body Problem
Outline
1.Memory
2.Identity
3.Trauma and Dissociation
4.Integrating Trauma and Stress
5.Reconstructing Personal Identity

4. Brain Structures Involved in Different Types of Memory

5. Identity Integration Is a Task, not a Given
Identity
Consciousness
Memory

6. Day-to-Day Identity
Social Perception
Somatic Awareness
Motor Control
Control

7. Trauma: His Brain/Your Body
Social Perception
Somatic Awareness
Motor Control
Control

11. Science 303:232-235, 2004

12. Science 303:232-235, 2004
Dorsolateral Prefrontal Cortex Activation During
Memory Suppression

13. Science 303:232-235, 2004
Hippocampal Inhibition During Memory Suppression

14. Trauma
Dissociative defenses may be an adaptive mechanism and directed at maintaining control at times of overwhelming stress
Problem: some trauma victims develop persistent dissociative, amnestic and anxiety- like symptoms

15. The traumatic experience causes disruption to normal ways of processing perception, cognition, affect, and relationships.

16. The traumatic experience forces its victims to reorganize mental and psycho-physiological processes in order to buffer the immediate impact of the trauma (Maldonado & Spiegel 1994)

17. Traumatic events:
•Induce a separation from the environment in an attempt to prevent the full impact of the trauma
Consequences:
•Disrupts the victims beliefs about what is safe, secure, and predictable
•Creates a damaged sense of self
•Creates a sense of lack of control over their bodies and future
•Memories become distorted, distant, and incomplete, and are not readily available, making it difficult to work through and put into perspective the trauma
Trauma & Psychopathology

18. Dancu, C. V., Riggs, D. S., Hearst-Ikeda, D. E., Shoyer, B. G., & Foa, E. B. (1996). Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape. Journal of Traumatic Stress, 9, 253-267.
.
.
Does dissociation decline in the days and weeks following exposure to trauma?
Dissociation level in adults exposed to sexual and adults exposed to
physical assault at 1, 4, 8, and 12 weeks after assault and comparison control group.

19. Dissociation and Risk for Traumatization
Koopman C, Classen C, Spiegel D. Dissociative Responses in the Immediate Aftermath of the Oakland/Berkeley Firestorm. J Traumatic Stress. Jul 1996;9(3):521-540.

20. Adj.DO BPD (68%) DID
ASD (25%) (MPD)
PTSD (75% PA)
(100%) (70-97% SA)
(68% incest)
Trauma & Psychopathology
Trauma
Maldonado JR, Spiegel D. Dissociative States in Personality Disorders. In Oldham, Skodol, Bender (Eds.) Textbook of Personality Disorders (pp. 493-521). Washington, DC: American Psychiatric Publishing, Inc., 2005

21. Childhood Trauma and Response to Depression Treatment
Nemeroff et al., PNAS 100 (24), 14293-296, 2003

22. Emotion Modulation in PTSD:
Clinical and Neurobiological Evidence for a Dissociative Subtype
Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, Spiegel D
American Journal of Psychiatry, 2010; 167 (6) 640-647

23. Dissociative Subtype of PTSD in DSM-5
•With Dissociative Symptoms: The individual’s symptoms meet the criteria for PTSD and the individual experiences persistent or recurrent symptoms of either of the following:
•1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream, feeling a sense of unreality of self or body, or of time moving slowly).
•2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
•NOTE: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts), or another medical condition (e.g., complex partial seizures).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association. All rights reserved

24. Stein, D. J., K. C. Koenen, et al. (2013). "Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys." Biol Psychiatry 73(4): 302-312.
•METHODS: Interviews were administered to 25,018 respondents in 16 countries in the World Health Organization World Mental Health Surveys. The Composite International Diagnostic Interview was used to assess 12-month DSM-IV PTSD and other common DSM-IV disorders. Items from a checklist of past-month nonspecific psychological distress were used to assess dissociative symptoms of depersonalization and derealization. Differences between PTSD with and without these dissociative symptoms were examined across a variety of domains.

25. Stein, D. J., K. C. Koenen, et al. (2013). "Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys." Biol Psychiatry 73(4): 302-312.
•RESULTS: Dissociative symptoms were present in 14.4% of respondents with 12-month DSM-IV/Composite International Diagnostic Interview PTSD and did not differ between high and low/middle income countries. Symptoms of dissociation in PTSD were associated with high counts of re-experiencing symptoms and net of these symptom counts with male sex, childhood onset of PTSD, high exposure to prior (to the onset of PTSD) traumatic events and childhood adversities, prior histories of separation anxiety disorder and specific phobia, severe role impairment, and suicidality.

26. Stein, D. J., K. C. Koenen, et al. (2013). "Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys." Biol Psychiatry 73(4): 302-312.
•CONCLUSION: These results provide community epidemiologic data documenting the value of the dissociative subtype in distinguishing a meaningful proportion of severe and impairing cases of PTSD that have distinct correlates across a diverse set of countries.

27. IOM Report: Psychotherapies
•Evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD
•So you must revisit the trauma – reoccupy the territory as your own to overcome dissociative and other trauma-related symptoms
•Evidence is inadequate to determine the efficacy of:
–EMDR
–Cognitive restructuring
–Coping skills training
–Therapy delivered in group formats

28. Psychotherapies for PTSD
•Exposure-Based
•Fear de-conditioning
•Stress response management
•Modify conditioned associations to fear stimuli
•Cognitive Restructuring
•Shame, guilt, anger
•Less emphasis on reliving trauma
•Restructure self- assessment

29. Components of Cognitive Therapies for PTSD
1.Psychoeducation
2.Distress management
3.Exposure
4.Cognitive restructuring

30. Dissociative disorders can be understood as the pathological separation of aspects of mental functioning, including perception, memory, identity, and consciousness, which would normally be processed together.
Dissociative Disorders

31. Pierre Janet: Dissociation as “Mental Disconnection”
“Desagregation mentale”
• Janet, P., L'automatisme psychologique. 1889, Paris: Felix Alcan.
• Janet, P., The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University. 1907, New York: Macmillan.

32. DSM-5 Definition of Dissociation
•Pathological dissociation is an involuntary response with a subjective loss of integration of information or control over mental processes that, under normal circumstances, are available to conscious awareness or control. Dissociative symptoms can manifest in every area of psychological functioning. Dissociative symptoms are characterized by (a) unbidden and unpleasant intrusions into awareness and behavior, with an accompanying loss of continuity in subjective experience: i.e., “positive” dissociative symptoms; and/or (b) an inability to access information or control mental functions that are normally amenable to such access or control: i.e., ” negative” dissociative symptoms.

33. Dissociative Disorders
Syndrome: Problem: Lack of integration in
Dissociative Amnesia Memory
Depersonalization/Derealization Perception
Dissociative Identity D/O Identity &
consciousness

34. Dissociative Amnesia (Psychogenic Amnesia)
•Hallmark: inability to recall important personal information (too extensive)
•The most common of all dissociative disorders
•Amnesia is a disorder & a symptom found in a number of other dissociative and anxiety disorders (ASD, PTSD, somatization disorder, dissociative amnesia, and dissociative identity disorder)
•Dissociative fugue is a subtype of DA

35. Dissociative Amnesia (Psychogenic Amnesia)
•Amnesic patients are:
–usually aware of their memory loss
–capable of learning new information
–have intact cognition
•Memory deficits: usually reversible as the amnesia causes difficulties in retrieval rather than encoding or storage

36. Williams, L. M. (1994). Recall of childhood trauma: A prospective study of women's memories of child sexual abuse. J Consult Clin Psychol, 62, 1167-1176.

37. Depersonalization/Derealization Disorder
•Hallmark: persistent or recurrent episodes of feelings of detachment or estrangement from one's self
•Reality testing is intact
•Incidence and prevalence is unknown
•Has even be transiently experienced by people with no psychiatric condition at all

38. Depersonalization/Derealization Disorder
•The symptom of depersonalization has been described as being the third most common psychiatric symptom
•Under severe stress up to 50% of all adults have experienced at least one single brief episode of depersonalization
•Sex distribution: unknown
•Incidence: women 2-4:1 men
•Population prevalence 1.5-2%

39. Dissociative Identity Disorder (Multiple Personality Disorder)
•Presence of 2 or > distinct identities or personality states that recurrently take control of the subject’s behavior
•May involve an experience of ‘possession’ in some cultures
•Problem: failure to integrate various aspects of identity, memory and consciousness
•Memory gaps in personal history with asymmetric & selective amnesia

40. Dissociative Identity Disorder (Multiple Personality Disorder)
•Symptoms: memory deficits, including for everyday events, thought intrusion, moodiness, erratic and unpredictable behavior, depression, self-mutilation, suicidal ideation or attempts, or the overt manifestation of an alternate personality
•Transition is usually sudden and is commonly triggered by environmental factors

41. Dissociative Identity Disorder (Multiple Personality Disorder)
•Demographics:
–Female to male ratio:
•5:4 for children & adolescents
•9:1 for adults respectively
–Females present more personalities (average of 15) than men (average of 8)
–High incidence of first-degree relatives who have the disorder
–Average time from the appearance of symptoms to an accurate diagnosis is 6 years

44. Can Psychotherapeutic Support
• recontextualize traumatic memories?
• restore integration of identity?

45. Dissociative Identity Disorder Treatment of Choice
•Hypnosis as a treatment tool:
Allows for the recovery and reprocessing of recovered memories at a pace the patient can tolerate
Properly done, hypnosis facilitates symbolic restructuring of the traumatic experience
There are no systematic studies regarding its efficacy

47. Effects of Trauma on Components of Memory
•Encoding - Absorption
•Storage - Dissociation
•Retrieval - Suggestibility

49. •Hypnosis as a treatment tool:
It allows for the recovery and reprocessing of recovered memories at a pace the patient can tolerate (Pacing).
Facilitates symbolic restructuring of the traumatic experience.
May teach patients about the amount of control they have over these states of mind which they experience as automatic, uncontrollable and unpredictable.
Trauma-Related Disorders Treatment Techniques Using Hypnosis

50. Cognitive Restructuring
•Traumatic Stressor
•Adaptive Response

51. •The Condensed Hypnotic Approach:
–Make conscious repressed memories
–Develop congruence between memories & self
–Confrontation of fears, trauma, reality
–Condensation of memories (symbolic image)
–Control over memories/behavior
–Development of mature defenses
–Practice mastery of new behavior/reality
Trauma-Related Disorders Treatment Techniques Using Hypnosis

52. Dissociation Is:
A response to trauma
–Common during and acutely after
–Problematic if it persists longer
A failure of integration of:
Memory: Dissociative Amnesia
Perception: Depersonalization/Derealization
Identity and Consciousness: DID
Treatable with psychotherapy

53. Tranceformation of Control over Language and Perception
•Ordinary Consciousness:
•We respond to perceptions (posterior portion of the brain) and manipulate language (anterior)
•Hypnosis:
•We respond to language and manipulate perception

54. Social Perception: Medial Prefrontal Cortex

55. Shakespeare on Commiserating
“When we our betters see bearing our woes,
We scarcely think our miseries our foes
…the mind much sufferance doth overskip
When grief hath mates and bearing fellowship”
Edgar, King Lear

56. fMRI: Those with High Ability to Use Hypnosis Show Functional Connectivity of left DLPFC in Salience Network (dACC)
Hoeft, F., Reiss, A., Whitfield-Gabrieli, S., Gabrieli, J., Greicius, M., Menon, V., Spiegel D. Archives of General Psychiatry 2012:69(10) 1064-1072

57. Anterior Cingulate Cortex: Context Generator
Subgenual cingulate

58. Trauma: His Brain/Your Body
Social Perception
Somatic Awareness
Motor Control
Control

60. Continuity of Memory Makes for Continuity of Identity
Social Perception
Somatic Awareness
Motor Control
Control

61. Treatment of DID

62. Stanford Center on Stress and Health
Research Funded By:
National Institute on Aging
PO1 5P01AG018784
on Stress, the HPA, and Health in Aging
National Cancer Institute
RO1CA118567 Sleep and Breast Cancer
National Center for Complementary and Alternative Medicine
P30 AT005886 Treating Sleep Disorders in Cancer
RC1 AT0005733 Neuroimaging of Hypnosis
National Institute of Mental Health
RO1 MH47226 Group Therapy and Cancer Survival
California Breast Cancer Research Program
Charles A. Dana Foundation
John D. and Catherine T. MacArthur Foundation

63. “My feeling is that while we should have the deepest respect for reality, we should not let it control our lives.”