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On the Relationship of Trauma Amnesia and Psychopathology An

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					„On the Relationship of Trauma, Amnesia and Psychopathology"
                                  An empirical pilot study1

Dr. phil. Anke Kirsch2, Prof. Dr. phil. Rainer Krause2




                                                 Summary

Objectives: In the present study, we examined the facial-affective behavior of acutely
traumatized patients in the process of EMDR therapy, in order to determine if an increase in
the facial-affective behavior presents itself as an indicator for the lifting of emotional
numbing and the extent to which it is associated to a reduction of symptoms. Amnestic
tendencies were used as a moderator variable.
Methods: The facial-affective behavior was coded using the Emotional Facial Acting Coding
System, an instrument for the registration of facial movements associated with primary
emotions. The facial-affective behavior of the patients’ first and last EMDR session was
compared.

Results: A significant increase in the facial-affective behavior resulted, which, however, was
not followed by symptomatic relief. The reduction of amnestic tendencies did not result in a
reduction of symptoms.

Conclusions: Under the influence of the treatment, it was possible to improve the access to
the episodic affective memory. Nevertheless, a positive influence could not be registered at
the end of the treatment.

                                                Key words
Emotional Numbing, PTSD, facial-affective behavior, EMDR, amnesia, reduction of
symptoms



1. Introduction

The relationship of the so-called traumatic disorders to psychoneuroses has not yet been
clarified in its essential parts. This situation is due, on the one hand, to an insufficiently

1
  PD Dr. med. Günter Seidler contributed to this study. The patients originated from his Heidelberger EMDR and
violence victim study (Seidler et al., 2003a, Seidler et al., 2003b).
2
  Saarland University, Psychological Department, Chair for Clinical Psychology and Psychotherapy.
stringent theory and concept, and, on the other hand, to the related inadequate research. In the
following, we shall try to improve both.

Conceptual Clarification in Respect to Trauma, Amnesia and Psychoneuroses

With regard to both illness environments, the definition criterion of psychoneuroses is the
existence of an unconscious intrapsychic conflict as a causal agent for pathological
development (Rüger et al. 2005, p. 31). In respect of traumatic disorders, “unconsciousness”
is excluded by definition. The ICM-10 gives the following definition: repeated inevitable
retrospection of the event or mental reproduction, daydreams and nightly dreams (so-called
intrusion) are said to be an obligate symptom for the determination of the diagnosis (Dilling,
1997). From this point of view, an intersection between traumatic disorders and
psychoneuroses is excluded by definition. However, there is only a constraint consensus on
the definition and operationalization of the unconsciousness on events. Undoubtedly, there is
an extensive number of documented events which would be commonly considered as
traumatic. These events become unconscious at a later point in time in the sense that their
remembrance “lacks knowledge” of the precise way in which the person his or herself was
involved. A study of Meyer and Williams (1994), which is regarded as prospective, examined
206 young women, ages 10 – 12, who, in the time between 1973 and 1975, were victims of
documented sexual assaults. Between 15 – 17 years later, 38 % of them had no memories on
the documented assaults involving their own person. In awareness of this study, one cannot
assume that the events were unknown in all cases. For instance, the documented episode is
remembered as something that befell someone else. Such a process cannot be described as
amnesia or repression. A shift and / or a projection is the explanation model more likely to be
adequate. Needless to say, there are other documented forms of shifts into unconsciousness.
For example, some patients place similar events onto a later point in time of their biography
and use them to explain their symptoms. Krause (1998, 1999) denominated these events as
“covering traumas”. Hence, it is conceivable that in this group of 38%, a possible acute stress
reaction transformed itself into a psychoneurosis, passing through a form of unconsciousness.
Meyer’s research does not give way to inferences on the magnitude of the prevalence rate of
psychic disorders in the sample of patients reremind of their trauma in comparison to the total
population, nor on difference in the illness frequency of the groups with conscious or
unconscious memories of the events. The terms amnesia and suppression are certainly
inadequate to describe the events (Loftus et al. 1994).
A conflict-related amnesia would give rise to the pathology since the trauma of amnesia
decays and shows its pathological effects as an unconscious conflict, as suggested in the
classic model of psychoneuroses. A contrary model could explain the emergence of the illness
by claiming that there is no memory loss, which results in permanent remembrances that
influence the life of the affected person pathologically. This logic does not allocate space for
the possibility that the influence of a benevolent amnesia could lead to complete healing. In
addition to the development of psychoneuroses, their respective posttraumatic stress disorders
and healings, other parallel developments are conceivable. In this way, one could postulate
that persons who were traumatized in former times do not predominantly drift into the
psychoneurotic group with unconscious conflicts, but into that of personality disorders,
especially of borderline personality disorders, in which 70% of all grown-up female patients
and 45% of all men with this diagnosis remember having been sexually abused (Paris 2000, p.
161).

If we suppose that these memories are accurate, and that one third of all amnesia disappears, it
could be presumed that the “70% group” of women in Meyer’s random sample who were able
to remember, developed a borderline personality, and that the “38% group“ with amnesia,
developed a psychoneurosis. In this case, healing up would be excluded.

Affectivity, Trauma and Amnesia

Emotional numbing is often assumed of traumatized patients (cp. Litz et al. 2000). With
regard to the visible facial affectivity of distinct implementations of traumatization, Kirsch
and Seidler (2004) have detected on a primal analysis, that emotional numbing is present on
traumatized patients in the first measurement after traumatization. Those patients who,
according to the DSM-III-R scale for traumatization, where most severely traumatized
(catastrophically), presented 46 facial movements on a time lapse of four minutes, of which
4.5 were unambiguously identifiable affects. The healthy group, however, presented 224.25
facial movements of which 15 were affects. The group of severely traumatized patients
(extremely severe) on the DSM scale, showed 142.75 facial movements and 10 affects. This
reduction did not apply to patients who exhibited comorbidity of the anxiety-depression field
and were traumatized long before. The frequency distribution of the overall facial activity in
comparison with the healthy group was 162.6 vs. 182.84 with respective standard deviations
79.93 and 108.32 (Kirsch et al. 2004). However, this applies to other patient groups and
subgroups as well. Such reduction phenomena are found in borderline and anxiety patients as
well (Benecke & Krause 2005).
Emotional numbing on severely traumatized patients is limited to the expressive part of the
affective system, since the affective memories are introspectively and embarrassingly
conscious. Subjectively, the decay of the memories into amnesia would be a gain for the
patients; their behavior serves this purpose. Expressional numbing could just as well be an
attempt to alleviate pain; however, it could also be linked to the incapacity of conveying and /
or talking about the trauma.

One cannot assert that real amnesia are present in any of the groups. If pathogenic memory
processes had developed an effect at all, they could only have been active in the second
group, in the sense of the false memory syndrome, i.e. of the possibly hallucinatory
realization of a traumatic episode which could not have taken place, at least not in this form.
This can be excluded in the first group since they were sent to therapy after the investigations
made by the police.

In the environment of neuroses, lifting amnesia is claimed to be curative and indispensable
since otherwise, the persons would unconsciously create situations that would lead to
repetition of the traumatic experiences. This benevolent effect will only present itself if the
traumatic impact is no longer present. If the impact continues to be present, derealization,
dissociation, and denial of the traumatizing impact may become present.

The application of trauma-specific treatments on trauma disorders is very popular, even
though it cannot either be asserted that the mechanisms of action are known nor that specific
indications exist. Exposing the available hypotheses on this matter would go beyond the scope
of this work. One could draw the supposition from the work of Kirsch and Seidler that one of
the mechanisms of action could consist in lifting or alleviating emotional numbing and thus
leading to the reduction of the symptoms, e.g. through the capability of speaking affectively
after the treatment. This, however, would include the risk that the patient’s attempt to forget
could be lifted or weakened, which would result in a subjectively worsened state. In the
following, the course of some of the relevant parameters during such treatments will be
examined, namely emotional numbing, symptoms and memory shift.

Depiction of the Problem

The objective was to find out if an increase in the facial-affective behavior as and indicator
for the reduction of emotional numbing was present in the course of the therapy and to assess
its association to the reduction of symptoms. The disposition to memory shifts in the sense of
unspecific amnestic tendencies was examined as a moderator variable.
2. Methods

Random Samples

The study described in this work emerged in association with the Heidelberger EMDR and
Violence Victims Survey (HeiGOS; Heidelberger Gewaltopferstudie) (Seidler et al., 2003a;
Seidler et al., 2003b). In this survey, all violence victims in Heidelberg in a year were
examined on the quest for predictors for the development of disorders caused by traumas. The
participants of the HeiGOS were recruited from three sources: Violence victims from the
HeiGOS in need of therapy, outpatients from the psychosomatic outpatient clinic,
psychosomatic department, Heidelberg; and patients from generalist and gynecological
practices with acute disorders caused by traumas. In order to participate in the survey, the
patients had to be of full age and able to communicate without an interpret, the event criterion
according to ICD-10 had to be fulfilled within the last twelve months, and psychological
strain with diagnosed Acute Stress Disorder had to be present or at least two symptom
complexes of PTSD fulfilled. Individuals with solely complex-traumatic disorders as a
consequence of a persistent traumatization that occurred a lot of time before, and patients with
known or, according to the clinical impression, expected psychotic crises, suicidality or drug
problems were excluded from the study. The diagnoses were made in clinical interviews and
were supported by questionnaires. All participants were additionally safeguarded with a SKID
interview (Wittchen, Zaudig, Fydrich, 1997). After the SKID-I interview, two measurements
followed in order to document the achieved changes: the first one shortly before the beginning
of the EMDR therapy, the second one shortly before the end. Nine patients out of the sixteen
participants in the study were treated with EMDR and included in the analysis; the seven
victims remaining were assigned another treatment plan (see Hain et al. 2004).

The patients went through an intervention in an outpatient resource-oriented group for acutely
traumatized patients (twice a week, for about ten weeks), after that, EMDR therapy started,
which, according to the number of therapeutic sessions assigned, lasted for up to ten weeks.
EMDR sessions were held every two weeks. The patients were assigned an EMDR individual
therapist who clarified if there were any counter-indications for the application of EMDR.
After this, EMDR sessions were held in the clinically necessary number. One patient received
one session, three patients three sessions, four patients seven sessions, and one patient eight
sessions.

Therapeutic Method

EMDR and a special form of group therapy (Hain et al., 2004) were selected as therapeutic
methods. EMDR is an acronym for Eye Movement Desensitization and Reprocessing, a
method to treat traumatized persons (Shapiro 1989).

Analysis Methods of the Project

The Emotional Facial Action Coding System (EMFACS) (Ekman, & Friesen, 1984) was used
to analyze the affectivity of the patients. This method evolved from the Facial Action Coding
System (FACS) (ibid., 1978, Ekman, Friesen & Hager, 2002). Both of them are used to
measure facial expression objectively.

Behavioral sequences of the subjects are analyzed in interactions with the aid of video
recordings and special techniques (split screen, slow motion, etc.). Trained coders assign
numbers to single movements of the face muscles or combinations of them (Action Units;
AU). For EMFACS, only affectively relevant AU’s are coded, which are evaluated by means
of a computational program. In this study, the first four minutes following the question “What
stresses you the most at the time?” were coded. The traumatized patients narrated their
traumatic experience; the healthy subjects generally described relationship problems from
their personal environment, mostly familial.

Psychopathology was registered with the Symptom Checklist of Derogatis (SCL-90-R,
Franke 1995). The amnestic tendencies were registered with the Questionnaire on
Dissociative Symptoms (Freyberger, Spitzer & Stieglitz 1999). The questionnaires were filled
out by the patients at the beginning and at the end of the therapy and serve as a measure for
success and change. The Symptom Checklist of Derogatis is comprehensive disorder self-
judgment procedure in the form of a questionnaire that measures the subjectively perceived
impairment arising from physical and psychical symptoms in a time lapse of seven days.
Evaluation is multidimensional and the test is adequate for measurement repetitions in course
examinations.

The 90 items of the nine primary scales describe the following areas: somatization,
compulsiveness, insecurity in social contact, depressivity, anxiety, aggressivity / hostility,
phobic fear, paranoid thought and psychotizism. Three global specific values provide
information on the response behavior in all items. The Global Severity Index (GSI) measures
fundamental psychic stress, the positive syndrome distress index (PSDI) measures the
intensity of the responses, and the positive symptom total (PST) provides information on the
number of symptoms that display stress. There are representative norms for healthy subjects
and empirically proven quality criteria.

The Questionnaire on Dissosiative Symptoms (FDS; Fragebogen zu dissoziativen
Symptomen) is a self-judgment procedure for adults. This instrument was designed to record
traits; however, it is possible to register sufficiently valid changes during a therapeutic
process. The FDS registers amnesia, absorption, derealization and conversion in subscales.
The subscale for amnesia includes items that relate to events like not remembering how one
came to a certain place, wearing clothes without remembering about them or having them put
on. On the behavioral level, memory gaps concerning actions and written documents are
measured as well as reproaches to lie. The inability to recognize friends and family is assessed
as an amnestic characteristic, just as being called a name one cannot remember or possessing
objects whose purchase one cannot remember. The questionnaire does not register any
memory disorders specifically concerning the traumatic experience of the patient. The
questionnaires were filled out by the patients at the beginning and at the end of the therapy
and serve as a measure for success and change.



3. Results

Hypotheses

In this study, the following hypotheses were dealt with:

Hypothesis group 1:

   •   The treatment of acutely traumatized patients with EMDR is followed by an increase
       in the expressive parts of the affective system (repeated increase).

   •   The treatment of acutely traumatized patients with EMDR is followed by recovery in
       the sense of a reduction of symptoms.

   •   The EMDR treatment is followed by a reduction of a possible amnestic tendency.

Hypothesis group 2:

   •   The possible increase of movements in the expressive system of the face is followed
       by a reduction of symptoms.

   •   The lifting of the amnestic tendency is followed by an increase in symptoms.

   •   The possible increase of the action units is followed by the lifting of amnestic
       tendencies.

   According to our hypothesis, an increase in the facial-affective behavior of severely
   traumatized patients in the course of EMDR sessions could be found. Kirsch and Seidler
had demonstrated already that acutely traumatized patients show a reduction (Seidler et al.
2004; Kirsch & Seidler, in press).

The overall facial activity of the patients during the anamnesis session increased in
comparison to the last session (m = 98.56 / m = 118.78). This difference was proved
significant by means of the Wilcoxon test with z = -2.57 and p = 0.01.

The primary affects of the patients increased during the course of the therapy, with a value
of m = 6.44 on the anamnesis session to a value of m = 9.22 on the last session. The
Wilcoxon test showed that the difference in the number of primary affects with z = -1.31
and p = 0.19 was not significant; however, significant changes were registered with
respect to fear and anger. Fear decreased significantly from m = 0,44 to m = 0,00 (z = -
2,00; p = 0,046).Anger increased from m = 1.67 to m = 4.44. This change is significant (z
= -2.83; p = 0.005). Grief decreased from m = 0.66 to m = 0.11, but had only the tendency
to become significant (z = -1.89; p = 0,056).

The first hypothesis in group 1 holds altogether, i.e. the treatment of acutely traumatized
patients with EMDR is followed by an increase in the expressive parts of the affective
system (see table 1).

Table 1: Mean value and standard deviation of the facial affect expression of the patients. The first and last
EMDR sessions were compared, respectively (Wilcoxon test for incorporated random samples).

     Facial
     expression             Session             Mean value         Standard        Wilcoxon p
                                                                   Deviation
     Action       unit      Anamnesis
                                                98,56              60,62
     total
                            Last session        118,78             61,20           z = -2,57; p = 0,01


Concerning pathology, there were no significant differences in the values of any particular
scale. All values except for somatization exhibited a slight increase in the SCL-90.
According to it, the treatment of the acutely traumatized patients was not followed by a
reduction of the symptoms. All values lie at the beginning of the therapy and after it in the
clinical interval (see table 2).
Table 2: Mean value and standard deviation for SCL-90, global specific values in anamnesis and last
session.

 Questionnaire                                Mean         Standard
 measure               Session            N   value        Deviation

 GSI (SCL)             Anamnesis          9   60,33        10,36
                       Last session       9   66,00        14,85
 PST (SCL)             Anamnesis          9   65,78        13,88
                       Last session       9   68,33        12,77
 PSDI (SCL)            Anamnesis          9   66,11        11,41
                       Last session       9   66,89        11,26
Note: GSI (global severity index); PSDI (positive syndrome distress index); PST (positive symptom total)



All values of the FDS increase, except for those concerning anmestic tendencies
(amnesia), which decrease slightly (see table 3).


Table 3: Mean value and standard deviation for the FDS scales in anamnesis and last session.

 Questionnaire                                Mean         Standard
 Measure                   Session        N   Value        Deviation

 Amnesia (FDS)             Anamnesis      9   4,86        4,31
                           Last session   9   4,70        2,56
 Absorption (FDS)          Anamnesis      9   15,79       7,64
                           Last session   9   18,57       6,07
 Derealization (FDS)       Anamnesis      9   7,59        4,34
                           Last session   9   9,86        9,51
 Conversion (FDS)          Anamnesis      9   5,55        6,16
                           Last session   9   8,69        8,19
 FDS z-value (FDS)         Anamnesis      9   ,91         ,80
                           Last session   9   1,29        1,05


In order to evaluate hypothesis group 2, correlations of the standardized difference values
of the beginning and end of the therapy concerning facial overall activity, distress (SCL-
90) and amnesia (FDS) were computed. The difference values for the patients’ overall
facial activity correlated negatively with the difference value for amnesia (FDS) (r = -.65 /
p = .057), i.e. the more facial activity the patients showed in the course of the therapy, the
less amnestic they were. The difference value of the overall facial activity correlates
positively with the difference value for distress (PSDI; SCL-90) (r = + .85 / p = .004), but
negatively with those for amnesia (r = -.71 / p = .03), i.e., the higher the distress in the
course of the therapy, the lower the amnestic tendencies and the higher the overall facial
activity.

This makes clear that the application of EMDR therapy, short time after the trauma, helps
induce a decrease in the amnestic tendencies, i.e. a memory shift and an increase in the
overall facial activity, which however, happens at the cost of the patient’s overall psychic
stress (see figure 1).

Figure 1: Correlations of the standardized difference values (beginning / end) of the overall mimic activity
(AU total), amnesia (FDS) and overall strain (SCL-90) of the patients (non-parameterized correlations:
Spearman-Rho, two-sided).

                                                  Action Unit


                                             +.85**
                                                                   r = −.65/p=.057

                                 Distress                              Amnesia
                                                      −.71*




The calculation of partial correlations by partialing out the difference values for amnesia
yields a positive correlation between the difference value for the SCL-90 depression scale
(r = +.65; p = .08). The positive correlation between overall facial activity and distress
(PSDI) in the SCL-90 persists (r = +.65; p = .08). Furthermore, distress (PSDI) correlates
strongly and positively with depression (r = .88; p = .004) (see figure 2).

Figure 2: Correlations of the standardized difference values (beginning / end) of the overall mimic activity
(AU total), depression (SCL-90) and strain (SCL-90) of the patients (non-parameterized correlations:
Spearman-Rho, two-sided).




                                              Action Unit



                               .65 /p =.08                    r = .65/p=.08

                            Distress                               Depression
                                                 .88**



Thus, the first hypothesis in hypothesis group 2 does not hold, i.e. the possible recurrence
of action units in the expressive system is not followed by a reduction of the symptoms.
However, the following two hypotheses hold, for the lifting of an amnestic tendency is
followed by a reduction of the symptoms and a possible increase in the action units comes
along with the lifting of the amnestic tendencies.
4. Discussion

The results for hypothesis group 1 showed that the therapy was followed by an increase in
the expressive parts of the affective system, but not by a reduction of the symptoms.

The results for hypothesis group 2 showed that the repeated increase of the action units is
followed by an increase in the symptoms and a decrease in the amnestic tendencies.

Partialing out amnesia yields a positive correlation between the overall facial activity and
the depression score (SCL-90) of r = .65. The positive correlation between overall facial
activity and distress persists r = .65. Under the influence of the therapy, it was possible to
improve the access to episodic affective memories. A positive influence of this process
could not be registered, at least not at the end of the therapy, since the overall state of the
patients worsened. This poses a question that this study cannot answer: are there specific
indications that promote amnesia instead of lifting them and / or is the carrying capacity of
the therapeutic setting of the reactivation of such memories sufficiently different from the
original traumatization? It is left to further research to find out which magnitude in the
proportion of reenactment of the trauma in the here and now is needed or allowed and
whether these processes, like asserted by some authors, should be avoided at all cost. It
seems to be that such processes, even with the best intentions and knowledge, cannot be
avoided. As known from the descriptions of individual cases, the exposure to the trauma
through the authorities, policemen and criminal proceedings was associated, at least for
some of the acutely traumatized patients, to a considerable re-traumatization. Thus, the
opening of the episodic memory in the environment of a further pursuit to which the
therapist belongs nolens volens could lead to worsening the burden of the symptoms
(Anstadt et al. 1996).

In some cases, it seems more favorable not to touch the trauma. It is possible that the
proportion of supportive therapeutic elements that provide foothold, which should be met
in this study by means of group therapy, was not sufficient. The application time of
EMDR itself was very different from case to case. Termination was not always bound to a
medical indication.

A positive effect concerning the processing of the trauma should be noted: the expression
of fear and grief decreased and that of anger increased, which suggests that the patients
express their anger towards that which befell them and do not see themselves as much in
the role of the victim.
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Contact:

Dr. phil. Anke Kirsch
University Campus
Building A 1.3
66041 Saarbrücken
Germany
mail: a.kirsch@mx.uni-saarland.de
Phone: 0049 681 302 3674
Fax: 0049 681 302 4437

				
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