Anxiety Disorders: Holmes EA

Holmes EA, Bourne C. · Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. · Acta Psychol (Amst). · Pubmed #18234153 No free full text.

Abstract: Highly affect-laden memory intrusions are a feature of several psychological disorders with intrusive images of trauma especially associated with post-traumatic stress disorder (PTSD). The trauma film paradigm provides a prospective experimental tool for investigating analogue peri-traumatic cognitive mechanisms underlying intrusion development. We review several historical papers and some more recent key studies that have used the trauma film paradigm. A heuristic diagram is presented, designed to simplify predictions about analogue peri-traumatic processing and intrusion development, which can also be related to the processing elements of recent cognitive models of PTSD. Results show intrusions can be induced in the laboratory and their frequency amplified/attenuated in line with predictions. Successful manipulations include competing task type (visuospatial vs. verbal) and use of a cognitive coping strategy. Studies show that spontaneous peri-traumatic dissociation also affects intrusion frequency although attempts to manipulate dissociation have failed. It is hoped that further use of this paradigm may lead to prophylactic training for at risk groups and an improved understanding of intrusions across psychopathologies.

Holmes EA, Brown RJ, Mansell W, Fearon RP, Hunter EC, Frasquilho F, Oakley DA. · MRC Cognition and Brain Sciences Unit, 15 Chaucer Road, Cambridge, CB2 2EF, UK. · Clin Psychol Rev. · Pubmed #15596078 No free full text.

Abstract: This review aims to clarify the use of the term 'dissociation' in theory, research and clinical practice. Current psychiatric definitions of dissociation are contrasted with recent conceptualizations that have converged on a dichotomy between two qualitatively different phenomena: 'detachment' and 'compartmentalization'. We review some evidence for this distinction within the domains of phenomenology, factor analysis of self-report scales and experimental research. Available evidence supports the distinction but more controlled evaluations are needed. We conclude with recommendations for future research and clinical practice, proposing that using this dichotomy can lead to clearer case formulation and an improved choice of treatment strategy. Examples are provided within Depersonalization Disorder, Conversion Disorder and Posttraumatic Stress Disorder (PTSD).

Brewin CR, Holmes EA. · Subdepartment of Clinical Health Psychology, University College London, Gower Street, London WC1E 6BT, UK. · Clin Psychol Rev. · Pubmed #12729677 No free full text.

Abstract: We summarize recent research on the psychological processes implicated in posttraumatic stress disorder (PTSD) as an aid to evaluating theoretical models of the disorder. After describing a number of early approaches, including social-cognitive, conditioning, information-processing, and anxious apprehension models of PTSD, the article provides a comparative analysis and evaluation of three recent theories: Foa and Rothbaum's [Foa, E. B. & Rothbaum, B. O. (1998). Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press] emotional processing theory; Brewin, Dalgleish, and Joseph's [Psychological Review 103 (1996) 670] dual representation theory; Ehlers and Clark's [Behaviour Research and Therapy 38 (2000) 319] cognitive theory. We review empirical evidence relevant to each model and identify promising areas for further research.

Holmes EA, Mathews A, Dalgleish T, Mackintosh B. · MRC Cognition and Brain Sciences Unit, Cambridge, UK. · Behav Ther. · Pubmed #16942975 No free full text.

Abstract: Therapists often assume a special association between mental imagery and emotion, though empirical evidence has been lacking. Using an interpretation training paradigm, we previously found that imagery had a greater impact on anxiety than did verbal processing of the same material (Holmes & Mathews, 2005). Although the finding of a differential impact of imagery versus verbal processing of negative material was replicated, findings did not extend to benign material. Results therefore left open the question of whether there may be a special association between imagery and positive emotion. The current experiment examined positive interpretation training. Numerous scenarios were presented with initial ambiguity as to positive outcome or not, with final information then yielding consistently positive resolutions. Participants were asked to either imagine these positive events or to listen to the same descriptions while thinking about their verbal meaning. Those participants in the imagery condition reported greater increases in positive affect and rated new descriptions as being more positive than did those in the verbal condition. Results suggest that positive training can be enhanced through imagery as opposed to verbal processing. This study also provides the first test of a standardized intervention using an "interpretive bias training" paradigm to improve positive mood.

Holmes EA, James EL, Coode-Bate T, Deeprose C. · Department of Psychiatry, University of Oxford, Oxford, United Kingdom. · PLoS One. · Pubmed #19127289 links to  free full text

Abstract: BACKGROUND: Flashbacks are the hallmark symptom of Posttraumatic Stress Disorder (PTSD). Although we have successful treatments for full-blown PTSD, early interventions are lacking. We propose the utility of developing a 'cognitive vaccine' to prevent PTSD flashback development following exposure to trauma. Our theory is based on two key findings: 1) Cognitive science suggests that the brain has selective resources with limited capacity; 2) The neurobiology of memory suggests a 6-hr window to disrupt memory consolidation. The rationale for a 'cognitive vaccine' approach is as follows: Trauma flashbacks are sensory-perceptual, visuospatial mental images. Visuospatial cognitive tasks selectively compete for resources required to generate mental images. Thus, a visuospatial computer game (e.g. "Tetris") will interfere with flashbacks. Visuospatial tasks post-trauma, performed within the time window for memory consolidation, will reduce subsequent flashbacks. We predicted that playing "Tetris" half an hour after viewing trauma would reduce flashback frequency over 1-week. METHODOLOGY/PRINCIPAL FINDINGS: The Trauma Film paradigm was used as a well-established experimental analog for Post-traumatic Stress. All participants viewed a traumatic film consisting of scenes of real injury and death followed by a 30-min structured break. Participants were then randomly allocated to either a no-task or visuospatial ("Tetris") condition which they undertook for 10-min. Flashbacks were monitored for 1-week. Results indicated that compared to the no-task condition, the "Tetris" condition produced a significant reduction in flashback frequency over 1-week. Convergent results were found on a clinical measure of PTSD symptomatology at 1-week. Recognition memory between groups did not differ significantly. CONCLUSIONS/SIGNIFICANCE: Playing "Tetris" after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact. Pathological aspects of human memory in the aftermath of trauma may be malleable using non-invasive, cognitive interventions. This has implications for a novel avenue of preventative treatment development, much-needed as a crisis intervention for the aftermath of traumatic events.

Holmes EA, Geddes JR, Colom F, Goodwin GM. · University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom. · Behav Res Ther. · Pubmed #18990364 No free full text.

Abstract: Cognitions in the form of mental images have a more powerful impact on emotion than their verbal counterparts. This review synthesizes the cognitive science of imagery and emotion with transdiagnostic clinical research, yielding novel predictions for the basis of emotional volatility in bipolar disorder. Anxiety is extremely common in patients with bipolar disorder and is associated with increased dysfunction and suicidality, yet it is poorly understood and rarely treated. Mental imagery is a neglected aspect of bipolar anxiety although in anxiety disorders such as posttraumatic stress disorder and social phobia focusing on imagery has been crucial for the development of cognitive behavior therapy (CBT). In this review we present a cognitive model of imagery and emotion applied to bipolar disorder. Within this model mental imagery amplifies emotion, drawing on Clark's cyclical panic model [(1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470]. We (1) emphasise imagery's amplification of anxiety (cycle one); (2) suggest that imagery amplifies the defining (hypo-) mania of bipolar disorder (cycle two), whereby the overly positive misinterpretation of triggers leads to mood elevation (escalated by imagery), increasing associated beliefs, goals, and action likelihood (all strengthened by imagery). Imagery suggests a unifying explanation for key unexplained features of bipolar disorder: ubiquitous anxiety, mood instability and creativity. Introducing imagery has novel implications for bipolar treatment innovation--an area where CBT improvements are much-needed.

Grey N, Holmes EA. · South London & Maudsley NHS Trust, King's College London, UK. · Memory. · Pubmed #18720224 No free full text.

Abstract: "Hotspots" refer to memories of detailed moments of peak emotional distress during a traumatic event. This study investigates hotspot frequency, and the emotions and cognitions contained in hotspots of memory for trauma, to replicate a previous study in this area (Holmes, Grey, & Young, 2005). Participants were patients receiving treatment for post-traumatic stress disorder (PTSD) at a specialist outpatient clinic after experiencing a range of traumatic events. The main finding was that, after fear, the most common emotions reported were anger and sadness. Cognitions related to psychological threat to the self were more common than those related to physical threat.

Holmes EA, Creswell C, O'Connor TG. · Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JK, UK. · J Behav Ther Exp Psychiatry. · Pubmed #18023425 No free full text.

Abstract: Threatening intrusive images are central to posttraumatic stress disorder. It has been suggested that intrusive imagery in the context of a sense of threat leads to the development and persistence of posttraumatic stress symptoms. This study investigates London school children's (N=76; age 10-11 years) self-reported posttraumatic stress symptoms in response to viewing the attacks of September 11, 2001 on television. Assessments were made at two time points. A minority of participants reported moderate-severe symptoms with functional impairment at 2 months (14.5%) and 6 months (9.2%) after viewing the September 11 events. After controlling for symptom stability, persistent symptoms were associated with peri-traumatic factors, notably perceiving that one's life was in danger. The combined effect of intrusive imagery and peri-traumatic life threat was associated with symptom persistence. Assessments of intrusive image content via checklist and free-report indicated that the images were directly related to September 11 and were fairly stable over time. Implications for treating children's intrusive images following stressful events are explored.

Steel C, Mahmood M, Holmes EA. · Department of Psychology, School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK. · Br J Clin Psychol. · Pubmed #18001518 No free full text.

Abstract: OBJECTIVE: This study investigated whether trait positive schizotypy or trait dissociation was associated with increased levels of data-driven processing and symptoms of post-traumatic distress following a road traffic accident. METHODS: Forty-five survivors of road traffic accidents were recruited from a London Accident and Emergency service. Each completed measures of trait positive schizotypy, trait dissociation, data-driven processing, and post-traumatic stress. RESULTS: Trait positive schizotypy was associated with increased levels of data-driven processing and post-traumatic symptoms during a road traffic accident, whereas trait dissociation was not. CONCLUSIONS: Previous results which report a significant relationship between trait dissociation and post-traumatic symptoms may be an artefact of the relationship between trait positive schizotypy and trait dissociation.

Holmes EA, Oakley DA, Stuart AD, Brewin CR. · Royal Society Dorothy Hodgkin Fellow, University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK. · J Trauma Dissociation. · Pubmed #17182495 No free full text.

Abstract: We investigated the hypothesis that inducing a dissociative response (detachment) in healthy volunteers while they were watching a trauma film would lead to increased numbers of intrusive memories of the film during the following week. Hypnotized participants were given suggestions to dissociate during part of the film, and to watch the rest of the film normally from their own perspective. The order of these conditions, and the section of film watched under the two conditions, were counterbalanced. As predicted, watching the film under both conditions led to increases in dissociation. Explicit suggestions to dissociate were generally effective in inducing higher levels of dissociation. Contrary to prediction, there were no more intrusive memories of sections of the film for which participants had received dissociation suggestions. Implications of our results for views of the relationship between peri-traumatic dissociation and intrusive memories are discussed.

Stuart AD, Holmes EA, Brewin CR. · University College London, Sub-department of Clinical Health Psychology, Gower Street, London WC1E 6BT, UK. · Behav Res Ther. · Pubmed #15979563 No free full text.

Abstract: Nonclinical participants watched a trauma film under two processing conditions. During part of the film participants carried out a concurrent visuospatial grounding task consisting of the construction of shapes out of plasticine (modelling clay), while the rest of the film constituted a control, no task condition. The visuospatial task was predicted to selectively compete for processing resources required for intrusive image formation. As predicted, spontaneous intrusive images during the succeeding week were significantly less common from those parts of the film that coincided with the concurrent task. The task had no effect on levels of distress or peritraumatic dissociation, consistent with the hypothesis that intrusions were reduced because the task competed for resources necessary for encoding into an image-based memory system.

Holmes EA, Grey N, Young KA. · Traumatic Stress Clinic, Camden & Islington Mental Health & Social Care NHS Trust, 15 Chaucer Road, Cambridge, CB2 2EF, UK. · J Behav Ther Exp Psychiatry. · Pubmed #15687006 No free full text.

Abstract: This study aimed to investigate the emotions and cognitions contained in "hotspots" of memory for trauma, as well as their associated images. Thirty-two participants at a specialist outpatient trauma clinic had experienced a range of traumatic events and met diagnostic criteria for Posttraumatic Stress Disorder (PTSD). Data were collected within an agreed protocol, involving reliving therapy. Patients described the different intrusive images of the trauma that they were re-experiencing. Their reports of cognitions and emotions during "hotspots" in their memory of the traumatic experience were recorded as part of reliving therapy. Hotspots refer to moments of peak emotional distress during the event. There was a high degree of match reported between intrusive images and hotspots. The cognitive and emotional contents of hotspots were qualitatively analysed into themes. The relative of frequency of these peritraumatic themes is presented. The exploratory findings are discussed with respect to our understanding and treatment of intrusive imagery in PTSD.

Day SJ, Holmes EA, Hackmann A. · University College London, UK. · Memory. · Pubmed #15487538 No free full text.

Abstract: Recent cognitive models suggest that mental imagery can help us understand the maintenance of anxiety disorders (e.g., de Silva, 1986; Hackmann, Surawy, & Clark, 1998). However, imagery is relatively unexplored within agoraphobia. Such images are also thought to be useful in uncovering memories that occurred around the onset of a disorder (Hackmann, Clark, & McManus, 2000). A total of 20 patients with agoraphobia and 20 matched controls took part in this investigation. Participants described any recurrent images they experienced in agoraphobic situations, and also any associated memories. All patients with agoraphobia (but no control participants) reported having distinct recurrent images in "agoraphobic situations". Most images involved several sensory modalities and in the majority of cases appeared to be linked with unpleasant memories of events experienced many years previously. While these exploratory findings require replication, potential treatment implications are discussed.

Hackmann A, Holmes EA. · Oxford University, and Institute of Psychiatry, London, UK. · Memory. · Pubmed #15487536 No free full text.

Abstract: The authors provide an overview of the papers in the special issue of Memory on mental imagery and memory in psychopathology. The papers address emotional, intrusive mental imagery across a range of psychological disorders including post-traumatic stress disorder (PTSD), agoraphobia, body dysmorphic disorder, mood disorders, and psychosis. They include work on information processing issues including modelling cravings, conditioning, and aversions, as well as imagery qualities such as vividness and emotionality. The overview aims to place the articles in a broader context and draw out some exciting implications of this novel work. It provides a clinical context to the recent growth in this area from a cognitive behavioural therapy (CBT) perspective. We begin with PTSD, and consider links to imagery in other disorders. The clinical implications stemming from this empirical work and from autobiographical memory theory are discussed. These include consideration of a variety of techniques for eliminating troublesome imagery, and creating healthy, realistic alternatives.

Holmes EA, Steel C. · MRC Cognition and Brain Sciences Unit, Cambridge, United Kingdom. · J Nerv Ment Dis. · Pubmed #14718773 No free full text.

Abstract: Intrusive mental experiences occur within posttraumatic stress disorder (PTSD) and some psychotic disorders. Similarities in the phenomenology and content in the intrusions of both disorders have been noted. Currently there is little understanding of any common etiology in terms of information-processing styles. This study investigated predictors of analogue posttraumatic intrusive cognitions within a nonclinical sample, including schizotypy, dissociation, and trauma history. Forty-two participants watched a trauma video and recorded trauma-related intrusions occurring for 1 week. More reported intrusive experiences were associated with high positive symptom schizotypy. Our findings are discussed in relation to the possible role of trauma-related intrusions within psychotic disorders.

Holmes EA, Moulds ML, Kavanagh D. · No affiliation provided · Science. · Pubmed #18079384 No free full text.

This publication has no abstract.

Holmes EA, Arntz A, Smucker MR. · Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. · J Behav Ther Exp Psychiatry. · Pubmed #18035331 No free full text.

Abstract: Although imagery rescripting has long been part of cognitive behaviour therapy (CBT), recent years have seen a growing interest in the use of imagery rescripting interventions in CBT, especially with patients who struggle with distressing, intrusive imagery. This growth in the clinical applications of imagery has led to the creation of the current special issue of collected papers on imagery rescripting, which is designed to: (a) present research and clinical applications of imagery rescripting techniques to problematic mental imagery, (b) consider problematic imagery across a wide range of psychological disorders that might be a target for imagery rescripting (including novel areas such as mental contamination, bulimia and suicidality), (c) explore a variety of imagery rescripting techniques in the treatment of PTSD, as well as depression, social phobia, and snake phobia, and (d) stimulate interest for future treatment innovation in the use of imagery rescripting techniques to address other clinical disorders. The aim of this editorial is to summarise the collected papers presented and the links between them. A working definition of two types of imagery rescripting is provided, along with a heuristic framework for conceptualising the range of imagery techniques in cognitive therapy.