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re. Inconsistency in reporting potentially traumatic events
- Jane Herlihy, Stuart Turner (19 July 2006)
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Re: re. Inconsistency in reporting potentially traumatic events (Authors’ reply)
- Urs Hepp, Alex Gamma, Gabriella Milos, Dominique Eich, Vladeta Ajdacic-Gross, Wulf Rössler, Jules Angst, Ulrich Schnyder (2 August 2006)
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Jane Herlihy, Clinical and Research Psychologist Trauma Clinic, Stuart Turner
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j.herlihy{at}traumaclinic.org.uk Jane Herlihy, et al.
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“Understanding the relation between emotion and memory is one of the major challenges presently facing the scientific community” (Brewin, 2003). Hepp et al. show that we have to take great care when relying on people’s recall – that is remembering and reporting the most distressing moments of their lives. This is not just an academic pursuit. As Hepp et al. remind us, the reliability of reports of potentially traumatic events (PTEs) underpins our research and clinical practice. In the refugee context, an individual seeking state protection can be refused sanctuary if they cannot provide a convincing, coherent and consistent account of the traumatic events they have experienced. If their recall of traumatic events is intrinsically unreliable, this may invalidate the decision making process that they rely upon for protection. A refugee sample A study of Kosovan and Bosnian refugees showed a similar picture of inconsistency to previous reports cited by Hepp et al. (Roemer, Litz, Orsillo, et al, 1998; Southwick, Morgan, Nicolaou, et al, 1997). Like these previous studies, the higher the levels of PTSD symptoms, the more inconsistencies arose in participants’ stories over time (Herlihy, Scragg & Turner, 2002). Unlike previous studies, the people in this study were drawn from a community of mass migrants, brought to the UK under a United Nations programme. Interpersonal violence and consistency Hepp et al. find that many people who have experienced an interpersonal trauma are consistent. Yet, as they note, this still leaves a significant proportion of their sample who have experienced some form of assault or sexual violence, who do not seem to remember it, or do not report it, when interviewed (29% of them in 1993; 52.6% of them in 1999). This pattern of inconsistent disclosure fits with many practitioners’ experience of the interviewing of asylum seekers, although more often, more material is disclosed as time goes on. Some of the inconsistencies in Hepp et al.’s study may be disclosure issues (didn’t report 1993, did in 1999). We see this sometimes in clinical practice and often in official asylum interviews (see also a forthcoming study on disclosure in the Home Office interview, Bogner, Herlihy & Brewin, submitted). The late disclosure of sexual violence attracts hypotheses about shame, PTSD avoidance symptoms and dissociation, as suggested by Van Velsen, Gorst- Unsworth and Turner (1996), who found an association of sexual torture with high levels of avoidance in a group of refugees diagnosed with PTSD. Moving towards a consensus? One outstanding question from this paper is in the discussion of the association of the types of PTSD symptoms with consistency. In our study of refugees, higher levels of PTSD symptoms were associated with greater inconsistency (Herlihy, Scragg & Turner, 2002), and this seemed to be in line with the previous findings of Roemer et al. (1998) and Southwick et al (1997). In their community study, with presumably lower overall levels of PTSD symptoms, Hepp et al. seemed to find the opposite - a “higher mean number of PTSD symptoms in consistent reporters”, yet they argue that their findings are in line with these same earlier studies. If this is indeed the case, it would be helpful to see this argument clarified, so that we might move towards a consensus on this issue, if that is the way the data are leading us. References Bogner, D., Herlihy, J. & Brewin, C. (submitted) The Impact of Sexual Violence on Disclosure during Home Office Interviews. British Journal of Psychiatry. Brewin, C. (2003) Posttraumatic Stress Disorder: Malady or Myth? London: Yale University Press. Herlihy, J., Scragg, P. & Turner, S. (2002) Discrepancies in Autobiographical Memories: Implications for the Assessment of Asylum Seekers: repeated interviews study. British Medical Journal, 324, 324-327. Roemer, L., Litz, B. T., Orsillo, S. M., et al (1998) Increases in retrospective accounts of war-zone exposure over time: the role of PTSD symptom severity. Journal of Traumatic Stress, 11, 597-605. Southwick, S., Morgan, C. A., Nicolaou, A., et al (1997) Consistency of Memory for Combat-Related Traumatic Events in Veterans of Operation Desert Storm. American Journal of Psychiatry, 154, 173-177. Van Velsen, C., Gorst-Unsworth, C. & Turner, S. (1996) Survivors of torture and organized violence: demography and diagnosis. Journal of Traumatic Stress, 9, 181-193. Declaration of Interests : None |
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Urs Hepp, M.D. Psychiatrische Dienste Aargau, Baden, Switzerland, Alex Gamma, Gabriella Milos, Dominique Eich, Vladeta Ajdacic-Gross, Wulf Rössler, Jules Angst, Ulrich Schnyder
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urshepp{at}bluewin.ch Urs Hepp, et al.
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We thank Herlihy & Turner for their comments on the topic of the reliability of reports of potentially traumatic events (PTEs). We agree that this has implications for clinical practice as well as in the legal context. However, our results are based on a non-clinical sample based on the general population of the Canton of Zurich. None of our participants fulfilled the criteria for PTSD at the time of the interviews, and even subthreshold PTSD was rare in both assessments in 1993 and 1999 (Hepp et al, 2006). Therefore, these results have to be interpreted with caution and may not be applicable to refugees or people from conflict regions with a high prevalence of PTSD (de Jong et al, 2001). Herlihy et al. (Herlihy et al, 2002) are concerned about the relationship between PTSD symptoms and consistency in recall of traumatic events. They found that in asylum seekers, higher levels of PTSD symptoms were associated with greater inconsistency, which points to a possible contradiction between their findings together with results from previous studies, and ours. Roemer et al. reported an increase in retrospective accounts of frequency of exposure to war-zone stressors over time and found PTSD symptom severity, particularly intrusive symptoms, to be positively associated with changes in frequency reports (Roemer et al, 1998). Southwick et al. stated that subjects with more PTSD symptoms tend to amplify their memory of traumatic events over time (Southwick et al, 1997). Thus, there is indeed some evidence suggesting that participants with high PTSD symptom levels tend to report more traumatic experiences, with PTSD symptoms apparently triggering “memories”. However, this might be an effect that vanishes over time: In the Roemer et al. and the Southwick et al. studies, the fist assessment took place shortly after the PTE, and the second assessment was performed 2 respectively 1-3 years later. In our study, the interval between PTEs and the interviews was much longer (mean 15 years, range 0-39 years). We re-analysed our data and found that consistent and inconsistent participants did not differ with regard to the time between PTE and the interview. Further, consistent participants reported a higher mean number of PTSD symptoms in the 1993 and 1999 interviews, scoring higher on cluster B (re-experiencing), cluster C (avoidance), and cluster D (hyper-arousal) symptoms. Could it be that after a number of years memory consolidation reaches a steady state in which trauma survivors remember and recall their traumatic events more consistently depending on the events' emotional impact, and the patients’ PTSD symptom levels? Declaration of Interests : None References de Jong, J. T., Komproe, I. H., Van Ommeren, M., et al (2001) Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Jama, 286, 555-562. Hepp, U., Gamma, A., Milos, G., et al (2006) Prevalence of exposure to potentially traumatic events and PTSD: The Zurich Cohort Study. Eur Arch Psychiatry Clin Neurosci, 256, 151-158. Herlihy, J., Scragg, P. & Turner, S. (2002) Discrepancies in autobiographical memories--implications for the assessment of asylum seekers: repeated interviews study. Bmj, 324, 324-327. Roemer, L., Litz, B. T., Orsillo, S. M., et al (1998) Increases in retrospective accounts of war-zone exposure over time: the role of PTSD symptom severity. J Trauma Stress, 11, 597-605. Southwick, S. M., Morgan, C. A., 3rd, Nicolaou, A. L., et al (1997) Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm. Am J Psychiatry, 154, 173-177. |
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