School Library Association ofNew Zealand Aotearoa Conference CONCURRENT SESSIONS abstract / biographies COLLABORATIVE FORCES WELLINGTON 2–4 JULY 2007 Wellington High School, Upper Taranaki Street, Wellington intersections COLLABORATIVE FORCES WELLINGTON 2–4 JULY 2007 ANETTE AINSWORThA Fortunate Life — The JourneyABSTRACTThe joy of being a teacher librarian has provided the opportunity to listen to many authors and illustrators discuss their books and to gain an understanding of the background to the stories. Come with me on a journey visiting Australian authors and illustrators and the remarkable work that they produce. Many of these books are then linked to the use of Literature Circles with primary school students. Explore the use of this form of reading unit to engage students with literature.
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"Am not was": Cognitive-
behavioural therapy for
adjustment and identity change
following herpes simplex
Bonnie-Kate Dewar a & Fergus Gracey b
a MRC Cognition and Brain Sciences Unit , Cambridge
b Oliver Zangwill Centre for Neuropsychological
Rehabilitation , Ely, Cambridgeshire, UK
Published online: 06 Aug 2007.
To cite this article: Bonnie-Kate Dewar & Fergus Gracey (2007) "Am not was":
Cognitive-behavioural therapy for adjustment and identity change following herpes
simplex encephalitis, Neuropsychological Rehabilitation: An International Journal,
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NEUROPSYCHOLOGICAL REHABILITATION2007, 17 (4/5), 602 – 620 "Am not was": Cognitive-behavioural therapy for adjustment and identity change following herpes simplex encephalitis Bonnie-Kate Dewar1, and Fergus Gracey2 1MRC Cognition and Brain Sciences Unit, Cambridge, 2Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, Cambridgeshire, UK The cognitive sequelae of encephalitis are well documented, and it is increas-ingly recognised that disorders of mood and anxiety can accompany thesesequelae. Loss of identity is emerging as a key theme in psychotherapeuticinterventions in adjustment following acquired brain injury (ABI). Cognitive-behavioural therapy can be applied to construct a new model of the self inthe context of behavioural, cognitive and social sequelae of the ABI, with con-sideration of pre-illness identity. Behavioural experiments, in particular, maybe an effective means of redefining the meaning of current situations tocreate a positive sense of self. In the current paper we describe the therapeuticintervention to address anxiety and changes in identity in a woman recoveringfrom herpes simplex viral encephalitis. The intervention highlights the need totake into account the interplay between cognitive changes, such as memory andexecutive function, with emotion in adjustment following herpes simplex viralencephalitis.
The cognitive sequelae of herpes simplex viral encephalitis (HSVE) are well Downloaded by [King's College London] at 07:44 04 March 2014 documented and include an anterograde and retrograde memory loss (seeHokkanen & Lannes, 2007 this issue), in addition to other cognitive deficits Correspondence should be sent to Bonnie-Kate Dewar, MRC Cognition and Brain Sciences Unit, Box 58, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
E-mail: [email protected] The authors would like to thank VO for her contributions, including the title of the paper, which was taken from one of her poems.
# 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business CBT FOR ADJUSTMENT AND IDENTITY CHANGE such as executive dysfunction. Less is known about the affective sequelae ofHSVE or other forms of encephalitis (see Pewter et al., 2007 this issue).
However, as depression and anxiety are common following acquired braininjury (ABI; Hibbard, Uysal, Kepler, Bogdany, & Silver, 1998), in excessof community base rates for both disorders (Cantor et al., 2005), affectivechanges following encephalitis may be not unexpected. Application of thera-peutic techniques to treat affective disorders following ABI, in particular forsurvivors of encephalitis, is in its infancy. Cognitive-behavioural therapy(CBT) has traditionally been advocated as the treatment of choice foranxiety and mood disorders (Roth & Fonagy, 1996), with an extensiveevidence base to support this claim.
There is growing recognition of the complexity of psychological reactions to ABI. Affective disturbances arise from a complex interaction of neurologi-cal and psychosocial factors including premorbid personality, coping systems,the emotional trauma of the event, and the nature and severity of the injury(Whitehouse, 1994; Williams, Evans, & Fleminger, 2003; Tate, 2002). ABIcan have a major impact on survivors' beliefs about themselves (McGrath& King, 2004). Changes and "threats" to identity have been described by sur-vivors of traumatic brain injury (Tyerman & Humphrey, 1984; Nochi, 1998;Cantor et al., 2005) as they struggle to understand their present selves in thecontext of these cognitive, physical and psychosocial changes. Tyerman andHumphrey (1984) report that people identified strongly with their pre-injuryself and held on to the hope of returning to this positively rated self, to thepotential detriment of rehabilitation and long-term adjustment. Cantor et al.
(2005) suggest that following TBI an individual has two self-images –"Who I was before the injury" and "Who I am now" – with implicationsfor who "I" might become. They found that the discrepancy between theseself-images was associated with anxiety and depression. Nochi (1998) ident-ified three areas of "loss of self" following TBI from a narrative study ofsurvivors' accounts of identity change. Loss of self was described in relationto pre- to post-injury comparison, loss of self in the eyes of others, anddiscontinuity of identity through lost or disrupted memories.
Downloaded by [King's College London] at 07:44 04 March 2014 Although specific to the TBI population, these findings may be of rel- evance to understanding the adjustment issues facing survivors of HSVE.
While the pathologies differ, issues concerning loss and changes of rolesand abilities resulting from a sudden traumatic event, in the context of under-lying significant cognitive impairment, and the need for the family and indi-vidual to adjust to these changed circumstances, are perhaps comparable.
Regarding pathology, the organic contribution to emotional consequencesof HSVE may centre more on temporal lobe damage, unilaterally or bilater-ally, with some frontal involvement, whereas in TBI frontal and diffusedamage, with associated neurotransmitter changes, is more prevalent, withsome involvement of anterior temporal lobes. The role of memory processes in relation to sense of self may be particularly pertinent in survivors ofencephalitis. Conway (2005) has formulated a model of identity derivedfrom research into autobiographical memory, again implicating the temporallobes in identity-related processing. Individuals with amnesia may draw uponimmediate memory as a reference point for their sense of self (Bachna,Sieggreen, Cermak, Penk, & O'Conner, 1998) or, conversely, upon intactlong-term memories in the face of everyday memory problems. Given suchpathology and related cognitive impairment, survivors of encephalitis mayhave difficulty incorporating new information and life experiences intotheir existing self-related representations (Tate, 2002).
Thus, there is converging evidence that discrepant self-representations contribute to affective distress following TBI, and possibly following ence-phalitis. Furthermore, helping survivors to redefine their identity and acceptthis new self emerges as a core goal of psychotherapy post-ABI (Prigatano,1991; Whitehouse, 1994; Ylvisaker & Feeney, 2000). However, there islittle description, and no systematic evaluation, of rehabilitation approachesto the management of affective disturbance relating to adjustment and identitychange.
Modifications to established psychotherapeutic techniques for use in an ABI population have been described (see Kinney, 2001; McGrath & King,2004; Whitehouse, 1994). Within cognitive-behavioural psychotherapy,behavioural experiments may help to provide a powerful means of redefiningpersonal meanings of current situations (McGrath & King, 2004; Whitehouse,1994). Bennett-Levy et al. (2004) suggest that behavioural experiments inCBT facilitate change at the underlying "implicational" level of processing(Ylvisaker & Feeney, 2000; Teasdale, 1996) thus being more focused onchange in core representations of self, others and the world. A recentsurvey of psychotherapeutic strategies in the UK (Judd & Wilson, 2005) indi-cated that therapists rated behavioural experiments as the most effectivemeans of addressing differences in expectations in traumatic brain injury sur-vivors. Single case evidence for the possible effectiveness of CBT for thetreatment of anxiety following ABI has been reported (Gracey, Oldham, & Downloaded by [King's College London] at 07:44 04 March 2014 Kritzinger, 2007; Williams, Evans, & Fleminger, 2003). However, therehave been few presentations of the affective sequelae and adjustment post-encephalitis.
In the current paper we describe our client VO, with retrograde autobio- graphical memory loss, prosopagnosia and significant distress associated witha sense of disrupted identity following HSVE. We present a cognitive-beha-vioural formulation attempting to draw clinical links between social, cogni-tive and emotional processes in terms of an ongoing sense of discrepant orthreatened identity. We describe and compare the client's response to specificCBT techniques (anxiety management, negative automatic thought challen-ging, behavioural experiments) applied alone and integrated into work on CBT FOR ADJUSTMENT AND IDENTITY CHANGE improving social and family roles and participation. As this is a clinicaldescription, we do not aim to test specific hypotheses regarding the natureof hypothesised processes involved in affective disturbance and identitychange post-HSVE. Rather we seek to highlight the way in which CBTmay provide a vehicle for formulating relevant processes as identified inthe literature and to use this to guide treatment.
Case Description: VO VO was admitted to the district hospital at the age of 43 with confusion, fol-lowing a 4-day history of pyrexial illness and headache. Magnetic resonanceimaging (MRI) indicated high signal intensity in the right mesial temporallobe, extending into the adjacent basal ganglia, insula and inferior frontallobe. Limited high signal change was also evident in the left temporal lobe.
VO was diagnosed with HSVE and treated with aciclovir. There was noprior medical history of note and she denied a premorbid history of depressionor anxiety.
At the time of her admission, VO worked as a school nurse. She had com- pleted approximately 12 years of school prior to specific training as a nurse. Aword reading test (National Adult Reading Test – Revised, Nelson, 1982)indicated that her premorbid level of functioning was in the high averagerange. VO lived with her husband and four children, aged 16, 14, 11 and 9at the start of intervention.
Neuropsychological assessment was carried out at 1 month, 7 months and 16 months post-illness. Neuropsychiatric assessment was carried out 7 and 16months post-illness. Detailed, integrated assessment of cognition, emotionaladjustment, communication and functional restrictions and social partici- Downloaded by [King's College London] at 07:44 04 March 2014 pation (see Wilson et al., 2000) was carried out 16 months post-illness.
Ongoing assessment of social participation was carried out through thesetting and evaluation of goals during 6 months of holistic rehabilitation,which started 18 months post-illness.
VO's principal cognitive complaint was of being unable to recognise fam- iliar faces, including her own children and husband. She also reported auto-biographical memory problems, such as a poor memory for how she knewfriends. Neuropsychological assessment results are reported in Table 1.
There was evidence of a severe episodic and semantic memory impairment atthe initial assessment. Executive function was variable, whereas attention wasrelatively preserved. Review assessments indicated ongoing difficulties with Neuropsychological test scores at initial and review assessments MemoryRBMT-E overall RMT Faces (percentile) WMS-3 Logical Memory 1 (ss) Logical Memory 2 (ss) Visual Reproduction 1 (ss) Visual Reproduction 2 (ss) Elevator Counting with Distraction (ss) Visual Elevator (ss) Telephone Search (ss) Telephone Search While Counting (ss) LanguagePyramids and Palm Trees Metaphor Written Test BADS Rule Shift (ps) Action programme (ps) Temporal Judgement (ps) Downloaded by [King's College London] at 07:44 04 March 2014 Six Elements (ps) Face testsBenton Face Recognition RBMT-E ¼ Rivermead Behavioural Memory Test – Extended (Wilson et al., 1999), RMT ¼ Recognition Memory Test (Warrington, 1984), WMS-3 ¼ Wechsler Memory Scale Third Version(Wechsler, 1997), TEA ¼ Test of Everyday Attention (Robertson, Ward, & Ridgeway, 1994), Pyra-mids and Palm Trees (Howard & Patterson, 1992), GNT ¼ Graded Naming Test (McKenna & War-rington, 1983), BNT ¼ Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983), the Awarenessof Social Inference Test (McDonald, Flanagan, & Rollins, 2002), BADS ¼ Behavioural Assessmentof the Dysexecutive Syndrome (Wilson, Alderman, Burgess, Emslie & Evans, 1996), ps ¼ profilescore, ss ¼ scaled score, nt ¼ not tested.
CBT FOR ADJUSTMENT AND IDENTITY CHANGE delayed visual recall, aspects of verbal memory, and word retrieval. Planningand abstraction were impaired. However, improvements were noted inmemory function at review. In addition, face processing was satisfactory.
Sixteen months following her illness, problems identifying both simple andparadoxical sarcasm and social inference were identified from assessment onthe Awareness of Social Inference Test (TASIT; McDonald, Flanagan, &Rollins, 2002).
Assessment of emotional adjustment, mood and behaviour VO stated that she became overwhelmed, anxious, and tearful in everyday situations, with associated shaking, pins and needles and headaches, such thatshe could not perform her pre-injury tasks. VO described her mood as low,with a loss of interest and feelings of hopelessness about the future. Shealso described sleep difficulties. The symptoms described by VO were notsufficient to warrant a formal diagnosis of a major depressive episode. VOmet the criteria for an Axis I generalised anxiety disorder as an indirect con-sequence of an organic injury on the DSM-IV (American Psychiatric Associ-ation, 1994) with her excessive anxiety and worry over at least a 6-monthperiod, and poor control of this worry. Her anxiety symptoms may havehad an organic basis (Wise & Rundell, 1999).
Social participation restrictions VO was unable to return to work and experienced substantial limitations in her ability to fulfil her roles as mother, wife and friend. Her husband andchildren had taken on responsibilities to manage the household. VO's socialcontacts continued but were limited in part through her concern about notrecognising people or remembering personal semantic and autobiographicalinformation relating to social relationships.
Efficacy of therapy and rehabilitation was measured through assessment of Downloaded by [King's College London] at 07:44 04 March 2014 symptoms of anxiety and depression with the Beck Anxiety Inventory (BAI;Beck, 1993), and the Beck Depression Inventory (BDI; Beck, Steer, &Brown, 1996). Changes in self-esteem were measured with the RobsonSelf-Concept Questionnaire (SCQ; Robson, 1989), a questionnaire measureof self-esteem validated with healthy controls and psychotherapy patients.
A personal rating scale was also devised with VO based on repertory gridtechnique (Winter, 1992) to identify personal constructs relating to her con-strual of pre- and post-injury identity. The BDI was administered throughouther rehabilitation programme. Measures of the BAI, SCQ and personal ratingscale were taken at the beginning, middle (week 12) and end (week 24) of herrehabilitation programme. Impact of therapy was also qualitatively assessed through within-session self-reports of confidence levels, and behaviourallythrough attainment of functional goals at the end of rehabilitation.
VO's main presenting issue related to altered sense of identity, feeling "discrepant" from her self, consistent with previous research with TBI survi-vors (Cantor et al., 2005; Nochi, 1998; Tyerman & Humphrey, 1984). Thecognitive model of post-traumatic stress disorder (PTSD) presented byEhlers and Clark (2000) has as a central feature the notion of threat to selfarising following a traumatic event. In part this relates to the meaning ofthe trauma and trauma symptoms given the individual's pre-trauma experi-ences and related beliefs and assumptions. While specific post-traumaticstress symptoms were not present for VO, it was felt helpful to draw on thenotion of enduring threat to self and barriers to processing or updatingbeliefs and assumptions from this model to support formulation which is pre-sented in Figure 1 and described below.
VO described her threatened sense of identity in terms of a distressing sense of being a "was" and articulated her broad goal for adjustment interms of "becoming an ‘am'". VO's report of her identity was very much tiedup in her roles as mother, wife, friend and nurse. Of key significance was thepresence of rigid assumptions such as, "If I can't recognise/remember myfriends then I am a bad/uncaring person", or "If I don't do things for my chil-dren then I am a bad mother". These played a significant role in establishingvulnerability to specific trigger situations. Additional vulnerability factors relat-ing to the impact of the encephalitis were also included in the formulation. Withevidence of damage to the right insula and inferior frontal lobe, it may be thatcircuits mediating responses to threat were compromised (see Adolphs, 2001)such that her neurophysiological response to anxiety was exaggerated or difficultto switch off. Loss of autobiographical memories for a substantial period prior toher illness and the impact of this on adjustment post-illness were also included.
Her inability to identify people due to her prosopagnosia was a significant factor Downloaded by [King's College London] at 07:44 04 March 2014 contributing to her vulnerability to distress in many situations.
Specific trigger situations were identified as those highlighting a loss of, or threat to, identity, in that they directly challenged her assumptions and rules.
These included: . Failing to recognise or remember someone.
. Others doing things for her (especially at home and when the task was something she identified as her role).
. Family "not getting along" (especially fitting certain expectations such as always having meals together).
Downloaded by [King's College London] at 07:44 04 March 2014 Figure 1. Longitudinal adapted CBT formulation presenting hypothesised vulnerability and maintenance factors for VO, including neurological, cognitive, andfamily factors.
Maintenance factors were the activation of thoughts relating to the personal meaning of losses and changes (such as her prosopagnosia, auto-biographical memory loss, and inability to work). Attempts to reduce thedistress and sense of threat to self in the short term were formulated aspreventing adjustment in the longer term. Furthermore, selective attentionto threats when in this anxious state contributed to biases in recall againcontributing to an ongoing sense of threat to self and generalised beliefsabout loss of self-worth and not belonging. In keeping with this model,self-discrepant appraisals of the meaning of poor coping were also seenas relevant.
Following VO's illness, her family attempted to reclaim their identity by taking on domestic chores, reassuring VO and continuing pre-illness asmuch as possible. VO felt disconnected from her family, in part due to theautobiographical memory loss and prosopagnosia. However, in addition herpost-illness expectations of family behaviour were based on long-term mem-ories of her own upbringing rather than current family life. Thus her family'sbehaviour was a trigger and maintaining factor for her own threatened iden-tity. Her attempts to take control, to look after her children and to impose rigidrules were experienced by the family as a threat to the family way of doingthings, leading to disagreements that acted as further triggers.
Background to treatment VO was initially seen fortnightly on an outpatient basis to address her goals of face identification and adjustment to the encephalitis. She wasthen referred to the Oliver Zangwill Centre (OZC) and underwent a holisticneuropsychological rehabilitation programme (see Wilson et al., 2000). Inbrief, the programme consists of a combination of group and individual ses-sions organised around client-centred goals, split into two consecutive 12-week phases. VO's CBT continued within this context, and was integratedinto her rehabilitation as described by Williams et al. (2003) and Gracey,Brentnall, and Megoran (2005).
Downloaded by [King's College London] at 07:44 04 March 2014 A range of functional goals were identified in independent living skills (to effectively use a memory and planning system to achieve at least 75% ofplanned activities, and to have a shared system with her family), socialleisure, vocation (including testing work skills in a voluntary work place-ment) and self-advocacy (to develop a shared understanding of her illnesswith her family). In order to make gains in these areas a number of psycho-logical, cognitive and communicative goals were set to address lost skills,to compensate for impairments and to facilitate emotional adjustmentindividually and in the family. Goals for her CBT included reductionin anxiety, increasing confidence and developing a more positive sense ofself.
CBT FOR ADJUSTMENT AND IDENTITY CHANGE Intervention I: "Standard" CBT techniques Intervention followed a broad CBT protocol starting with education and socialisation to the model, and development of the therapeutic relationship.
Following this, sessions focused on self-monitoring of emotional responsesand learning to identify negative automatic thoughts (Padesky & Greenber-ger, 1995), learning in-situ breathing techniques to manage anxiety symptomsand development of an initial, maintenance cycle based collaborative formu-lation. Adaptations to this due to the sequelae of her encephalitis initiallyincluded provision of information about cognitive changes subsequent toencephalitis and management of subjective complaints of memory, fatigueand person identification deficits.
Intervention II: Use of behavioural experiments to facilitate The initial maintenance cycle formulation of anxiety was elaborated with VO, and lead to the formulation as presented in Figure 1. The focus of theintervention changed to address VO's identity-related cognitive represen-tations at an implicational level of processing. Formulating adjustment interms of responses to threats to self and related psychological and neurocog-nitive barriers led to consideration of the need to reduce self-discrepancy inthe following ways: . Providing new positive experiential learning opportunities.
. Reducing "loss of self" through compensation or relearning lost per- sonal semantic autobiographical memory and face recognition.
. Addressing threat to self associated with role changes with VO and her family by supporting the family to find a shared understanding.
Experiments were devised to test specific unhelpful cognitions that VO held about her self (McGrath & King, 2004) and to consolidate new appraisals Downloaded by [King's College London] at 07:44 04 March 2014 or explore alternate meanings (Mooney & Padesky, 2000). These experimentscommenced during her outpatient treatment and continued as a centralvehicle of her holistic rehabilitation programme. Key experiments aredescribed in Table 2 to illustrate the problems and the process involved.
At the conclusion of the integration phase of rehabilitation, the strategies and learning experiences developed through these and other experimentsand experiences during rehabilitation were summarised into tables to act as Examples of key experiments conducted during stand-alone CBT and within the context of holistic rehabilitation (AM ¼ autobiographical Value as a friend and AM Rigid assumptions about Social communication at Family culture and AM Loss of AM for many Insisting on doing things Failure to pick up on Concern about loss of face Retrograde amnesia for for her children, humour and sarcasm recognition. Unwilling much of her married disagreements with to use compensatory strategies or ask the sense of detachment "I am a bad friend" "If I don't do my utmost "My family are being "It's unfriendly/rude to "The family don't "Without my memories for my children I'm a cruel and rejecting" ask people who they get along . . I've failed I can't be a friend" are – they will be "They think I don't "If I don't do things for "This might not be the "Mistakes are acceptable, them maybe it's not the case, it might be my others won't judge me end of the world" harshly, reject me and it is not a sign I'm no interpreting what's "If the assumptions are true, then they will notwant to see me, and Iwill not be able to feelincluded with them" Downloaded by [King's College London] at 07:44 04 March 2014 Develop friendship book Resist making coffee/tea Learning about verbal and Staff and clients do not VO and her family set one to support relearning of non-verbal cues in wear name badges for a night per week to review old family Monitoring these at memories and provide strategy to ask others in a focus for interacting rehab centre if unsure Successful, enjoyable, Held back from making Identified specific Observed others were not Family gathered once a positive experiences drinks for her children situations in which offended when asked week to watch old family were using videos together. Family negative feedback humour or sarcasm and shared stories and got along, engaged in retrospectively to "Even though I have "Able to not do things for "My family do care for "It's okay to ask others "My family do get along memory problems, it children without this about who they are if . . I do belong." does not take away our meaning I'm a bad increased sense of Reported being able to special friendship" mother. Maybe I can be belonging at home more flexible about memories. This was some of my rules" further reinforced with the family in a familytherapy session Downloaded by [King's College London] at 07:44 04 March 2014 a "strategy tool box" for VO to refer to in the future. Individual and couplesCBT sessions were set up to facilitate extension of learning and adjustment infamily, work and social contexts.
VO's scores on the BDI are shown in Figure 2. She scored in the moderate tosevere range of symptoms of depression at the time of her 7 and 16-monthassessments. However, this jumped to a severe level of depressive symptomsat the beginning of her rehabilitation programme. There was some milddecline of ratings of depressive symptoms during her programme to the mod-erate level at the beginning of the integration phase, returning to the severerange towards the end of the programme.
VO's scores on the BAI are reported in Figure 3. Seven months after her illness, there was evidence of a severe level of anxiety symptoms. Atthe time of her detailed assessment, 16 months after her illness, anxietylevels remained in the moderate range. Ratings of anxiety remained in thesevere range throughout her rehabilitation programme.
At the beginning of VO's intensive rehabilitation programme, 16 months after her illness, the SCQ indicated that her self-esteem was more than twostandard deviations below the norm for controls. Over the first threemonths of rehabilitation, her score remained in this range. However,towards the end of her programme self-esteem had improved with herscore moving to just over one standard deviation below the norm, droppingagain slightly at six-week follow-up.
On a personal construct scale developed with VO, she rated her pre-injury and ideal self with traits including confidence, belonging, being there for Downloaded by [King's College London] at 07:44 04 March 2014 Figure 2. VO's scores on the Beck Depression Inventory. PA ¼ Preliminary Assessment,DA ¼ Detailed Assessment, Week ¼ Weeks of OZC rehabilitation programme.
CBT FOR ADJUSTMENT AND IDENTITY CHANGE Figure 3. VO's scores on the Beck Anxiety Inventory. PA ¼ Preliminary Assessment,DA ¼ Detailed Assessment, Week ¼ Weeks of OZC rehabilitation programme.
others, independence, happiness, and doing things that "Reinforce who I am".
In contrast, at the start of her rehabilitation, VO perceived her present self asuncertain, struggling in social situations with a reduced sense ofbelonging, dependent, and with low confidence and mood. There was a highdegree of overlap between her ideal self and how she saw herself beforethe encephalitis. This was interpreted as indicating significant current-pastand current-ideal discrepancy. At the beginning of the integration phase –week 12 of her OZC rehabilitation programme – there had been some shiftin her ratings with 17/25 items rated as closer to her ideal self than at thestart of rehabilitation. The greatest ratings of change (four points on aseven-point scale) were in relation to adjustment. Positive change was alsorated in relation to optimism, being there for others, independence, happinessand social confidence. However, VO continued to rate herself as, "Uncertain ofwhere things were going', and "I've lost me". This pattern was broadly repli-cated in her ratings at the end of rehabilitation.
In terms of social participation, by the end of rehabilitation VO had achieved goals of developing a shared understanding of her illness with her Downloaded by [King's College London] at 07:44 04 March 2014 family and reported feeling comfortable and understood by her family. Shewas making effective use of her memory and planning system to achieveroutine domestic tasks. VO had completed two voluntary work placementsin the second phase of rehabilitation, effectively managing the impact ofher difficulties in these work settings.
In this paper we have described the psychotherapeutic intervention with awoman who presented with symptoms of anxiety and depression following HSVE. We formulated her affective distress in terms of changes to identity,specifically her negative interpretation of the discrepancy between her pre-illness self and her post-illness role fulfilment. Neuropsychological factors,especially prosopagnosia and autobiographical memory loss, also contributedto her presentation. Changes to the neurophysiological modulation of anxietyas a result of her encephalitis may also have contributed to her distress. Ses-sions initially introduced in situ anxiety management strategies involvingcontrolled breathing and recording and challenging automatic thoughts inanxiety provoking situations. When these interventions did not prove fruitful,therapy focused on testing assumptions and beliefs related to VO's self-rep-resentations through the use of behavioural experiments. At the conclusion ofher rehabilitation programme, VO's qualitative feedback indicated a moreintegrated pre- and post-encephalitis identity, with increased confidence inher functional abilities. A personal construct rating scale indicated positiveadjustment towards ratings of constructs of her pre-injury and current selfsuch as independence, control, having a role with others, and self-acceptance.
This measure thus indicated a reduction in self-discrepancy as rated by VO. Astandardised measure of self-esteem indicated ratings of increased self-esteemat the end of her programme, although still below the norm. VO attained goalsrelating to personal and family understanding of her illness and its conse-quences. However, standardised measures of anxiety and depressive symptomsremained elevated.
Weaknesses of the current paper mainly centre on the fact that this is a case description, supported by some measurement but without a methodology thatallows firm conclusions about the relative merits of components of CBT andrehabilitation in relation to identity, affective distress and social participationto be drawn. Measures were not administered systematically throughout allaspects of intervention and rehabilitation. Medication changes occurredduring treatment, including the prescription of an antidepressant at the startof rehabilitation. While descriptive accounts of the stand-alone, adaptedCBT and behavioural experiment-based approaches are provided, theseapproaches are not systematically compared, and issues such as intensity of Downloaded by [King's College London] at 07:44 04 March 2014 treatment and ordering effects may account for apparent differentialresponses. Further issues concern the relevance of choice of measures,especially the BDI, which includes biological and cognitive symptoms thatoverlap significantly with the consequences of HSVE.
Nevertheless, reduced self-discrepancy and improved acceptance was indi- cated from the personal construct and self-esteem measures, in addition togoal attainment. As such, the current case highlights the potential usefulnessof behavioural experiments in the treatment of adjustment-related affectivedisorders subsequent to neurological injury, as suggested by McGrath andKing (2004). We suggest that behavioural experiments may be effective inproducing change because processing of information occurs at an CBT FOR ADJUSTMENT AND IDENTITY CHANGE implicational level where mental models of the self are constructed (Bennett-Levy et al, 2004; Ylvisaker & Feeney, 2000). The process of behaviouralexperiments carried out with VO may have facilitated reduction in discre-pancy between self-representations as highlighted in pre – post-illness com-parisons, loss of autobiographical memory, and social and familyinteractions. These experiments also allowed appreciation of alternative per-spectives, contributed to more flexible rules about herself and others, andallowed exploration and development of appropriate strategies for managingcognitive changes.
Ylvisaker (personal communication) advocates that people will only incor- porate a positive sense of self if they are doing something that gives a sense ofreality to the positive aspects of this sense of self. The notion that CBT, and inparticular behavioural experiments, may be particularly well suited for use ina neurological population, with the structured approach to problem solving,emphasis on learning opportunities, and use of documentation to record out-comes, is supported. The experimental approach appears to lend itself well tointegration into multidisciplinary rehabilitation. The concrete feedback pro-vided in a behavioural experiment may facilitate awareness not only ofbalanced appraisals as in the case of VO but also of the impact of cognitiveimpairments on function (Judd & Wilson, 2005), and support therapists incollaborating with clients in evaluating the utility of compensatory strategies.
Inclusion of family in rehabilitation, and the need to consider identity changesin terms not only of intrapersonal factors (e.g., comparison of pre – post-ABIself, loss of memories) but also interpersonal factors, is again highlighted(Yeates, Henwood, Evans, & Gracey, 2007). In this case, the notions ofself-discrepancy (Cantor et al., 2005; Tyerman & Humphrey, 1984) and ofloss of self (Nochi, 1998) appear relevant to adjustment following HSVE.
The specific interactions between cognitive change, altered experience ofidentity, and neural processes required to support psychotherapeutic changerequire further elucidation. The developing field of the cognitive neuro-science of psychotherapies (predominantly CBT, see Kumari, 2006, for areview) may help provide a neurological basis for devising and adapting psy- Downloaded by [King's College London] at 07:44 04 March 2014 chotherapies for ABI to be optimally effective where processes implicated inemotional and behavioural change may be impaired.
Psychotherapeutic intervention in neurological populations thus continues topresent challenges. The formulation developed and presented here was basedon an integration of findings from the limited TBI and ABI literature on iden-tity and affective disturbance, and established cognitive models of identityand post-traumatic stress. This must be seen as a highly tentative model and further evaluation of hypothesised neurocognitive processes involved inidentity and psychotherapy following ABI, including encephalitis, is war-ranted. However, issues relating to self-discrepancy, and both intrapersonaland interpersonal aspects of loss of self are relevant areas for further investi-gation. Behavioural experiments appear to be a viable way of integratingemotional adjustment, cognitive rehabilitation and increased social partici-pation in multidisciplinary rehabilitation. Further research into the interplaybetween neurobiological, rehabilitative and psychotherapeutic processes fol-lowing ABI such as encephalitis is needed in order for effective treatmentapproaches addressing cognitive and emotional changes together to bedeveloped.
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La grippe A / H1N1 Docteur CUVEILLIER - Médecin du travail Docteur SPIDO - Médecin du travail Anne CLARISSON – Infirmière SST La grippe A H1N1 - INF 027 V1 – 23 septembre 2009 La grippe La grippe est une infection respiratoire aigue virale : - Très contagieuse, - Due aux virus influenzae A, B ou C,