Memory and Self : Memory and Self : Theoretical Theoretical Approaches and Implications

Memory and Self : Theoretical
Approaches and Implications
for Cancer Patients
Francis Eustache and Bénédicte Giffard
Inserm‐EPHE‐Université de Caen Basse Normandie, Unité de Recherche U1077, Caen, France
Memory and Self : Theoretical
Approaches and Implications for
Cancer Patients
•
What is Memory? What is Self? And what are the links between both?
•
The central concept of Autobiographical Memory (AM) – Examples with Amnesic syndromes and Alzheimer’s Disease
•
AM functioning in Depression and PTSD
•
Implications and first results in Cancer patients
Patient H.M.
(Scoville & Milner, Corkin)
Patient K.C.
(Tulving)
Sergeï Korsakoff
What is Memory?
I spent my holidays in Italy
last summer
«ToI dial
remember
a number»
Rome is the capital of Italy
« I know »
Perceptive priming
Tulving’s SPI model (1995)
To go cycling
MEMORY SYSTEM
CONSCIOUSNESS
Autonoetic
Noetic
Anoetic
Tulving (1985)
Eustache & Desgranges, MNESIS model (2008)
What is Self?
The concept of self results from two complementary aspects:
- a set of personal complex and multidimentional mental
representations about ourselves
- the flow of self-consciousness which is associated
SELF
Structural dimension
Functional dimension
Self Representations
Self‐
consciousness
Klein & Lax, 2010
Structural dimension
Self Representations
Semantic self‐representations
= Conceptual self
Abstract traits knowledge about oneself
I’m an honest
person
Semantic AM
General knowledge of personal
significance
Episodic self‐representations
Episodic AM
Specific personal
information closely
related to unique self‐
experienced events
My name is
Francis
I’m a sensitive person, because yesterday the movie made me cry
Temporal perspective
Past self
Present self
Futur, possible self
Fonctional dimension
Self‐
consciousness
‐ Mobilized in various cognitive activities (e.g., self‐
evaluation, self‐projection into time)
‐ Accompanies subjective and phenomenological
experiences  sense of continuity and coherence
Bidirectional relationship between Memory and Self
Memory both shapes, and is shaped by Self
MEMORY
SELF
Memory should be conceived ‘‘not as an ability to revive
accurately impressions once obtained, but as the integration of
impressions into the whole personality and their revival according
to the needs of the whole personality.’’
Rapaport (1952/1961). Emotions and memory. New York: Science Editions
The central concept of Autobiographical Memory
Autobiographical memory is the memory for information and
experiences of one’s personal life that gives a sense of identity
and self‐continuity.
 Extended over time
 At the core of one’s identity
Autobiographical memory
Episodic component
I precisely
remember the day I
broke my arm
Specific events
• Situated in a precise spatiotemporal context
• Retrieved with
phenomenological details
• Autonoetic consciousness
Semantic component
I know the name of
my school mates
General events
• On one’s life
• Repeated or extended over time
• Independent of a spatiotemporal context
• Noetic consciousness
Autobiographical memory constructive framework
(adapted from Conway, 2005)
Generative retrieval mode
Direct retrieval
mode
Event‐specific knowledge
Episodic
memories
Generic events
Semantic
knowledge
Life time periods
Working
memory
“Working
self”
Conceptual self
attitudes, values,
aims, beliefs,
desires…
The working self moderates between the demands of
coherence and correspondence in the formation of memories
and in their construction.
Memories
CORRESPONDENCE
COHERENCE
memory should correspond to experience
memory should be consistent with ones current goals and self‐image
The most crucial components of the AM retrieval network
FOR: feeling‐of‐rightness (correspondence/coherence)
Cabeza & St Jacques, 2007
Amnesic hippocampal
patients
HM
controls
•Insight into his memory problems, ability to reflect on them
•Understood the concept of time and that the life is a continuum
Patient K.C. Tulving et al., 1988; Tulving, 2001
Retrograde amnesia
Anterograde amnesia
Episodic
component
Semantic
component
-
+
Unable to relive personal events with “warmth and intimacy”
Lacks autonoetic consciousness and the ability to project himself into the past or future
• Semantic AM largely intact
• Retains accurate abstracted trait self‐knowledge about his identity
•
•
→ Dissociation between episodic and semantic self‐representation
→ We do not need episodic AM to maintain a self‐identity, but self‐
representations are less rich and more fossilized
Alzheimer’s disease
William Utermohlen (1933‐2007). Self Portraits.
Patient PH
• Hehman et al., 2005 : 83 years‐old, severe
stage AD (MMS=7)
• self‐knowledge not updated
• Temporally graded breakdown in semantic
memory function
Autobiographical memory in AD
Controls
16
AD
14
12
10
8
6
4
2
0
0-17 yrs
18-30 yrs
> 30 yrs
last 5 yrs
last 12
months
Piolino et al., Brain (2003)
AM functioning in Depression
• Mood‐congruent memory effect
– spontaneously recall more negative than positive memories
• Overgeneral memories
– Tendency to recall repeated events rather than specific events
– In response to the cue word party: « I never enjoy parties » rather than
« I went to a terrible party last Friday »
• Intrusive memories and related avoidance
– Spontaneous, painful and enduring memories, often related to stressful
events
– Avoidance is positively correlated with overgenerality
• Mood congruent effect : may be explained by the current (depressed) self
• Overgenerality (generative retrieval) :
– affect regulation hypothesis : reduced specificity represents a cognitive strategy to protect the self against stressful memories (voluntary process)?
– Related to executive dysfunction + current (depressed) self?
• Intrusive memories (automatic retrieval) : lack of executive control during
Generative retrieval mode
direct retrieval  accidental access at the event‐specific level
Event‐specific knowledge
Generic events
Life time period
Working memory
“Working self”
Conceptual self
attitudes, values…
• Mood congruent effect : may be explained by the current (depressed) self
• Overgenerality (generative retrieval) :
– affect regulation hypothesis : reduced specificity represents a cognitive strategy to protect the self against stressful memories (voluntary process)?
– Related to executive dysfunction + current (depressed) self?
• Intrusive memories (automatic retrieval) : lack of executive control during
Generative retrieval mode
direct retrieval  accidental access at the event‐specific level
Event‐specific knowledge
Generic events
Life time period
Working memory
“Working self”
Conceptual self
attitudes, values…
• Mood congruent effect : may be explained by the current (depressed) self
• Overgenerality (generative retrieval) :
– affect regulation hypothesis : reduced specificity represents a cognitive strategy to protect the self against stressful memories (voluntary process)?
– Related to executive dysfunction + current (depressed) self?
• Intrusive memories (automatic retrieval) : lack of executive control during
direct retrieval  irrepressible access at the event‐specific level
Direct retrieval
mode
Event‐specific knowledge
Generic events
Life time period
Working memory
“Working self”
Conceptual self
attitudes, values…
Differences in hemodynamic activity during AM recall in depressed (MDD) subjects vs. controls
(Young et al., 2012, Psychol Med)
Memory dysfunction in PTSD
• Persistent re‐experience of the traumatic event
(includes intrusive memories, flashbacks, nightmares…)
• Persistent avoidance of stimuli associated with the trauma • Both memory intensification for the core traumatic event and memory impairment for the context surrounding the trauma: may be due to peritraumatic dissociation (disrupts processes of elaboration and consolidation)
 trauma memories are disorganized and poorly integrated with other autobiographical memories and views of oneself
• Overgeneral non‐traumatic memories
Some symptoms are common between PTSD and Depression, but…
• PTSD is a more dissociative disorder than depression 
intrusions:
→ For depressed patients: the event is experienced as belonging to the past
→ For PTSD: the sense that the event is actually reoccurring in the present:
trauma memories are disorganized and poorly integrated with other
autobiographical memories and views of oneself
• Posttraumatic distress, unlike depression, is not reliably
associated with marked deficits in executive control 
overgenerality:
– For PTSD: levels of memory specificity might be more associated with
affect regulation than with executive control,
– For depressed patients, reduced executive control capacity may play a
greater role
PTSD
VOLUMETRIC ABNORMALITIES
Anterior cingulate cortex
Corpus callosum
Hippocampal volume on MRI Hippocampus
FUNCTIONAL ABNORMALITIES
Hypoactivation
Rostral anterior cingulate cortex
Medial prefrontal cortex
mPF dysfunction during exposure to traumatic
slides and sounds
Hippocampus
Hyperactivation
Amygdala
From Bremner, 2007
Amygdala activation during acquisition of fear learning
Bremner’s theory (2007)
+
ACC hypoactivation (-) involves
Amygdala hyperactivation(+)
hyperactivation(+)
Bremner’s theory (2007)
-
Hippocampus
atrophy
+
ACC hypoactivation (-) involves
Amygdala hyperactivation(+)
hyperactivation(+)
Hippocampus atrophy
Layton & Krikorian, 2002
Implications and first results
Implications and first results in Cancer patients
Cancer, PTSD and Depression
• DSM‐IV: PTSD may be precipitated by life‐threatening illness, such as being diagnosed with cancer
• Prevalence rate of cancer‐related PTSD (Kangas et al., 2002): 3‐22% (4%‐6% in most Breast Cancer studies)
• Yet many survivors report one or more PTSD symptoms (intrusion and hyperarousal symptoms)
• Prevalence rates of depression: 20‐27% (Lee et al., 2007)
• Expression of psychological effect, of cytokine deregulation…
• Relationship between depression and ASD/PTSD following
trauma, including cancer, frequently observed (Mundy et al., 2000)
 Intrusive memories of specific negative events (Brewin et al. 1998): one of the common symptoms
Distinctive features of Cancer‐related PTSD and Depression
• Major depressive episodes after cancer diagnosis : – reactive depression, short duration
– non‐specificity of somatic symptoms (fatigue, anxiety…)
• Cancer‐related PTSD:
– Chronicity of threat:
• Protracted nature of cancer
• Multiple traumatic experiences (diagnosis, treatments, recurrence…)
• future‐oriented anxiety concerning cancer recurrence and death
– Internality of threat: bodily signs as persistent reminders of the trauma
• Cancer associated with other factors (neurotoxic treatments, biological
changes…)
No significant difference in hippocampal volume between breast cancer (BC) survivors with depression vs BC without depression
Inagaki et al., 2004, Am J Psychiatry
Yoshikawa et al., 2006, Biol Psychiatry
No significant difference in hippocampal volume between BC survivors with PTSD vs without PTSD (Hara et al., 2008, J Neuropsychiatry Clin Neurosci)
Nakano et al., 2002, Am J Psychiatry
• Intrusive symptoms, rather than cancer‐related PTSD, are associated with smaller hippocampal volume • comparison with healthy controls?
Smaller orbitofrontal cortex (right BA11) in BC survivors with PTSD compared to survivors without PTSD and to healthy controls (Hakamata et al., 2007, Neurosci Res)
BC with PTSD vs BC without PTSD
(3‐15 months after BC surgery)
BC with PTSD vs healthy controls
(2 years after the first scan)
Autobiographical Memory in Cancer Depressed vs non‐
depressed cancer patients (Brewin et al, 1998)
• Intrusive memories of stressful
events and related avoidance
mainly in depressed patients
• Overgeneral memories in response to cue‐words in depressed patients (correlation
with intrusion and avoidance)
Autobiographical Memory in Cancer Depressed vs non‐
depressed cancer patients (Brewin et al, 1998)
• Intrusive memories of stressful
ASD vs non‐ASD cancer patients (Kangas et al, 2005)
In newly diagnosed cancer patients events and related avoidance
(within 1 month of the diagnosis):
mainly in depressed patients
Overgeneral memories in response
• Overgeneral memories in response to cue‐words in depressed patients (correlation
with intrusion and avoidance)
to cue‐words in ASD patients
Overgenerality in Depression or post‐stress disorders (generative retrieval):
Generative retrieval mode
– Affect regulation hypothesis (to protect the self against stressful memories)?
– Related to executive dysfunction + current (depressed/stressed) self?
Event‐specific knowledge
Generic events
Life time period
Working memory
“Working self”
Conceptual self
attitudes, values…
AM in Cancer patients without a stress‐related
psychiatric disorder
• Overgeneral memories in BC patients compared with healthy
controls (Nilsson‐Ihrfelt et al, 2004; Bergouignan et al, 2011)
• Smaller hippocampal volume (post.) in BC patients relative to healthy controls
Bergouignan et al, 2011, PlosOne
Inagaki et al., 2004; Yoshikawa et al., 2006
AM in Cancer patients without stress‐related psychiatric disorder
• Overgeneral memories in BC patients compared with healthy
controls (Nilsson‐Ihrfelt et al, 2004; Bergouignan et al, 2011)
• Smaller hippocampal volume (post.) in BC patients relative to healthy controls
Smaller post Hpc + deficits of episodic AM: Reflect the effect of :
‐Cumulative stressful events
‐Aggressive treatments
Bergouignan et al, 2011, PlosOne
(McDonald et al, 2010; Deprez et al 2012; de Ruiter et al 2011…)
AM in BC patients before any adjuvant therapy
Patients without any psychiatric symptom and self‐willed
TEMPau: To retrieve specific events located in time and space, which occurred once and lasted less than 1 day (Piolino et al, 2009)
CANCER DIAGNOSIS
TEMPau task
START OF CT
Surgery
PERIOD 1 (18‐30 yrs old)
reminiscence bump
PERIOD 2
‘before cancer’ period
1 event
1 event
State of consciousness
Spatio‐temporal score
noetic
autonoetic
Factual score
Emotional score
PERIOD 3
‘cancer’ period
1 event no cancer
BC patients vs Healthy controls: No overgeneral memories
*
*
*
*
*
* P<0.05
Active adaptation process in these patients with « fighting spirit »?
Adaptation process different from that used by depressed patients
In conclusion, AM in Cancer patients
Lots of questions and some hypotheses:
•
Aggressive treatments at the origin of many cognitive impairments, notably overgeneral AM (medial temporal, prefrontal  retrieval, executive functions…)
•
Different psychological profiles (from psychiatric disorders to « fighting spirit ») would lead to different patterns of AM ?
•
AM and Self
In conclusion, AM in Cancer patients
Lots of questions and some hypotheses:
•
Aggressive treatments at the origin of many cognitive impairments, notably overgeneral AM •
Event‐specific (medial temporal, prefrontal  retrieval, executive
functions…)
knowledge
Different psychological profiles (from psychiatric disorders to « fighting spirit ») would lead to different
patterns of AM ?
Generic events
•
AM and Self
Life time period
Working memory
Conceptual self
“Working self”
attitudes, values,
aims, beliefs, desires…
Inserm U1077, Caen
Collaboration: Unité de recherche clinique
Centre F. Baclesse (Pr Florence Joly)
Many thanks to Armelle Viard and Nastassja Morel