1. People at risk of PTSD
victims of violent crime (e.g. physical and sexual assaults, sexual abuse, bombings, riots)
members of the armed forces, emergency services, journalists, prison service, healthcare staff!
victims of war, torture, state-sanctioned violence or terrorism, and refugees
survivors of accidents and disasters

2. Who are the victims?
Generally between 70-80% of people will experience a traumatic event over the course of a lifetime
The US National Co-Morbidity Survey – 35% of men and 25% of women reported more than one traumatic event in their lifetime
Worldwide 40 million people killed in wars and conflicts since WWII
Disasters have affected lives of 128 million people
Estimated life-time prevalence 7.8%
Elevated among women and previously married
Traumas most currently associated with PTSD – combat exposure and witnessing (men); rape and sexual molestation (women)

3. Post Traumatic Stress Disorder
Time Course
Acute Stress Disorder
Lasts for a minimum of 2 days and a maximum of 4 weeks
Occurs within 4 weeks of the trauma
Post Traumatic Stress Disorder
Acute – less than 3 months duration of symptoms
Chronic – symptoms last longer than 3 months
Delayed Onset – 6 months between trauma and onset of symptoms

4. ICD–10
PTSD may develop after ‘a stressful event or situation ... of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone’.
(World Health Organization, 1992: p. 147)
Give handout

5. Diagnostic criteria for 309.81 Post Traumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour
DSM III, (APA, 1980) - PTSD first appeared as a psychiatric diagnosis.

6. DSM-IV: PTSD
“The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”

7. Diagnostic criteria (cont’d)
B. The traumatic event is persistent re-experienced in 1 (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event
(2) recurrent distressing dreams of the event
(3) acting or feeling as if the traumatic event were recurring
(4) intense psychological distress at exposure to internal or external cues
(5) physiological reactivity on exposure to internal or external cues

8. Diagnostic criteria (cont’d)
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness …..:
3 (or more) needed
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places or people
(3) inability to recall an important aspect
(4) markedly diminished interest
(5) feeling of detachment from others
(6) restricted range of affect
(7) sense of a foreshortened future

9. Diagnostic criteria (cont’d)
D. Persistent symptoms of increased arousal:
2 (or more) needed
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hyper vigilance
(5) exaggerated startle response

10. How common is PTSD?
Probability of developing PTSD after a traumatic event:
Men 8% to 13%
Women 20% to 30%
Annual prevalence of PTSD: % to 3%
PTSD: the management of PTSD in adults and children
in primary and secondary care
NICE (2005)
SLIDE FOR ALL
Community based studies in the US indicate a life time prevalence for PTSD of approx 8% of the adult population
GP practices can have between people with PTSD. These people may not necessarily present or be diagnosed with PTSD.

11. Comorbidity in PTSD
80% of individuals with PTSD meet criteria for another psychiatric disorder

12. Co-morbidity Major depressive disorder Generalised anxiety disorder
Phobic disorders
Panic disorder
Substance abuse
Borderline personality disorder

13. What is the natural history of PTSD?
Traumatic Event
1 month
9 months
3 years
SLIDE FOR CLINICIANS: This slide relates to PTSD as a result of a single traumatic event
Secondary problems
Substance use disorders
Depression including the risk of suicide
Other anxiety disorders e.g. panic attacks
Many recover without treatment within months/years of event (45-80% natural remission at 9 months)
Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems
Usual onset of symptoms

14. Time between trauma and help seeking
The chances that a person with PTSD will benefit from treatment do not decrease with time elapsed since the event (Gillespie, et al 2002; Resnick et al, 2002).

15. NICE Clinical Guidelines Published: March 2005
Post-traumatic Stress Disorder (PTSD): the management of PTSD in adults and children in primary and secondary care.
NICE Clinical Guidelines
Published: March 2005
break them into groups and ask them to each list 3 -4 key recommendations from the guidelines - that would give an idea of how much they know, think they know, don't know etc.... make it very quick so they don't have too much time to ponder etc - just bullet points and then each group to give a quick resume of their points and the next group only says anything if they have something new to add etc..
-----
Recommendations for good practice based on best available evidence
DH document ‘Standards for better health’ includes an expectation that organisations will work towards implementing Clinical Guidelines
Healthcare Commission will monitor compliance with NICE guidance.
------
Guide covers:
Recognise, screen and diagnose the symptoms of PTSD
Assess and coordinate care
Treat all people with PTSD, including children
Support families and carers.
---
Does not cover:
Treating those people with ‘Enduring personality changes after catastrophic experience’
DESNOS (complex-PTSD)
Dissociative disorders
Adjustment disorders

16. Trauma focussed CBT treatment of choice (16 RCTs)
EMDR is an effective treatment
Other therapies ~ counselling, supportive non-directive therapies, psychodynamic therapy, hypnotherapy are not effective
Exposure (live and imaginal) reduce PTSD symptoms
CBT approaches reduce PTSD symptoms between 45-70%
Foa et al, 1991; Richards et al, 1994; van Etten & Taylor, 1998; NICE Guidelines, 2005

17. How to treat PTSD? What isn’t recommended…
Debriefing (single session as a treatment! – no criticism of CISM as a crisis support strategy)
Ineffective psychological treatments
Drug treatments NOT a first line treatment
What is recommended…
Watchful waiting
Trauma-focussed treatments (CBT and EMDR) for adults and children
De-briefing here refers to brief single-session interventions that focus on a traumatic incident.
Trauma focussed treatments:
Watchful waiting within 4 weeks if low level symptoms

18. How to treat PTSD? Offer 8-12 sessions +) Manage sleep disturbance
Drug treatments:
Develop shared management approaches between primary and secondary care
Brief psychological interventions ( 5 sessions) may be effective if treatment starts within the first month after the traumatic event other wise 8-12 sessions. For severe PTSD, treatments can extend beyond 12 sessions
TF-CBT should be offered to those who present with PTSD within 3 months of event, or those with severe PTSD in the first month
Management of sleep disturbance – hypnotic medication for short-term use, suitable anti-depressant for longer term use, introduced at an early stage to reduce later risk of dependence
Drug treatments: For general use – paroxetine or mirtazapine
Mental health specialists can prescribe: amitriptyline or phenelzine
Shared management between primary and secondary care: establish a written agreement outlining the responsibilities for monitoring individuals. Where appropriate use the Care Programme Approach (CPA) and share with patient, family and carers

19. Drug Treatment Sertraline, Fluoxetine, or Paroxetine Venlafaxine
Mirtazapine, Amitriptyline, Phenelzine
Augmentation of AD with Olanzapine or Risperidone
Southern Health Anxiety dis Treat GLs 12

20. Risk Factors ~ Pre-event
Female gender
Psychiatric history
Childhood abuse
Previous trauma
Family psych’ history
Trauma severity
Lack of social support
Subsequent life stress
Brewin et al (2000)

21. Risk Factors ~ During Event
Helplessness/mental defeat
Subjective life threat often shown to predict PTSD
APA, 1994
Helplessness/mental defeat – future slides

22. Factors to consider ~ During Event
Was trauma human induced or act of nature?
Cultural environment in which the trauma is experienced and in which the individual recovers
Frequency, duration, intensity and nature of trauma
Single or multiple trauma?
Coping strategies (previous and current)
Poor social (or organisational support)

23. Factors to consider ~ During Event…. cont’
Magnitude of bereavement
Speed of onset
Degree of displacement of person/community
Proportion of community affected
Exposure to death
Were traumas clearly delineated incidents?
Was trauma a culmination of a number of experiences?

24. Risk Factors ~ Post Event
Subsequent life stressors
‘Meaning’
Social support
Avoidance

25. ‘Meaning’ of the trauma
*Role of survivor ~ Active/Passive -
Was the individual a helpless victim?
Was he/she active in any way to alter the situation?
Were there any options for acting differently?
How do they perceive the meaning and outcome of their actions?
Idiosyncratic meaning of the specific trauma
Helplessness/mental defeat – future slides

26. ‘Meaning’ of the trauma (cont’d)
Attribution and meaning
What are the new views of self, others and the world?
Are there new personal outlooks in place?
What does the trauma mean in terms of the survivors’ plans for the rest of their life?
Is the person focused on the unfairness of the past or on the possibilities of the future?

27. Maintaining behaviours
Thought suppression
Avoidance of reminders
Avoidance of people
Situational avoidance
Numbing (drugs/alcohol/medication)
Self-harm
Dissociation

28. Measures Impact of Events Scale (IES & IES-R)
Post Traumatic Stress Diagnostic Scale (PDS)
Clinician Administered Post traumatic Stress Scale for DSM-IV (CAPS - DX IV)
Peri-traumatic Dissociation Questionnaire (PDEQ)
Beck Depression Inventory (BDI)
General Health Questionnaire (GHQ - 28)
Hospital Anxiety and Depression Scale (HADS)

29. Examples of TF-CBT Models
Horowitz (1986) states that overall the goal of any school of psychotherapy is to help the person to the stage where s/he:
“IS ABLE TO FREELY THINK ABOUT, AND FREELY NOT THINK ABOUT THE EVENT”. (p.265).

30. intrusions, strong emotions
matching
triggers
negative assessments of
trauma/subsequent events
nature of trauma
memory
strategies intended to control threat/symptoms
current threat
arousal symptoms
intrusions, strong emotions
arrows indicate the following relationships
leads to
prevents
change in
influences

31. Dual Representation Theory (Brewin, et al 1996)
Based on multiple memory systems to explain features of trauma memory.
According to this theory trauma memories are stored in two formats
Verbally accessible memory (VAM)
Situational accessible memory (SAM)

32. Verbally Accessible Memory
VAM contains information of factual type that occurred before, during and after the trauma,.
Can be accessed through normal autobiographical memory processes and discussed with others – but contains limited information.
High arousal narrows attention only allows limited information to be registered and
transferred to VAM.

33. Situationally Accessible Memory
SAM contains much more extensive data about the traumatic event from sensory input from eyes, ears, olfactory & touch receptors, plus emotional and physiological changes….SAM are retrieved automatically in situations where the person is exposed to trauma-related cues.
Does not contain a verbal code and therefore is hard to communicate
with VAM.

34. Dual Representation Theory
Theory is that in PTSD people have failed to create a detailed VAM representation, therefore considerable amounts of information reside in SAM, producing the characteristic intrusions.
Treatment involves transferring information from SAM to VAM, thus constructing a VAM memory that exerts control over SAM
SAM becomes encoded in VAM…given spatial and temporal context .
…if safety restored, flashbacks are replaced by memories that locate danger in the past….

35. Shattered assumptions
Traumatic reactions and PTSD are the result of
certain basic assumptions about self and the
world being shaken or shattered.
the belief in personal invulnerability
a perception of the world as meaningful and
comprehensible
a positive view of self and others
Janoff-Bulman(1985)

36. How to treat PTSD

37. Treatment of PTSD.
Horowitz (1986) states that overall the goal of any school of psychotherapy is to help the person to the stage where s/he:
“IS ABLE TO FREELY THINK ABOUT, AND FREELY NOT THINK ABOUT THE EVENT”. (p.265).
The common element to apparently successful treatment modalities is an attempt to expose the patient to the fear memory and allow the patient reprocess or reattribute the threat associated with the original memory.
(Sharpe, Tarrier and Rotundo, 1994)

38. Components of TF-CBT Treatment
Developing an empathic and supportive relationship.
Psycho-education and providing a rationale for treatment.
Stress management.
Exposure
Imaginable (prolonged)
In-vivo
Cognitive re-structuring

39. Rationale for treatment
Explain that PTSD is a normal reaction to an abnormal event.
Explain that strategies they are using ‘make sense’ but actually may be maintaining the reactions
Treatment involves removing or changing maintaining factors

40. Overview of Re-living Initially neutral imagery;
Then complete sequence of traumatic imagery, verbal or written to start - (possible hierarchical list);
Rewind and hold - concentrate on the worst part of memory, freeze and hold image, while repeatedly describing in detail all they can remember of the trauma;
Cognitive restructuring during exposure;
Audio-tape;
Constant rating of anxiety - use SUD’s scale;
Listen to tape as homework
Intersession tasks

41. Hotspots
Notice changes in affect (What was going through your mind? How does it feel?)
Discuss ‘meaning’ associated with hotspots
Verbal re-appraisal of hotspots (or imagery) to deal with them
Re-living just hotspots (re-wind and hold)
Build in new meanings

42. After re-living
Rate vividness
Ask how they found doing it
How it compared to what they thought it would be like?
Were they holding anything back?
H/W

43. Imagery Rescripting
What would happen if you allowed the image to continue? Can you change the ending…
What would the image look like projected onto a cinema screen, or seen from a moving train?
Imagine watching the image on TV – switching it off, dimmer,…freeze the image or make it black & white.
Through a zoom lens - make it smaller,
out of focus or further away

44. Additional treatment strategies
Exposure in vivo
Behavioural experiments (to ‘test out’ unhelpful appraisals – “I’m going out of control”, “I’m vulnerable/weak” etc)

45. Cognitive Restructuring
Appraisals of the traumatic event –
“this could happen again”
“I should have been able to prevent it”
Appraisals of symptoms of PTSD –
“I am going mad”
“I should be over this by now”
Some characteristic biases / thinking errors –
Using hindsight to evaluate what happened
Personalisation
Overgeneralization (e.g.. of risk)
Catastrophisation (e.g.. if I face my memories ….)

46. Useful ‘Restructuring’ Questions
What other explanations might there be?
Who else was involved?
How much power did you actually have to influence what happened?
How did things appear to you at the time?
What was your reason for acting as you did, at the time?
How could you have known what was going to happen?

47. Useful ‘Restructuring’ Questions: (cont)
How much time for reflection and choosing the best course of action did you have?
What was your emotional and physical state at the time?
What did you do that was helpful?
If this was another person, what more would you expect of them? How would you explain their behaviour?
Apart from your feelings, what else might you take into account when considering how you acted?

48. matching
triggers
negative assessments of
trauma/subsequent events
nature of trauma
memory
strategies intended to control threat/symptoms
current threat
arousal symptoms
intrusions, strong emotions
arrows indicate the following relationships
leads to
prevents
change in
influences
reconstruct the
fragmented trauma memory & anchor it in the past through discussion, tapes & writing 
change toxic beliefs with education, understanding,
imagery rescripting,
behavioural experiments,
& compassion
understand & reduce avoidance, encourage desensitization, tackle substance abuse