Presentation on theme: "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."— Presentation transcript:
1People at risk of PTSDvictims 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 refugeessurvivors of accidents and disasters
2Who are the victims?Generally between 70-80% of people will experience a traumatic event over the course of a lifetimeThe US National Co-Morbidity Survey – 35% of men and 25% of women reported more than one traumatic event in their lifetimeWorldwide 40 million people killed in wars and conflicts since WWIIDisasters have affected lives of 128 million peopleEstimated life-time prevalence 7.8%Elevated among women and previously marriedTraumas most currently associated with PTSD – combat exposure and witnessing (men); rape and sexual molestation (women)
3Post Traumatic Stress Disorder Time CourseAcute Stress DisorderLasts for a minimum of 2 days and a maximum of 4 weeksOccurs within 4 weeks of the traumaPost Traumatic Stress DisorderAcute – less than 3 months duration of symptomsChronic – symptoms last longer than 3 monthsDelayed Onset – 6 months between trauma and onset of symptoms
4ICD–10PTSD 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
5Diagnostic 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 behaviourDSM III, (APA, 1980) - PTSD first appeared as a psychiatric diagnosis.
6DSM-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.”
7Diagnostic 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
8Diagnostic 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
9Diagnostic 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
10How 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 childrenin primary and secondary careNICE (2005)SLIDE FOR ALLCommunity based studies in the US indicate a life time prevalence for PTSD of approx 8% of the adult populationGP practices can have between people with PTSD. These people may not necessarily present or be diagnosed with PTSD.
11Comorbidity in PTSD80% of individuals with PTSD meet criteria for another psychiatric disorder
13What is the natural history of PTSD? Traumatic Event1 month9 months3 yearsSLIDE FOR CLINICIANS: This slide relates to PTSD as a result of a single traumatic eventSecondary problemsSubstance use disordersDepression including the risk of suicideOther anxiety disorders e.g. panic attacksMany 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 problemsUsual onset of symptoms
14Time 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).
15NICE 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 GuidelinesPublished: March 2005break 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 evidenceDH document ‘Standards for better health’ includes an expectation that organisations will work towards implementing Clinical GuidelinesHealthcare Commission will monitor compliance with NICE guidance.------Guide covers:Recognise, screen and diagnose the symptoms of PTSDAssess and coordinate careTreat all people with PTSD, including childrenSupport families and carers.---Does not cover:Treating those people with ‘Enduring personality changes after catastrophic experience’DESNOS (complex-PTSD)Dissociative disordersAdjustment disorders
16Trauma focussed CBT treatment of choice (16 RCTs) EMDR is an effective treatmentOther therapies ~ counselling, supportive non-directive therapies, psychodynamic therapy, hypnotherapy are not effectiveExposure (live and imaginal) reduce PTSD symptomsCBT approaches reduce PTSD symptoms between 45-70%Foa et al, 1991; Richards et al, 1994; van Etten & Taylor, 1998; NICE Guidelines, 2005
17How to treat PTSD? What isn’t recommended… Debriefing (single session as a treatment! – no criticism of CISM as a crisis support strategy)Ineffective psychological treatmentsDrug treatments NOT a first line treatmentWhat is recommended…Watchful waitingTrauma-focussed treatments (CBT and EMDR) for adults and childrenDe-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
18How to treat PTSD? Offer 8-12 sessions +) Manage sleep disturbance Drug treatments:Develop shared management approaches between primary and secondary careBrief 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 sessionsTF-CBT should be offered to those who present with PTSD within 3 months of event, or those with severe PTSD in the first monthManagement 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 dependenceDrug treatments: For general use – paroxetine or mirtazapineMental health specialists can prescribe: amitriptyline or phenelzineShared 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
19Drug Treatment Sertraline, Fluoxetine, or Paroxetine Venlafaxine Mirtazapine, Amitriptyline, PhenelzineAugmentation of AD with Olanzapine or RisperidoneSouthern Health Anxiety dis Treat GLs 12
20Risk Factors ~ Pre-event Female genderPsychiatric historyChildhood abusePrevious traumaFamily psych’ historyTrauma severityLack of social supportSubsequent life stressBrewin et al (2000)
21Risk Factors ~ During Event Helplessness/mental defeatSubjective life threat often shown to predict PTSDAPA, 1994Helplessness/mental defeat – future slides
22Factors 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 recoversFrequency, duration, intensity and nature of traumaSingle or multiple trauma?Coping strategies (previous and current)Poor social (or organisational support)
23Factors to consider ~ During Event…. cont’ Magnitude of bereavementSpeed of onsetDegree of displacement of person/communityProportion of community affectedExposure to deathWere traumas clearly delineated incidents?Was trauma a culmination of a number of experiences?
24Risk Factors ~ Post Event Subsequent life stressors‘Meaning’Social supportAvoidance
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 traumaHelplessness/mental defeat – future slides
26‘Meaning’ of the trauma (cont’d) Attribution and meaningWhat 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?
27Maintaining behaviours Thought suppressionAvoidance of remindersAvoidance of peopleSituational avoidanceNumbing (drugs/alcohol/medication)Self-harmDissociation
28Measures 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)
29Examples 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).
30intrusions, strong emotions matchingtriggersnegative assessments oftrauma/subsequent eventsnature of traumamemorystrategies intended to control threat/symptomscurrent threatarousal symptomsintrusions, strong emotionsarrows indicate the following relationshipsleads topreventschange ininfluences
31Dual 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 formatsVerbally accessible memory (VAM)Situational accessible memory (SAM)
32Verbally 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 andtransferred to VAM.
33Situationally 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 communicatewith VAM.
34Dual 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 SAMSAM becomes encoded in VAM…given spatial and temporal context .…if safety restored, flashbacks are replaced by memories that locate danger in the past….
35Shattered assumptions Traumatic reactions and PTSD are the result ofcertain basic assumptions about self and theworld being shaken or shattered.the belief in personal invulnerabilitya perception of the world as meaningful andcomprehensiblea positive view of self and othersJanoff-Bulman(1985)
37Treatment 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)
38Components of TF-CBT Treatment Developing an empathic and supportive relationship.Psycho-education and providing a rationale for treatment.Stress management.ExposureImaginable (prolonged)In-vivoCognitive re-structuring
39Rationale 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 reactionsTreatment involves removing or changing maintaining factors
40Overview 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 homeworkIntersession tasks
41HotspotsNotice changes in affect (What was going through your mind? How does it feel?)Discuss ‘meaning’ associated with hotspotsVerbal re-appraisal of hotspots (or imagery) to deal with themRe-living just hotspots (re-wind and hold)Build in new meanings
42After re-livingRate vividnessAsk how they found doing itHow it compared to what they thought it would be like?Were they holding anything back?H/W
43Imagery RescriptingWhat 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
44Additional treatment strategies Exposure in vivoBehavioural experiments (to ‘test out’ unhelpful appraisals – “I’m going out of control”, “I’m vulnerable/weak” etc)
45Cognitive 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 happenedPersonalisationOvergeneralization (e.g.. of risk)Catastrophisation (e.g.. if I face my memories ….)
46Useful ‘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?
47Useful ‘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?
48matchingtriggersnegative assessments oftrauma/subsequent eventsnature of traumamemorystrategies intended to control threat/symptomscurrent threatarousal symptomsintrusions, strong emotionsarrows indicate the following relationshipsleads topreventschange ininfluencesreconstruct thefragmented trauma memory & anchor it in the past through discussion, tapes & writingchange toxic beliefs with education, understanding,imagery rescripting,behavioural experiments,& compassionunderstand & reduce avoidance, encourage desensitization, tackle substance abuse