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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.

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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:

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 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 Who are the victims?

3 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)

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 persons response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour

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 ones 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 (contd) 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 (contd) 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 (contd) 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:1.5% to 3% PTSD: the management of PTSD in adults and children in primary and secondary care NICE (2005)

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 month9 months3 years Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems Many recover without treatment within months/years of event (45-80% natural remission at 9 months) 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 Post-traumatic Stress Disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. NICE Clinical Guidelines Published: March 2005

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 isnt 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

18 How to treat PTSD? Offer 8-12 sessions +) Manage sleep disturbance Drug treatments: Develop shared management approaches between primary and secondary care

19 1.Sertraline, Fluoxetine, or Paroxetine 2.Venlafaxine 3.Mirtazapine, Amitriptyline, Phenelzine 4.Augmentation of AD with Olanzapine or Risperidone Southern Health Anxiety dis Treat GLs 12 Drug Treatment

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

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?

23 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? Factors to consider ~ During Event …. cont

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

26 Meaning of the trauma (contd) 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

30 arrows indicate the following relationships leads to prevents change in influences 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

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 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. Situationally Accessible Memory

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

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 0 -10 SUDs 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 – Im going out of control, Im 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 arrows indicate the following relationships leads to prevents change in influences 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 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

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