Presentation on theme: "Complex PTSD Dr Felicity De Zuluetta Consultant Psychiatrist"— Presentation transcript:
1Complex PTSD Dr Felicity De Zuluetta Consultant Psychiatrist The Maudsley HospitalDr Walter BusuttilMedical Director & Consultant Psychiatrist.Combat Stress
2Aims of Workshop Part One Define Simple and Complex PTSD Multiple Traumatisation in Children and AdultsCo-morbidity vs CPTSDCommon presentationsDifferential DiagnosisWhat is the relationship between Complex PTSD, Dissociative Disorders, Borderline PD and PsychosisPart TwoManagement & Treatment StrategiesTherapeutic Models of Intervention individual and Group TreatmentsHighlight outcomes of a 90-day inpatient programme for treatment of Complex PTSDHighlight new inpatient ward programme for Women Forensic Service
7Aetiological Models of PTSD Information Processing Model Prime model on which others are based on.Psychosocial Model Support before, during and after exposureBehavioural Model Triggers & stimulus generalisationCognitive Model Cognitive distortions (Ehlers & Clark)Cognitive Appraisal Model Meaning of stressor & its effects on the future, -man-made vs acts of God.Dual Representation Theory Situationally accessible memory versus verbally accessible memoryBiological Models Unproven & various FMRI studiesAttachment Theory Models
9Biological Models for PTSD Several neuro-transmitters involved.Stimulation challenge tests – trigger exposure tests: Pre-frontal; Limbic; Peri-occipitalFunctional MRI Scans: Amygdala, ‘fuse box’ blow-out. Proximity to narrative centresIn Borderline PD FMRI abnormalities are very similar indeed!
10What is Complex PTSD? Multiple vs Single Trauma Multiple Exposureeg: CSA for five yearsRoad Traffic AccidentFalklands WarLockerbie Clear up operationSingle Exposureeg Lockerbie Clear- up operation
11Multiple Traumatisation Considerations: PersonalNature and Extent of TraumaAge and Developmental StageReason / Cause / IdeologySupport - Group vs IsolationSustained - predictable / unpredictableIntermittentGeneral
12Traumatisation in Childhood ABUSE:Physical vs Sexual vs Emotional vs MixedPerpetrator / Power, Control, Choice.Drug induced stateSystematic vs Non-Systematic: Organized? Eg Pornographic ring?Within an institution?AgeContext - act of God / act of Man?Multiple vs SingleDose response?MeaningDevelopmental StageBrain developmentAttachmentsOpen vs SecretIndividual vs Group
13DSM-IV Complex PTSD Working Party Study Multiple traumatisation below the age of 26 years predicted development of Complex PTSDExposure to Multiple traumatisation after the age of 26 years did not predict Complex PTSD
14Simple & Complex PTSD Simple PTSD Single Trauma Complex PTSD Multiple TraumaTraumatised Under age of 14 / 26Developmental stageAttachmentsNeuro-developmental stage
15Busuttil & Turner (UK Trauma Group 2000 discussion) Postulation that adult victims of torture and incarceration (multiple trauma), more likely to develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex PTSD.CPTSD is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994).
16Alterations in 7 dimensions: Complex PTSD DSM-IV Field Trials Adult survivors of CSA (van der Kolk et al, 1994)Alterations in 7 dimensions:Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation.Attention & concentration: dissociation, amnesia, depersonalizationSelf-Perception: helplessness, guilt, shame.Perception of perpetrator: idealization of the perpetrator or feelings of vengeance.Relationships with others: isolation, mistrust, victim role, victimization of othersSomatisation: GIT; CVS; Chronic pain, conversion etc.Systems of meaning: despair, hopelessness, major changes to previously well held beliefs
17Disorders of Extreme Stress Not Otherwise Specified (DESNOS) (Herman, 1992) Defined in Adult Survivors of Childhood Sexual AbuseDESNOS + PTSD = Complex PTSD (1995/6)
184th Edition Text Revision – DSM-IV-TR, 2000 mentions: An “associated constellation of symptoms may occur in association with an interpersonal stressor:impaired affect modulation,self–destructive and impulsive behaviour;dissociative symptoms;somatic complaints;feelings of ineffectiveness;shame, despair or hopelessness.
19And J Herman who first described the syndrome notes that they also Feel permanently damaged;Sustain a loss of previously sustained beliefs;Show social withdrawal;feel constantly threatened;Show impaired relationships with othersShow a change from the individual’s previous personality characteristics”.
20Characterological / personality changes Repetition of Harm Complex PTSD: A diagnostic framework- disturbance on three dimensions (Bloom, 1997)SymptomsCharacterological / personality changesRepetition of Harm
21Complex PTSD Disturbance on Three Dimensions (after Bloom 1999) Symptoms of : PTSDSomaticAffectiveDissociationCharacterological Changes of:Control: Traumatic BondingLens of FearRelationships: Lens of extremity-attachment versus withdrawalIdentity Changes:Self structuresInternalized images of stressMalignant sense of selfFragmentation of the selfRepetition of HarmTo the self - faulty boundary settingBy others - battery, abuseOf others - become abusersDeliberate self harm
22Complex PTSD Dynamic Model (Busuttil 2006 after Bloom 1998) Trapped in TimePTSDMemory FormationAutomaticConsciousDevelopmental / AttachmentsPhysicalPsychologicalSocialRepeated TraumaAdaptive Over-Coping(Dissociation)AvoidanceDissociationNumbingAngerAggressionAddictionsLearned HelplessnessMaladaptive CopingLearned CopingPoor SupportOther LEsPersonalityDepression
23Recent Concepts Developmental Trauma Disorder in children & adolescents: ExposureTriggered dysregulation in response to trauma cuesPersistently altered attributions and expectationsFunctional Impairment.
24Developmental Trauma Disorder: Exposure to multiple or developmentally adverse interpersonal traumaeg abandonment, betrayal, physical or and sexual assaults threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death.Subjective experience – rage, betrayal, fear, resignation, defeat , shame.
25Developmental Trauma Disorder: 2 Triggered dysregulation in response to trauma cuesDysregulation (low or high) in presence of cues. Changes persist & do not return to baseline; not reduced in intensity by conscious awareness.AffectiveSomaticBehaviouralCognitiveRelationalSelf-attribution
26Developmental Trauma Disorder: Persistently altered attributions and expectationsNegative self attributionDistrust of protective carerLoss of expectancy of protection by othersLoss of trust in social agencies to protectLack of recourse to social justice /retributionInevitability of future victimisation
28Domains of impairment children and Adolescents (Task Force) Attachment- uncertainty about the reliability & predictability of the world; boundary problems, distrust & suspiciousness; social isolation; interpersonal difficulties; difficultly attuning others emotional states; difficulty with perspective thinking; difficulty enlisting other people as allies.Biology – Sensorimotor developmental problems; hypersensitivity to physical contact; Analgesia; Problems with coordination, balance, body tone, difficulties localising skin contact; somatisation; increased medical problems across a vast span eg: pelvic pain; asthma; skin problems; autoimmune disorders; pseudo seizures.Affect Regulation - Difficulty with emotional self regulation; difficulty describing feelings and internal experience; problems knowing and describing internal states; difficulty communicating wishes and desires.Dissociation – Distinct alterations in states of consciousness; amnesia; depersonalisation and derealisation; two or more distinct states of consciousness, with impaired memory for state based events.
29Domains of impairment children and Adolescents (Task Force) contd 5 Behavioural Control – poor modulation of impulses; self destructive behaviour; aggression against others; pathological self soothing behaviours; sleep disturbances; eating disorders; substance abuse; excessive compliance; oppositional behaviour ; difficulty understanding and complying with rules; communication of traumatic past by re-enactment in day to day behaviour or play (sexual, aggressive etc). 6 Cognition – Difficulties in attention regulation and executive functioning; lack of sustained curiosity; problems with processing novel information; problems focussing on and completing tasks; problems with object constancy; difficulty planning and anticipating; problems understanding own contribution to what happens to them; learning difficulties; problems with language development; problems with orientation in time and space; acoustic and visual perceptual problems; impaired comprehension of complex visual spatial patterns. 7 Self-Concept – Lack of a continuous predictable sense of self; poor sense of separateness; disturbances of body image; low self esteem; shame and guilt
30Clinical Presentation: Developmental Trauma Disorder Complex Trauma Task Force of the National Child Traumatic Stress NetworkArguments put forward by the Task Force to take up the DSM-IV CPTSD Working Party criteria – still relevantCo-morbidity: studies of abused children include in order of frequency:Separation anxiety disorderOppositional Defiant DisorderPhobic DisordersPTSDADHD??? Developmental Trauma Disorder is a useful diagnostic frame work
32Limitations of the individual based anxiety model of PTSD Most events qualifying for PTSD are not ‘beyond the range of usual human experience’.None is so powerful that exposure typically leads to PTSD (Kessler et al,1999)PTSD occurs less in well integrated communities than in fragmented ones.Lack of social support is a major risk factor (NICE, 2005) eg Asylum seekers in the UK.
33The case for PTSD as a Sensitisation disorder of the Attachment system Yehuda found that only victims of an RTA whose stress response led to a lower than normal release of cortisol developed PTSD.She postulated that PTSD may reflect a ‘biologic sensitisation disorder rather than a post traumatic stress disorder’(1997).Wang attributes this sensitisation to changes in the attachment system ie suppression of cortisol levels observed in insecurely attached children (1997).
34The effects of PTSD are transmitted down the generations Low urinary cortisol levels in adult holocaust survivors with PTSD and in their adult offspring (Yehuda, 1997, 2002).Israeli soldiers whose parents were Holocaust survivors had higher rates of PTSD than their counterparts.Children of mothers who suffered from PTSD following 9/11 have lower levels of cortisol.Low cortisol levels predispose to PTSD in later life.
35Transmission of vulnerability to PTSD Attachment research shows a 75% correspondence between a mother’s attachment and that of her infant (Van Ijzendoorn et al. 1997) which can be reversed if mother’s behaviour is altered towards the child.These findings show there is non-genetic transmission of the potential for PTSD and trauma related violence in PTSD afflicted communities.This underlies the importance of prevention and socially based treatment interventions.
36Non genetic transgenerational transmission 75% correspondence found between parents’ mental representation of attachment and the infant’s attachment security (Van Ijzendoorn, 1997).Transmission of mother’s low levels of cortisol when suffering from PTSD to her infant (Yehuda et al., 2005)Traumatised individuals who respond to stress with lower levels of cortisol than normal develop PTSD (Yehuda, 1997). important implications in terms of genetic evidence and anti-social behaviour transmission.
37Complex PTSD & Disorganised attachments Patients with CPTSD can be understood as suffering from disorganised attachments with associated symptoms of PTSD which can be severe.
38Attunement with baby’ and Affect regulation The caregiver responds to the infant’s signals by holding, caressing, smiling, feeding, stimulating or calming, giving meaning.Her empathic interaction results in a child who can put himself in the mind of another and interact successfully
39Laying down the Templates for future interactions These daily interactions provide the memories that the infants synthesize into internal “working models” (Bowlby).These are internal representations or templates of how the attachment figure is likely to respond to the child’s attachment behaviour both now and in the future.
40The Brain substrate of Attachment Behaviour InvolvesA great part of the right hemisphere.the supra orbital area of the brain which is crucial in enabling us to empathise with othersPartly mediated by: endogenous Opiates and oxytocin (feel good factor)dopamine (energised state of feeling)serotonin (linked to levels of dominance in hierarchy).
41Representation of the Self & Secure attachments Is closely intertwined with the internal representation of the attachment figure.A securely attached child has a mental representation of the caregiver as responsive in times of trouble.These children feel confident and are capable of empathy and forming good attachments.A secure attachment is a primary defence against trauma induced psychopathology (Schore 1996).
42Reflective Functioning The caregiver induces reflective functioning in the infant by:giving meaning to the infant’s experiences,sharing and predicting his/her behaviourThis enables people to understand each other in terms of mental states, to interact successfully with others and is key to developing a sense of agency and continuity.(Fonagy and Target, 1997)
43(Single external carer) Resilience factorEmpathic understanding from an outsider (teacher or relative) can compensate for effects of childhood abuse and protect against re-enactment and trauma.(Single external carer)
44Insecure attachmentsAn insecure attachment is one in which the infant does not have a mental representation of a responsive caregiver in times of need.These infants develop different strategies to gain proximity to their caregiver in order to survive.There are 3 types of insecure attachment behaviour:Group C: Anxious ambivalent type (12%)Group A: Avoidant type (20-25%)Group D: Disorganised (15%)
45Disorganised Attachment Behaviour Their caregivers are frighteningOr they themselves are frightened because the child is already suffering, from PTSD.This behaviour leaves the child in a state of fear without solution (Main & Hesse 1992; 1999).Reflective functioning is severely impaired: the more impaired, the more disturbed is the individual.
461. Attachment and Dissociation The infant’s psychobiological response to such states comprises 2 response patterns:1. ‘Fight-flight’ response mediated by Sympathetic system:Blocks the reflective symbolic processing > traumatic experiences stored in sensory, somatic, behavioural and affective states.
472. Attachment and dissociation If ‘fight-flight response is not possible, a parasympathetic dominant state takes over and the infant ‘freezes’ in order to conserve energy,feign death and foster survival.Vocalisation is inhibited.
483. Attachment and dissociation In traumatic states of total helplessness, both responses are hyper-activated leading to an ‘inward flight’ or dissociative response.Eg: child looks down from the ceiling watching herself being abused.
49B. The resulting features of the Traumatic Attachment The Moral Defence:Child cannot survive without a parent so child will take the blame for their suffering and thereby preserve their attachment and hope for a better parent in the future.By blaming themselves, these children retain power and control as well as hope for a better parenting future (Fairbairn 1952).This reinforces the identification with the the abusing parent like the Stockholm syndrome in adults.
50Origin of the triangle of abuse Work with survivors of child abuse demonstrate that the abused child will usually be most most angry with the parent who let it happen ie the ‘Mother’.This abusive triangle is internalised in the survivors ‘working models’ to be replayed as abuser, victim or observer depending on the context.
521. The Psycho-biology of child neglect & abuse Changes in the HPA axis in response to stress or separationReduced levels of cortisol and increased glucocorticoid receptors : increase PTSD vulnerabilityRelease of endogenous opiates : increase analgesia by cutting or self harm.
531. The Psycho-biology of child neglect & abuse A limited capacity to modulate:Sympathetic dominant affects: terror, rage and elation,Parasympathetic dominant affects: shame, disgust, and hopeless despair.Results in:Self-medication with drugs or alcoholResort to violence to counter threat to Self
54The ASSESSMENT should be carried out: In relation to the external system of social attachmentsIn terms of the internal system of working models and resulting cognitions and behaviour and levels of dissociation.Need for a potential SECURE BASE to be established BEFORE starting treatment.
55Assessment of the external attachment system Social network in community and in mental health services ie levels of family support, social support and involvement of Community Mental Health Teams.Genogram to spot deaths in family and important information left out of interview.Bubble chart of services and people involved with client to pre-empt problems due to ‘splitting’, failure of communication etc
56Assessment of the external attachment system (cont) Cultural issues need to be taken into account:Eg: Bangladesh familyRespect for parents in many cultures in Africa, Middle EastImplications of rape in similar culturesReinforcement & Maintaining Factors: Important in relation to patients involved in domestic violence or sexual abuse or when patient’s illness is systemically reinforced by the family.Eg of assessment failureEg domestic violence treatment problematic
57Assessment of the Internal Attachment System Through the assessment of the internal world of working models (object relations) and security of attachment:Use of questions in Adult Attachment Interview:ie. when you were little whom did you go to when you were hurt or upset?Incoherence in time: use of present when talking of somebody who has died.Capacity for reflective functioning ie putting him or herself into mind of the other
58Assessing the disorganised or ‘traumatic attachment’ Look for the main features:a strong ‘moral defence’idealisation and splitting,resistance to change> traumatic attachment bonds to caregiver.Look for levels of dissociation:Use of Dissociation Evaluation Scale (DES)
59Implications of the phenomenon of dissociation The phenomenon of dissociation should no longer be ignored in our understanding of such phenomena as:Inexplicable shifts in affectDiscontinuities in train of thought.Changes in facial appearance, speech and mannerisms.Apparently inexplicable behaviour.Somatic dissociative phenomena.
61Complex Trauma Reactions What is the central Hub of CPTSD? Somatoform SymptomsPTSDBorderlinePD Psychotic SymptomsDissociativeSymptoms
62Relationship between PTSD and Psychosis Psychotic symptoms among patients with primary PTSD (PTSD symptoms that are psychotic). – high dose stressor; chronic disorder; multiple childhood traumaPTSD in the context of dual diagnosis – e.g. co-morbid drug induced psychosis, co-morbid schizophreniform functional disorder, co-morbid psychotic affective disorder.Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (common??)
63Re-experiencing Psychosis Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (very very common!!) Phenomenology: Single event or Simple PTSDRe-experiencingNightmaresRecurrent intrusive images, thoughts, perceptionsRecurrent Feelings as if it were recurring (incl reliving –illusions, hallucinations, dissociative flashbacks incl those occurring on wakening)Psychol distress on exposure to reminders of traumaPhysiological reactivityPsychosis1. Was this screened for in history taking?2. Perceptual hallucinations; thought disorder3. Flashbacks can occur in any sensory modality and can be misinterpreted as psychotic hallucinations / delusions in any sensory modality4. ?behavioural disturbance? Disinhibition?5. ?agitation?
67Borderline Personality Disorder Complex PTSDSymptoms of : PTSDSomaticAffectiveDissociationCharacterological Changes of:Control: Traumatic BondingLens of FearRelationships: Lens of extremity-attachment versus withdrawalIdentity Changes:Self structuresInternalized images of stressMalignant sense of selfFragmentation of the selfRepetition of HarmTo the self - faulty boundary settingBy others - battery, abuseOf others - become abusersDeliberate self harmBorderline Personality DisorderSymptoms of : Transient Paranoid IdeationAffectiveDissociationImpulsivityCharacterological Changes of:Control: Traumatic BondingLens of FearRelationships: Lens of extremity-attachment versus withdrawalIdentity Changes:Self structuresInternalized images of stressMalignant sense of selfFragmentation of the selfRepetition of HarmTo the self - faulty boundary settingBy others - battery, abuseOf others - become abusersDeliberate self harm
68Dissociation and PTSD: easy practical classification Primary: dissociation at time of trauma – peri-traumatic –Secondary: dissociation as part of a flashback – re-enactmentsTertiary: ‘flight to safety’- ‘blanking it off’-
69Dissociative Disorders Dissociative AmnesiaDissociative FugueDissociative Identity DisorderDepersonalization SyndromeDissociative disorder not otherwise specifiedNB: Dissociative symptoms also included in criteria for ASD; PTSD & Somatisation Disorder. An additional Dissociative Disorder diagnosis is not given if the dissociative symptoms occur exclusively within one of these disorders.
73Aetiology of Concentration Camp Syndrome Organic vs Psychological / Psychiatric vs Combination of BothOrganic brain damage - from starvation, avitaminosis, head trauma and fevers such as “spotted fever” (Eitinger 1961, 64; Thygersen, 1970).In POWs of WWII & Korean war, Weight loss of 35% or over correlates with high incidence of more severe biological and psychological insult and PTSD and depression more likely to be present (Sutker et al, 1990; Speed et al, 1989).
74Multiple Traumatisation in Adults Hostages and POWs (Busuttil, 1992) Stress Disorders (incl ASD & PTSD): pre-captivity experiences; initial captivity experience; torture; solitary & group confinementDepressive Disorders: torture, loss events, captivity experience itselfCognitive Defect States: weight loss, vitamin deficiencies, CNS infections, head traumaPsychotic States: isolation and confinementPersonality - Character Changes: captivity experience itself: coping style and locus of controlPhysical Illness - Somatiform & Genuine
75Busuttil & Turner (UK Trauma Group 2000 discussion for DSM-V) Postulation that victims of torture and incarceration develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex PTSD.The latter is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994).
76Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) Prolonged exposure to life threat/sPTSD may precede the disorderfeatures seen after exposure to threat:a hostile mistrustful attitude towards the worldsocial withdrawalfeelings of emptiness or hopelessnesschronic feelings of being on edge or threatenedestrangement
77Management Issues (W.Busuttil) Part TwoManagement Issues(W.Busuttil)
781 Politics: NICE Treatment Guidelines 2005 Deal with Simple PTSD onlyGuidelines do NOT deal with Complex PTSD or Chronic PTSD.Next instalment might deal with CPTSD and Chronic PTSD(in four years time)
79UK Trauma Group Statement on CPTSD (May 2008) NICE states that PTSD develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, and examples that are given include single events such as assaults or road traffic accidents.For adults, we believe that this refers to “simple” PTSD, which commonly develops following a single traumatic event occurring in adulthood. The recommended treatment is brief, trauma-focused psychological therapy.However, the guideline does not apply to situations involving complex trauma, for example where there is a history of multiple traumatic events, including previous childhood trauma and attachment disorder.
80UK Trauma Group (May 2008)The NICE guidelines do not provide adequate guidance in relation to the assessment and treatment of Complex PTSD.This results in lack of appropriate provision, resources and training to treat people with Complex PTSD, and ensuing limited access to effective treatment services.We propose that a review of the literature on complex PTSD is urgently needed to refine the definition of complex PTSD, and provide more detailed guidance for good practice in the assessment and treatment of complex PTSD.We advise that the multi-phasic treatment recommendations outlined above should be followed as best practice for the treatment of Complex PTSD as we currently understand it.
81UK Trauma Group (May 2008)Literature on effective treatment for complex PTSD is limited, but what there is so far shows that multi-phasic and multi-modal treatment is indicated for children and adults (e.g. Luxenberg et al., 2001).The literature recommends that the following three stages are included:Establishing stabilisation and safety;Psychological therapy, incorporating trauma-focused elements and some exposure to the trauma;Rehabilitation.
82Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999) Stabilization & SafetyWorking through of Traumatic material – disclosure – psychotherapyRehabilitation
83Treatment of PTSD: Basic Principles Multimodal AssessmentStabilise – Enhance Coping , MedicationTherapyOutpatient vs InpatientSafety - supports
84Common maintaining factors Treatment Pitfalls:Common maintaining factorsNature and duration of traumaRole in traumaMeaning of traumaHas trauma ended?Isolation - attachmentsGuilt - omission / commissionGuilt - survivorOther FactorsCo-morbidity - treat this first?Alcohol & Illicit DrugsMotivationCo-operationComplianceTherapeutic qualities of patient & therapist
87Safety & Stabilisation Safe environmentSkills training, eg: DBTInteractive PsychoeducationWard Structure and ProgrammeReward good behaviourLittle attention to DSHMedications: used to stabilize patient in order to allow psychotherapy to be conducted primarily. After psychotherapy is finished, attempt should be made to reduce medications.
89Sensori-Motor Interventions EmergingOverlap with other approachesBody symptoms, automatic responses, posture, body language etcPaying attention to the body,Uses body rather than cognition or emotion as primary entry point to access trauma
90TF-CBT Psycho-education Disclosure / Exposure / Working Through of Traumatic MaterialCognitive restructuringProblem solvingUse of behavioural techniquesfor example anxiety management
91TF-CBT Approaches Exposure: The therapist helps confrontation of the traumatic memories (written, verbal, narrative).Detailed recounting of the traumatic experience –repetition.In vivo repeated exposure to avoided and fear-evoking situations that are now safe but that are associated with the traumatic experience.
92CBT Approaches Cognitive Therapy Focus on the identification and modification of misinterpretations that lead PTSD sufferer to overestimate current threat (fear)Modification of beliefs related to other aspects of the experience and how the individual interprets their behaviour during the trauma (eg: issues concerning shame and guilt).
93Other - CBT Approaches Stress Management Relaxation Trg Breathing re-TrgPositive thinking and Self-talkAssertiveness TrainingThought StoppingStress Inoculation Trg
94EMDR (Eye movement Desensitisation and Reprocessing) Therapeutic rapportImagery / envisioning of traumatic scenesFocus on sensations of anxietyCognitive restructuringSaccadic movements of EyesExtinguishing of the memoryOther methods - eg Counting MethodNeed training - Criticisms
95EMDRStandardised, trauma focussed procedure with several elements, always involving the use of bilateral physical stimulation (eye movements, taps, tones), thought to stimulate the individual’s own information processing in order to help integrate the targeted event as an adaptive contextualised memory
96Requires individual to focus on a traumatic memory and generate a statement summarising thoughts of the trauma eg I should have done ‘X’Patient is instructed to visualise traumatic scene , briefly rehearse the belief statement that best summarised their memories, concentrate on their associated physical sensations, and visually track the therapist’s index finger.Finger moved rapidly /rhythmically back & forth across line of vision – extreme l eft to right distance of 30-35cm from face at a rate of two back and forth movements per second.
97This is repeated 12 – 24 times after which patient asked to blank picture out and take a deep breath At the same time patient asked to focus on bodily experience associated with image as well as on an incompatible belief statement (eg I did my best; It is all in the past).Therapist records subjective unit of distress (SUD), if has not decreased checks that scene has not changedIf has changed peocedure is repeated with new scene before returning to old one (Shapiro, 1989)
98ARC Model: Attachment; Self Regulation and Competency Model Specific Treatment Models Children and Adolescents Development Trauma DisorderARC Model: Attachment; Self Regulation and Competency Model(Kinniburgh et al, 2005)Outpatient basedGrounded in theory and empirical knowledgeIncludes systematic family interventionRecognises the core effects of trauma exposure on attachment, self regulation and development competencies.Emphasises the importance of understanding and intervening with the child in own contextPhilosophy that systemic change leads to effective and sustainable outcomesNot a manualised treatment protocol – a guideline framework tailor made for the individual.
100Treating CPTSD in Adults Models:DBT followed by TF WorkSelf- Trauma Model & Trauma Focussed workPsychodynamic therapy followed by Trauma Focussed workSchema Focussed TherapyStructured Group Therapy Programmes
101Dialectic Behaviour Therapy DBT : developed by Marsha LinehanA form of CBT developed to address Borderline PD and associated problemsEspecially suicidal and self harming behaviours
102Dialectic Behaviour Therapy For:Life threatening BehavioursSuicidal behaviours – attempts and ideationAggression & ViolenceProblems associated with Quality of LifeAlcohol & drug abuseDisordered eatingEmotional and mood disturbancePoor impulse controlInterpersonal problems
103Dialectic Behaviour Therapy: ProgrammeOne year longOnce weekly individual therapy sessions with DBT trained therapist (1 hour long)Once weekly group skills training session 1-2 hours longOnce weekly Consultation Meeting between therapists
104Functions and Modes of DBT: Learning new skillsIncreasing MotivationGeneralisation to the environmentTherapists’ support and assuring motivationModesSkills training groupsIndividual therapy(Ward based milieu)Team consultation
105DBT: Hierarchy of Targets: Pre-therapy:OrientationCommitmentStability, Connection & SafetyDecrease in:Suicidal / self harming behavioursTherapy Interfering behavioursQuality of life Interfering behavioursIncrease inBehavioural skills
106DBT: Skills Modules:Mindfulness: control the mind: wise mind integration of emotion and reason, balanced knowing, intuition, peace of mind.Emotional Regulation: objectives effectiveness; relationship effectiveness; self respect effectiveness.Interpersonal Effectiveness: identifying factors that interfere with interpersonal effectiveness: lack of skill; worry thoughts and myths; excessive emotions; indecisive about priorities; environmental restraints.Distress Tolerance: Crisis survival skills; Gudelines for accepting reality
107Skills Training Increase Decrease Mindfulness Identity confusion EmptinessCognitive DysregulationInterpersonal SkillsInterpersonal ChaosFears of abandonmentEmotional Regulation SkillsAffect labilityExcessive AngerDistress ToleranceImpulsive BehaviourSuicidal ThreatAutomultilation
108DBT Individual Therapy StructuresBehaviouralCognitive -BehaviouralTeaching guiding modelling testing outStrategies to over come invalidating environmentWeekly Home work; monitoring diary
109Structure of the training Skills TrainingStructure of the trainingTwo times sequence over one yearEvery module comprises six weeksEvery session takes 2.5 hours incl breaksTrainer and Co –trainerVideotapingTelephone consultation only possible to repair contact or to inform about home workNo psychodynamic group therapyThe trainers are members of the (staff) consultation team
110The Self Trauma Model (Briere) Integrated ApproachCBT & RelationalTake symptoms beyond PTSD into account – address themTitrated exposure to traumatic materialAffect regulation trainingTrigger identificationMindfulness as cognitive and affect regulation
111Therapeutic relationship emphased Attendance / complianceContext for support / validation / safetyActivates relations schema which then can be addressed.Counter conditions relational trauma memories
112Affect regulation training Dealing with acute intrusions – groundingBreathing trainingIdentifying and discriminating emotionsCountering intrusive and exacerbating intrusionsDevelopment of equimany through mindfulnessRepeated exposure and processing as affect regulation trainingAffect Regulation – the content is not as important as the skill itself
113Mindfulness as a cognitive intervention Self observation:Moment by moment of awareness of internal experience without judgementLearning to let go of thoughts & feelings without avoidance or suppressionFocus on monkey mind / apes moviesEspecially childhood memoriesThoughts are not perceptions, perceptions do not necessarily reflect realityMediation of abuse related cognitive distortions and associated emotions
114Central Components of Trauma Processing ExposureActivation – triggers associated thoughts feelings – relivingDisparity – although in activated state – now able to talk to therapist in safe environment: fear is therefore not reinforced : negative state generated in a safe environmentCentral focus is on awareness: reliving trauma memories, thoughts, feelings – yet maintain current awareness experience ( safe): able to perceive the disparity memory of bad experience activated but need to be present in the here and now co awareness remember it as past aware that this is present.Working with traumatic memory – activate the specifics of the memory cue her memory by asking question about what happened – helps processing
115Therapeutic WindowTitrated exposureBalance between therapeutic challenge and overwhelming internal experienceMaximal possible exposure & reactivation within the limits of affect regulation activityOvershooting vs undershooting the window
116Identity DevelopmentExploration of self in the context of the therapeutic relationshipSelf knowledgeSelf directednessValue of not leaving open-ended questionsAvoiding over use of interpretations
117What is schema therapy? (Dr Julie Parker) Schema therapy developed as a result of limitations of CBT in dealing with problems presented by people with underlying personality disorderMany patients who have poor CBT outcome with Axis 1 disorder have an underlying PDe.g. a male patient undergoes CBT for OCD, when his symptoms are treated he has to face a life almost devoid of social contact. This lifestyle is a result of such an acute sensitivity to slights/rejections that he has avoided most social contact since childhood. He must grapple with the ‘defectiveness schema’ that underlies this problem if he is to have a rewarding life.
118Problems with CBT & PD issues Traditional CBT assumes that patients:will comply with necessary aspects of therapyare motivated & able to work with the therapist to reduce symptoms, build skills etc – for PD patients some primary symptoms are schema copingcan access thoughts & feelings –many PD patients engage in cognitive & affective avoidancecan change problem cognitions/behaviours through logical analysis, experimentation – PD patients are often psychologically rigidcan collaborate with the therapist – many PD patients have had disturbed relationships throughout their lives and have difficulty forming trusting relationshipsPD patients ‘symptoms’ are ego-syntonic – they feel right & like a part of them
119How does schema therapy differ from CBT? Expands on CBT by drawing on techniques from other schools of therapyGreater emphasis onExploring childhood & adolescent origins of psychological problemsOn emotive techniquesOn the therapist-patient relationshipOn maladaptive coping stylesOften undertaken in conjunction with other therapies & medsFor treating characterological problems not acute symptoms
120Psychodynamic / TF-CBT Models Contrast with Briere’s Model:De Zulueta’s (2002) model of intervention at the Maudsley Trauma Therapy Unit uses individual psychodynamic psychotherapies to deal with interpersonal and attachment issues before using Trauma-Focussed Cognitive-Behavioural Therapy (TF-CBT).
121Dealing with dissociation Its management requires a good attachment relation in therapy and techniques to reduce its frequency and intensity.Aim when dealing with trauma is to maintain ‘one foot in the past and one in the present’.Issues of shameGrounding techniques for dissociation.
122Importance of therapist’s right brain involvement Traumatisation involves the right hemisphere (feelings, memories, attachment).Inevitability of re-enactment of abuse in therapy.Importance of reparation during the therapeutic process: saying sorry!
123Dissociation and Reflective function Use of video or tape-recording in severely dissociated patients.> The development of mentalisation or mindfulness.
124Therapist’s survival Safety of therapeutic setting Importance of peer or other supervision because of likely-hood of re-enactment.Secondary traumatisation is inhererent to this type of work and needs to be addressed at all levels: self care, case load, support.
125Complex PTSD Programme 90 Days of structured work - 600 hours Three One Month Phases :Interactive Psycho-Education & Adjustment of Medication.Individual Disclosure of the TraumaCognitive Restructuring and Problem Solving
126CPTSD Programme content: Multimodal Multidisciplinary Assessment ProtocolGroup cohesion and boundary settingHighly structured work scheduleTherapeutic MilieuPsychoeducation – Trauma, Coping, RelationshipsMedicationsDisclosure on an individual basisCognitive restructuring / CBTBehavioural TechniquesDischarge planning and Liaison
128Subject Data 34 (consecutive) patients entered programme Small groups 4 to 630 patients completed programmeMean age 26.2 years (r=17-45).27 female; 3 male.4 did not finish: 2 became too dangerous to self or staff. 2 were afraid to get better!
129Results: Open outcome data first 30 patients: Parametric and non-parametric statistics
130Results: Open outcome data first 30 patients: Parametric and non-parametric statistics
131Other findings Of first 25 patients: 18 were transferred directly from inpatient wards where they had been treated cumulatively for 27 years (average 2 years 1 month)At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospitalSelf harm, eating disorders, OCD much improved.Several got employment for first time in years or went to full or part-time education.
132Other findings Of first 25 patients: 18 were transferred directly from inpatient wards where they had been treated cumulatively for 27 years (average 2 years 1 month)Estimate have saved approx £1.2 million on admission times.At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospitalSelf harm reduced by 95%, eating disorders, OCD much improved.Several got employment for first time in years or went to full or part-time education.
133The Dene: Forensic Service Medium Secure Hospital for Women Elizabeth Anderson Ward: Personality Disorder and Trauma Unit StrategyStabilizationDisclosure / Working throughCognitive restructuring
134Rolling Programme Assessment Protocol Therapeutic Milieu / General Adult WardDialectic Behaviour Therapy Skills groups and individual treatmentOpen admission / rolling group programmeTrauma Psychoeducation GroupsMedicationsDisclosure / Therapy on an individual basisCognitive restructuringCBT, Behavioural, Body Therapy GroupsRehabilitation / Discharge planning and Liaison
135DBT Promotes team working in MDT Promotes validates the patient Promotes boundaried response in times of crisis eg DSHOutcome studies: good results for borderline personality disorderLimited outcome studiesExpensive to train
137Complex PTSD Disturbance on Three Dimensions Symptoms of : PTSDSomaticAffectiveDissociation(reach psychotic intensity)Characterological Changes of:Control: Traumatic BondingLens of FearRelationships: Lens of extremity-attachment versus withdrawalIdentity Changes:Self structuresInternalized images of stressMalignant sense of selfFragmentation of the selfRepetition of HarmTo the self - faulty boundary settingBy others - battery, abuseOf others - become abusersDeliberate self harm
138Conclusions: CPTSD – A useful diagnostic framework: Very easy to mis-diagnose – few understand the concept of CPTSD.Easy to label patient as Borderline PD and say they are untreatableEasy to acknowledge co-morbid syndromes that are more conventional such as psychotic depressionEasy to diagnose schizophrenia / schizo-affective disorder.
139Post Script Special groups: Veterans Refugees Its not just about social support its about good enough attachments as well
140Why is Working With Veterans Complicated? Mental health problems can arise from a variety of causes in Veterans:Pre service vulnerabilities – many join to escape a difficult life situation, poor education levels, IQ?Military life itself – instutionalization, alcohol, family issues; bullying, non-operational occupational mental health injury; Operational service – traumatic exposure: single / multipleEarlier onset of physical disorders related to military life – mainly orthopaedic including chronic pain / ENT problems; Physical disorders associated with mental health illnessLeaving the service and adjusting to civilian life – institutionalisation Loss of attachmentsHelp seeking Issues surrounding being macho, avoidance of seeking help, lack of understanding of and by civilians, shame, stigma, guilt, you were not there etcCombination of the above
141The Needs of the Combat Stress Population: Clinical Audit Data All audits N=608%Significant Physical illness71Physical injury during military service48History of Psychiatric illness diagnosed prior to contact with Combat Stress as a measure of chronicity80Multiple exposure to military psychological trauma92Present and past history of alcohol and drug dependence and abuse69Significant attachment difficulties in childhood /adolescence incl CSA and other abuse52Commonest diagnosis PTSD75 (N=508)
142Reading listBriere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage.johnbriere.comBriere & Langtree (2008) Integrative treatment of complex trauma for adolescents (ITCT-A).
143Recommended readingBusuttil, W. (2009) Complex PTSD: A useful diagnostic frame work? Psychiatry, 8:8,Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane & Friedman, M J. Guilford Press: New York.Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J Garrick). Howarth Press: New York, USA.M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Routledge: London.Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van der Kolk, B. (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in Psychiatry, 26, ppVan der Kolk, B., Roth, S, Pelcovitz, D., Sunday S. & Spinazolla, J. (2005). Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress, 18 (5), pp
144ReferencesBloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London: Routledge,Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation and Treatment. Thousand Oaks, CA: SageBusuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA.Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M Nasser, K Baistow & J Treasure). Routledge: London.Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and competency. Psychiatric Annals 35,Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in a nationally representative sample. Journal of Traumatic Stress, 18,