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Treatments for Psychological Trauma: From Acute PTSD to Chronic Traumatization James L Spira, Ph.D., MPH, ABPP Clinical Professor, Department of Psychiatry,

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Presentation on theme: "Treatments for Psychological Trauma: From Acute PTSD to Chronic Traumatization James L Spira, Ph.D., MPH, ABPP Clinical Professor, Department of Psychiatry,"— Presentation transcript:

1 Treatments for Psychological Trauma: From Acute PTSD to Chronic Traumatization James L Spira, Ph.D., MPH, ABPP Clinical Professor, Department of Psychiatry, UCSD Clinical Director, Casa Palmera Residential Treatment Facility

2 Overview Part 1: Understanding Trauma and Trauma Tx Part 1: Understanding Trauma and Trauma Tx Part 2: Clinical Methods Which Can Be Easily Part 2: Clinical Methods Which Can Be EasilyUsed Part 3: Applications to Counseling Center Part 3: Applications to Counseling Center Settings with Non-specialized Staff

3 Outline, Part 1 Types of Trauma Types of Trauma Psychophysiology of Trauma Psychophysiology of Trauma Predispositions to Develop Trauma Predispositions to Develop Trauma Traditional Treatments and Efficacy Traditional Treatments and Efficacy Recent Developments in Treatment and Improved Efficacy Recent Developments in Treatment and Improved Efficacy Adapting Methods for Therapy with Students Adapting Methods for Therapy with Students

4 Types of Trauma Recent Single Event Recent Single Event ASD (dissociative and hypervigilant qualities) ASD (dissociative and hypervigilant qualities) PTSD Acute (hypervigilant and avoidant qualities) PTSD Acute (hypervigilant and avoidant qualities) PTSD Chronic ( > 3 mo) PTSD Chronic ( > 3 mo) Complex Acute PTSD Complex Acute PTSD Other co-existing psychological or physical problems Other co-existing psychological or physical problems Complex Chronic PTSD/Trauma Complex Chronic PTSD/Trauma Ongoing Childhood Abuse, by caregiver Ongoing Childhood Abuse, by caregiver Adolescent Adolescent by authority figure by authority figure by partner by partner Delayed PTSD Delayed PTSD

5 Types of Trauma Childhood chronic abuse Childhood chronic abuse Not necessarily fitting PTSD Criteria Not necessarily fitting PTSD Criteria Involved in personality development Involved in personality development Understanding of relationship and sexuality Understanding of relationship and sexuality Bonding Difficulty Bonding Difficulty Avoidant or anxious attachment Avoidant or anxious attachment Trusting and intimacy Trusting and intimacy Borderline Spectrum Borderline Spectrum Influences interpretation of and coping with new ‘traumatic’ incidents Influences interpretation of and coping with new ‘traumatic’ incidents

6 Types of Trauma Delayed PTSD Delayed PTSD Delayed Onset (several months) Delayed Onset (several months) Long Delayed (years) Long Delayed (years) Early chronic trauma influences later susceptibility to PTSD from a traumatic event Early chronic trauma influences later susceptibility to PTSD from a traumatic event Example of childhood molestation influencing susceptibility to later relationship abuse Example of childhood molestation influencing susceptibility to later relationship abuse Case: 19 y/o SWF; victimized as 12 y/o by father’s business partner; father did not take appropriate action; but later got her ‘counseling’ from a married 52 y/o Church of Scientology “counselor” who then started a sexual relationship with her, which quickly turned controlling with threats Case: 19 y/o SWF; victimized as 12 y/o by father’s business partner; father did not take appropriate action; but later got her ‘counseling’ from a married 52 y/o Church of Scientology “counselor” who then started a sexual relationship with her, which quickly turned controlling with threats Other cases are similar in getting involved in abusive relationships, which are seen as normal, or from which the victim can’t find a way out. Other cases are similar in getting involved in abusive relationships, which are seen as normal, or from which the victim can’t find a way out.

7 Psychophysiology of Trauma Imaging shows: Imaging shows: Enhanced Reticular Activating System arousal Enhanced Reticular Activating System arousal Enhanced Periaquiductal Grey arousal Enhanced Periaquiductal Grey arousal Limbic Involvement Limbic Involvement Acute trauma related to Acute trauma related to increased limbic/hippocampal processing increased limbic/hippocampal processing Increased cortisol and glutamate/NMDA receptor changes Increased cortisol and glutamate/NMDA receptor changes Chronic trauma related to decreased limbic morphology Chronic trauma related to decreased limbic morphology Possibly due to excessive cortisol and glutamate involvement Possibly due to excessive cortisol and glutamate involvement

8 Psychophysiology Hypothalamic-Pituitary-Adrenal Axis Hypothalamic-Pituitary-Adrenal Axis Situation interpreted as emergency Situation interpreted as emergency Classical Conditioning of paired emotion-episodic memory (amygdala- hippocampus) Classical Conditioning of paired emotion-episodic memory (amygdala- hippocampus) Continual Reprocessing of Reaction Continual Reprocessing of Reaction Internal recall kept active, since situation could recur Internal recall kept active, since situation could recur External generalizability of situation to similar elements External generalizability of situation to similar elements Frontal interpretation (serious life threatening problem – deal with it)  Limbic Reaction (keep brain and body in emergency status)  Limbic Reaction (keep brain and body in emergency status)  Frontal Interpretation (Stay alert in case emergency returns!)  Frontal Interpretation (Stay alert in case emergency returns!)  Limbic Reaction (keep brain and body in emergency status)  Limbic Reaction (keep brain and body in emergency status)  Etc. (focusing on the problem keeps the problem real)  Etc. (focusing on the problem keeps the problem real)

9 Prevalence According to the National Institutes of Mental Health, 5.2 million Americans aged have PTSD. According to the National Institutes of Mental Health, 5.2 million Americans aged have PTSD. Untold millions have had traumatic experiences that affect their lives Untold millions have had traumatic experiences that affect their lives The Veteran's Administration (VA) operates more than 140 specialized programs for the treatment of PTSD through VA Medical Centers and Clinics. In 2001, more than 77,300 veterans were treated for PTSD by VA specialists. The Veteran's Administration (VA) operates more than 140 specialized programs for the treatment of PTSD through VA Medical Centers and Clinics. In 2001, more than 77,300 veterans were treated for PTSD by VA specialists. National Institute of Mental Health. Reliving Trauma, Post-traumatic Stress Disorder. Available at: National Institute of Mental Health. Reliving Trauma, Post-traumatic Stress Disorder. Available at: Department of Veterans Affairs. Fact Sheet: VA programs for veterans with Post-Traumatic Stress Disorder (PTSD). Available at: Department of Veterans Affairs. Fact Sheet: VA programs for veterans with Post-Traumatic Stress Disorder (PTSD). Available at:

10 Predisposition to PTSD Prior psychological difficulties Prior psychological difficulties Prior traumatic event Prior traumatic event Especially which was not coped with well Especially which was not coped with well Especially which was chronic Especially which was chronic Especially which involved caregivers Especially which involved caregivers Prior psychological diagnosis Prior psychological diagnosis (especially Anxiety disorders) (especially Anxiety disorders) Personality / Coping Style Personality / Coping Style Very reflective and sensitive (hyper-reflective anxious PTSD) Very reflective and sensitive (hyper-reflective anxious PTSD) Blunted and non-reflective (angry/repressive type PTSD) Blunted and non-reflective (angry/repressive type PTSD) Meaninglessness Meaninglessness

11 Prevalence and Time Course A prospective longitudinal study assessed 967 consecutive patients who attended an emergency clinic shortly after a motor vehicle accident, again at 3 months, and at 1 year. A prospective longitudinal study assessed 967 consecutive patients who attended an emergency clinic shortly after a motor vehicle accident, again at 3 months, and at 1 year. The prevalence of posttraumatic stress disorder (PTSD) The prevalence of posttraumatic stress disorder (PTSD) 23.1% at 3 months 23.1% at 3 months 16.5% at 1 year. 16.5% at 1 year. Chronic PTSD was related to some objective measures of trauma severity Chronic PTSD was related to some objective measures of trauma severity perceived threat, and dissociation during the accident, perceived threat, and dissociation during the accident, to female gender, to previous emotional problems, and to litigation. to female gender, to previous emotional problems, and to litigation. Maintaining psychological factors enhanced the accuracy of the prediction Maintaining psychological factors enhanced the accuracy of the prediction negative interpretation of intrusions, rumination, thought suppression, and anger cognitions negative interpretation of intrusions, rumination, thought suppression, and anger cognitions The most important predictors of PTSD symptoms at 1 year were: The most important predictors of PTSD symptoms at 1 year were: Negative interpretation of intrusions, persistent medical problems, and rumination at 3 months, Negative interpretation of intrusions, persistent medical problems, and rumination at 3 months, Cases of delayed onset related to anger cognitions, injury severity, and prior emotional problems Cases of delayed onset related to anger cognitions, injury severity, and prior emotional problems Ehlers, A, Mayou, R, Bryant, B (1998) Psychological Predictors of Chronic Posttraumatic Stress Disorder After Motor Vehicle Accidents Journal of Abnormal Psychology; 107(3)

12 Prevalence and Time Course Gray, MJ, Bolton, EE & Litz, BT (2004). Longitudinal Analysis of PTSD Symptom Course : Delayed-Onset PTSD in Somalia Peacekeepers; JCCP; 2004, Vol. 72, No. 5, 909–913. N=1035 sample followed over one year SampleType PTSD Sx Score Time 1Time Resilient (few Sx) Acute onset, no remittance Remitters (acute onset, remitted) Delayed Onset 3452 (about 14% of sample developed significant Sx, about ½ was delayed onset)

13 Typical Treatments Medications Medications For each type of PTSD For each type of PTSD Cognitive Behavioral Therapies Cognitive Behavioral Therapies For each type of PTSD For each type of PTSD Rational vs automatic responses Rational vs automatic responses Individual vs group Individual vs group Critical Incident Stress Debriefings (CISD) Critical Incident Stress Debriefings (CISD) Immediately following a disaster to prevent PTSD Immediately following a disaster to prevent PTSD

14 Typical Treatments: Medication Acute Stress D/O Acute Stress D/O Beta Blockade Beta Blockade Benzodiazepine Benzodiazepine Acute PTSD Acute PTSD SSRI, TCA SSRI, TCA Chronic PTSD Chronic PTSD SSRI SSRI Anti-Psychotic Anti-Psychotic Benzodiazepine? Benzodiazepine? Sleep Support Sleep Support

15 Typical Treatments: CBT for Complex PTSD 121 female rape victims, most of whom had extensive histories of trauma, were randomly assigned to cognitive-processing therapy, prolonged exposure, or a delayed-treatment waiting-list condition. 121 female rape victims, most of whom had extensive histories of trauma, were randomly assigned to cognitive-processing therapy, prolonged exposure, or a delayed-treatment waiting-list condition. Both types of treatment were equally effective for treating complex PTSD symptoms, Both types of treatment were equally effective for treating complex PTSD symptoms, The sample was then divided into two groups depending upon whether they had a history of child sexual abuse. Both groups improved significantly over the course of treatment with regard to PTSD, depression, and the symptoms of complex PTSD as measured by the Trauma Symptom Inventory. Improvements were maintained for at least 9 months. The sample was then divided into two groups depending upon whether they had a history of child sexual abuse. Both groups improved significantly over the course of treatment with regard to PTSD, depression, and the symptoms of complex PTSD as measured by the Trauma Symptom Inventory. Improvements were maintained for at least 9 months. These findings indicate that cognitive-behavioral and exposure therapies are effective for patients with complex trauma histories and symptoms patterns. These findings indicate that cognitive-behavioral and exposure therapies are effective for patients with complex trauma histories and symptoms patterns. Resick PA. Nishith P. Griffin MG. (2003) How well does cognitive-behavioral therapy treat symptoms of complex PTSD? An examination of child sexual abuse survivors within a clinical trial. Cns Spectrums. 8(5): Resick PA. Nishith P. Griffin MG. (2003) How well does cognitive-behavioral therapy treat symptoms of complex PTSD? An examination of child sexual abuse survivors within a clinical trial. Cns Spectrums. 8(5): Resick PANishith PGriffin MGResick PANishith PGriffin MG

16 Typical Treatments Critical Incident Stress Debriefing / Management (CISD/CISM) Critical Incident Stress Debriefing / Management (CISD/CISM) Makes Clinical Sense Makes Clinical Sense Unlikely to do harm Unlikely to do harm Likely to be useful as screening assessment Likely to be useful as screening assessment Likely to be useful to normalize therapy for future Likely to be useful to normalize therapy for future Not good evidence of value in reducing PTSD Dx or Sx in studies and meta analysis, and therefore not as widely recommended as it once was Not good evidence of value in reducing PTSD Dx or Sx in studies and meta analysis, and therefore not as widely recommended as it once was

17 Experiential Therapies: Dissociation Relaxation Relaxation Physical (Autonomic) Emphasis Physical (Autonomic) Emphasis PSNS retraining PSNS retraining Muscle relaxation Muscle relaxation Slow breathing Slow breathing Biofeedback Biofeedback Efficacy? Efficacy? Alone has limited effects Alone has limited effects More effective in combination with other techniques More effective in combination with other techniques

18 Experiential Therapies: Dissociation Meditation Meditation Attentional retraining Attention is enhanced processing: Attention is enhanced processing: Whatever you attend to, you enhance Whatever you attend to, you enhance (worry, pain, noise, arousal / breath, warmth, work) (worry, pain, noise, arousal / breath, warmth, work) Your brain/body support what you attend to: Your brain/body support what you attend to: H-P-A axis H-P-A axis (ANS activation; PAG relay; Limbic arousal; frontal interpretation – for SNS or PSNS) (ANS activation; PAG relay; Limbic arousal; frontal interpretation – for SNS or PSNS) If you can address a problem, then do so, otherwise focus on neutral or positive sensations or activity If you can address a problem, then do so, otherwise focus on neutral or positive sensations or activity Meditation helps reduce background “noise” and enhance foregrounded signal Meditation helps reduce background “noise” and enhance foregrounded signal ZEN MEDITATION (signal emphasis) ZEN MEDITATION (signal emphasis) VIPASSANA MEDITATION (noise reduction) VIPASSANA MEDITATION (noise reduction)

19 Experiential Therapies: Controlled Dissociation Hypnosis Hypnosis Principles Principles Controlled dissociation (x4) Controlled dissociation (x4) Hypnotizability Hypnotizability Methods Methods Light trance Light trance CBT + relaxation + graded exposure CBT + relaxation + graded exposure Bypasses typical conscious resistance (schema) Bypasses typical conscious resistance (schema) Deep trance Deep trance Bypasses conscious resistance/habit schema Bypasses conscious resistance/habit schema Reassociates new emotions with old memories Reassociates new emotions with old memories Efficacy? Efficacy? Reportedly high for highly hypnotizable pts Reportedly high for highly hypnotizable pts Highly hypnotizable pts may do worse w/o tx, better w/tx Highly hypnotizable pts may do worse w/o tx, better w/tx

20 Experiential Therapies: Dissociation EMDR EMDR Principles Principles Methods Methods Efficacy? Efficacy? Meta analyses and comparative studies show it may be effective in PTSD, but is not more effective than other therapies Meta analyses and comparative studies show it may be effective in PTSD, but is not more effective than other therapies May be only exposure therapy with ritual May be only exposure therapy with ritual

21 Experiential Therapies: EMDR The authors examined the efficacy, speed, and incidence of symptom worsening for 3 treatments of posttraumatic stress disorder (PTSD): prolonged exposure, relaxation training, or eye movement desensitization and reprocessing (EMDR) N = 60. Treatments did not differ in attrition, in the incidence of symptom worsening, or in their effects on numbing and hyperarousalsymptoms. Compared with EMDR and relaxation training, exposure therapy (a) produced significantly larger reductions in avoidance and reexperiencing symptoms, (b) tended to be faster at reducing avoidance, and (c) tended to yield a greater proportion of participants who no longer met criteria for PTSD after treatment. EMDR and relaxation did not differ from one another in speed or efficacy. Taylor, S. Thordarson, D. Maxfield, L. Fedoroff, I. Lovell, K. Ogrodniczuk, J. (2003). Comparative Efficacy, Speed, and Adverse Effects of Three PTSD Treatments: Exposure Therapy, EMDR, and Relaxation Training Journal of Consulting and Clinical Psychology; 71(2)

22 Experiential Therapies: EMDR Meta Analyses: Eye movement desensitization and reprocessing (EMDR), a controversial treatment suggested for posttraumatic stress disorder (PTSD) and other conditions, was evaluated in a meta-analysis of 34 studies that examined EMDR with a variety of populations and measures. Process and outcome measures were examined separately, and EMDR showed an effect on both when compared with no treatment and with therapies not using exposure to anxiety-provoking stimuli and in pre-post EMDR comparisons. However, no significant effect was found when EMDR was compared with other exposure techniques. No incremental effect of eye movements was noted when EMDR was compared with the same procedure without them. R. J. DeRubeis and P. Crits-Christoph (1998) noted that EMDR is a potentially effective treatment for noncombat PTSD, but studies that examined such patient groups did not give clear support to this. In sum, EMDR appears to be no more effective than other exposure techniques, and evidence suggests that the eye movements integral to the treatment, and to its name, are unnecessary. Davidson, P. Parker, K. (2001) Eye Movement Desensitization and Reprocessing (EMDR): A Meta- Analysis. JCCP 69(2); Davidson, P. Parker, K. (2001) Eye Movement Desensitization and Reprocessing (EMDR): A Meta- Analysis. JCCP 69(2);

23 Experiential Therapies: Exposure In the 1980’s, Terence Keane and colleagues found that exposure therapy was effective in treating the PTSD symptoms of Vietnam War veterans. In the 1980’s, Terence Keane and colleagues found that exposure therapy was effective in treating the PTSD symptoms of Vietnam War veterans. In the 90s, research by Edna Foa and her colleagues showed that exposure therapy was perhaps the most effective Tx for reducing PTSD symptoms of rape victims, including persistent fear. Improvements were seen immediately after exposure therapy, and sustained during a three-month follow-up. In the 90s, research by Edna Foa and her colleagues showed that exposure therapy was perhaps the most effective Tx for reducing PTSD symptoms of rape victims, including persistent fear. Improvements were seen immediately after exposure therapy, and sustained during a three-month follow-up. Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). The treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). The treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, Keane, T. M. & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, Keane, T. M. & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduced symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduced symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20,

24 Experiential Therapies: Exposure Flooding Flooding Sudden and total immersion into arousing environment Sudden and total immersion into arousing environment (not recommended for PTSD due to potential for retraumatizing) Graded Exposure Graded Exposure Gradually increasing immersion into arousing environment, as the patient is able to tolerate. Gradually increasing immersion into arousing environment, as the patient is able to tolerate. Re-associate previously traumatic cognitions with comfortable or neurtral affect Re-associate previously traumatic cognitions with comfortable or neurtral affect Discussion (CISD) Discussion (CISD) Procedure Procedure Efficacy with different populations Efficacy with different populations Imagery Imagery Using internal visual images for those with imagery capacity (-20%) Using internal visual images for those with imagery capacity (-20%) Virtual Reality Virtual Reality

25 VR Assisted Graded Exposure VR assisted GRADED EXPOSURE with biofeedback/attentional retraining VR assisted GRADED EXPOSURE with biofeedback/attentional retraining Combining the best of high tech and low tech Combining the best of high tech and low tech

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33 With Medication that soothes limbic arousal With Medication that soothes limbic arousal Does de-arousing medication: Does de-arousing medication: Allow greater mental and physical relaxation Allow greater mental and physical relaxation Yes Yes allow greater exposure allow greater exposure Yes Yes Prevent generalizability post treatment? Prevent generalizability post treatment? Doesn’t seem to; instead, it extends long term outcome at least in one small, well conducted study using DCS Doesn’t seem to; instead, it extends long term outcome at least in one small, well conducted study using DCS (Ressler et al (Nov 2004); Cognitive Enhancers as Adjuncts to Psychotherapy. Arch Gen Psychiatry, ) (Ressler et al (Nov 2004); Cognitive Enhancers as Adjuncts to Psychotherapy. Arch Gen Psychiatry, )

34 Meta Analyses Van Etten and Taylor analyzed 61 treatment trials that included pharmacotherapy and modalities such as behavior therapy (particularly exposure therapy), eye movement desensitization and reprocessing (EMDR), relaxation training, hypnotherapy, and dynamic psychotherapy. Overall, this meta-analysis found that exposure therapy was more efficacious than any other type of treatment for PTSD when measured by clinician rated measures. Van Etten and Taylor analyzed 61 treatment trials that included pharmacotherapy and modalities such as behavior therapy (particularly exposure therapy), eye movement desensitization and reprocessing (EMDR), relaxation training, hypnotherapy, and dynamic psychotherapy. Overall, this meta-analysis found that exposure therapy was more efficacious than any other type of treatment for PTSD when measured by clinician rated measures. Specifically, the effect size for all types of psychotherapy interventions was 1.17 compared with 0.69 for medication. Perhaps more significant, the mean dropout rate in medication trials was 32% compared with 14% in psychotherapy trials. Specifically, the effect size for all types of psychotherapy interventions was 1.17 compared with 0.69 for medication. Perhaps more significant, the mean dropout rate in medication trials was 32% compared with 14% in psychotherapy trials. A second meta-analysis of psychotherapeutic treatments found that treatment benefits for target symptoms of PTSD and for general psychological symptoms (intrusion, avoidance, hyperarousal, anxiety, and depression) were significant, with effect sizes ranging from 0.2 to 0.49 A second meta-analysis of psychotherapeutic treatments found that treatment benefits for target symptoms of PTSD and for general psychological symptoms (intrusion, avoidance, hyperarousal, anxiety, and depression) were significant, with effect sizes ranging from 0.2 to 0.49 Van Etten ML, Taylor S. Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy 1998;5:144–54. Van Etten ML, Taylor S. Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy 1998;5:144–54. Sherman JJ. Effects of psychotherapeutic treatments for PTSD. J Trauma Stress 1998;11:413–6 Sherman JJ. Effects of psychotherapeutic treatments for PTSD. J Trauma Stress 1998;11:413–6

35 Consensus Panel on PTSD Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ. Foa EB. Kessler RC. McFarlane AC. Shalev AY. Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ. Foa EB. Kessler RC. McFarlane AC. Shalev AY. Ballenger JCDavidson JRLecrubier YNutt DJFoa EBKessler RCMcFarlane ACShalev AY Ballenger JCDavidson JRLecrubier YNutt DJFoa EBKessler RCMcFarlane ACShalev AY Title: Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Title: Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Source: Journal of Clinical Psychiatry. 61 Suppl 5:60-6, Source: Journal of Clinical Psychiatry. 61 Suppl 5:60-6, EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONCLUSION: Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed. CONCLUSION: Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.

36 Summary SSRI & Sleep support along with Experiential Therapies which focus on development of cognitive and somatic skills are very beneficial in the treatment of simple acute PTSD. SSRI & Sleep support along with Experiential Therapies which focus on development of cognitive and somatic skills are very beneficial in the treatment of simple acute PTSD. SSRI along with Cognitive and Interpersonal Therapies in combination with Experiential Therapies may be necessary in the treatment of complex chronic PTSD. SSRI along with Cognitive and Interpersonal Therapies in combination with Experiential Therapies may be necessary in the treatment of complex chronic PTSD.

37 Adapting for Counseling Centers Assess: Assess: simple acute vs chronic complex simple acute vs chronic complex existing coping skills vs need for medication support (sleep, unable to engage in or benefit from therapy) existing coping skills vs need for medication support (sleep, unable to engage in or benefit from therapy) willingness to develop personal skills to improve vs needing continued external interpersonal support and understanding willingness to develop personal skills to improve vs needing continued external interpersonal support and understanding

38 Adapting for Counseling Centers Provide a cognitive frame Provide a cognitive frame Psychoeducation for how trauma symptoms occur Psychoeducation for how trauma symptoms occur Normalize Normalize Explain the psychophysiology Explain the psychophysiology Explain the Sx Explain the Sx Cognitive Therapy for understanding Cognitive Therapy for understanding Habit stimuli, cog/emot/physiol/behavioral reactions Habit stimuli, cog/emot/physiol/behavioral reactions Optimal / healthy reactions Optimal / healthy reactions Skills needed to obtain these optimal reactions Skills needed to obtain these optimal reactions

39 Adapting for Counseling Centers Offer interpersonal support if need be: Offer interpersonal support if need be: Group process (but be careful not to develop a “sick role attitude” Group process (but be careful not to develop a “sick role attitude” Time limited Time limited CBT oriented with interpersonal discussion CBT oriented with interpersonal discussion Family/couple therapy Family/couple therapy

40 Adapting for Counseling Centers If complex/chronic If complex/chronic Address current crisis Address current crisis Consider dynamic approach Consider dynamic approach Discuss early childhood traumas Discuss early childhood traumas How these influence current: How these influence current: Personality and Beliefs about self, others, world Personality and Beliefs about self, others, world Interpretations of and reactions to past critical and current events Interpretations of and reactions to past critical and current events Discuss optimal / normal interpretations & reactions Discuss optimal / normal interpretations & reactions

41 Adapting for Counseling Centers Introduce Experiential Methods: Introduce Experiential Methods: 1 st : develop skills of being comfortably in the moment 1 st : develop skills of being comfortably in the moment 2 nd : take a mildly uncomfortable event and practiced with it: 2 nd : take a mildly uncomfortable event and practiced with it: Tolerate sustaining attention to it Tolerate sustaining attention to it Distance as necessary to sustain attention to it Distance as necessary to sustain attention to it Return to being comfortably in the moment Return to being comfortably in the moment Go back and forth several times to teach basic skill Go back and forth several times to teach basic skill (optimally with biofeedback monitoring; otherwise minimal cues and verbal SUDS) (optimally with biofeedback monitoring; otherwise minimal cues and verbal SUDS)

42 Adapting for Counseling Centers Experiential Methods Experiential Methods 3 rd – Take more relevant but moderately arousing event, and repeat step 2 above 3 rd – Take more relevant but moderately arousing event, and repeat step 2 above 4 th – Take most relevant and arousing event, and repeat step 2 above 4 th – Take most relevant and arousing event, and repeat step 2 above Continue until no major arousal occurs Continue until no major arousal occurs Note: Each step could take several sessions This can be done in group as well (but give This can be done in group as well (but give warnings not to use very arousing stimuli at first) warnings not to use very arousing stimuli at first)

43 Adapting for Counseling Centers Typical Session: Typical Session: Review Sx since last session Review Sx since last session Review practice since last session Review practice since last session Practice meditation (attentional retraining) Practice meditation (attentional retraining) If successful, introduce moderate stressor If successful, introduce moderate stressor Arousal, distance as necessary Arousal, distance as necessary Return to meditation (alternate every few minutes) Return to meditation (alternate every few minutes) If successful, introduce stronger stressor If successful, introduce stronger stressor Arousal, distance as necessary Arousal, distance as necessary Return to meditation (alternate, every few minutes) Return to meditation (alternate, every few minutes) Debrief and discuss practice times and situations Debrief and discuss practice times and situations

44 Adapting for Counseling Centers Practice: Practice: In group In group With partners With partners

45 Adapting for Counseling Centers Discuss issues related to implementation in counseling center context Discuss issues related to implementation in counseling center context Settings/sessions Settings/sessions Non-specialized staff therapists Non-specialized staff therapists Difficult students Difficult students


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