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Special populations Headaches CRPS/Complex trauma GAD UTI/Vaginismus Complicated bereavement Mark Grant.

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Presentation on theme: "Special populations Headaches CRPS/Complex trauma GAD UTI/Vaginismus Complicated bereavement Mark Grant."— Presentation transcript:

1 Special populations Headaches CRPS/Complex trauma GAD UTI/Vaginismus Complicated bereavement Mark Grant

2 Headaches One of most common pain complaints 1 year prevalence rate 12-14% (migraine) Often a symptom of trauma 25% of headache sufferers (migraine clinic) have PTSD 50% of combat veterans Higher likelihood of physical or sexual abuse Mark Grant

3 Mark Grant. MA, MAPs Headache case. Headaches, fatigue, TMJ Shift work, insomnia, health problems, unhappy marriage Emotional neglect and criticism

4 EMDR ‘targets’ Mark Grant MA EventNC PAST TRAUMA:Fathers criticismI’m not good enough EmigratingI’m bad PRESENT STRESS: Relationship Old job New job I’m trapped I’m not good enough PRESENT PAIN:HeadachesWhats wrong with me? FatigueI can’t cope

5 EMDR (present pain) Present pain (Headache) NC: Whats wrong with me? DAS/Bls Relaxed Less pain PC: ‘I can learn to control my pain’ Mark Grant

6 Caution! When is a headache not a headache? Sudden onset Non-responsive to medication Other symptoms (seizures, changes in vision or hearing) Aggravated by coughing or sneezing Mark Grant MA

7 CRP/RSD Trauma can be a predisposing factor following injury Median PTSS-10 score similar to trauma survivors (118 patients) Similar neurological profile to PTSD CRPS has been reported to be elicited by stress exacerbation in patients with PTSD (Huge et al, 2011) Mark Grant MA

8 Mark Grant. MA, MAPs CRPS/complex trauma. Neck & shoulder pain Agitated, can’t relax Injury and disability Carer for sick grandmother, family conflict Abandoned by mother, unstable early life,

9 EMDR targets Mark Grant MA EventNC PAST TRAUMA:Mother leavingI’m unloveable Unstable home lifeI’m not safe PRESENT STRESS: Injury & disability No family I’m useless I’m alone PRESENT PAIN:Arm painWhats wrong with me? Back painWhats wrong with me? Injury Disability I’m vulnerable I’m not safe

10 EMDR (present pain) Present pain (spiky red ball) NC: I’m defeated DAS/Bls More Relaxed Pain is less distressing PC: ‘I can beat it’ (3/7 – 4/7) Mark Grant

11 Elements of treatment (complex trauma) 1.Extended preparation stage 2.Teaching of grounding techniques 3.Addressing ‘fear of feelings” 4.Teaching client how to self-soothe instead of self-injure 5.Teaching client how to attend to their pain by showing appropriate care and concern 6.Challenge feelings of unworthiness 7.Developing resources 8.Ego-state work Mark Grant. MA, MAPs

12 Generalized Anxiety Disorder Mark Grant MA Prevalence = 2 - 5% of general pop’n DSM criteria somatic symptoms; restlessness, fatigue, concentration problems, irritability, muscle tension and sleep disturbance. Often associated with somatic complaints such as low back pain and headaches and insomnia One study found 50% of IBS sufferers also had GAD 17% of PTSD sufferers also have GAD

13 Mark Grant. MA, MAPs GAD case. Headaches, Tinnitus dizzy spells, fatigue, Family stress (baby, uni studies), insomnia, financial stress, past influenza Premature birth, anxious mother, distant father

14 EMDR targets Mark Grant MA EventNC PAST TRAUMA:Mother’s anxietyIts not safe PRESENT STRESS: Fatigue & disability Not working Struggling with studies I can’t cope I’m a failure I’m not good enough PRESENT PAIN:Dizziness, tinglingThere is something wrong with me

15 EMDR (present pain) Symptoms of GAD ‘Whats wrong with me?’ Dizziness & tingling DAS/Bls Calm decreased symptoms ‘I’m ok’ ‘I can control my feelings’ Mark Grant

16 UTI/vaginismus Trauma is a predisposing factor 1 in 5 women will have a UTI in lifetime Women sufferers more than twice as likely to report some form of sexual molestation during childhood UTI can lead to or exacerbate vaginismus Mark Grant MA

17 Mark Grant. MA, MAPs UTI/vaginismus case. Pain in uretha Headaches, bloating 2 x miscarriages, job stress, bullying coach, health issues, work + motherhood Rejected and abused by mother and sister

18 EMDR targets Mark Grant MA EventNC PAST TRAUMAMothers criticismI’m unloveable 2 x miscarriagesI’m a failure Breakdown at workI’m a failure PRESENT STRESSConflict with sons coachI’m weak helpless Holding family togetherI’m responsible for everyone PRESENT PAINPain in stomach and uretha Whats wrong with me?

19 EMDR (past trauma) Mothers criticism Anxious ‘I’m unloveable’ DAS/Bls Calm decreased symptoms ‘I’m okay’ Mark Grant

20 Complicated bereavement Pain is symptom of trauma Prevalence = 2% of normal pop’n 20% of soldiers from Afghanistan, Iraq Physical symptoms can include shortness of breath, heart palpitations, headaches, lethargy Health issues (increased risk of); – cancer, – cardiac problems, – suicidality, – substance abuse Mark Grant MA

21 Mark Grant. MA, MAPs Complicated bereavement TMJ, chest pains Death of grandson 12 months ago Family breakup?

22 EMDR targets Mark Grant MA EventNC PAST TRAUMADeath of grandsonI’m helpless PRESENT STRESSProblems eating PRESENT PAINPain in jaw and heartI’m helpless

23 EMDR (past trauma + present pain) Death of grandson Sad, grief- stricken ‘I’m helpless’ DAS/Bls Calm decreased pain ‘I can remember him with love not pain’ Mark Grant

24 Key points: Although triggered by current stress/trauma, Pain is often a symptom of earlier trauma. Target sequence addresses both past trauma and present pain, depending on client readiness. Target may incorporate past and present pain. Reprocessing often starts with present pain because of safety issues (also easier to address past trauma after present pain is better managed). Duration of treatment, outcomes and need for additional inputs depends upon complexity of trauma Mark & Ana Grant

25 Complex trauma and pain Victims of long-term sexual and physical abuse Victims of emotional neglect Victims of childhood abuse and neglect who have also suffered later trauma (eg; serious accident, rape, combat, workplace bullying) + injury, IIIness, disability Mark Grant. MA, MAPs

26 Elements of treatment 1.Extended preparation stage 2.Teaching of grounding techniques 3.Address ‘fear of feelings” 4. Teaching client how to self-soothe instead of self-injure 5. Teaching client how to attend to their pain by showing appropriate care and concern 6. Challenge feelings of unworthiness 7. Developing resources 8.Ego-state work Mark Grant. MA, MAPs

27 Grounding techniques Interpersonal: “Its okay, you are safe now, you are here with me…” Somatic: “Can you feel your feet touching the floor?” ”Can you pay attention to your breathing..” “look at your hands or feet.. you’re a big boy/girl now.” Mark Grant. MA, MAPs

28 Addressing fear of feelings Facilitating accepting atmosphere (showing empathy, acceptance) Psychoeducation about the meaning of feelings, including pain Normalizing feelings, including feelings of wellness/feeling okay Mark Grant. MA, MAPs

29 Self-soothing techniques Psychoeducation (teaching how to self-soothe instead of self- injure); “Pain means you are hurt and need help” “What does an animal do when its wounded” “Humans are the only creature capable of ignoring pain” Developing self soothing strategies; “What things or places make you feel the most relaxed/safe/secure?” (hints; a trusted friend, a pet, a room or place, music, activity such as craft etc) Mark Grant. MA, MAPs

30 Self-care skills training Attending to the pain experience; “Even though I can’t feel your pain, I can see you are hurting and I am going to TRY TO help you” “You’re not alone - I am here” (reparenting) Addressing feelings of unworthiness; “What have you done that makes you so underserving of even basic medical attention/self-care?” “What have you done to feel that you only deserve to suffer.. forever?” “Everyone is entitled to a pain-free life” Mark Grant. MA, MAPs

31 Body resource exercise “I want you to mentally scan your whole body… and find a relaxed, calm place… somewhere that feels normal …and just notice how it feels there…maybe soft… warm…loose…maybe a certain size, shape or colour… just noticing how it feels…different to the rest of your body… and maybe you can get an image of how that calm place feels.. and that image can remind you that you can feel better”

32 Mark Grant. MA, MAPs Pendulation “Now I want you to notice the area of pain [or discomfort] … and notice how that feels… and when you have that clear enough … take your mind back to that relaxed, calm place …and notice how that feels again there… just noticing how it feels…and how different it feels to the pain …and then when you have got that clear, I want you to notice the pain again… and how it feels.. And whether it feels any different to before..” and so on… (Adapted from Peter Levine)

33 Ego state therapy “..based on the premise that personality is composed of separate parts, rather than being a homogeneous whole. These parts (which everyone has) are called ego states. The therapist learns to work directly with the state that can best benefit from change, rather than merely working with an intellectual, talkative state.” Emmerson, Mark Grant. MA, MAPs

34 Solo mother with chronic pain T: I can almost feel how heavy and defeated you must be feeling CL: I do feel defeated – but I don’t want this to affect my children (staring into space) T: You seem lost CL: That’s how I feel - I dunno where I am at the moment T: I guess you’re just taking things one day at a time – before the pain you sort of had your life figured out but now.. Mark Grant. MA, MAPs

35 Solo mother with chronic pain CL: (interrupts) No, I had it ALL figured out, I was in control of everything, now I can’t even be bothered cleaning the bathroom. I feel like a complete failure. T: What about the children? CL: Oh well of course I get up and make their breakfast and school lunch etc.. T: I’m hearing that there’s a defeated part, but that there’s also a part that won’t quit, who gets up and makes the children’s breakfast no matter how tired and defeated she feels.. Mark Grant. MA, MAPs

36 Solo mother with chronic pain Cl: That part is the only part I feel I have control over T: have you ever thought how maybe those parts might compliment each other? Cl: Huh? T: Well the defeated part is telling you to rest, but then the ‘in control’ part tells you to try harder, and motivates the responsible part to keep looking after the children. Cl: I never thought of things that way T: What I’m saying is that you need BOTH parts; Mark Grant. MA, MAPs

37 Solo mother with chronic pain T:..and they need to work together, but at the moment they’re kind of pulling in different directions. Cl: Uhuh T: So what if the defeated part could say to the ‘in- control’ part, ‘I’m tired and I need a rest’ and the ‘in- control’ part could actually hear that and use it to pace yourself better? Cl: I dunno… Th: Actually, its already happening, you don’t do as much now so as to conserve energy for the children Mark Grant. MA, MAPs

38 Solo mother with chronic pain T: The problem is that the ‘in-control’ part labels this as failure instead of seeing it as a form of self- preservation. CL: Yes, that’s true T: So if we could talk to the part that feels defeated first, what do you think it would say to the ‘in-control’ part? CL: I simply can’t do as much as I used to be able to T: And what would the control part say back? CL: I have to adjust my expectations.. Mark Grant. MA, MAPs

39 CRP/RSD Trauma can be a predisposing factor following injury Median PTSS-10 score similar to trauma survivors (118 patients) Similar neurological profile to PTSD CRPS has been reported to be elicited by stress exacerbation in patients with PTSD (Huge et al, 2011) Mark Grant MA

40 Mark Grant. MA, MAPs CRPS/complex trauma. Neck & shoulder pain Agitated, can’t relax Injury and disability Carer for sick grandmother, family conflict Abandoned by mother, unstable early life,

41 EMDR targets Mark Grant MA EventNC PAST TRAUMA:Mother leavingI’m unloveable Unstable home lifeI’m not safe PRESENT STRESS: Injury & disability No family I’m useless I’m alone PRESENT PAIN:Arm painWhats wrong with me? Back painWhats wrong with me? Injury Disability I’m vulnerable I’m not safe

42 Elements of treatment (complex trauma) 1.Extended preparation stage 2.Teaching of grounding techniques 3.Addressing ‘fear of feelings” 4.Teaching client how to self-soothe instead of self-injure 5.Teaching client how to attend to their pain by showing appropriate care and concern 6.Challenge feelings of unworthiness 7.Developing resources 8.Ego-state work Mark Grant. MA, MAPs

43 Complex trauma case #2. Stabbing pains in stomach and bowel, IBS, CLBP, nightmares, flashbacks, anxiety Health problems (diriticulitis), chronic depression, 5 years of sexual abuse, abandoned by father, violent first marriage

44 EMDR ‘targets’ Mark Grant MA EventNC PAST TRAUMA:AbuseI’m bad Sound of bath fillingI’m not safe PRESENT STRESS: Going to bed at night IBS, CLBP Hydroencephalitis Camping trips I’m not safe Whats wrong with me? I’m gonna die I’m not safe PRESENT PAIN:CLBPWhats wrong with me? FatigueI can’t cope

45 EMDR target (past trauma) Uncle having sex with her NC; ‘I’m trapped’ Pain and Anxiety 10/10 DAS/Bls Calmer, less pain I’m safe now Mark Grant

46 Hysteria “A hysteric is someone who cannot tell a story.. At least a coherent story – a story whose disparate parts hang together. When a hysterics narrative reaches its climax it tends to hang fire … an explanatory scene is missing.” Deborah Elise White, 1989 Mark Grant. MA, MAPs

47 Summary. Long preparation phase; don’t start EMDR until affect tolerance evaluated and addressed. Lots of resourcing (ego states) Obtain consensus from the ‘parts’ for dissociated or DID clients Start small (not even a small ‘t’) “Baby steps” “Baby steps” “Baby steps” Pacing - EMDR interspersed with… Lots of re-evaluation, psychoeducation (Acknowledgment: Forgash & Knipe, 2008)


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