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What’s special about Trauma? Collaborative Mental Health Care Network CME February 19 th 2010 Clare Pain MD.

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Presentation on theme: "What’s special about Trauma? Collaborative Mental Health Care Network CME February 19 th 2010 Clare Pain MD."— Presentation transcript:

1 What’s special about Trauma? Collaborative Mental Health Care Network CME February 19 th 2010 Clare Pain MD

2 Does everyone who is traumatized get PTSD? PREVALENCE OF PTSD IN USA General population 60.5% of men and 51.2% of women had one Criterion A event. Life time prevalence of PTSD 5.0% for men and 10.4% for women

3 Longitudinal Course of PTSD Symptoms 3 months 9 months 15-25% 58% recovered 53% recovered Weeks 6% recovered YEARS UNRECOVERED Shalev & Yehuda, Psychological Trauma 1998

4 Relationship of Childhood Abuse and Household Dysfunction ADVERSE CHILDHOOD EVENTSPREVALENCE Abuse: Psychological11.1% Physical10.8% Sexual22.0% Living with household members who are: Substance abuser25.6% Mentally ill or Suicidal18.8% Violence against mothers12.5% Jail 3.4% (Felitti et al Am J Prev Med 1998)

5 Relationship of Childhood Abuse and Household Dysfunction 10 ADULT RISK BEHAVIOURS Smoking Severe obesity Physical inactivity Depressed mood Suicidal attempts Alcoholism Any drug abuse IV drug abuse  50 Sex Partners History of STD DISEASES Ischemic Heart Disease Any Cancer Stroke COPD Diabetes Hepatitis or Jaundice Skeletal fractures Poor self-rated health (Felitti et al am J Prev Med 1998)

6 Relationship Between Adverse Childhood Events and Mental and Physical Health Graded Relationship Between the Number of Adverse Childhood Events and Mental and Physical Health  50% had one  50% had one Adverse Childhood Event 25% had  2 25% had  2 Adverse Childhood Event 6% had  4 6% had  4 Adverse Childhood Event  4-12 fold - 4+ events compared to 0:  4-12 fold - alcoholism, drug abuse, depression and suicide attempts  2-4 fold 4+ events compared to 0:  2-4 fold - smoking, poor self- rated health,  50 sex partners, history STD

7 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional motivating systems – fear emotional motivating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

8 (Episodic) Model of Acute PTSD Leading to Chronic Complex PTSD TRAUMA INTRUSIVE RECOLLECTIONS Support ++ communication rest and food Accommodate Physiologic reactivity Psychological distress SUBSTANCE DISORDERS SOMATOFOR M DISORDERS No Work No Friends No Life PERSONALITY DISORDERS DISSOCIATION DEPRESSION “PSYCHOSIS” PHOBIA ANXIETY PANIC AROUSAL +++ AVOIDANCE of triggersAVOIDANCE of triggers NUMBING of general responsesNUMBING of general responses Poor SleepPoor Sleep Chronic IrritabilityChronic Irritability Bursts Of AngerBursts Of Anger Poor ConcentrationPoor Concentration HypervigilenceHypervigilence JumpyJumpy BIPOLAR DISORDER AGOROPHOBIA SEXUAL DISORDER COGNITIVE DISORDERS MEMORY DISORDER SLEEP DISORDER

9 “Trauma Spectrum Disorders”  Acute Stress Reaction  Acute Stress Disorder  PTSD - acute  Partial PTSD  PTSD – Chronic  PTSD and co-morbidity  Chronic Complex PTSD (dissociation, somatoform disorders, anger subs abuse, self harm, chronic suicidality, depression - anger – social isolation avoidance – shame – affect sensitivity – alcohol/drugs  Dissociative Disorders ( Amnesia, Fugue, Depersonalization,NOS)  Dissociative Identity Disorder

10 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional motivating systems – fear emotional motivating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

11 Emotional motivational systems Seeking – curiosity…always on, pleasure turns off seeking curiosity Attachment Play Fear – when activated takes precedenceFear – when activated takes precedence Sociability Caretaking Sexuality/Sensuality

12 Fear TERROR IntimacyVigilance Fear Rest Alarm TERROR Frontal Cortex Brainstem Assoc. Cortex Limbic Midbrain (Bruce Perry, 1994)

13 Cascade of Fear Defences (Janet, van der Hart, Ogden) Cry Freeze (a.) increased arousal Flight Fight Freeze (b.) decreased arousal, empty emotional content Detachment depersonalization/derealization Submit robotic compliance Recuperate pain, trembling “Mobilizing defenses” “Immobilizing defenses”

14 Dissociation High levels of stress reduce the efficiency of memory encoding: – High levels of stress reduce the efficiency of memory encoding: – e.g. peritraumatic dissociation – when events may be subjectively slowed down or viewed from an alternative ‘out of body’ perspective. Peritraumatic dissociation Peritraumatic dissociation is associated with an increase in spontaneous memory intrusions and with disorganization in deliberate trauma recall - PTSD

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16 Mentalizing and choice Procedural Memory Automatic Behaviour THREAT Mentalizing Choice

17 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional motivating systems – fear emotional motivating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

18 Attachment—Strange Situation Secure Autonomous 60% Insecure Avoidant/resistant Dismissing 25% Anxious Preoccupied 15% Disorganized Unresolved 10% Correspondence between infant and parent classification 70-80%

19 Attachment and mentalizing The precondition for reliable mentalizing is a secure attachment (Fonagy, pg. 687, 1997) Successful parental mentalizing —reflects understanding of cause of distressaffective cause of distress and appreciation of the child’s affectivestance Just as secure attachment is a necessary precondition for mentalizing, so a secure therapeutic base is required for the ‘exploration’ of psychotherapy (Not “trust” but a secure base – parentified child….) …Help them find their mind, via your mind

20 What is Mentalizing? Attending to mental states in oneself and others Holding mind in mind Understanding misunderstanding Seeing oneself from the outside and others from the inside Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) Involves appreciating intentionality as different from behaviour (e.g. the half eaten chocolate bar)

21 Impaired mentalizing in maltreated children Less inclined to engage in symbolic play Less conversation about internal emotional states Difficulty understanding emotional expressions Less likely to respond empathically to peers’ distress Show more emotionally-dysregulated behavior “Small t trauma”

22 Risk Factors for PTSD Brewin 2000, Shalev 2002 Pre Trauma: Gender Younger age at trauma SEC Education Intellect Race *Psychiatric History *Childhood abuse Other previous trauma Other adverse childhood events *Family Psychiatric History Trauma: Trauma Severity Post trauma: Lack of social support Ongoing life stressors <0.2 >

23 AROUSAL DYSREGULATION FOLLOWING TRAUMA/NEGLECT Ogden and Minton 2000 AROUSALAROUSAL HYPERAROUSAL OPTIMAL AROUSAL ZONE NUMBING/FROZEN/ DISSOCIATED

24 OPTIMAL AROUSAL Ogden and Minton 2000 AROUSALAROUSAL HIGH ACTIVATION AROUSAL CAPACITY BOUNDARIES LOW ACTIVATION

25 Stimulation Gaze AvertCry Smile Laugh Gaze Avert AROUSAL (Heartrate) Differences between the behavioral curves of normal and high- risk infant-mother dyads (Field, 1985 )

26 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional activating systems – fear emotional activating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

27 PTSD AND CO-MORBIDITY (COMPLEX PTSD) DISORDER OF EXTREME STRESS NOS PTSD “comorbidity” 78% with one other Axis I conditions 44% with 3+ other Axis I conditions Substance abuse60-80% Depression65% General anxiety Phobia - simple 31% - social 50% Panic disorder 20% Somatization Psychotic - dissociation Personality disorders30-50% (Antisocial/borderline)

28 DSM-IV ASSOCIATED FEATURES AND DISORDERS IN PTSD X 14  Guilt feelings  Phobic avoidance  Impaired affect modulation  Self destructive and impulsive behavior  Dissociative symptoms  Somatic complaints  Feelings of ineffectiveness, shame, despair, or hopelessness  Feeling permanently damaged  Loss of previously sustaining beliefs  Hostility  Social withdrawal  Feeling constantly threatened  Impaired relationships with others  A change from the individual’s previous personality characteristics

29 Disorders of Extreme Stress Not Otherwise Specified (DESNOS) - Proposed Criteria A: ALTERATIONS IN REGULATION OF AFFECT AND IMPULSES Chronic affect dysregulation Difficulty modulating anger Self-destruction and suicidal behaviour Difficulty modulating sexual involvement Impulsive and risk-taking behaviour B: ALTERATIONS IN ATTENTION OR CONSCIOUSNESS Amnesia Dissociation C: SOMATIZATION GI; chronic pain; cardiopulmonary; sexual

30 Disorders of Extreme Stress Not Otherwise Specified (DESNOS) - Proposed Criteria D:ALTERATIONS IN SELF-PERCEPTION Chronic guilt and responsibility; shame; feelings of self-blame and ineffectiveness; of being permanently damaged; feeling no one can understand; a tendency to minimize E:ALTERATIONS IN PERCEPTION OF PERPETRATOR Adopting distorted beliefs and idealizing the perpetrator F:ALTERATIONS IN RELATIONS WITH OTHERS An inability to trust others A tendency to be re-victimized; a tendency to victimize others G:ALTERATIONS IN SYSTEMS OF MEANING Despair and hopelessness Loss of previously sustaining belief

31 Hyper-arousal Startle GAD Panic AvoidanceDepressionSocial Phobia Numbing Isolation Self-mutilation Truncation of Future Somatization Priming Traumatic Event Stressors Dissociation Schematic Illustration of Emerging Symptoms of Post Traumatic Stress Disorder (Post et al, 1998) (*GAD = General Anxiety Disorder) Cue Precipitated Flashbacks Re-exposure Re-traumatization Flashbacks Nightmares Spontaneous Flashbacks Explosive Anger Explosive Alcohol/Substance Abuse Irritability

32 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional activating systems – fear emotional activating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

33 Suicide and Psychological Trauma Symptoms….  Mood disorders…vs affect dysregulation, biphasic pattern of PTSD spectrum disorders, grief?  Self harm…vs trying to calm down  “Impulsivity and Aggression”?...vs fear panic and escape  Personality Disorder…vs chronic self punishment and poor interpersonal skills  Substance Abuse…are you prescribing?  Family history of sexual abuse…6x increase of risk for suicide

34 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional motivating systems – fear emotional motivating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

35 Psychological sequelae of 9/11 – Galea et al NEJM March 2002 Prevalence of PTSD 7.5% vs 3.6% Prevalence of Depression 9.7% vs 4.9% Either/or 13.4% Both 3.7% Significant Predictors: Of PTSD Of Depression Of PTSD Of Depression Hispanic Ethnicity Hispanic Ethnicity 2 or more stressors 1 yr 2 or more stressors 1 yr Panic Attack Panic Attack Residence south of Canal St. Level of social support Loss of possessions Death of friend/relative Loss of possessions Death of friend/relative Loss of job Loss of job

36 Grief vs Trauma adaptive Grief and grief work are adaptive and fairly predictable. Cocoanut Grove fire in Boston 1944 Lindemann Normal grief (?) has much in common with depression though not equivalent. depression though not equivalent. Sad, disturbed sleep, agitation, decreased ability to carry out day-to-day tasks. Resolve without treatment in 2-4 months (?) as the bereaved person gradually weans from remembered experiences with the loved one. Reengagement with people and activities. (?) Increase in medical visits? Differentiate from depression: which may include suicidal ideas, preoccupation with worthlessness and psychomotor retardation.

37 Abnormal grief: delayed or distorted grief reactions Delayed Delayed: grief is postponed and experienced long after the loss, e.g. when achieves age of unmourned loved one – may not be recognized as such, precipitated by more recent less difficult loss. Distorted Distorted: immediately or years later, no sadness or dysphonic mood, but MUS present (same as the deceased?) which have precipitated multiple medical visits. Lots of variants…over activity, social withdrawal, anger, numb, or ‘too much’. ?PTSD-like symptoms

38 Treatment for depression centered on grief. 1.Facilitate the delayed bereavement process 2.Help patient reestablish interests and relationships that substitute for what has been lost. Elicit feelings and non judgmental exploration - think about the loss- discuss the sequence of events prior, during and after the death- explore associated feelings Reassurance - shame, fear, rage, guilt, survivor guilt, fear of identification, sadness Reconstruction of the relationship - maybe fixated on the death and avoid the complexities of their relationship Development of awareness Behavioral change

39 Likelihood of Abnormal Grief if: Multiple losses Inadequate grief in the bereavement period Avoidance behavior about the death Symptoms around significant dates Fear of the illness that caused the death History of preserving the environment as it was when the loved one died Absence of family or other social supports during the bereavement period NB: Arousal from emotions not from the body – differential trauma from loss

40 Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? emotional motivating systems – fear emotional motivating systems – fear dissociation dissociation fast pathways, procedural memory and choice fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties phase 1. ~ STABILIZE and symptom reduction phase 1. ~ STABILIZE and symptom reduction phase 2: ~ Treatment of traumatic memories phase 2: ~ Treatment of traumatic memories phase 3: ~ (Re) integration and rehabilitation phase 3: ~ (Re) integration and rehabilitation Map for talk

41 The problems of traumatic experience 1.An unmentalized child is unprepared to understand him/herself and others = a poor mentalizer… (t) 2.If an event trauma - big T trauma – happens, there is little resilience and few resources to cope. 3. The combination in childhood  provokes extreme, repeated stress  undermines the development of the capacity to regulate distress 4.Result = PTSD to Chronic Complex PTSD Appreciation that automatic behaviours were originally adaptive, feel reliable, and are hard to modify or surrender. Behaviour occurs in lieu of mature mentalizing.

42 Trauma is the failure to process a serious and severe experience – goals of treatment: “the ability to create symbolic representations of terrifying experiences promotes the taming of terror and desomatization of traumatic memories.” (Van der Kolk 1994) “Making sense” notPromote mentalizing not discovering a secret, or elucidating a symptom to thinkto be able to think about what happened – make sense of it with the help of another/s - figure out what it means and what if anything needs to be done – reestablish a “continuous me” or autobiographical competence. …if this is not possible, things may get worse… psychological distress changes and problems accrue

43 Role of mentalizing in trauma AFRAID, terrified, overwhelmed, helpless, out of control + ALONE, abandoned, neglected, unloved, without needed comforting and making sense TRAUMATRAUMA unmentalized +

44 Phase Approach to Trauma Disorders (Herman, van der Kolk, van der Hart) Phase 1: Stabilization Phase 2: Attention to trauma memories – exposure techniques? Phase 3: Re-integration Re-habilitation

45 Take a thorough history – this can take a while (longer if you need an interpreter)…don’t just ask about the difficulties – get to know what she was like before the trouble began – what she liked, who she enjoyed being with, what she enjoyed doing, what make her laugh, what her ambitions were what her worries were… Ensure you check for current safety – physical, sexual and emotional …housing, money, debt, literacy, job-school, alcohol/drugs, access to services……… Psychological stability – sleep min. 5 consecutive hrs, max 10 hrs lying down, eating, ability to relax, what makes her feel better? avoidance? anxiety? depression? anger? (shame?) When and how is she afraid? Check again on co-morbidity, social and occupational function (get the details), addictions and affect regulation strategies Medications… Phase I STABILIZE: bio-psycho-social-cultural (think body!)

46 Work on all the issues that need to be sorted out…often this is a long task and once stable sometimes there is no need for phase II memory work – can she work, play, love? For new Canadians often the best “trauma treatment” is encouragement to learn English Phase I STABILIZE cont…

47 Desensitization Phase I Memory Work

48 Help the patient maintain a good connection with you - a secure base, the feeling of safety - This phase is about taking up life again having been able to know and think about her past: MOURNING HER LOSSES What about her health? – gyne exam – dentist? How are friendships, spousal relationship different? Closer? More laughter? How is child care different? What is work like? How does she feel about her new life? What has she learned? What is she planning for next year? How will Christmas/Ramadan be different? What will she tell another new Canadian? Her grandchildren? How will it be to leave therapy? Phase III – Reintegration Re-habilitation

49 Join us – and connect! The International Society for the Study of Trauma and Dissociation


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