Transcript workshop

Targeting PTSD
Dr Walter Busuttil
Treatment of Complex PTSD: Basic Principles
(Herman 1992; Bloom 1999)
• Stabilization & Safety
• Working through of Traumatic material – disclosure
– psychotherapy
• Rehabilitation
First line and TopFirst
second
interventions targeted
to symptom
sets
Most Prominent
Line line
Interventions
Top second
line interventions
Symptom Set
Re experiencing
Education about trauma
Narration of Trauma Memory
Cog Restructuring / emotional
regulation / Anx/Stress mgt
Avoidance/Constriction
Education about trauma
Emotional regulation
Cog Restructuring / Narration of
trauma memory /Meditation
Mindfulness/ Interpersonal skills
training.
Hyperarousal
Education about trauma
Emotional regulation
Anx/stress mgt
Narration of Trauma Memory . Cog
restructuring
Affect Dysregulation
Education about trauma
Emotional regulation
Cog Restructuring / Narration of
trauma memory /Meditation
Mindfulness/ Anxiety reduction,
Narration of trauma memory
/Interpersonal skills training.
Relationship Difficulties
Education about trauma,
Interpersonal skills trg/ Cog
restructuring
Emotional regulation
Narration of the truama
Treatment of CPTSD
Most Prominent Symptom
Set
First Line Interventions
Top second line interventions
Disturbances in meaning
Education about the trauma/
cognitive restructuring
Narration of trauma memories,
emotional regulation
Behavioural Dysregulation
Education about the trauma,
emotional regulation
Cog restructuring,
interpersonal effectiveness,
meditation, mindfulness.
Attentional Dysregulation
Education about the trauma,
emotional regulation
Meditation/mindfulness;
anxiety/stress management;
narration of the trauma
memory
Somatic Symptoms
Education about the trauma;
Anxiety/stress mgt
Emotional regulation,
Narration of trauma memory,
Cog restructuring
Dissociation
Education about trauma
Emotional regulation
Narration of truama memories,
anx/stressmgt/ meditation
mindfulness.
Identity Disturbance
Education about trauma
Emotional regulation,
meditation / mindfulness
Medications:
Medications: used to stabilize patient in order to allow psychotherapy to be
conducted primarily. After psychotherapy is finished, attempt should be made to
reduce medications.
Medication
Indication
• Antidepressant
• PTSD & Depressive symptoms
• Neuroleptic
• Pseudo-hallucinations;
Dissociation; Tranquilization
• Mood Stabilizer /
Antiepileptic
• PTSD Symptoms & Mood stabilizing
properties
• Anti-impulse
• Impulse control - self- harm /
depression
Case 1
• John is aged 24 he successfully completed DBT
training and feels more in control.
• He tell you he still suffers from sleep problems,
he dreams a lot
• He wakes up startled and in a sweat.
• He wakes up early every morning at 0400 and he
feels he has no energy.
• He feels jumpy when someone shouts.
• What do you do next?
Case 1
• John is aged 24 he successfully completed DBT training
and feels more in control.
• He tell you he still suffers from sleep problems, he
dreams a lot ?nightmares?
• He wakes up startled and in a sweat. ? Hyperarousal
on waking from a nightmare?
• He wakes up early every morning at 0400 and he feels
he has no energy ? Depressed?
• He feels jumpy when someone shouts.
?hyperaroused?
• What do you do next?
John is assessed further
• He is thought to be suffering from PTSD – he is
hyperaroused, he has nightmares and flashbacks,
he avoids thinking about his childhood abuse – he
is coping better than before.
• He is also depressed
• You also know that he used to drink 25 bottles of
beer a week and 1 litre of whiskey a week. The
DBT treatment has reduced this to five bottles of
beer a week.
• What should happen next?
John is assessed further
• He is thought to be suffering from PTSD – he is
hyperaroused, he has nightmares and flashbacks, he
avoids thinking about his childhood abuse – he is coping
better than before.
• He is also depressed
• You also know he used to drink 25 bottles of beer a
week and 1 litre of whiskey a week. The DBT treatment
has reduced this to five bottles of beer a week.
• What should happen next? He should be stabilised
further ? Assess and prescribe antidepressant; also tell
him to stop drinking alcohol altogether – why?
John is stabilised further
• John is feeling better on an antidepressant.
Mirtazepine 45 mgs. This has reduced his
nightmares, he sleeps better, his hyperarousal is
better, he feels less numb, he is less depressed.
• He has stopped drinking alcohol.
• He wants more help for his PTSD.
• What are you going to offer him?
psychotherapy
• What kind and why?
Specific treatment models
Engagement, Stabilisation / Skills trg:
• Art Therapy
• DBT
• Psychodynamic / analytical Psychotherapy
Trauma Focussed Therapy
• Cognitive Behaviour Therapy / Cognitive Processing
Therapy: promote Info Processing & Exposure
• Prolonged exposure
• Narrative Exposure Therapy
• Eye Movement Desensitisation and Reprocessing
(EMDR)
Treatment Pitfalls:
Common maintaining factors
• Nature and duration of
trauma
• Role in trauma
• Meaning of trauma
• Has trauma ended?
• Isolation - attachments
• Guilt - omission /
commission
• Guilt – survivor
• Is the patient drinking
alcohol? Using illicit drugs?
Before or after therapy?
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Other Factors
Co-morbidity - treat this
first?
Alcohol & Illicit Drugs
Motivation
Co-operation
Compliance
Therapeutic qualities of
patient & therapist
Treating CPTSD in Adults
Models:
• DBT followed by TF Work (Linehan)
• Self-Trauma Model & Trauma Focussed work
(Briere)
• Psychodynamic therapy followed by Trauma
Focussed work (de Zulueta)
• Structured Group Therapy Programmes (Busuttil,
Cloitre)
The Self Trauma Model
(Briere)
• Integrated Approach
• CBT & Relational
• Take symptoms beyond PTSD into account
– address them
• Affect regulation training
• Trigger identification
• Mindfulness as cognitive and affect
regulation
• Titrated exposure to traumatic material
Therapeutic relationship emphasised (Briere)
• Attendance / compliance
• Context for support / validation / safety
• Activates relations schema which then can be
addressed.
• Counter conditions relational trauma
memories
Therapeutic Window
Titrated exposure
• Balance between therapeutic challenge
and overwhelming internal experience
• Maximal possible exposure & reactivation
within the limits of affect regulation
activity
Identity Development
• Exploration of self within the context of the
therapeutic relationship
• Self knowledge
• Self directedness
• Value of not leaving open-ended questions
• Avoiding over use of interpretations
Dissociation and Reflective function
• Use of video or tape-recording in severely
dissociated patients.
> The development of mentalisation or
mindfulness.
Affect regulation training
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Dealing with acute intrusions – grounding
Breathing training
Identifying and discriminating emotions
Countering intrusive and exacerbating intrusions
Development of equilibrium through mindfulness
Repeated exposure and processing as affect regulation
training
• Affect Regulation – the content is not as important as
the skill itself
Mindfulness as a cognitive intervention
Self observation:
• Moment by moment of awareness of internal
experience without judgement
• Learning to let go of thoughts & feelings without
avoidance or suppression
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Especially for childhood memories
Thoughts are not perceptions.
Perceptions do not necessarily reflect reality.
Mediation of abuse related cognitive distortions and
associated emotions.
Affect regulation training (Briere)
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Dealing with acute intrusions – grounding
Breathing training
Identifying and discriminating emotions
Countering intrusive and exacerbating intrusions
Development of through mindfulness
Repeated exposure and processing as affect regulation
training
• Affect Regulation – the content is not as important as
the skill itself
Mindfulness as a cognitive intervention (Briere)
Self observation:
• Moment by moment of awareness of internal
experience without judgement
• Learning to let go of thoughts & feelings without
avoidance or suppression
• Especially childhood memories
• Thoughts are not perceptions, perceptions do not
necessarily reflect reality
• Mediation of abuse related cognitive distortions and
associated emotions
Central Components of Trauma Processing (Briere)
• Exposure
• Activation – triggers associated thoughts feelings – reliving
• Disparity – although in activated state – now able to talk to
therapist in safe environment: fear is therefore not reinforced :
negative state generated in a safe environment
• Central 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: awareness
to remember it as past; aware that this is now the present.
• Working with traumatic memory – activate the specifics of the
memory cue by asking question about what happened – helps
processing
Psychodynamic / 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).
TF-CBT
• Psycho-education
• Disclosure / Exposure / Working Through of
Traumatic Material
• Cognitive restructuring
• Problem solving
• Use of behavioural techniques
for example anxiety management
TF-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 fearevoking situations that are now safe but that are
associated with the traumatic experience.
• Identification of triggers
• Hot spots
CBT Approaches
• 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).
Cognitive Processing Therapy (Resick )
• PTSD is believed to emerge due to the
development of a fear network in memory
that elicits escape and avoidance behaviour.
• Repeated exposures to the traumatic memory
are thought to result in habituation or a
change in the information about the event,
and subsequently, the fear structure.
• Fear extinguishes when repeated expoasure to
feared stimulus is facilitated
• CPT is designed to bring patients into their own
awareness of the inconsistent and/or dysfunctional
thoughts maintaining their PTSD.
• Cornerstone part of the practice of CPT is Socratic
questioning. Throughout the course of treatment,
therapists should be consistently using Socratic
questioning to induce change, with the goal of teaching
patients to question their own thoughts and beliefs.
• ‘Stuck ppoints are identified and challenged.
• For
12
session
manual
down
load:
http://depts.washington.edu/hcsats/PDF/research/Cogni
tive%20Processing%20Therapy%20Manual%208.08.pdf
EMDR
(Eye movement Desensitisation and Reprocessing)
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Therapeutic rapport
Imagery / envisioning of traumatic scenes
Focus on sensations of anxiety
Cognitive restructuring
Saccadic movements of Eyes
Extinguishing of the memory
• Other methods - eg Counting Method
• Need training - Criticisms
EMDR
• Standardised, 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
• Requires 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.
• This 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 changed
• If has changed peocedure is repeated with new
scene before returning to old one (Shapiro,
1989)
Complex PTSD Programme
90 Days of structured work - 600 hours
Three One Month Phases :
• Interactive Psycho-Education &
Adjustment of Medication.
• Individual Disclosure of the Trauma
• Cognitive Restructuring and Problem
Solving
Case Study
• DF 26 years previously civil servant, husband left her
decompensated
• H/O DSH ligatures
• Dissociation+++, Flashbacks, nmares, emotional numbing,
affect dysregulation, outbursts, low mood depressed, alcohol
misuse in past.
• Eventually admitted to CSA+ porno/paedo ring
• Medications: SSRI, Carbamazepine,
• DBT, grounding place of safety mindfulness Psychoeducation;
TF-CBT, rehabilitation, off detention mental health act section
• Move to low secure services – discharged.
• Not Borderline Personality Disorder