Transcript PTSD - Dual Diagnosis

PTSD
Matthew Gaskell C.Psychol AFBPsS
Consultant Psychologist/Clinical Lead LAU
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Ground Rules
 Confidentiality
 Anonymity of Cases
 Openness & honesty
 Look after self
 be aware how this impacts upon you
 feel free to take time out (indirect traumatisation)
Questions to consider
 What are the signs and symptoms of PTSD?
 Why do some develop chronic PTSD whereas others recover
from a trauma?
 Why does PTSD persist?
 What treatments work?
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Shell shock
 http://www.youtube.com/watch?v=RRv56gsqkzs&feature
=fvwrel
PTSD CRITERIA AND SYMPTOMS
What are the key signs and symptoms?
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The trauma event
 What kinds of experiences may lead to developing PTSD?
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Events…..
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 Rape
 Torture
 Violent physical attack
 Natural disaster
 Combat
 Terrorism
 Car accident
 Kidnapping
 Waking during an operation
 Others?
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Key Symptoms
 Re-experiencing (as if it is happening ‘now’)
 Avoidance
 Hyperarousal
 Emotional numbing
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EPIDEMIOLOGY
Prevalence, life course and risk factors for
PTSD
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Epidemiology
 Approx 60% of men and 50% of women report at least one
trauma in their lifetime – only a minority develop PTSD
 Lifetime prevalence in community samples range from 6.8%
to 7.8%
 Women are twice as likely to meet criteria for PTSD as are
men (10% vs. 5%)
 Most common precipitating events are sexual abuse for
women and combat for men
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Prevalence & Incidence
US National Comobidity Study
Prevalence
 Kessler et al.,1995: Lifetime prevalence
 7.8%
 women 10.4%,
 men 5.0%
Incidence
 Kessler et al.,1995: Risk of PTSD after a traumatic event
 8.1% men
 20.4% women
Epidemiology
 Victims of rape have prevalence rates between 31% and 57%
(Foa & Riggs, 1994)
 Combat veterans have a 20% occurrence (Benish et al.,
2008)
 For those who meet criteria for PTSD about half have
spontaneous remission of symptoms by 3 months
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PTSD Co-Morbidity
 The rule rather than the exception
 88% of men and 79% of women reporting at least one
other psychiatric disorder (Dunner, 2001)
 59% of men and 49% of women have three or more
concurrent diagnoses (Schoenfeld, Marmar, & Neylan,
2004)
 Among combat veterans the rate of comorbidity is 98.9%
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Common Co-morbid Problems
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Depression
Substance misuse
Panic
GAD
OCD
Psychosis
Anger
Forensic/criminal issues
Neuropsychological impairments
Chronic pain
Health problems
Why ?
Substance Abuse & Comorbidity (Dunner,
2001; Schoenfeld et al., 2004)
 Alcohol abuse in 51.9% of men and 27.9% of women with
PTSD
 Other forms of substance abuse are found n 34.5% and
26.9% of women
 Depression in 48% of cases (usually following PTSD)
 Other anxiety disorders in 55% of cases
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WHY DO SOME GET CHRONIC PTSD
WHEREAS OTHERS RECOVER
SPONTANEOUSLY?
Risk factors for developing PTSD
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Exercise:
 Why might PTSD develop and persist? What makes someone
more at risk?
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Traumatic Event Characteristics
PTSD Risk
 Natural Disaster
Lowest
 Technological Disaster
 Interpersonal Violence
WHY ?
Highest
Risk of PTSD
 Ozer et al (2003)
 Prior trauma
 Previous psychological adjustment
 Family history mental health problems
 Perception of life threat
 Post-trauma social support
 Peri-traumatic emotional response
 Peri-traumatic dissociation
Personal Factors Risk of PTSD: Brewin (2000)
 Military risk factors
 Younger age
 Lower IQ
 Physical violence childhood
 Trauma severity
 Lack of social support
 Civilian
 Female
 Younger age
 Low socio-economic status
 Previous trauma
 Trauma severity
 Life stress
Cognitive Risk Factors
 Negative cognitions about self, world & self-blame
 Foa et al., 1999
 Negative appraisals of symptoms, negative responses from
others, & permanent change
 Dunmore et al., 1999, 2001
 Alienation, perceived permanent change, & ‘Mental defeat’
 Ehlers, et al., 2000
 EXAMPLES?
THEORIES OF PTSD
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Current Theories…..
 Behavioural Theory: Mowrer (1960) Two Factor Theory
based on classical & operant conditioning
1) Anxiety/fear become associated with cues at time
of trauma (classical)
2) Avoidance – cues induce anxiety & so are
avoided which reduces anxiety and so
avoidance is
rewarding & persists, thereby maintaining the problem
(prevents
habituation to the cues)
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Cognitive Theory
 Information processing is the most significant factor in
understanding PTSD
 Pre-trauma negative beliefs are strengthened by trauma
 Pre-trauma positive beliefs are ‘shattered’
 Perceptions/meaning attached to behaviour within trauma
 Perceptions/meaning attached to after effects of trauma
 Result in perceptions related to safety, personal competence
& likelihood danger
Trauma Processing &
Dual Representation Theory
 Underpins TF-CBT. Proposes:
 2 memory systems function independently of each other
 VAMS – Verbally Accessible Memories
 SAMS – Situationally Accessible Memories
 The emotional intensity of trauma inhibits full encoding in
VAM system – resulting in incomplete narrative memories
(flashbacks result from activation of strongly encoded SAM
memories)
VAMS: Conscious Processing
Verbally Accessible Memories
 The way ‘everyday’ memories are processed
 Deliberately retrieved from the store of
autobiographical knowledge & Integrated with other
memories
 Contain info person attended to before, during and after the
event
 “When I was making a strawberry smoothie in the blender I
remember losing a finger and I yelled out oh bother”
VAMS: Conscious Processing
 Info that receives enough
conscious processing
 Hippocampus
SAMS: Non-conscious processing
Situationally Accessible Memories
 Not accessed consciously
 accessed automatically
 When triggered by physical features or meaning are similar to
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that of the trauma situation
 E.g. when smells strawberries
No verbal coding
Body responses at the time of the trauma
No interaction / updates by autobiographical memory
“Fear memory”
SAMS:
Non-conscious processing
 Flashbacks/ re-experiencing
 Triggered by situational reminders (SAM processing)
 Nature – static, retain identical form on each intrusion
 Even when the individual has learned new information that directly
contradicts the info in intrusive memory
 Emotions restricted to primary emotions experienced peri-traumatically
 Body memory activated – sensory/ physical
 Fragmented – no time tag – ‘nowness’
SAMS: Non-conscious processing
 SAM mediated by amygdala
 In high levels of stress – amygdala is more
active
 Involved in:
 Processing of emotions
 Arousal
 Autonomic Responses Associated with Fear
 Emotional Responses
 Hormonal Secretions
 Memory
Cognitive Theory & recovery
 The process of recovery from PTSD is believed to involve the
integration of SAM memories into the VAM system
 Once this happens the trauma is recalled primarily through
the VAM system & inhibits access to the SAM system, thus
reducing re-experiencing symptoms
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EVIDENCE-BASED TREATMENT FOR
PTSD
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NICE Guidelines PTSD: 2005
 http://www.nice.org.uk/CG26
 Trauma focused CBT or EMDR
 Duration 8-12 sessions
 Extended – if multiple trauma, severe symptoms, significant co-morbidity
 Trusting relationship
 Significantly little guidance – more complex problems
Trauma-Focused CBT
What is it?
Does it work?
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Model of PTSD
 Let’s look at the model and make sense of PTSD and why it
persists………
 Handout
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What maintains PTSD?
Key processes:
 Fragmented unprocessed trauma memory (SAMs)
 Triggers for re-experiencing
 Negative appraisals
 Strategies to avoid and suppress trauma memory being
triggered
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Exercise
 Work in Groups of 3
 Formulate client case ‘Matt’ using Ehlers & Clark (2000)
Model
Trauma-focused CBT
 Looking at the CBT model what do you think the goals of
treatment might be?
 Where do we need to intervene?
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Goals of CBT
 1) Modify excessively negative appraisals of the trauma and
after effects
 2) Reduce re-experiencing by elaboration of the trauma
memories and discrimination of triggers
 3) Drop unhelpful strategies designed to control threat
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Therapy: Clark & Ehlers (2004)
Exercise – which bits of model will therapy
address & how?
Nature of Trauma
Memory
Negative Appraisals of
trauma and/or after-effects
Modify
Elaborate
Triggers
Discriminate
Current threat
Reduce
Strategies intended to control threat / symptoms
Cut
What maintains PTSD?
Traumatic Memory
 Trauma memories (SAMs involvement)
 Incomplete recall common
 Fragmented / poorly organised
 Not complete context in time and place
 Not linked up with before & after
 Feels like happening NOW
 Poorly incorporated into autobiographical memory
 Sensory impressions – not thoughts
 Emotions same as original emotions experienced in trauma
 Involuntarily triggered intrusive memories
 Temporally related/ associative memory?
Maintenance Factors:
Why does PTSD Persist?
 Strategies intended to control threat/ symptoms
 Increase/produce PTSD symptoms
 Prevent change in appraisals - prevent disconfirmation
 Prevent change in the trauma memory –inhibits change to VAM
 What strategies are these?
 Avoidance
 Safety behaviours
 Thought suppression
 Rumination
 Dissociation
 Deprive self of sleep (deliberately or consequence nightmares)
 Alcohol/drug use
Maintenance of PTSD
 Thought suppression
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Pink elephant
 Evidence
 Wegner et al (1987) ‚White bear experiments
 Davies & Clark (1998) rebound effect experiment
 ‘Don’t mention the war’
 http://www.youtube.com/watch?v=7xnNhzgcWTk
TF-CBT – Elhers & Clark (2000)
 Twelve 1½ hour sessions
 Psycho-education about trauma & therapy
 Reliving
 To arrive a coherent semantic account
 To identify key negative appraisals
 Integration of new meaning / perspective into trauma memory
 Cognitive therapy for negative appraisals
 Reclaiming of life (interweave within all sessions)
 Therapist-guided return to trauma site (or near match)
Ehlers et al. (2005)
 Protocol from Ehlers & Clark (2000) model
 RCT compared:
 14 people with PTSD; TF-CBT Ehlers & Clark protocol
 14 people in a PTSD wait-list condition
 TF-CBT
 significant improvement of PTSD symptoms
 well maintained treatment gains
 low drop out rate
 Treatment outcome associated with changes in post-traumatic cognitions.
Intensive CBT: Ehlers et al 2010
 18 hours of therapy 5 to 7 days
 1 session a week later
 up to 3 follow-up sessions
 85.7 % no longer had PTSD
 Similar to weekly CT-PTSD
 but intensive treatment shorter time
 greater reductions in depression
Contraindications for therapy
 What contraindications might there be for therapy?
 Emotionally very unstable
 High suicide / homicide risk (Crisis support services)
 Very high substance misuse (get help first)
 Ongoing trauma risk
 Dom. violence with partner / on duty emergency services etc
 Asylum seekers (low stability of life situ/ moves)
 Active psychosis
 No motivation for therapy apart from medico-legal issue
Therapy: Clark & Ehlers (2004)
 Summary of Change
 Trauma needs to be elaborated and integrated into life (SAMs –
VAMs)
 Negative appraisals modified
 Improving discrimination of triggers
 Stop unhelpful efforts to control threat (maintenance factors)
 avoidance & safety behaviours
 Sleep avoidance/Alcohol / drug misuse etc
 Social withdrawal
Eye Movement Desensitisation and
Reprocessing (EMDR)
What is it?
Does it work?
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What is EMDR?
 https://www.youtube.com/watch?v=GTLLfdcJE0Q
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EMDR
 Developed by Psychologist Francine Shapiro in 1980s
 Client asked to recall worst aspects of trauma as well as the
negative cognitions & associated bodily sensations
 Simultaneously they are directed to move their eyes from side to
side (Bilateral stimulation)
 The effect is to desensitise the client to the distressing memory,
but more importantly, to reprocess the memory so that the
associated cognitions become more adaptive
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 Accordingly the distressing memory is fully processed; the
memory system has accommodated the new, updated
information; the event can now be verbalised without the
inappropriate emotions and physical sensations
 Cognitions tend to shift spontaneously with EMDR during
processing – but some ‘cognitive interweave’ is required
when processing becomes stuck
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Active ingredients of EMDR? – not yet
fully understood…….
 Exposure
 Processing the fragmented memory and updating it
 Exposure
 Mindfulness
 Mastery and self-efficacy
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Active ingredients of EMDR?
 BLS: Studies have shown that the effect size is large and
significant when EMDR is used with eye movements (BLS)
than when not (e.g. Lee & Cuijpers, 2013)
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Why does ‘Eye Movement’ work?
 1) The REM hypothesis (Stickgold, 2002)
Eye movements in EMDR produce a brain state similar to REM
sleep
REM sleep serves a range of adaptive functions, including
memory consolidation
“EMDR reduces trauma related symptoms by altering
emotionally charged autobiographical memories into a more
generalised semantic form”
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Why does ‘Eye Movement’ work?
 2) ‘Interhemispheric Communication’ (see Propper & Christman,
2008)
 Retrieval of episodic memories is enhanced by increased
interhemispheric communication
 3) ‘Working Memory’:
 Horizontal eye movements tend to tax working memory, and the
dual tasks involved in EMDR create ‘competition’ in memory
resources, such that images become less emotional and vivid.
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An EMDR Clinician:
 “The distancing effect caused by the degradation of working
memory enables the client to ‘stand back’ from the trauma
and thereby re-evaluate the trauma and their understanding
of it because they can re-experience the trauma whilst not
being overwhelmed by it” (Robin Logie, 2014)
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Effectiveness
 A meta-analysis of 38 RCT’s has established that EMDR and
TF-CBT are the two most efficacious treatments for adults
with PTSD (Bisson et al., 2007) and with children
(Rodenburg et al., 2009)
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Conclusions
 There are four key signs and symptoms
 It is a highly prevalent ‘dual disorder’
 Causes lots of problems and impairments
 Treatment works!
 Screen & refer to IAPT, LAU, or Psychology
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