Transcript PTSD Treatment

PTSD
Anushka Pai
Tyler Davis
Darrell Worthy
Cindy Stappenbeck
Clinical Factors of PTSD
• Rexperiencing symptoms
– Intrusive memories
– Nightmares
• Protective reactions
– Emotional numbing
– Amnesia
– Cognitive avoidance
• Arousal symptoms
– Startle response
– Hyper vigilance
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Negative emotions & cognitions
– Sadness
– Anger
– Guilt
Typical characteristics
• Typically characterized by an alternation
between re-experiencing and avoiding
• Re-experiencing is rapid and spontaneous, vivid,
and arousing
– Different than normal LTM retrieval in that emotions
are felt in original intensity
– May be able to dispassionately discuss traumatic
experience, but still experience trauma related
emotions when cued
• Occurs in 25-30% of the population given a
traumatic experience
• Decreases over time, but can last up to 40 years
PTSD and Stress Responses
• Can be explained somewhat in terms of stress
responses within the normal range of human experience
• Bereavement
– Bowlby’s Attachment Theory
– Parkes Psycho-Social Transitions
• Does not account for all aspects of PTSD such as
negative flashbacks, startle responses, and high
physiological arousal. Can’t explain individual
differences.
• Do you think that the differences between PTSD and
these general models of responses to stressful events
could be related to differences between the stress
inducing stimuli, rather than differences in cognitive
architecture for handling different types of stress?
Influences on the development and
time course of PTSD
• Object exposure (how close were you to
the trauma?)
• Levels of social support
• Locus of control (internal vs. external)
• Do you think the locus of control is another
example of how our authoritarian ego is
actually a safety mechanism?
Comorbidity
• 80% of PTSD sufferers have a comorbid
disorder
– Commonly
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Somatization
Psychosis
Anxiety disorder
Depression
• Shares features of comorbid disorders, but
cannot be explained by them
Cognitive Biases in PTSD
• Increased skin conductance for combat related
words in PTSD vets vs controls
– Are normal people appropriate controls for this?
• Slower in stroop task with trauma related words
with personal relevance
• Difficulty retrieving specific memories to cues
• Judge negative events as more probable in the
future than controls
• PTSD itself cannot be explained by comorbid
disorders, however do you think that most or all
of the cognitive biases can be?
Trauma Processing and
Dual Representation
Theory
Dual Representation Theory
Conscious Processing
• Verbally Accessible Memories (VAMs) –
can be consciously retrieved from the
store of autobiographical knowledge
• E.g. – “I remember losing a finger in the
hot-dog cooker”
• Conscious processing of the accident
• May have selective recall – anxiety
increases attentional selectivity and
decreases short-term memory capacity
Non-conscious processing
• Situationally Accessible Memories (SAMs)- not
accessed consciously; may be accessed
automatically when the person is in a context
where the physical features or meaning are
similar to that of the trauma situation
• Hormonal effects of trauma may diminish neural
activity in areas associated with conscious
processing – motor aspects represented in
analogical codes
SAMs
• This picture could
induce a situationally
induced memory in a
person who has
suffered hot dog
machine trauma
• The four finger hands
could make SAMs
even more likely to be
activated
Emotional Processing
• Activation of SAMs to aid the process of
readjustment
• Conscious attempt to search for meaning and
make judgments about cause and blame
• Editing of VAMs to bring perceptions of the event
into line with prior expectations
• Need to consciously reassert perceived control
• Need to prevent the continued automatic
activation of SAMs
• This processing is necessary for overcoming
trauma
Endpoints of Emotional Processing
• How can
completion/integration
be distinguished from
premature inhibition
of processing?
• How can we be
certain that traumatic
memories will not
resurface in the
future?
Premature inhibition
• Dual representation theory distinguishes
between verbally and situationally
accessible knowledge
• Authors propose that trauma processing
can be prematurely inhibited
• What is the right amount of processing?
• Should patients dwell on what happened
to them – could it make things worse?
• Are these good recommendations?
Overview of persistent PTSD
• Pre-trauma Variables
• Cognitive processes during Trauma
• Memory for Trauma
• Appraisals-perception of current threat
• Strategies to control threat and symptoms
Ehlers and Clark (2000)
Pre-trauma Variables
• Prior Beliefs (Positive or Negative)
• Previous traumas
• Coping style
Cognitive processes in trauma
• Conceptual vs. Data driven
• Influenced by
– High arousal and fear
– Duration and predictability
– Perception of control
– State factors
– Low intellectual ability
Memory for trauma
• Reexperiencing
• Strong S-S and S-R associations
• Strong perceptual priming
• Poor elaboration and incorporation
Appraisals of traumatic event
• Overgeneralize from event
– FEAR
• Overestimate probability of another trauma
– FEAR
• How they felt/behaved during trauma
– SHAME
Appraisals of trauma sequelae
• Interpretations of common symptoms
• Interpretations of others’ reactions
• Interpretations of consequences in other
domains
Maladaptive strategies
• Strategies are meaningfully linked to
appraisals
• Maladaptive because
– Directly produce PTSD symptoms
– Prevent change in negative appraisals
– Prevent change in the nature of trauma
memory
Maladaptive Strategies Cont.
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Thought Suppression
Selective Attention to threat cues
Safety Behaviors
Trying not to think about the trauma
Avoidance of reminders
Rumination
Dissociation when reminded of trauma
Alcohol or substance use
PTSD Treatment
Putting Trauma in the Past
• Memory needs to be integrated into
person’s experience to reduce problematic
reexperiencing
• Appraisals of the trauma need to be
modified
• Avoidance techniques and safety
behaviors need to be eliminated
Assessment & Treatment Rationale
• Attempt to assess coping strategies, what
they avoid, how they deal with intrusions,
what their fear is about dwelling on trauma
• These identified to use in later treatment
• Reexperiencing symptoms are isolated
memory fragments triggered by matching
cues
– Experienced as if happening in the “here and
now” because they are not integrated into
other autobiographical info
Treatment Components
• Thought suppression causes more of the
unwanted thoughts
– Instructed to accept intrusive thoughts
• Education
• Reclaim one’s former life
Treatment Components
• Reliving Trauma
– Make image realistic including thoughts and
feelings as well as what was happening
– Verbally describe event in present tense
– Therapist uses questions to keep client
focused on feelings and thoughts
– Patients rate distress at different points
– Cognitive restructuring used to change
problematic thoughts & beliefs about event
Treatment Components
• Reliving (cont.)
– As therapy progresses, narrative tends to become
more coherent
• Memory loses the “here and now” quality
– Works by facilitating elaboration of the trauma
memory
– Facilitates retrieval of elements of the trauma memory
difficult to otherwise access
– Verbalization of visual and sensory cues may make it
more difficult to retrieve original sensory impressions
from memory
Treatment Components
• In vivo exposure
– Revisiting the site of event
– Engage in feared/avoided behaviors to obtain
disconfirming evidence
• Imagery Techniques
– Useful in changing meaning of the trauma
memory
– Allows patients to explore consequences of
actions not taken
Treatments Not Covered in Article
• Eye Movement Desensitization
• Stress Inoculation Training
– Muscle relaxation
– Breathing control
– Role Playing
– Thought Stopping