Transcript The Psychological Effects of Trauma What to look for and what to do

The Psychological Effects of
Trauma
What to look for and what to do
Kerry Young
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Consultant Clinical Psychologist
Annual Student Health Association Conference
Bristol 2014
1. Forced Migration Trauma Service, Central and North West London NHS Foundation Trust
2. EPACT – Experimental Psychopathology and Cognitive Therapy Lab Department of
Psychiatry, University of Oxford
Kerry Young, CNWL NHS
Foundation Trust 2014
Who am I to talk to you about this?
Kerry Young
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Trained as Clinical Psychologist in Oxford, qualified 1994
1997-2004 Traumatic Stress Clinic, London
2001-2010 Clinical Director, Doctoral Training Programme in Clinical
Psychology, UCL
2005 – 2010 Refugee and Asylum Seeker Service, St Ann’s Hospital,
London
2012 – 2013 Consultant Clinical Psychologist, The Haven, Paddington
2011 – Clinical Lead, Forced Migration Trauma Service, Central and
North West London
2012 – Clinical Psychologist, EPACT, Dept. Psychiatry, Oxford
University
Teach, train and supervise in CBT (general and specific)
Particular interest in how to treat PTSD in refugees and asylum seekers
Kerry Young, CNWL NHS
Foundation Trust 2014
Kerry Young, CNWL NHS
Foundation Trust 2014
Aims
• To inform you about the common psychological
effects of trauma
• To help you identify PTSD in particular
• To inform you about the treatment options for PTSD
• To answer any questions you may have
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Foundation Trust 2014
Examples of traumatic events
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Natural disasters (e.g. Tsunami)
Man-made disaster s (e.g. London bombings)
Accidents (e.g. Fall, RTA, train crash, medical)
Physical assault
Robbery
Murder
Sexual assault or rape
War
Ethnic cleansing
Torture
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Foundation Trust 2014
Outcomes After Trauma
• Acute Stress
Disorder
• PTSD
• Phobias
• Somatization
• Depression
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OCD
Suicide
Substance Abuse
Psychosis
Neurological
damage
• Pain
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Focus on PTSD today
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Foundation Trust 2014
How common is it after
trauma?
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Conditional risk of PTSD across
specific traumas (Breslau et al.,
1998)
Trauma type
Held captive/tortured/kidnapped
Rape
Badly beaten up
Sexual assault (other than rape)
Other serious accident
% PTSD
53.8
49.0
31.9
23.7
16.8
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Conditional risk of PTSD across
specific traumas (Breslau et al.,
1998)
Trauma type
Shot/stabbed
Sudden unexpected death of associate
Child's life-threatening illness
8.0
Mugged/threatened with weapon
Witness killing/serious injury
3.8
Natural disaster
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Foundation Trust 2014
%PTSD
14.3
10.4
7.3
2.3
So quite likely after an
inter-personal trauma
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Foundation Trust 2014
What is PTSD?
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Foundation Trust 2014
Historical Perspectives
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1666, Great Fire of London - Samuel Pepys’ diaries, trauma-related
nightmares, “..much terrified in the nights nowdays with dreams of fire
and falling down of houses” (1667)
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Debate for many years about whether symptoms were organic or
psychological in origin:
- 19th Century - “railway spine”
- World War I - “shell shock”
- World War II - “concentration camp syndrome”
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War in Vietnam – large numbers of sufferers showing similar
psychological reactions to overwhelming stress
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PTSD officially defined DSM-III, 1980
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Foundation Trust 2014
DSM-IV Diagnostic Criteria
• NB now DSM-V….
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Post-traumatic Stress Disorder
• Criterion A
– Experience/witness actual/threatened
death/serious injury/threat to physical integrity
self/others
– intense fear, helplessness or horror
• Symptoms (present for >1 month)
– Re-experiencing
– Avoidance / numbing
– Hyper-arousal
• Must cause clinically significant distress/
impairment
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Foundation Trust 2014
Re-experiencing Symptoms
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Intrusive recollections of trauma
Nightmares of trauma
Reliving the trauma - flashbacks
Intense distress at reminders
Physiological reactivity at reminders
• Need 1 or more
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Foundation Trust 2014
Avoidance Symptoms
• Avoid thoughts,
feelings, conversations
• Avoid activities, places,
people associated with
trauma
• Psychogenic amnesia
• Diminished
interest/participation in
significant activities
• Feelings detachment/
estrangement from
others
• Restricted range of
affect
• Sense of foreshortened
future
• Need 3 or more
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Foundation Trust 2014
Increased Arousal
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Difficulty sleeping
Irritability
Difficulty concentrating
Hypervigilance
Exaggerated startle response
• Need 2 or more
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Foundation Trust 2014
Case Example: Ahmed
• Student, 6 months ago, assaulted on
way home at night by group of youths
• Has PTSD
• What symptoms can you notice?
• Huge thanks to Deborah Lee for DVD
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Foundation Trust 2014
Play DVD
Scene 1 - 6:33 to 12:57
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Foundation Trust 2014
Ahmed: PTSD Symptoms
Re-experiencing
• Intrusive images of assailant/bottle (feel
‘pathetic’, frightened)
• Nightmares
• Flashbacks to image of bottle
• Distress at reminders (crowds of young
people, stuff on TV)
• Physiological arousal at reminders (sweaty,
tense)
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Foundation Trust 2014
Ahmed: PTSD Symptoms
Avoidance
• Avoid thinking about it
• Avoid TV, places with young people, going out,
college
• Doesn’t enjoy anything
• Doesn’t feel connected
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Foundation Trust 2014
Ahmed: PTSD symptoms
Increased Arousal
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Difficulty sleeping
Irritable with friends
Difficulty concentrating
Looking over shoulder all of the time,
think will be attacked again
• Jumpy at door banging
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Foundation Trust 2014
DSM-V – changes May 2013
• Event
Expanded to include repeated exposure to aversive details trauma &
learning event happened to close person
• Intrusive Sx
About the same
• Avoidance Sx
Narrowed to avoidance thoughts and things/places
• Negative alterations in cognition and mood
New category, some as before, plus change belief about
self/world/others, blame self/others, persistent
fear/horror/anger/guilt/shame
• Hyperarousal
As before
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Foundation Trust 2014
Keep using DSM-IV until
measures normed on DSM-V
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Foundation Trust 2014
What is Acute Stress Disorder
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What is Acute Stress Disorder
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• Remember most people will have PTSD
symptoms in month after trauma (94% after
rape in one study) – it is ‘normal’
• ASD refers to a more dissociative version of
PTSD that occurs within 2-30 days of trauma
• Rates 6-33% of those involved in trauma
Kerry Young, CNWL NHS
Foundation Trust 2014
What is Acute Stress Disorder
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• All criteria as for PTSD plus
• Dissociative Sx:
– Numb, detached, emotionally unresponsive
– Reduced awareness of surroundings
– De-realization (your environment seems not real)
– De-personalization (your thoughts/emotions don’t seem
real/to come from you)
– Dissociative Amnesia (can’t remember significant aspects of
trauma in absence of TBI)
• Need 3 or more
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Foundation Trust 2014
What is Acute Stress Disorder
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• Highly predictive of subsequent PTSD
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Need:
Psychiatric evaluation
Hospitalization if risk
Information
CBT
Medication
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Foundation Trust 2014
Back to PTSD
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Foundation Trust 2014
How to identify it
• If someone recently involved in a
trauma
• Complaining of any of the PTSD Sx
• Give them Trauma Screening
Questionnaire (Brewin et al., 2002)
• 6 or more positive responses indicate at
risk of having PTSD diagnosis
Kerry Young, CNWL NHS
Foundation Trust 2014
Kerry Young, CNWL NHS
Foundation Trust 2014
What to do if they look like
they might have PTSD
• Refer to appropriate mental health service i.e.
- IAPT
- student counselling service if offer evidence based
PTSD treatments (CBT or EMDR)
Kerry Young, CNWL NHS
Foundation Trust 2014
What to do if they look like
they might have PTSD
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In meantime, leaflets a good idea
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Student counselling service may have PTSD information leaflet
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Or suggest obtain PTSD psycho-educational material online;
- Royal College of Psychiatry
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstr
essdisorder.aspx
- NICE
http://www.nice.org.uk/nicemedia/live/10966/29782/29782.pdf
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Foundation Trust 2014
What are evidence based
PTSD treatments?
Kerry Young, CNWL NHS
Foundation Trust 2014
NICE Guidelines – early
intervention
• Consider watchful waiting when symptoms
are mild and have been present for less than
4 weeks after a trauma
• Arrange a follow up contact within 1 month
• For individuals who have experienced a
traumatic event, do not routinely offer brief
single session interventions (debriefing)
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Foundation Trust 2014
NICE Guidelines – after 1
month
• All PTSD sufferers should be offered a
course of tfCBT (trauma-focused
cognitive behavioural therapy) or EMDR
(Eye Movement Desensitization and
Reprocessing) regardless of the time
since the trauma
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Foundation Trust 2014
What is tfCBT ?
• Based on the understanding that trauma
memories aren’t properly integrated into
memory
• Need to get the patient to ‘re-process’
the memory so it can be integrated and
will stop popping into their heads when
they don’t want it to
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Foundation Trust 2014
Duvet and Cupboard
Imagine that memory is a little bit like a linen cupboard:
lovely and organized, with towels on one shelf, sheets and
pillow cases on another and, finally, duvet covers and
blankets on the last shelf.
When you are involved in a trauma, it is as if someone runs
at you with a huge duvet in their arms, screaming “PUT
THAT IN THE CUPBOARD RIGHT NOW!” You take the
duvet, stuff it in, jam the door shut and walk away. As you
do so, the cupboard door opens and the duvet flops out.
The person screams at you again, their face right up against
your face, “PUT IT BACK IN, PUT IT BACK IN NOW!” You grab it off the floor,
bundle it back in, jam the door shut and walk away. Again the door opens and
again the duvet spills out onto the floor. Growing increasingly agitated, the
person screams, “PUT IT BACK IN, PUT IT BACK IN, PUT IT BACK IN!”
Kerry Young, May 2011
Duvet and Cupboard cont.
In the end, you find that the only way to keep the duvet in the cupboard is to stand
with your back against the door. But you can’t do that forever and, anyway, you will
need to go into the cupboard eventually to get other things out. When you do, the
duvet will tumble out again.
Kerry Young, May 2011
What is tfCBT ?
• Involves talking about the traumatic event in a
lot of detail, including all five senses,
emotions and thoughts
• Worst moments of the trauma narrative are
re-scripted with new/corrective information so
that the memory can be nicely packed away
• 10-12 sessions on average for one-off trauma
Kerry Young, CNWL NHS
Foundation Trust 2014
Does it work?
Kerry Young, CNWL NHS
Foundation Trust 2014
CT for PTSD: Effect sizes for change before versus after treatment
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CT for PTSD studies
Chronic PTSD – RCT
(Ehlers et al, 2005)
Kerry Young, CNWL NHS
Foundation Trust 2014
Play DVD
• Scene 5 – 5:20 to 10
Kerry Young, CNWL NHS
Foundation Trust 2014
Medication and PTSD
• NICE say medication a second-line treatment ONLY to be
used if tfCBT/EMDR failed/not indicated
• Recommend paroxetine and mirtazepine (NICE Evidence
Update 2013 – fluoxetine and venlafaxine might also be useful)
• Worth considering if co-morbid depression
• No robust evidence for mood stabilizers (e.g. carbamazepine) or
benzodiazepines (e.g.clonazepam)
• Review Jonathon Bisson (2007) need doses at higher end of
therapeutic range and delay decisions about usefulness
Kerry Young, CNWL NHS
Foundation Trust 2014
What else to watch out for
• Co-morbidity with substance misuse,
depression, panic
• Increased rates of suicide
• NB may not want to tell you what
happened (especially if sexual
assault/rape)
Kerry Young, CNWL NHS
Foundation Trust 2014
Take home message
• PTSD is quite likely after inter-personal
trauma
• PTSD is very treatable (you can expect
remission from diagnosis after 10-12
sessions)
• PTSD needs a psychological treatment
(tfCBT or EMDR)
Kerry Young, CNWL NHS
Foundation Trust 2014
Questions?
Kerry Young, CNWL NHS
Foundation Trust 2014
Contact details
• [email protected]
Kerry Young, CNWL NHS
Foundation Trust 2014