Matthew Gaskell C.Psychol AFBPsS Consultant Psychologist/Clinical Lead LAU 1 PTSD.

Matthew Gaskell C.Psychol AFBPsS Consultant Psychologist/Clinical Lead LAU 1 PTSD

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 3 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?

Shell shock http://www.youtube.com/watch?v=RRv56gsqkzs&feature =fvwrel http://www.youtube.com/watch?v=RRv56gsqkzs&feature =fvwrel

What are the key signs and symptoms? 5 PTSD CRITERIA AND SYMPTOMS

The trauma event 6 What kinds of experiences may lead to developing PTSD?

Events.. 7 Rape Violent physical attack Combat Car accident Waking during an operation Torture Natural disaster Terrorism Kidnapping Others?

Key Symptoms 11 Re-experiencing (as if it is happening now) Avoidance Hyperarousal Emotional numbing

Prevalence, life course and risk factors for PTSD 13 EPIDEMIOLOGY

Epidemiology 14 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

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 16 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

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%

Common Co-morbid Problems 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) 20 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

Risk factors for developing PTSD 21 WHY DO SOME GET CHRONIC PTSD WHEREAS OTHERS RECOVER SPONTANEOUSLY?

Exercise: 22 Why might PTSD develop and persist? What makes someone more at risk?

Traumatic Event Characteristics Natural Disaster Technological Disaster Interpersonal Violence PTSD Risk Lowest Highest WHY ?

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?

27 THEORIES OF PTSD

Current Theories.. 28 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)

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 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 36 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

37 EVIDENCE-BASED TREATMENT FOR PTSD

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

What is it? Does it work? 39 Trauma-Focused CBT

Model of PTSD 40 Lets look at the model and make sense of PTSD and why it persists Handout

What maintains PTSD? 42 Key processes: Fragmented unprocessed trauma memory (SAMs) Triggers for re-experiencing Negative appraisals Strategies to avoid and suppress trauma memory being triggered

Exercise Work in Groups of 3 Formulate client case Matt using Ehlers & Clark (2000) Model

Trauma-focused CBT 44 Looking at the CBT model what do you think the goals of treatment might be? Where do we need to intervene?

Goals of CBT 45 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

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 Current threat Strategies intended to control threat / symptoms Triggers Elaborate Modify Discriminate Cut Reduce

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 Pink elephant Evidence Wegner et al (1987) White bear experiments Davies & Clark (1998) rebound effect experiment Dont mention the war http://www.youtube.com/watch?v=7xnNhzgcWTk

TF-CBT Elhers & Clark (2000) Twelve 1 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

What is it? Does it work? 55 Eye Movement Desensitisation and Reprocessing (EMDR)

What is EMDR? 56 https://www.youtube.com/watch?v=GTLLfdcJE0Q

EMDR 57 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

58 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

Active ingredients of EMDR? not yet fully understood. 59 Exposure Processing the fragmented memory and updating it Exposure Mindfulness Mastery and self-efficacy

Active ingredients of EMDR? 60 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)

Why does Eye Movement work? 61 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

Why does Eye Movement work? 62 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.

An EMDR Clinician: 63 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)

Effectiveness 64 A meta-analysis of 38 RCTs 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)

Conclusions 65 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

Matthew Gaskell C.Psychol AFBPsS Consultant Psychologist/Clinical Lead LAU 1 PTSD.

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