PTSD english

7/28/2019 PTSD english

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Trauma and PTSD


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,


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PTSD DSM-IV Criteria

Exposure to traumatic event with

Actual or threatened death or serious

injuryand

Response involving intense fear,

helplessness, or horror

American Psychiatric Association. DSM-IV. 1994.


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Symptom Clusters

Re-experiencing: intrusive recollections,

recurrent dreams, dissociative flashbacks

Avoidance and numbness: avoidance ofcognitions/activities related to trauma,

decreased interest, feeling detached

Hyperarousal: hypervigilance, insomnia,

exaggerated startle response


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PTSD DSM-IV Criteria

Re-experiencing the traumatic event

Persistent avoidance of stimuli associated with event

Numbing of general responsiveness Symptoms of increased arousal

At least 1 months duration (otherwise can diagnose

Acute Stress Disorder)

Significant distress or impairment in social,occupational, or other functioning

American Psychiatric Association. DSM-IV. 1994.


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PTSDAssociated Features

Alcohol/drug problems

Aggression/violence

Suicidal ideation, intent, attempts

Dissociation Distancing

Problems at work

Marital problems

Homelessness


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Epidemiology of PTSD

National Comorbidity Study 7.8% of adults in the U.S. (lifetime)

Type of trauma most often the basis for

PTSD: rape in women (46% risk)

combat in men (39% risk)

1/3 of cases have duration of many years 88% of cases have psychiatric comorbidity

Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.


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Combat-Related PTSD:

Epidemiology

Lifetime Prevalence:

30% in Vietnam veterans

5-10% of Gulf War I deployed veterans 10-20% in Operation Enduring Freedom

and Operation Iraqi Freedom

VIETNAM: Kulka RA, et al. Trauma and the Vietnam war generation: Report of the findings from the National Vietnam Veterans

Readjustment Study. 1990, New York: Brunner/Mazel.

GULF WAR: Stretch RH et al. Military Medicine. 1996;161:407-410.IRAQ WAR: Hoge, C.W., et al. R.L. N Engl J Med. 2004;351:13-22.


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0

1020

30

4050

60

70

80

Numbe

rof

Individ

uals

McFarlane, et al. Ann N Y Acad Sci. 1997;821:437-441

Responses to Trauma Are Heterogeneous

Primary Psychiatric Disorder

6 Months Following Trauma


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Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

3mW 9m Years

94%

47%

42%

30%?

Longitudinal Course of PTSD

Symptoms


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Risk Factors for PTSD

Severity of trauma (ie, threat, duration, injury, loss)

Prior traumatization

Gender

Ethnicity Prior mood and/or anxiety disorders

Family history of mood or anxiety disorders

Education


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Screening Questions for

PTSDWhats the worst thing that ever happened toyou?

How did you react when it happened?

Do memories of _______ still bother you? Didyou get over it?

Do you avoid situations that might remind you of

____? Have your relationships suffered because of____?

Have you become more nervous since ___? Is ithard for you to relax because of ____?


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Functional Neuroanatomy of Traumatic Stress

Amygdala

Hippocampus

Locus Coeruleus

Pituitary

Hypothalamus

OrbitofrontalCortex

Cerebral Cortex

Adrenal

CRF

ACTH NE

Extinction to fearthrough amygdala

inhibition

Long-term storage oftraumatic memories

Conditioned fear

Cortisol

Output tocardiovascularsystem

Prefrontal

Cortex

Parietal Cortex Stress

Attention and vigilance - fear behaviorDose response effect on metabolism

Glutamate


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PTSD Treatment Options

Psychotherapy

Pharmacotherapy

Complementary Alternative

Interventions

Yoga

Exercise

Meditation

Multimodal treatment


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Early Post-Trauma Interventions Crisis InterventionsShort cognitive behavioral therapy (CBT):

Psychological Debriefingequivocal or harmful

Cognitive Behavioral Prevention Programs: Prolonged Exposure (PE) Prolonged Exposure + Stress Inoculation Training (PE/SIT)

Psychotherapy Brief dynamic psychotherapy for traumatic grief Supportive counseling Spiritual counseling

Pharmacotherapy Propranolol

Foa EB, et al. J Clin Psychiatry. 1999;60(suppl 16):1-34.

Mitchell JT. JEMS. 1983;8:36-9.


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Psychological Treatments for

Chronic PTSD

Psychotherapy

Exposure therapy

Cognitive processing therapy

Anxiety managementAdditional treatments

Eye Movement Desensitization andReprocessing (EMDR)

Hypnotherapy

Psychodynamic therapy

Expressive therapies


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Treatment

Psychotherapy is the treatment of choice

Meds are not the primary treatment but should

target specific symptoms as they arise

Restoring a sense of control over emotions


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Issues with pharmacological treatment

Efficacy across symptom clusters

Comorbidity/Associated sxs

depression and substance abuse common

guilt, shame, distrust significant marital, occupational, financial, health problems

Discontinuation of meds original symptoms returning

Response to meds not guaranteed

Changes not necessarily large


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Medication

Selective Serotonin Reuptake Inhibitors Benzodiazepines Tricyclic Antidepressants (TCAs)


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TCAs

1st antidepressants used

Prevent reuptake of monoamines (serotonin ornorepinephrine) by the presynaptic neurons in the CNS,thus prolonging the effects of these NTs

Numerous side effects: blurred vision, dry mouth, constipation,weight gain, dizziness when changing position, increased sweating,difficulty urinating, changes in sexual desire, decrease in sexualability, muscle twitches, fatigue and weakness

Overdose delirium, hypotension, cardiac arrhythmiasand death.


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SSRIs

1st line of treatment

Antidepressants that block reuptake of serotonin at

presynaptic neurons in the brain

Side effects: nausea, sweating, fatigue, sleepiness, andsexual side effects.

Generally safer than TCAs if overdose is taken


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Benzodiazepines

Relatively fast-acting

Use has declined

concerns over dependence and abuse

Lower anxiety by vigilance, eliminating muscle tension,

and causing sedation

act on the g-aminobutyric acid (GABA)/benzodiazepine (BZ)

receptor complex

Side effects: concentration problems, a mild form of amnesia,drowsiness and a loss of coordination; fatigue and mental slowing or

confusion

dangerous to drive or operate heavy machinery


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Cognitive behavioral therapy

(CBT) interventions designed to change the way

people think about and understand

situations and behaviors. This reduces the

frequency of distressing negative reactionsand emotions.


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PTSD Thinking Distortions

Two erroneous beliefs

the world is dangerous and the individual with PTSD is incompetent.

CBT is used to change these beliefs, and

successful CBT will result in the patient no

longer believing that the world is

dangerous or that they are incompetent


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CBT normally lasts from 9-12 individual

sessions, lasting about 60-90 minutes,

administered once or twice weekly.

Patients are normally also assignedhomework to practice specific

interventions on their own between

sessions.


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The most often used

interventions include exposure therapy stress inoculation training (SIT) cognitive restructuring These therapies may be used on their own

or they may be combined. Another type of

CBT is eye movement desensitization and

reprocessing (EMDR).


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Exposure Therapy

Exposure therapy is a treatment designed to

help you confront safe but feared

thoughts, situations, objects, people,

places, or activities. These thingselicit anxiety in the PTSD sufferer and are

avoided, which takes a negative toll on

everyday life.
http://www.epigee.org/mental_health/anxietyvspanic.htmlhttp://www.epigee.org/mental_health/anxietyvspanic.html


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The goal of exposure therapy

help the individual

confront and process traumatic memories and

correct erroneous thoughts about the world

and the self that derive from them.


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PTSD patients are also exposed to real life

situations and objects that trigger anxiety andavoidance.

Each person, place, situation and activity thattriggers anxiety and avoidance is identified and

evaluated for safety and relevance to thepatient's normal functioning.

Then these things are repeatedly confronted

until anxiety and avoidance centered on them

goes away. Therapy starts small and works its

way to more feared and challenging situations


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Exposure therapy designed for PTSD involvesimaginative exposure to the trauma memory.

The patient is instructed to close her eyes and

remember the traumatic event by imagining thatit's currently happening.

They will provide detailed descriptions of all

thoughts, physical sensations, and emotional

reactions to the memory. This is repeated

several times over the course of therapy and it is

taped to be listened to later as homework.


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Stress Inoculation Training

Teaching the PTSD sufferer how to manage their

anxiety reactions to situations, memories, etc.They normally fear and avoid.

For the physical manifestations : controlledbreathing and progressive muscle relaxation.

For intrusive thoughts and worrying: how to

interrupt their thought patterns and think of

positive imagery.


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Cognitive Restructuring

helps patients identify and challenge theirerroneous beliefs and interpretations.

It is based on the idea that it is not actual

events that cause negative emotional

reaction but the interpretation of thoseevents.


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Cognitive restructuring seeks to replace worry

and anxiety with more positive and productiveemotions through the way a patient thinks.

People undergoing this therapy are taught tolook at their negative beliefs and evaluate the

pros and cons of maintaining them. They

carefully consider the likelihood of their fears

and the cost of those outcomes and look forpossible alternative explanations and ways of

thinking.


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Approach to Trauma Treatment

Evaluation and Assessment

Type of trauma & Type of trauma client

Safety

Risk assessment

Mental status & co-morbid disorders

Medical History

Family and occupational functioning

Medication


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Approach to Trauma Treatment

Psychoeducation about trauma

Coordination of care with medical providers

Affect management skills

Safe place exercise, grounding Container method

Calming the body down

Meditation, breathing

Yoga, chanting

Integration of Traumatic Memories via EMDR


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What is Eye-Movement Desensitization

and Reprocessing (EMDR)?

A type of psychotherapy for treating

emotional difficulties that are caused by

disturbing life experiences, ranging

from traumatic events such as combat

stress, assaults to upsetting events.

EMDR is also being used to alleviate

performance anxiety, generalized

anxiety, sleep disturbances, phobias,

grief, relapse prevention, andperformance enhancement.

Francine Shapiro

Adaptive Information Processing: A


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Adaptive Information Processing: A

Theoretical Model(Parnell, 2007; Shapiro, 1995)

We all have an information processing system

through which new experiences and information

are processed to an adaptive state.

Trauma or disturbing experiences becometrapped in the nervous system.

In EMDR, we ask the patient to focus on a target

memory.


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Adaptive Information Processing

Continued

When information stored in memory networks

related to a distressing or traumatic

experience is not fully processed it gives rise

to dysfunctional reactions. Eye movements or BLS stimulates

accelerated information processing.

The goal is to reach adaptive resolution -reduce vivid imagery and related affect & shift

negative beliefs about oneself.


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The Eight Phases of EMDR Treatment

The 8 phases of the EMDR protocol

represent a comprehensive treatment

approach.

1. Client History and Treatment Planning

2. Client Preparation

3. Assessment


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HOW WAS EMDR DEVELOPED?

Discovered and Developed by Francine Shapiro1987

She noticed that :

Disturbing Anxious Thoughts

Changed with spontaneous eye movements to:

LESS DISTURBING THOUGHTS LEADING

TO ADAPTIVE RESOLUTION

(ie. The negative charge was greatly

reduced)


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1987

EMDR : Eye Movement Desensitization

1990EMDR :

Eye Movement

Desensitization & Reprocessing

( Processed Traumatic Memories Into

Something More Adaptive And Functional)


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WHAT HAPPENS DURING EMDR?

TRAUMATIC MEMORY MEMORYEMDR

State-specific Form

In Implicit Memory

(Right Hemisphere)

Less disturbing Image, a

Positive Cognition,Appropriate Affect without

disturbing Physical

Sensations

Functional Form In

Explicit Memory

(Left Hemisphere)

Associated with disturbing

Image, Cognitions,Affect, Physical

Sensations

(fragmented, not integrated)

Re-experiencingTimeless RememberingSense of time


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HOW DOES EMDR WORK?

Not entirely clear! EMDR induces changes in regional brain

activation similar to REM sleep

EMDR increases prefrontal lobe activationleading to more appropriate responses totriggers

The Eye Movements or other dual

attention stimuli elicit an OrientingResponse which disrupts the traumaticmemory network, interrupting previouslinks to negative emotions and allows

integration of new information


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HOW DOES EMDR WORK?

EMDR has evolved into a synthesis oftraditional orientations:

Aspects of CBT

Brief /Interrupted exposure Free Association :

Directed and Non-directed

Focus on physical sensations

Dual attention stimulation

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