Download - Ptsd resolution5.2

PTSD research and statistics

Bill Andrews

Pragmatic Research Network

1Sunday, 6 February 2011

Bill Andrews


PTSD treatment: the facts; outcomes of therapy


Bill AndrewsResearch Coordinator



The HGIPRN is expanding now to inclue and encourage a wider audience. The HGIPRN will forma sub-set of the total number of data contributors.

Bill AndrewsSenior advisor

ICCEwww.centerforclinicalexcellence.com


The ICCE is a great resource.

http://www.centerforclinicalexcellence.com


What is PTSD? 1/6

DSM-IV-TR, APA, 2000


What is PTSD? 1/6

• A: An event(s), witnessed, experienced or confronted by; actual or threatened death of physical injury, or physical integrity of others AND the individual’s response was of intense fear, helplessness or horror



What is PTSD? 2/6



What is PTSD? 2/6

• B: The event(s) is re-expereinced in the form of intrusive thoughts, distressing dreams, and/or a feeling that the event is reoccurring



What is PTSD? 3/6



What is PTSD? 3/6

• C: Persistent avoidance of stimuli associated with the event(s)



What is PTSD? 4/6



What is PTSD? 4/6

• D: Elevated arousal that was NOT present prior to the event(s)



What is PTSD? 5/6



What is PTSD? 5/6

• E: The symptoms must persist for more than 1 month



What is PTSD? 6/6



What is PTSD? 6/6

• F: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning



Psychological Trauma


It’s easier to understand trauma on a continuum.


continuum




physiological arousal

continuum




physiological arousal PTSD

continuum




acute stress disorderphysiological arousal PTS PTSD

addictionsdepressionanxiety

continuum




• Scientific method



• Scientific method

• NICE guidelines (UK context)



• Evidence hierarchy




• RCT




• RCT

• Meta-analysis of RCT studies


Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed Adults


Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed Adults

2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.


2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.


Lack of social support is the greatest predictor of the risk of developing PTSD.

Predictors of PTSD


Predictors of PTSD

• lack of social support


Predictors of PTSD


• post-trauma life stress


Predictors of PTSD



• trauma severity


• PTSD treatmentNICE Guideline recommendations



• Trauma- focused CBT



• Trauma- focused CBT

• EMDR


Trauma Focused Treatment


The list.

Trauma Focused Treatment

• Prolonged exposure

• Image habituation training

• Imaginal flooding (implosive flooding) therapy

• Imaginal exposure and biofeedback-assisted desenitization treatment

• Cognitive reprocessing therapy

• Cognitive restructuring plus exposure

• Cognitive trauma therapy

• Brief eclectic therapy (elements of psychodynamic therapy)


The list.

Meta-analysis of PTSD treatments



• Australian Centre for Post-Traumatic Mental Health, 2007

• Bisson & Andrew, 2009

• Bisson et al, 2007

• Bradley et al, 2005

• Seidler & Wagner, 2006




Agreement of no difference between trauma focused treatments.


• Common focus on the patient’s traumatic memories of the traumatic event & personal meaning of the trauma




• Common focus on the patient’s traumatic memories of the traumatic event & personal meaning of the trauma

• NO DIFFERENCE between ANY of these trauma-focused treatments





Controversy over finding that in fact there is no difference between ANY studied treatments that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding has been robustly defended.


• Benish et al, 2008




• Benish et al, 2008

• NO DIFFERENCE in OUTCOMES between ANY bona fide treatments, WHETHER TRAUMA FOCUSED OR NOT



Bill Andrews 2010c

TM


Let’s be pragmatic.

Practice Research Networks


Practice Research Networks

www.hgiprn.org


http://www.hgiprn.org

http://www.hgiprn.org


Bill Andrews 2010c

TM

pragmaticresearchnetwork.blogspot.com


The main purpose of a network is to try to investigate what is going on in practice.

Ask the Customers (n = 130)


The data speaks for itself.


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The effect sizes are large.

Ask the very distressed (n = 44)


Clients seem to be moving to below the cut-off, even when the more distressed cohort are looked at.


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Ask the very distressed


The data compares very favourably with one of the studies into PTSD from Northern Ireland.


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Andrews et al n = 44CORE-34



Predictors of PTSD



• trauma severity


Likely Predictors of PTSD Resolution



• recognising the importance of social support




• teaching skills for management of post-trauma life stress





• Using effective techniques to help de-traumatize trauma





• Using effective techniques to help de-traumatize trauma

• Be guided by feedback from service users as to what seems to work in treatment




• (Controversially) NO DIFFERENCE between ANY bona fide treatments, WHETHER TRAUMA FOCUSED OR NOT


Where Scientists Agree


Possible Factors important to successful treatments of PTSD



• Therapists...ask yourself how many of these you can tick off




• Therapists...ask yourself how many of these you can tick off

• Service Users...ask yourself how many of these have been honoured in your treatment




• Cogent rationale that is acceptable to patient




• Set of treatment actions consistent with the rationale





• Development and monitoring of a safe, respectful, and trusting therapeutic relationship






• Agreement about tasks and goals of therapy







• Nurturing hope







• Nurturing hope

• Identifying patient resources, strengths, survival skills and intra and interpersonal resources in building resilience



• Education about PTSD




• Opportunity to talk about trauma if desired





• Ensuring the patient's safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse)






• Helping patients learn how to avoid re-victimization






• Helping patients learn how to avoid re-victimization

• Fostering independence and self efficacy



Pragmatic Approach


The Pragmatic Approach tries to find a middle ground between the different sides of the argument.

Pragmatic Approach

• “Coming down from the lofty perch of ideological purity, pragmatism meets the world as we find it and asks: How can we improve it - not in some ideal way with a predetermined endpoint, but in a practical way in the here and now, within a context of the social, cultural, political, and economic realities we are given?”

1999. Fishman, D.B. The Case for Pragmatic Psychology. New York University Press. New York


The Pragmatic Approach tries to find a middle ground between the different sides of the argument.

Pragmatic Research Implications for Innovative Psychological Trauma Treatments


• Put the feedback of the service user at the top of the agenda




• Gather robust pre/post data using internationally recognised self-report measures





• Benchmark the results with published data






• Map the innovative treatment onto existing approved treatments







• Carry out case study research to elaborate on the features of particular treatments from multiples of perspectives







• Carry out case study research to elaborate on the features of particular treatments from multiples of perspectives

• Where funding allows, carry out an RCT to establish the differential effectiveness of the innovative treatment over and above wait-list control



Steve Hollon

“ with respect to randomization I would paraphrase Churchill on democracy, that it is a terrible process that has little to recommend it except that it is better

than the alternatives”

(Hollon, S. 2009)


Paul Salkovskis

Salkovskis, (2002). Empirically grounded clinical interventions: Cognitive-behavioural therapy progresses through a multi-dimensional approach to clinical science. Behavioural and Cognitive Psychotherapy, 2002, 30, 3–9, Cambridge University Press.


Paul suggests we need to move away from this evidence hierarchy.

Paul Salkovskis“The risk inherent in the current practice of evidence-based mental health is that the field will degenerate into a parody, a kind of one-dimensional science, and there are signs that this has already occurred to some degree”

Salkovskis, (2002). Empirically grounded clinical interventions: Cognitive-behavioural therapy progresses through a multi-dimensional approach to clinical science. Behavioural and Cognitive Psychotherapy, 2002, 30, 3–9, Cambridge University Press.


Prof. Gordon Turnbull

Frontiers in Trauma Treatment

BILL: What in your opinion are the significant breakthroughs in Trauma Treatment?


The New Frontier


The New Frontier

• unprocessed trauma memories control and cause exaggerated function of the ANS


The New Frontier


• PTSD is truly a MIND/BODY experience


The New Frontier



• Emphasis shift to the body focussed therapies


The New Frontier




• Sensorimotor therapy


The New Frontier





• EFT


The New Frontier





• EFT

• Acupuncture


The New Frontier





• EFT

• Acupuncture

• Acupressure


The New Frontier


The New Frontier

• Soothing the chaos in the right hemisphere

• EMDR

•Mindfulness


The New Frontier


The New Frontier

•Using a treatment that works on soothing the ANS and works on the right hemisphere is likely to be a good idea


Medications


Medications

• Propranolol (lowering adrenaline) useful in the Acute Stress Reaction phase to reduce the ‘etching’ of the emotionally charged memories


Medications

• Propranolol (lowering adrenaline) useful in the Acute Stress Reaction phase to reduce the ‘etching’ of the emotionally charged memories

• Opiate antagonists (e.g. Naloxone) help to prevent dissociation, which is associated with endorphin flooding


Avoidance


Avoidance

• Avoidance is a key feature of PTSD and dissociation commonly occurs at the time of the trauma and so becomes an integral part of the flashback


Avoidance


• Dissociation is probably THE most common cause of treatment resistance


Avoidance


• Dissociation is probably THE most common cause of treatment resistance

• Even just going to see a Trauma Therapist is enough to make the endorphins ‘pop’


Bill’s take home message



• have a healthy sense of curiosity




• keep an open mind





• systematically reflect on your work





• systematically reflect on your work

• take a balanced and informed view of the research



• measure your outcomes




• support research and/or get involved in case study research yourself





• be respectful of other modalities





• be respectful of other modalities

• trust your clients



pragmaticresearchnetwork.blogspot.com


THE ENDwww.centerforclinicalexcellence.com

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