People at risk of PTSD • victims of violent crime (e.g. physical and sexual

assaults, sexual abuse, bombings, riots)• members of the armed forces, emergency

services, journalists, prison service, healthcare staff!

• victims of war, torture, state-sanctioned violence or terrorism, and refugees

• survivors of accidents and disasters

• Generally between 70-80% of people will experience a traumatic event over the course of a lifetime

• The US National Co-Morbidity Survey – 35% of men and 25% of women reported more than one traumatic event in their lifetime

• Worldwide 40 million people killed in wars and conflicts since WWII

• Disasters have affected lives of 128 million people

Who are the victims?

Time Course

Acute Stress DisorderLasts for a minimum of 2 days and a maximum of 4

weeksOccurs within 4 weeks of the trauma

Post Traumatic Stress DisorderAcute – less than 3 months duration of symptomsChronic – symptoms last longer than 3 monthsDelayed Onset – 6 months between trauma and

onset of symptoms

ICD–10

PTSD may develop after ‘a stressful event or situation ... of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone’.

(World Health Organization, 1992: p. 147)

Diagnostic criteria for 309.81 Post Traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:(1) the person experienced, witnessed, or was confronted

with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour

DSM-IV: PTSD

“The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”

Diagnostic criteria (cont’d)

B. The traumatic event is persistent re-experienced in 1 (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event

(2) recurrent distressing dreams of the event

(3) acting or feeling as if the traumatic event were recurring

(4) intense psychological distress at exposure to internal or external cues

(5) physiological reactivity on exposure to internal or external cues

Diagnostic criteria (cont’d)C. Persistent avoidance of stimuli associated with the

trauma and numbing of general responsiveness …..: 3 (or more) needed

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places or people(3) inability to recall an important aspect(4) markedly diminished interest(5) feeling of detachment from others(6) restricted range of affect(7) sense of a foreshortened future

Diagnostic criteria (cont’d)

D. Persistent symptoms of increased arousal:

2 (or more) needed

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hyper vigilance

(5) exaggerated startle response

How common is PTSD?Probability of developing PTSD after a traumatic event:

Men 8% to 13% Women 20% to

30%

Annual prevalence of PTSD: 1.5% to 3%

PTSD: the management of PTSD in adults and childrenin primary and secondary care NICE (2005)

Comorbidity in PTSD

• 80% of individuals with PTSD meet criteria for another psychiatric disorder

Co-morbidity

• Major depressive disorder

• Generalised anxiety disorder

• Phobic disorders

• Panic disorder

• Substance abuse

• Borderline personality disorder

What is the natural history of PTSD?

Traumatic Event 1 month 9 months 3 years

Generally 33% remain symptomatic for 3 years

or longer with greater risk of secondary problems

Many recover without treatment

within months/years of event (45-80%

natural remission at 9 months)

Usual onset of symptoms

Time between trauma and help seeking

The chances that a person with PTSD will benefit from treatment do not decrease with time elapsed since the event (Gillespie, et al 2002; Resnick et al, 2002).

Post-traumatic Stress Disorder (PTSD):

the management of PTSD in adults and children in primary and secondary

care.NICE Clinical Guidelines

Published: March 2005

Trauma focussed CBT treatment of choice (16 RCTs) EMDR is an effective treatment Other therapies ~ counselling, supportive non-

directive therapies, psychodynamic therapy, hypnotherapy are not effective

Exposure (live and imaginal) reduce PTSD symptoms

CBT approaches reduce PTSD symptoms between 45-70%

Foa et al, 1991; Richards et al, 1994; van Etten & Taylor, 1998; NICE

Guidelines, 2005

How to treat PTSD? What isn’t recommended…Debriefing (single session as a treatment! – no

criticism of CISM as a crisis support strategy)Ineffective psychological treatmentsDrug treatments NOT a first line treatment

What is recommended… Watchful waiting Trauma-focussed treatments (CBT and EMDR) for

adults and children

How to treat PTSD?

• Offer 8-12 sessions +)• Manage sleep disturbance • Drug treatments: • Develop shared management approaches

between primary and secondary care

1. Sertraline, Fluoxetine, or Paroxetine

2. Venlafaxine

3. Mirtazapine, Amitriptyline, Phenelzine

4. Augmentation of AD with Olanzapine or Risperidone

Southern Health Anxiety dis Treat GLs 12

Drug Treatment

Risk Factors ~ Pre-event

Female genderPsychiatric historyChildhood abusePrevious traumaFamily psych’ history

Trauma severity

Lack of social support

Subsequent life stress

Brewin et al (2000)

Risk Factors ~ During Event

Helplessness/mental defeat

Subjective life threat often shown to predict PTSD

APA, 1994

Factors to consider ~ During Event

• Was trauma human induced or act of nature?

• Cultural environment in which the trauma is experienced and in which the individual recovers

• Frequency, duration, intensity and nature of trauma

• Single or multiple trauma?

• Magnitude of bereavement

• Speed of onset

• Degree of displacement of person/community

• Proportion of community affected

• Exposure to death

• Were traumas clearly delineated incidents?

• Was trauma a culmination of a number of experiences?

Factors to consider ~ During Event…. cont’

Risk Factors ~ Post Event

• Subsequent life stressors

• ‘Meaning’

• Social support

• Avoidance

‘Meaning’ of the trauma

*Role of survivor ~ Active/Passive -

• Was the individual a helpless victim?• Was he/she active in any way to alter the

situation?• Were there any options for acting differently?• How do they perceive the meaning and outcome

of their actions?• Idiosyncratic meaning of the specific trauma

‘Meaning’ of the trauma (cont’d)

Attribution and meaning

• What are the new views of self, others and the world?

• Are there new personal outlooks in place?• What does the trauma mean in terms of the

survivors’ plans for the rest of their life?• Is the person focused on the unfairness of the past

or on the possibilities of the future?

Maintaining behaviours

• Thought suppression

• Avoidance of reminders

• Avoidance of people

• Situational avoidance

• Numbing (drugs/alcohol/medication)

• Self-harm

• Dissociation

Measures

•Impact of Events Scale (IES & IES-R) •Post Traumatic Stress Diagnostic Scale (PDS)• Clinician Administered Post traumatic Stress Scale for DSM-IV (CAPS - DX IV)•Peri-traumatic Dissociation Questionnaire (PDEQ)•Beck Depression Inventory (BDI)•General Health Questionnaire (GHQ - 28)•Hospital Anxiety and Depression Scale (HADS)

Examples of TF-CBT Models

arrows indicate the following

relationshipsleads to

preventschange in

influences

matching

triggers

negative assessments of trauma/subsequent

events

nature of traumamemory

strategies intended to control

threat/symptoms

current threatarousal symptomsintrusions, strong

emotions

Dual Representation Theory (Brewin, et al 1996)

• Based on multiple memory systems to explain features of trauma memory.

• According to this theory trauma memories are stored in two formats– Verbally accessible memory (VAM)– Situational accessible memory (SAM)

Verbally Accessible Memory

• VAM contains information of factual type that occurred before, during and after the trauma,.

• Can be accessed through normal autobiographical memory processes and discussed with others – but contains limited information.

• High arousal narrows attention only allows limited information to be registered and transferred to VAM.

• SAM contains much more extensive data about the traumatic event from sensory input from eyes, ears, olfactory & touch receptors, plus emotional and physiological changes….SAM are retrieved automatically in situations where the person is exposed to trauma-related cues.

• Does not contain a verbal code and therefore is hard to communicate with VAM.

Situationally Accessible Memory

Dual Representation Theory

• Theory is that in PTSD people have failed to create a detailed VAM representation, therefore considerable amounts of information reside in SAM, producing the characteristic intrusions.

• Treatment involves transferring information from SAM to VAM, thus constructing a VAM memory that exerts control over SAM

Shattered assumptions

Traumatic reactions and PTSD are the result of certain basic assumptions about self and theworld being shaken or shattered.

• the belief in personal invulnerability

• a perception of the world as meaningful and comprehensible

• a positive view of self and others

Janoff-Bulman(1985)

How to treat PTSD

Treatment of PTSD.

Horowitz (1986) states that overall the goal of any school of psychotherapy is to help the person to the stage where s/he:

“IS ABLE TO FREELY THINK ABOUT, AND FREELY NOT THINK ABOUT THE EVENT”. (p.265).

The common element to apparently successful treatment modalities is an attempt to expose the patient to the fear memory and allow the patient reprocess or reattribute the threat associated with the original memory.

(Sharpe, Tarrier and Rotundo, 1994)

Components of TF-CBT Treatment

• Developing an empathic and supportive relationship.

• Psycho-education and providing a rationale for treatment.

• Stress management.• Exposure

– Imaginable (prolonged)– In-vivo

• Cognitive re-structuring

Rationale for treatment

• Explain that PTSD is a normal reaction to an abnormal event.

• Explain that strategies they are using ‘make sense’ but actually may be maintaining the reactions

• Treatment involves removing or changing maintaining factors

Overview of Re-living

• Initially neutral imagery;• Then complete sequence of traumatic imagery,

verbal or written to start - (possible hierarchical list);• Rewind and hold - concentrate on the worst part of

memory, freeze and hold image, while repeatedly describing in detail all they can remember of the trauma;

• Cognitive restructuring during exposure;• Audio-tape;• Constant rating of anxiety - use 0 -10 SUD’s scale;• Listen to tape as homework• Intersession tasks

Hotspots

• Notice changes in affect (What was going through your mind? How does it feel?)

• Discuss ‘meaning’ associated with hotspots

• Verbal re-appraisal of hotspots (or imagery) to deal with them

• Re-living just hotspots (re-wind and hold)

• Build in new meanings

After re-living

• Rate vividness

• Ask how they found doing it

• How it compared to what they thought it would be like?

• Were they holding anything back?

• H/W

Imagery Rescripting

• What would happen if you allowed the image to continue? Can you change the ending…

• What would the image look like projected onto a cinema screen, or seen from a moving train?

• Imagine watching the image on TV – switching it off, dimmer,…freeze the image or make it black & white.

• Through a zoom lens - make it smaller, out of focus or further away

Additional treatment strategies

• Exposure in vivo

• Behavioural experiments (to ‘test out’ unhelpful appraisals – “I’m going out of control”, “I’m vulnerable/weak” etc)

Cognitive Restructuring

Appraisals of the traumatic event –

“this could happen again”

“I should have been able to prevent it”

Appraisals of symptoms of PTSD –

“I am going mad”

“I should be over this by now”

Some characteristic biases / thinking errors –

Using hindsight to evaluate what happened

Personalisation

Overgeneralization (e.g.. of risk)

Catastrophisation (e.g.. if I face my memories ….)

Useful ‘Restructuring’ Questions

• What other explanations might there be?• Who else was involved?• How much power did you actually have to

influence what happened?• How did things appear to you at the time?• What was your reason for acting as you did,

at the time?• How could you have known what was going

to happen?

Useful ‘Restructuring’ Questions: (cont)

• How much time for reflection and choosing the best course of action did you have?

• What was your emotional and physical state at the time?

• What did you do that was helpful?• If this was another person, what more would you

expect of them? How would you explain their behaviour?

• Apart from your feelings, what else might you take into account when considering how you acted?

arrows indicate the following

relationshipsleads to

preventschange in

influences

matching

triggers

negative assessments of trauma/subsequent

events

nature of traumamemory

strategies intended to control

threat/symptoms

current threatarousal symptomsintrusions, strong

emotions

reconstruct the reconstruct the fragmented trauma fragmented trauma memory & anchor memory & anchor

it in the past it in the past through discussion, through discussion,

tapes & writingtapes & writingchange toxic beliefs change toxic beliefs

with education, with education, understanding,understanding,

imagery rescripting,imagery rescripting,behavioural behavioural

experiments,experiments,& compassion& compassion

understand & understand & reduce avoidance, reduce avoidance,

encourage encourage desensitization, desensitization, tackle substance tackle substance

abuseabuse