Targeting PTSD

Dr Walter Busuttil

Treatment of Complex PTSD: Basic Principles Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999)(Herman 1992; Bloom 1999)

• Stabilization & SafetyStabilization & Safety

• Working through of Traumatic material – disclosure Working through of Traumatic material – disclosure – psychotherapy– psychotherapy

• RehabilitationRehabilitation

First line and Top second line interventions targeted to symptom setsMost Prominent Symptom Set

First Line Interventions Top second line interventions

Re experiencing Education about traumaNarration of Trauma Memory

Cog Restructuring / emotional regulation / Anx/Stress mgt

Avoidance/Constriction Education about traumaEmotional regulation

Cog Restructuring / Narration of trauma memory /Meditation Mindfulness/ Interpersonal skills training.

Hyperarousal Education about traumaEmotional regulation Anx/stress mgt

Narration of Trauma Memory . Cog restructuring

Affect Dysregulation Education about traumaEmotional regulation

Cog Restructuring / Narration of trauma memory /Meditation Mindfulness/ Anxiety reduction, Narration of trauma memory /Interpersonal skills training.

Relationship Difficulties Education about trauma, Interpersonal skills trg/ Cog restructuring

Emotional regulationNarration of the truama

Treatment of CPTSD

Most Prominent Symptom Set

First Line Interventions Top second line interventions

Disturbances in meaning Education about the trauma/ cognitive restructuring

Narration of trauma memories, emotional regulation

Behavioural Dysregulation Education about the trauma, emotional regulation

Cog restructuring, interpersonal effectiveness, meditation, mindfulness.

Attentional Dysregulation Education about the trauma, emotional regulation

Meditation/mindfulness; anxiety/stress management; narration of the trauma memory

Somatic Symptoms Education about the trauma; Anxiety/stress mgt

Emotional regulation, Narration of trauma memory, Cog restructuring

Dissociation Education about traumaEmotional regulation

Narration of truama memories, anx/stressmgt/ meditation mindfulness.

Identity Disturbance Education about trauma Emotional regulation, meditation / mindfulness

Medications:Medications:

MedicationMedication• AntidepressantAntidepressant

• NeurolepticNeuroleptic

• Mood Stabilizer / Mood Stabilizer / AntiepilepticAntiepileptic

• Anti-impulseAnti-impulse

IndicationIndication• PTSD & Depressive symptomsPTSD & Depressive symptoms

• Pseudo-hallucinations;Pseudo-hallucinations; Dissociation; TranquilizationDissociation; Tranquilization

• PTSD Symptoms & Mood stabilizing PTSD Symptoms & Mood stabilizing propertiesproperties

• Impulse control - self- harm / Impulse control - self- harm / depressiondepression

Medications: used to stabilize patient in order to allow psychotherapy to be conducted primarily. After psychotherapy is finished, attempt should be made to reduce medications.

Case 1• John is aged 24 he successfully completed DBT

training and feels more in control. • He tell you he still suffers from sleep problems,

he dreams a lot• He wakes up startled and in a sweat. • He wakes up early every morning at 0400 and he

feels he has no energy. • He feels jumpy when someone shouts.

• What do you do next?

Case 1• John is aged 24 he successfully completed DBT training

and feels more in control. • He tell you he still suffers from sleep problems, he

dreams a lot ?nightmares?• He wakes up startled and in a sweat. ? Hyperarousal

on waking from a nightmare?• He wakes up early every morning at 0400 and he feels

he has no energy ? Depressed? • He feels jumpy when someone shouts. ?

hyperaroused?

• What do you do next?

John is assessed further• He is thought to be suffering from PTSD – he is

hyperaroused, he has nightmares and flashbacks, he avoids thinking about his childhood abuse – he is coping better than before.

• He is also depressed• You also know that he used to drink 25 bottles of

beer a week and 1 litre of whiskey a week. The DBT treatment has reduced this to five bottles of beer a week.

• What should happen next?

John is assessed further• He is thought to be suffering from PTSD – he is

hyperaroused, he has nightmares and flashbacks, he avoids thinking about his childhood abuse – he is coping better than before.

• He is also depressed• You also know he used to drink 25 bottles of beer a

week and 1 litre of whiskey a week. The DBT treatment has reduced this to five bottles of beer a week.

• What should happen next? He should be stabilised further ? Assess and prescribe antidepressant; also tell him to stop drinking alcohol altogether – why?

John is stabilised further• John is feeling better on an antidepressant.

Mirtazepine 45 mgs. This has reduced his nightmares, he sleeps better, his hyperarousal is better, he feels less numb, he is less depressed.

• He has stopped drinking alcohol.• He wants more help for his PTSD. • What are you going to offer him?

psychotherapy

• What kind and why?

Specific treatment modelsSpecific treatment modelsEngagement, Stabilisation / Skills trg:Engagement, Stabilisation / Skills trg:• Art TherapyArt Therapy• DBTDBT• Psychodynamic / analytical PsychotherapyPsychodynamic / analytical Psychotherapy

Trauma Focussed TherapyTrauma Focussed Therapy• Cognitive Behaviour Therapy / Cognitive Processing Cognitive Behaviour Therapy / Cognitive Processing

Therapy: promote Info Processing & ExposureTherapy: promote Info Processing & Exposure• Prolonged exposureProlonged exposure• Narrative Exposure TherapyNarrative Exposure Therapy• Eye Movement Desensitisation and Reprocessing Eye Movement Desensitisation and Reprocessing

(EMDR)(EMDR)

Treatment Pitfalls: Treatment Pitfalls:

Common maintaining factorsCommon maintaining factors• Nature and duration of Nature and duration of

traumatrauma• Role in traumaRole in trauma• Meaning of traumaMeaning of trauma• Has trauma ended?Has trauma ended?• Isolation - attachmentsIsolation - attachments• Guilt - omission / Guilt - omission /

commissioncommission• Guilt – survivorGuilt – survivor• Is the patient drinking Is the patient drinking

alcohol? Using illicit drugs? alcohol? Using illicit drugs? Before or after therapy?Before or after therapy?

Other FactorsOther Factors• Co-morbidity - treat this Co-morbidity - treat this

first?first?• Alcohol & Illicit DrugsAlcohol & Illicit Drugs• Motivation Motivation • Co-operation Co-operation • ComplianceCompliance• Therapeutic qualities of Therapeutic qualities of

patient & therapistpatient & therapist

Treating CPTSD in AdultsTreating CPTSD in Adults

Models:Models:• DBT followed by TF Work (Linehan)DBT followed by TF Work (Linehan)• Self-Trauma Model & Trauma Focussed work Self-Trauma Model & Trauma Focussed work

(Briere)(Briere)• Psychodynamic therapy followed by Trauma Psychodynamic therapy followed by Trauma

Focussed work (de Zulueta)Focussed work (de Zulueta)• Structured Group Therapy Programmes (Busuttil, Structured Group Therapy Programmes (Busuttil,

Cloitre)Cloitre)

The Self Trauma ModelThe Self Trauma Model(Briere)(Briere)

• Integrated ApproachIntegrated Approach• CBT & RelationalCBT & Relational• Take symptoms beyond PTSD into account Take symptoms beyond PTSD into account

– address them– address them• Affect regulation trainingAffect regulation training• Trigger identificationTrigger identification• Mindfulness as cognitive and affect Mindfulness as cognitive and affect

regulationregulation• Titrated exposure to traumatic materialTitrated exposure to traumatic material

Therapeutic relationship emphasised (Briere)Therapeutic relationship emphasised (Briere)

• Attendance / compliance• Context for support / validation / safety• Activates relations schema which then can be

addressed. • Counter conditions relational trauma

memories

Therapeutic WindowTherapeutic Window

Titrated exposureTitrated exposure• Balance between therapeutic challenge Balance between therapeutic challenge

and overwhelming internal experienceand overwhelming internal experience

• Maximal possible exposure & reactivation Maximal possible exposure & reactivation within the limits of affect regulation within the limits of affect regulation activityactivity

Identity DevelopmentIdentity Development• Exploration of self within the context of the Exploration of self within the context of the

therapeutic relationshiptherapeutic relationship

• Self knowledgeSelf knowledge

• Self directednessSelf directedness

• Value of not leaving open-ended questionsValue of not leaving open-ended questions

• Avoiding over use of interpretationsAvoiding over use of interpretations

Dissociation and Reflective function

• Use of video or tape-recording in severely dissociated patients.> The development of mentalisation or mindfulness.

Affect regulation trainingAffect regulation training

• Dealing with acute intrusions – grounding• Breathing training• Identifying and discriminating emotions• Countering intrusive and exacerbating intrusions• Development of equilibrium through mindfulness• Repeated exposure and processing as affect regulation

training • Affect Regulation – the content is not as important as

the skill itself

Mindfulness as a cognitive interventionMindfulness as a cognitive interventionSelf observation:Self observation:• Moment by moment of awareness of internal

experience without judgement• Learning to let go of thoughts & feelings without

avoidance or suppression

• Especially for childhood memories• Thoughts are not perceptions. • Perceptions do not necessarily reflect reality. • Mediation of abuse related cognitive distortions and

associated emotions.

Affect regulation training (Briere)Affect regulation training (Briere)

• Dealing with acute intrusions – grounding• Breathing training• Identifying and discriminating emotions• Countering intrusive and exacerbating intrusions• Development of through mindfulness• Repeated exposure and processing as affect regulation

training • Affect Regulation – the content is not as important as

the skill itself

Mindfulness as a cognitive intervention (Briere)Mindfulness as a cognitive intervention (Briere)

Self observation:Self observation:• Moment by moment of awareness of internal Moment by moment of awareness of internal

experience without judgementexperience without judgement• Learning to let go of thoughts & feelings without Learning to let go of thoughts & feelings without

avoidance or suppressionavoidance or suppression• Especially childhood memoriesEspecially childhood memories• Thoughts are not perceptions, perceptions do not Thoughts are not perceptions, perceptions do not

necessarily reflect reality necessarily reflect reality • Mediation of abuse related cognitive distortions and Mediation of abuse related cognitive distortions and

associated emotionsassociated emotions

Central Components of Trauma Processing (Briere)Central Components of Trauma Processing (Briere)• ExposureExposure• Activation Activation – triggers associated thoughts feelings – reliving– triggers associated thoughts feelings – reliving• DisparityDisparity – although in activated state – now able to talk to – although in activated state – now able to talk to

therapist in safe environment: fear is therefore not reinforced : therapist in safe environment: fear is therefore not reinforced : negative state generated in a safe environmentnegative state generated in a safe environment

• Central focus is on awarenessCentral focus is on awareness: reliving trauma memories, : reliving trauma memories, thoughts, feelings – yet maintain current awareness experience thoughts, feelings – yet maintain current awareness experience (safe): able to perceive the disparity memory of bad experience (safe): able to perceive the disparity memory of bad experience activated but need to be present in the here and now: awareness activated but need to be present in the here and now: awareness to remember it as past; aware that this is now the present.to remember it as past; aware that this is now the present.

• Working with traumatic memory Working with traumatic memory – activate the specifics of the – activate the specifics of the memory cue by asking question about what happened – helps memory cue by asking question about what happened – helps processingprocessing

Psychodynamic / TF-CBT ModelsPsychodynamic / TF-CBT Models

• Contrast with Briere’s Model:Contrast with Briere’s Model:• De Zulueta’s (2002) model of intervention at the De Zulueta’s (2002) model of intervention at the

Maudsley Trauma Therapy Unit uses individual Maudsley Trauma Therapy Unit uses individual psychodynamic psychotherapies to deal with psychodynamic psychotherapies to deal with interpersonal and attachment issues before using interpersonal and attachment issues before using Trauma-Focussed Cognitive-Behavioural Therapy Trauma-Focussed Cognitive-Behavioural Therapy (TF-CBT). (TF-CBT).

TF-CBTTF-CBT

• Psycho-educationPsycho-education• Disclosure / Exposure / Working Through of Disclosure / Exposure / Working Through of

Traumatic MaterialTraumatic Material• Cognitive restructuringCognitive restructuring• Problem solvingProblem solving• Use of behavioural techniques Use of behavioural techniques for example anxiety managementfor example anxiety management

TF-CBT ApproachesTF-CBT Approaches• Exposure:Exposure:• The therapist helps confrontation of the The therapist helps confrontation of the

traumatic memories (written, verbal, narrative).traumatic memories (written, verbal, narrative).• Detailed recounting of the traumatic experience Detailed recounting of the traumatic experience

–repetition.–repetition.• In vivo repeated exposure to avoided and fear-In vivo repeated exposure to avoided and fear-

evoking situations that are now safe but that are evoking situations that are now safe but that are associated with the traumatic experience.associated with the traumatic experience.

• Identification of triggersIdentification of triggers• Hot spotsHot spots

CBT ApproachesCBT Approaches• Focus on the identification and modification of Focus on the identification and modification of

misinterpretations that lead PTSD sufferer to misinterpretations that lead PTSD sufferer to overestimate current threat (fear)overestimate current threat (fear)

• Modification of beliefs related to other aspects Modification of beliefs related to other aspects of the experience and how the individual of the experience and how the individual interprets their behaviour during the trauma (eg: interprets their behaviour during the trauma (eg: issues concerning shame and guilt). issues concerning shame and guilt).

Cognitive Processing Therapy (Resick )• PTSD is believed to emerge due to the

development of a fear network in memory that elicits escape and avoidance behaviour.

• Repeated exposures to the traumatic memory are thought to result in habituation or a change in the information about the event, and subsequently, the fear structure.

• Fear extinguishes when repeated expoasure to feared stimulus is facilitated

• CPT is designed to bring patients into their own awareness of the inconsistent and/or dysfunctional thoughts maintaining their PTSD.

• Cornerstone part of the practice of CPT is Socratic questioning. Throughout the course of treatment, therapists should be consistently using Socratic questioning to induce change, with the goal of teaching patients to question their own thoughts and beliefs.

• ‘Stuck ppoints are identified and challenged.

• For 12 session manual down load: http://depts.washington.edu/hcsats/PDF/research/Cognitive%20Processing%20Therapy%20Manual%208.08.pdf

EMDREMDR(Eye movement Desensitisation and Reprocessing)(Eye movement Desensitisation and Reprocessing)

• Therapeutic rapportTherapeutic rapport• Imagery / envisioning of traumatic scenesImagery / envisioning of traumatic scenes• Focus on sensations of anxietyFocus on sensations of anxiety• Cognitive restructuringCognitive restructuring• Saccadic movements of EyesSaccadic movements of Eyes• Extinguishing of the memoryExtinguishing of the memory

• Other methods - eg Counting Method Other methods - eg Counting Method • Need training - CriticismsNeed training - Criticisms

EMDREMDR

• Standardised, trauma focussed procedure Standardised, trauma focussed procedure with several elements, always involving the with several elements, always involving the use of bilateral physical stimulation (eye use of bilateral physical stimulation (eye movements, taps, tones), thought to movements, taps, tones), thought to stimulate the individual’s own information stimulate the individual’s own information processing in order to help integrate the processing in order to help integrate the targeted event as an adaptive contextualised targeted event as an adaptive contextualised memorymemory

• Requires individual to focus on a traumatic memory and Requires individual to focus on a traumatic memory and generate a statement summarising thoughts of the generate a statement summarising thoughts of the trauma eg I should have done ‘X’trauma eg I should have done ‘X’

• Patient is instructed to visualise traumatic scene , briefly Patient is instructed to visualise traumatic scene , briefly rehearse the belief statement that best summarised rehearse the belief statement that best summarised their memories, concentrate on their associated physical their memories, concentrate on their associated physical sensations, and visually track the therapist’s index sensations, and visually track the therapist’s index finger.finger.

• Finger moved rapidly /rhythmically back & forth across Finger moved rapidly /rhythmically back & forth across line of vision – extreme l eft to right distance of 30-35cm line of vision – extreme l eft to right distance of 30-35cm from face at a rate of two back and forth movements per from face at a rate of two back and forth movements per second.second.

• This is repeated 12 – 24 times after which This is repeated 12 – 24 times after which patient asked to blank picture out and take a patient asked to blank picture out and take a deep breathdeep breath

• At the same time patient asked to focus on At the same time patient asked to focus on bodily experience associated with image as well bodily experience associated with image as well as on an incompatible belief statement (eg I did as on an incompatible belief statement (eg I did my best; It is all in the past).my best; It is all in the past).

• Therapist records subjective unit of distress Therapist records subjective unit of distress (SUD), if has not decreased checks that scene has (SUD), if has not decreased checks that scene has not changednot changed

• If has changed peocedure is repeated with new If has changed peocedure is repeated with new scene before returning to old one (Shapiro, scene before returning to old one (Shapiro, 1989)1989)

Complex PTSD ProgrammeComplex PTSD Programme90 Days of structured work - 600 hours90 Days of structured work - 600 hours

Three One Month Phases :Three One Month Phases :• Interactive Psycho-Education & Interactive Psycho-Education &

Adjustment of Medication.Adjustment of Medication.

• Individual Disclosure of the TraumaIndividual Disclosure of the Trauma

• Cognitive Restructuring and Problem Cognitive Restructuring and Problem SolvingSolving

Case Study• DF 26 years previously civil servant, husband left her

decompensated• H/O DSH ligatures • Dissociation+++, Flashbacks, nmares, emotional numbing,

affect dysregulation, outbursts, low mood depressed, alcohol misuse in past.

• Eventually admitted to CSA+ porno/paedo ring• Medications: SSRI, Carbamazepine, • DBT, grounding place of safety mindfulness Psychoeducation;

TF-CBT, rehabilitation, off detention mental health act section• Move to low secure services – discharged.• Not Borderline Personality Disorder