Matthew Gaskell C.Psychol AFBPsS Consultant
Psychologist/Clinical Lead LAU 1 PTSD
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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)
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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?
What are the key signs and symptoms? 5 PTSD CRITERIA AND
SYMPTOMS
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The trauma event 6 What kinds of experiences may lead to
developing PTSD?
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Events.. 7 Rape Violent physical attack Combat Car accident
Waking during an operation Torture Natural disaster Terrorism
Kidnapping Others?
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Key Symptoms 11 Re-experiencing (as if it is happening now)
Avoidance Hyperarousal Emotional numbing
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Prevalence, life course and risk factors for PTSD 13
EPIDEMIOLOGY
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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
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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
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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
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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%
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
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Risk factors for developing PTSD 21 WHY DO SOME GET CHRONIC
PTSD WHEREAS OTHERS RECOVER SPONTANEOUSLY?
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Exercise: 22 Why might PTSD develop and persist? What makes
someone more at risk?
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
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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
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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?
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27 THEORIES OF PTSD
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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)
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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
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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)
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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
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VAMS: Conscious Processing Info that receives enough conscious
processing Hippocampus
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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
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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
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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
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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
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37 EVIDENCE-BASED TREATMENT FOR PTSD
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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
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What is it? Does it work? 39 Trauma-Focused CBT
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Model of PTSD 40 Lets look at the model and make sense of PTSD
and why it persists Handout
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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
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Exercise Work in Groups of 3 Formulate client case Matt using
Ehlers & Clark (2000) Model
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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?
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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
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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
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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?
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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
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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
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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)
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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.
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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
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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
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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
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What is it? Does it work? 55 Eye Movement Desensitisation and
Reprocessing (EMDR)
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What is EMDR? 56
https://www.youtube.com/watch?v=GTLLfdcJE0Q
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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
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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
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Active ingredients of EMDR? not yet fully understood. 59
Exposure Processing the fragmented memory and updating it Exposure
Mindfulness Mastery and self-efficacy
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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)
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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
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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.
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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)
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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)
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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