Trauma and PTSD

PTSD DSM-IV Criteria

Exposure

to traumatic event with Actual or threatened death or serious injury and Response involving intense fear, helplessness, or horror

American Psychiatric Association. DSM-IV. 1994.

Symptom Clusters

Re-experiencing: intrusive recollections, recurrent dreams, dissociative flashbacks Avoidance and numbness: avoidance of cognitions/activities related to trauma, decreased interest, feeling detached

Hyperarousal: hypervigilance, insomnia, exaggerated startle response

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.

PTSD
Associated Features

Alcohol/drug problems Aggression/violence Suicidal ideation, intent, attempts Dissociation Distancing Problems at work Marital problems Homelessness

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.

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.

Primary Psychiatric Disorder 6 Months Following Trauma

Responses to Trauma Are Heterogeneous
80 70 60 50 40 30 20 10 0

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

Number of Individuals

Longitudinal Course of PTSD Symptoms

94%

47%

42%

?
W 3m 9m
Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

30%

Years

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

Whats the worst thing that ever happened to

Screening Questions for PTSD

did you react when it happened?

you?
Do Do

How

memories of _______ still bother you? Did you get over it? you avoid situations that might remind you of ____? Have your relationships suffered because of ____?
Have

you become more nervous since ___? Is it hard for you to relax because of ____?

Functional Neuroanatomy of Traumatic Stress

Parietal Cortex

Stress
Cerebral Cortex
Long-term storage of traumatic memories

Prefrontal Cortex

Amygdala
Conditioned fear

Hippocampus
Glutamate

Orbitofrontal Cortex
Extinction to fear through amygdala inhibition

CRF Hypothalamus

Pituitary

ACTH

NE

Attention and vigilance - fear behavior Dose response effect on metabolism

Output to cardiovascular system

Locus Coeruleus Adrenal

Cortisol

PTSD Treatment Options

Psychotherapy Pharmacotherapy Complementary Alternative Interventions Yoga Exercise Meditation Multimodal treatment

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.

Psychological Treatments for Chronic PTSD

Psychotherapy

Exposure therapy Cognitive processing therapy Anxiety management Additional treatments Eye Movement Desensitization and Reprocessing (EMDR) Hypnotherapy Psychodynamic therapy Expressive therapies

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

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

Medication

Selective Serotonin Reuptake Inhibitors Benzodiazepines

Tricyclic Antidepressants (TCAs)

TCAs

1st antidepressants used Prevent reuptake of monoamines (serotonin or norepinephrine) 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 sexual ability, muscle twitches, fatigue and weakness

Overdose delirium, hypotension, cardiac arrhythmias and death.

SSRIs
1st line of treatment Antidepressants that block reuptake of serotonin at presynaptic neurons in the brain Side effects: nausea, sweating, fatigue, sleepiness, and sexual side effects. Generally safer than TCAs if overdose is taken

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

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 reactions and emotions.

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

 CBT

normally lasts from 9-12 individual sessions, lasting about 60-90 minutes, administered once or twice weekly. Patients are normally also assigned homework to practice specific interventions on their own between sessions.

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).

Exposure Therapy
Exposure therapy is a treatment designed to help you confront safe but feared thoughts, situations, objects, people, places, or activities. These things elicit anxiety in the PTSD sufferer and are avoided, which takes a negative toll on everyday life.

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.

PTSD patients are also exposed to real life situations and objects that trigger anxiety and avoidance. Each person, place, situation and activity that triggers anxiety and avoidance is identified and evaluated for safety and relevance to the patient'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

Exposure therapy designed for PTSD involves imaginative exposure to the trauma memory. The patient is instructed to close her eyes and remember the traumatic event by imagining that it'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.

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 : controlled breathing and progressive muscle relaxation. For intrusive thoughts and worrying: how to interrupt their thought patterns and think of positive imagery.

Cognitive Restructuring
helps It

patients identify and challenge their erroneous beliefs and interpretations. is based on the idea that it is not actual events that cause negative emotional reaction but the interpretation of those events.

Cognitive restructuring seeks to replace worry and anxiety with more positive and productive emotions through the way a patient thinks. People undergoing this therapy are taught to look 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 for possible alternative explanations and ways of thinking.

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 Meditation, breathing Yoga, chanting

Calming the body down

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, and performance enhancement.

Francine Shapiro
36

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 become trapped in the nervous system. In EMDR, we ask the patient to focus on a target memory.

37

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 Shapiro 1987 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)

1987 EMDR : Eye Movement Desensitization

1990
EMDR : Eye Movement Desensitization & Reprocessing ( Processed Traumatic Memories Into Something More Adaptive And Functional)

WHAT HAPPENS DURING EMDR?

TRAUMATIC MEMORY

EMDR

MEMORY

Associated with disturbing Image, Cognitions, Affect, Physical Sensations (fragmented, not integrated)

Less disturbing Image, a Positive Cognition, Appropriate Affect without disturbing Physical Sensations

State-specific Form In Implicit Memory (Right Hemisphere)

Functional Form In Explicit Memory (Left Hemisphere)

Re-experiencing Timeless

Remembering Sense of time

HOW DOES EMDR WORK?

Not

entirely clear! EMDR induces changes in regional brain activation similar to REM sleep EMDR increases prefrontal lobe activation leading to more appropriate responses to triggers The Eye Movements or other dual attention stimuli elicit an Orienting Response which disrupts the traumatic memory network, interrupting previous links to negative emotions and allows integration of new information

HOW DOES EMDR WORK?

EMDR

has evolved into a synthesis of traditional orientations: Aspects of CBT Brief /Interrupted exposure Free Association : Directed and Non-directed Focus on physical sensations Dual attention stimulation