* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Prof Ulrich Training Slides
Survey
Document related concepts
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Drug rehabilitation wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Memory disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
Veterans benefits for post-traumatic stress disorder in the United States wikipedia , lookup
History of mental disorders wikipedia , lookup
Combat stress reaction wikipedia , lookup
Externalizing disorders wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Posttraumatic stress disorder wikipedia , lookup
Transcript
TRaCS Conference on “Understanding human resilience”, 14.-20. August 2014, Changi General Hospital, Singapore Brief Eclectic Psychotherapy for PTSD: An introduction Prof. Ulrich Schnyder, M.D. Past President, ISTSS Head, Department of Psychiatry and Psychotherapy University Hospital Zurich, Switzerland [email protected] page 1 “There is an airplane in my head” page 2 Brief Eclectic Psychotherapy for PTSD (BEPP) Manualized, multimodal, 16 sessions, combination of psychoeducation, cognitive-behavioral and psychodynamic elements: ! Psychoeducation ! ! ! ! Imaginal exposure Writing tasks, working with mementos Domain of meaning and integration Farewell ritual ____________________________________________________________________ Gersons BPR, Carlier IVE, Lamberts RD, van der Kolk BA (2000) Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder. Journal of Traumatic Stress 13: 333-348 − Schnyder U, Müller J, Maercker A, Wittmann L (2011) Brief Eclectic Psychotherapy for PTSD: a randomized controlled trial. Journal of Clinical Psychiatry 72: 564-566 − page 3 Brief Eclectic Psychotherapy for PTSD (BEPP) Gersons BPR et al. (2000) Journal of Traumatic Stress 13: 333-348 1. Psychoeducation 2.-6. Imaginal exposure 3.-6. Writing tasks & mementos 7.-16. Domain of meaning 13.-16. Farewell ritual page 4 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 5 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 6 Trauma and PTSD: Epidemiology ! Lifetime prevalence for potentially traumatic events: 50-90% ! Posttraumatic stress disorders following traumatic events: ~10% ! Lifetime prevalence for posttraumatic stress disorders: 8% Men: 6% Women: 12% page 7 Trauma-related mental disorders ! Specific posttraumatic disorders: - Acute Stress Reaction (ICD-10) / Acute Stress Disorder (DSM-5) - Posttraumatic Stress Disorder (ICD-10 / DSM-5) - Enduring Personality Change after Catastrophic Exp. (ICD-10) ! Unspecific posttraumatic disorders, e.g.: - Depression - Anxiety Disorders - Somatoform Disorders - Obsessive Compulsive Disorder page 8 Posttraumatic Stress Disorder (DSM-5) A) Stressor criterion: − Exposure to death, serious injury, or sexual violence − Directly exposed, witnesssing, learning, or professional context B) Intrusion symptoms associated with the traumatic event (1 of 5) C) Persistent avoidance of specific stimuli (1 of 2) D) Negative alterations in cognitions and mood (2 of 7) E) Marked alterations in arousal and reactivity (2 of 6) F) Duration of disturbance more than one month G) Clinically significant distress or impairment in social, occupational, or other important areas of functioning page 9 The natural history of PTSD Traumatic Event 1 month Usual onset of symptoms 9 months 3 years Many recover without treatment within months/years of event (45-80% natural remission at 9 months) page 10 Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems PTSD is a disorder … ! …of the memory; the working memory is still loaded with the traumatic images ! …with scanning behavior and high arousal ! …with avoidance of the memory of details ! …with avoidance of the intense emotions connected ! …with expectation of new traumatic events page 11 Levels of psychological interventions after trauma ! Self help (± professional conselling) ! Peer support (± professional conselling) Counselors ! Psychoeducation (explanatory therapy) ! 4-6 CBT (group) sessions ! Evidence-based therapies, including exposure, cognitive restructuring, etc. page 12 Psychotherapists Psychotherapy versus Drug Treatment for PTSD van Etten & Taylor, 1998 Pre-Post Effect Size (d) 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Psychotherapy Pharmacotherapy page 13 Controls Psychotherapies for PTSD: The evidence ! Trauma-focused cognitive behavioral therapy (TF-CBT): - Exposure therapy, specifically „Prolonged Exposure“ (PE) - Cognitive Therapy, Cognitive Processing Therapy (CPT) - Eye Movement Desensitization and Reprocessing (EMDR) - Narrative Exposure Therapy (NET) - Brief Eclectic Psychotherapy (BEPP) ! Psychodynamic (psychoanalytic) approaches: - Currently no sufficient scientific evidence available, i.e., not empirically supported page 14 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 15 Why new psychotherapies for PTSD? Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201 1) ~ 20% dropout rates in empirically supported therapies for PTSD, including CBT and EMDR 2) ~ 50% who completed CBT are still diagnosed with PTSD at posttreatment assessment 3) ~ 50% of patients do not achieve good end-state functioning page 16 Prolonged Exposure versus Present-Centered Therapy for PTSD in female veterans: CAPS mean scores Schnurr et al. (2007) JAMA 297: 820-830 Intention to Treat Sample Completer Sample 80 80 70 60 50 40 70 60 50 40 Prolonged Exposure Present-Centered Therapy Prolonged Exposure Present-Centered Therapy page 17 Why new psychotherapies for PTSD? Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201 4) The mean duration of PTSD episodes amounts to several years. Thus, treatment for PTSD should not focus on specific symptoms such as flashbacks and avoidance only, but on basic life changes and existential questions as well, since such issues are important for patients who suffer from chronic PTSD page 18 Why new psychotherapies for PTSD? Schnyder U (2005) Psychotherapy and Psychosomatics 74: 199-201 5) Strict exclusion criteria in randomized controlled trials, and, in the majority of studies, failure to address comorbidity make it difficult to translate results of outcome research into clinical practice. Psychotherapy research should start evaluating multimodal, integrative treatment protocols that do justice to the various aspects of posttraumatic psychiatric morbidity in realistic clinical settings. page 19 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 20 Theoretical model of BEPP Crisis theory: Bereavement: Life events Psychotrauma " regaining control Process Exposure " working through Psychodynamic theory: Emotions are key Childhood " getting insight Learning theory: Conditioned learning Phobia " reconditioning Neurobiology: Amygdala Memory systems page 21 " resetting Why treatment? ! Working through traumatic events? ! Getting back control over life? ! Diminishing symptoms of PTSD? ! Lowering the fear response? page 22 Why eclectic? Limitations of: ! psychodynamic treatment ! cognitive behavioral treatment ! pharmacological treatment Eclectic because BEPP is based on a precise bringing together of psychodynamic, cognitive-behavioral and directive psychotherapeutic theory. page 23 BEPP: Protocol essentials 1. Psychoeducation 2.-6. Imaginal exposure 3.-6. Writing tasks & mementos 7.-16. Domain of meaning 13.-16. Farewell ritual page 24 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 25 Session 1 ! Partner or significant other is present if possible ! Psychoeducation ! Explanation of the treatment ! Recounting of the traumatic experience page 26 Psychoeducation Explain why the partner was invited: ! ! Clarify the therapy (techniques, rationale) Role of partner: background support Explain the goals of therapy: ! ! ! ! Acceptance of emotions Normalising disturbed views Symptom reduction Integration of the traumatic event into the patient’s life Explain the techniques to be used page 27 page 28 page 29 PTSD symptoms (CAPS) in accident survivors over 3 years (N=90) Hepp U, et al. (2008) British Journal of Psychiatry 192: 376-383 80 70 60 50 40 30 20 10 0 T1 T2 T3 page 30 T4 Psychoeducation Therapist describes: ! how symptoms interfere with functioning ! that client not only experienced traumatic event(s) in the past, but still behaves as if such events will strike again ! that his psychobiological make-up is dysfunctional This ‘framing’ of symptoms is essential to understand the elements of therapy page 31 Psychoeducation Therapist explains: ! that the symptoms still exist because extreme - frightening emotions are not tolerated to be felt and still hinder the fading away of symptoms ! how relaxation and imaginal exposure are tools to bring back the experience and to feel and express the extreme emotions ! how writing and the use of memorabilia are helpful to this end page 32 Psychoeducation Therapist further explains: ! how after the experience of all emotions the patient will pay attention to how he sees the world and him- or herself now and how he will adapt to the world ! and that a key problem of PTSD is to leave behind the traumatic experience in one’s own history ! That the farewell ritual is designed to help leaving behind the traumatic experience page 33 Neurobiology of human responses to traumatic events …involves mechanisms related to ! bodily survival ! learned conditioning ! autobiographical memory formation ! complex, socially-modulated, adaptation to change Shalev AY, Ursano RJ (2003) page 34 Neurobiology of human responses to traumatic events …is heavily modulated by ! Appraisal (perceived threat, available resources) ! Controllability ! Attribution of meaning ! Coping with tasks related to survival and learning ! Prior experiences ! Individual and group beliefs Shalev AY, Ursano RJ (2003) page 35 Important elements of the trauma reaction Frontal lobe: • Thinking • Basic assumptions Temperament: Vulnerability Anxiousness Biological rhythms Limbic system: • Amygdala • Hippocampus Amygdala: Emotions, particularly anxiety Hippocampus: Memory formation images, smells, noises etc. Brain stem: • Biological rhythms • Sleep page 36 Neurobiology of the trauma reaction Traumatic changes of awareness and memory (re-experiencing, dissociation) Avoidance behavior social withdrawal Activation of the arousal system: „constant alarm“ page 37 Neurobiology of human responses to traumatic events Fragments of seconds # defense reflexes such as auditory startle reaction Seconds # Sympathetic activation (epinephrin) Minutes # activation of the hypothalamicpituitary-adrenal axis (cortisol) Hours # early gene expression Days # memory consolidation Months # permanent changes in the CNS Shalev AY, Ursano RJ (2003) page 38 Successive and overlapping stages of the response to traumatic events Acute Response Early Syndromes 9M Survival…………….. Adjustment…………….. Appraisal…………….. Learning & integration…………….. Shalev AY, Ursano RJ (2003) page 39 Resting heart rate in PTSD and controls Shalev et al. (1998) Arch Gen Psychiatry 55: 553-559 100 95 PTSD 90 No PTSD 85 80 75 70 65 60 ER 1 week 1 month page 40 4 months Heart rate in patients who later develop PTSD, depression, or anxiety Shalev et al. (1998) Arch Gen Psychiatry 55: 553-559 100 95 PTSD Depression Anxiety Neither 90 85 80 75 Heart rate page 41 Recounting of the traumatic event Pay attention to: ! ! ! ! ! ! ! the details of the event salient cues that trigger emotions what happened just before? what happened afterwards? reactions of the patient, partner, others secondary victimization? ask about feelings but don’0t go into them deeply Ask the patient to bring memorabilia linked to the event for the next session. page 42 Session 2 ! Explanation of procedure ! Relaxation ! Imaginal exposure ! Examination of memorabilia page 43 Imaginal exposure The imaginal exposure is a technique to bring to the surface extreme emotions of anger, guilt, sorrow, grief and sadness which are not or not fully felt yet. The catharsis of yet unfelt emotions precedes psychodynamic insight which may lead to the domain of meaning. In contrast to most cognitive and/or behavioral therapies, BEPP does not use repeated exposure as a tool to diminish fear. BEPP rather uses a technique to help the person feel how fearful and terrible the experience was by remembering the traumatic event in great detail. page 44 Imaginal exposure Procedure: Short relaxation Here-and-now approach Start with bringing back the memories of the beginning of the day of the trauma and find out at what moment the first vivid sensory memories emerge The patient can stop the imaginal exposure at any moment by opening eyes, walking around, etc. ➜➜➜ control! page 45 Imaginal exposure Therapist asks the patient to tell exactly what he sees, hears, feels, in all sensory modalities as precisely as possible. Therapist encourages a vivid and sensory remembrance of the event and to focus on the feelings of fear, embarrassment, pain, anger, sadness, etc. during the imagined exposure. As a result, the patient will discover new memory details in which extreme fear or pain are hidden. Proceed very slowly, between 15 and 20 minutes per session. Going through the whole traumatic event in a chronological order bit by bit usually takes 4-6 sessions to complete. page 46 Imaginal exposure To avoid dissociation during the exposure: ! contralateral and short relaxation of distal muscle groups ! keep eyes open Dissociation often results from the therapist’s endeavor to speed up the session, not respecting the pace of the patient. page 47 Sessions 3 - 6 ! Review of past week ! Continue imaginal exposure ! Review of emotions ! Working with memorabilia ! Assignment of writing task page 48 Memorabilia Memorabila are things which have a concrete or symbolic relationship with a traumatic event: ! clothes people were wearing during the event ! newspaper articles and photos ! certain tools like a gun in police work ! a bag taken from an aircrash, etc. page 49 Writing task Helps expressing in a controlled way difficult, mainly aggressive feelings, but also guilt feelings towards those who are blamed or organizations to be blamed. Letters can also be written to say goodbye to those who died No censorship. Letter will not be sent to anyone but used in the farewell ritual Ask the patient to write every day for half an hour but not more to avoid becoming overwhelmed Patient reads the content of the letter during the following session while the therapist focuses on patient’s emotions page 50 Sessions 7 - 12 ! Discussion of writing assignment ! Cognitive restructuring and integration of meaning ! Pay attention to the real world issues page 51 Domain of meaning Patient starts to think about basic existential questions: How has the traumatic experience and the ensuing treatment changed ! patient’s life, his view on the world and himself ! patient’s family, work environment and so on ! detachment from the world ! “sadder but wiser” page 52 Domain of meaning ! After the catharsis of emotions, patients start to appreciate life and love more intense than before. ! Practical consequences such as resuming work ! “Illusion of safety” replaced by better anticipation page 53 page 54 Sessions 13-16 ! Planning of farewell ritual ! Evaluation of treatment page 55 Farewell ritual Before treatment, the patient’s behavior was determined by events in the past, as if the patient “lived with his back to the future”. The farewell ritual is done ! to leave behind the traumatic event, not to forget but to give it a place in one’s own life. ! to end treatment by grieving for one last time with close ones around, and to re-attach to the world and to close ones (transitional ritual) ! to celebrate the end a period of great disturbance in life With the ritual, it is time to turn around, to actively take part in the future, and to turn passive into active (no longer victim) page 56 Farewell ritual The patient, with the help of the therapist, develops an individually taylored and carefully planned farewell ritual. The ritual usually contains two parts: 1. Leaving behind: ! burning letters, clothes, drawings, and other mementos ! throwing pieces away, or burying them in the sea or river 2. Celebrating and reuniting with significant others: ! “Cleansing” ritual, e.g., taking a shower, visiting a Turkish bath or sauna ! Family dinner, party, picknick or similar page 57 page 58 page 59 Evaluation ! Repeat psychoeducation ! How does the patient look back on the relation between trauma and symptoms? ! Symptoms may reoccur! ! What has the patient learned? ! How to apply learning lessons in future situations? ! Ending the therapeutic relationship page 60 RCT of BEPP versus EMDR Nijdam et al. (2012) British Journal of Psychiatry 200: 224-231 100 BEP (N=70) IES-R Total scores 80 EMDR (N=70) 60 40 20 0 Time of Assessment (weeks) Significant difference between response patterns of BEP and EMDR, t(169)=3.49; p<0.005; no significant difference at endpoint, t(340)=0.70, p=0.48. page 61 Contra-indications Relative contra-indications: $ $ $ $ major depressive disorder substance use disorder panic disorder agoraphobia Absolute contra-indications: $ $ $ $ all psychotic disorders severe depressive disorder severe personality disorder severe substance use page 62 www.traumatreatment.eu page 63 Brief Eclectic Psychotherapy for PTSD (BEPP) Treatment manual available in English, German, Dutch, French, Italian, Lithuanian www.traumatreatment.eu [email protected] page 64 ISBN 978-3-319-07108-4 9 783319 071084 Schnyder Cloitre Editors Evidence Based Treatments for Trauma-Related Psychological Disorders A Practical Guide for Clinicians Evidence Based Treatments for Trauma-Related Psychological Disorders 1 Evidence Based Treatments for Trauma-Related Psychological Disorders Psychiatry & Psychotherapy Schnyder · Cloitre Eds. This book offers an evidence based guide for clinical psychologists, psychiatrists, psychotherapists and other clinicians working with trauma survivors in various settings. It provides easily digestible, up-to-date information on the basic principles of traumatic stress research and practice, including psychological and sociological theories as well as epidemiological, psychopathological, and neurobiological findings. However, as therapists are primarily interested in how to best treat their traumatized patients, the core focus of the book is on evidence based psychological treatments for trauma-related mental disorders. Importantly, the full range of trauma and stress related disorders is covered, including Acute Stress Reaction, Complex PTSD and Prolonged Grief Disorder, reflecting important anticipated developments in diagnostic classification. Each of the treatment chapters begins with a short summary of the theoretical underpinnings of the approach, presents a case illustrating the treatment protocol, addresses special challenges typically encountered in implementing this treatment, and ends with an overview of related outcomes and other research findings. Additional chapters are devoted to the treatment of comorbidities, special populations and special treatment modalities, and to pharmacological treatments for trauma-related disorders. The book concludes by addressing the fundamental question of how to treat whom, and when. page 65 A Practical Guide for Clinicians Ulrich Schnyder Marylène Cloitre Editors 1 23 Brief Eclectic Psychotherapy for PTSD: An introduction ! Trauma and trauma related disorders ! Why new psychotherapies for PTSD? ! BEPP Background ! BEPP protocol ! BEPP exercises (psychoeducation, exposure) page 66 Thank you for your attention! Prof. Ulrich Schnyder, M.D. Department of Psychiatry and Psychotherapy University Hospital Zurich Culmannstrasse 8 8091 Zurich Switzerland E-mail: [email protected] Phone: +41 44 255 52 51 Pablo Picasso: Le Bouquet page 67