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Targeting PTSD Dr Walter Busuttil Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999) • Stabilization & Safety • Working through of Traumatic material – disclosure – psychotherapy • Rehabilitation First line and TopFirst second interventions targeted to symptom sets Most Prominent Line line Interventions Top second line interventions Symptom Set Re experiencing Education about trauma Narration of Trauma Memory Cog Restructuring / emotional regulation / Anx/Stress mgt Avoidance/Constriction Education about trauma Emotional regulation Cog Restructuring / Narration of trauma memory /Meditation Mindfulness/ Interpersonal skills training. Hyperarousal Education about trauma Emotional regulation Anx/stress mgt Narration of Trauma Memory . Cog restructuring Affect Dysregulation Education about trauma Emotional 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 regulation Narration 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 trauma Emotional regulation Narration of truama memories, anx/stressmgt/ meditation mindfulness. Identity Disturbance Education about trauma Emotional regulation, meditation / mindfulness Medications: 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. Medication Indication • Antidepressant • PTSD & Depressive symptoms • Neuroleptic • Pseudo-hallucinations; Dissociation; Tranquilization • Mood Stabilizer / Antiepileptic • PTSD Symptoms & Mood stabilizing properties • Anti-impulse • Impulse control - self- harm / depression 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 models Engagement, Stabilisation / Skills trg: • Art Therapy • DBT • Psychodynamic / analytical Psychotherapy Trauma Focussed Therapy • Cognitive Behaviour Therapy / Cognitive Processing Therapy: promote Info Processing & Exposure • Prolonged exposure • Narrative Exposure Therapy • Eye Movement Desensitisation and Reprocessing (EMDR) Treatment Pitfalls: Common maintaining factors • Nature and duration of trauma • Role in trauma • Meaning of trauma • Has trauma ended? • Isolation - attachments • Guilt - omission / commission • Guilt – survivor • Is the patient drinking alcohol? Using illicit drugs? Before or after therapy? • • • • • • Other Factors Co-morbidity - treat this first? Alcohol & Illicit Drugs Motivation Co-operation Compliance Therapeutic qualities of patient & therapist Treating CPTSD in Adults Models: • DBT followed by TF Work (Linehan) • Self-Trauma Model & Trauma Focussed work (Briere) • Psychodynamic therapy followed by Trauma Focussed work (de Zulueta) • Structured Group Therapy Programmes (Busuttil, Cloitre) The Self Trauma Model (Briere) • Integrated Approach • CBT & Relational • Take symptoms beyond PTSD into account – address them • Affect regulation training • Trigger identification • Mindfulness as cognitive and affect regulation • Titrated exposure to traumatic material 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 Window Titrated exposure • Balance between therapeutic challenge and overwhelming internal experience • Maximal possible exposure & reactivation within the limits of affect regulation activity Identity Development • Exploration of self within the context of the therapeutic relationship • Self knowledge • Self directedness • Value of not leaving open-ended questions • Avoiding 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 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 intervention 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) • • • • • • 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) Self observation: • Moment by moment of awareness of internal experience without judgement • Learning to let go of thoughts & feelings without avoidance or suppression • Especially childhood memories • Thoughts are not perceptions, perceptions do not necessarily reflect reality • Mediation of abuse related cognitive distortions and associated emotions Central Components of Trauma Processing (Briere) • Exposure • Activation – triggers associated thoughts feelings – reliving • Disparity – although in activated state – now able to talk to therapist in safe environment: fear is therefore not reinforced : negative state generated in a safe environment • Central focus is on awareness: reliving trauma memories, thoughts, feelings – yet maintain current awareness experience (safe): able to perceive the disparity memory of bad experience activated but need to be present in the here and now: awareness to remember it as past; aware that this is now the present. • Working with traumatic memory – activate the specifics of the memory cue by asking question about what happened – helps processing Psychodynamic / TF-CBT Models • Contrast with Briere’s Model: • De Zulueta’s (2002) model of intervention at the Maudsley Trauma Therapy Unit uses individual psychodynamic psychotherapies to deal with interpersonal and attachment issues before using Trauma-Focussed Cognitive-Behavioural Therapy (TF-CBT). TF-CBT • Psycho-education • Disclosure / Exposure / Working Through of Traumatic Material • Cognitive restructuring • Problem solving • Use of behavioural techniques for example anxiety management TF-CBT Approaches • Exposure: • The therapist helps confrontation of the traumatic memories (written, verbal, narrative). • Detailed recounting of the traumatic experience –repetition. • In vivo repeated exposure to avoided and fearevoking situations that are now safe but that are associated with the traumatic experience. • Identification of triggers • Hot spots CBT Approaches • Focus on the identification and modification of misinterpretations that lead PTSD sufferer to overestimate current threat (fear) • Modification of beliefs related to other aspects of the experience and how the individual interprets their behaviour during the trauma (eg: 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/Cogni tive%20Processing%20Therapy%20Manual%208.08.pdf EMDR (Eye movement Desensitisation and Reprocessing) • • • • • • Therapeutic rapport Imagery / envisioning of traumatic scenes Focus on sensations of anxiety Cognitive restructuring Saccadic movements of Eyes Extinguishing of the memory • Other methods - eg Counting Method • Need training - Criticisms EMDR • Standardised, trauma focussed procedure with several elements, always involving the use of bilateral physical stimulation (eye movements, taps, tones), thought to stimulate the individual’s own information processing in order to help integrate the targeted event as an adaptive contextualised memory • Requires individual to focus on a traumatic memory and generate a statement summarising thoughts of the trauma eg I should have done ‘X’ • Patient is instructed to visualise traumatic scene , briefly rehearse the belief statement that best summarised their memories, concentrate on their associated physical sensations, and visually track the therapist’s index finger. • Finger moved rapidly /rhythmically back & forth across line of vision – extreme l eft to right distance of 30-35cm from face at a rate of two back and forth movements per second. • This is repeated 12 – 24 times after which patient asked to blank picture out and take a deep breath • At the same time patient asked to focus on bodily experience associated with image as well as on an incompatible belief statement (eg I did my best; It is all in the past). • Therapist records subjective unit of distress (SUD), if has not decreased checks that scene has not changed • If has changed peocedure is repeated with new scene before returning to old one (Shapiro, 1989) Complex PTSD Programme 90 Days of structured work - 600 hours Three One Month Phases : • Interactive Psycho-Education & Adjustment of Medication. • Individual Disclosure of the Trauma • Cognitive Restructuring and Problem Solving 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