Download Recovery from Traumatic Experience – a Body of Knowledge!

What’s special about Trauma?
Collaborative Mental Health Care Network
CME February 19th 2010
Clare Pain MD
Does everyone who is traumatized get
PTSD?
PREVALENCE OF PTSD IN USA
General population 60.5% of men and
51.2% of women had one Criterion A
event.
Life time prevalence of PTSD 5.0% for
men and 10.4% for women
Longitudinal Course of PTSD Symptoms
6% recovered
53% recovered
58% recovered
15-25%
UNRECOVERED
Weeks 3 months
9 months
Shalev & Yehuda, Psychological Trauma 1998
YEARS
Relationship of Childhood Abuse and Household
Dysfunction
ADVERSE CHILDHOOD EVENTS
Abuse:
• Psychological
• Physical
PREVALENCE
11.1%
10.8%
• Sexual
22.0%
Living with household members who are:
• Substance abuser
• Mentally ill or Suicidal
25.6%
18.8%
• Violence against mothers
• Jail
12.5%
3.4%
(Felitti et al Am J Prev Med 1998)
Relationship of Childhood Abuse and Household
Dysfunction
10 ADULT RISK
BEHAVIOURS
•
•
•
•
•
•
•
•
•
•
Smoking
Severe obesity
Physical inactivity
Depressed mood
Suicidal attempts
Alcoholism
Any drug abuse
IV drug abuse
 50 Sex Partners
History of STD
DISEASES
•
•
•
•
•
•
•
Ischemic Heart Disease
Any Cancer
Stroke
COPD
Diabetes
Hepatitis or Jaundice
Skeletal fractures
Poor self-rated health
(Felitti et al am J Prev Med 1998)
Relationship Between Adverse Childhood Events
and Mental and Physical Health
Graded Relationship Between the Number of Adverse
Childhood Events and Mental and Physical Health
•  50% had one Adverse Childhood Event
• 25% had  2 Adverse Childhood Event
• 6% had  4 Adverse Childhood Event
• 4+ events compared to 0:  4-12 fold - alcoholism, drug
abuse, depression and suicide attempts
• 4+ events compared to 0:  2-4 fold - smoking, poor
self- rated health,  50 sex partners, history STD
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional motivating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
(Episodic) Model of Acute PTSD Leading to
Chronic Complex PTSD
ANXIETY
SLEEP DISORDER
AROUSAL+++
BIPOLAR DISORDER
PANIC
“PSYCHOSIS”
AGOROPHOBIA
Physiologic reactivity
Psychological distress
TRAUMA
INTRUSIVE
RECOLLECTIONS
Accommodate
Support ++
communication
rest and food
•AVOIDANCE
of triggers
•NUMBING of
general
responses
PERSONALITY
DISORDERS
PHOBIA
DISSOCIATION
MEMORY DISORDER
COGNITIVE DISORDERS SUBSTANCE
DISORDERS
•Poor Sleep
•Chronic Irritability
•Bursts Of Anger
•Poor Concentration
•Hypervigilence
•Jumpy
SOMATOFOR
M DISORDERS
No Work
No Friends
No Life
SEXUAL DISORDER
“Trauma Spectrum Disorders”
 Acute Stress Reaction






Acute Stress Disorder
PTSD - acute
Partial PTSD
PTSD – Chronic
PTSD and co-morbidity
Chronic Complex PTSD (dissociation, somatoform disorders,
subs abuse, self harm, chronic suicidality, depression - anger –
social isolation avoidance – shame – affect sensitivity – alcohol/drugs
 Dissociative Disorders (Amnesia, Fugue, Depersonalization,NOS)
 Dissociative Identity Disorder
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional motivating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
Emotional motivational systems
• Seeking – curiosity…always on, pleasure turns
off seeking curiosity
• Attachment
• Play
• Fear – when activated takes precedence
• Sociability
• Caretaking
• Sexuality/Sensuality
Frontal
Cortex
Assoc.
Midbrain
Cortex
Brainstem
Intimacy
Fear
Vigilance
Rest
Alarm
(Bruce Perry, 1994)
TERROR
Cascade of Fear Defences
“Mobilizing defenses”
(Janet, van der Hart, Ogden)
“Immobilizing defenses”
Cry
Freeze (a.) increased arousal
Flight
Fight
Freeze (b.) decreased arousal, empty emotional
content
Detachment
Submit
depersonalization/derealization
robotic compliance
Recuperate pain, trembling
Dissociation
High levels of stress reduce the efficiency of
memory encoding: – e.g. peritraumatic
dissociation – when events may be subjectively
slowed down or viewed from an alternative ‘out of
body’ perspective.
Peritraumatic dissociation is associated with
an increase in spontaneous memory intrusions
and with disorganization in deliberate trauma
recall - PTSD
Mentalizing and choice
Procedural Memory
Automatic Behaviour
THREAT
Mentalizing
Choice
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional motivating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
Attachment—Strange Situation
Autonomous
60%
• Avoidant/resistant
Dismissing
25%
• Anxious
Preoccupied
15%
• Disorganized
Unresolved
10%
Secure
Insecure
Correspondence between
70-80%
infant and parent classification
Attachment and mentalizing
a
The precondition for reliable mentalizing is
secure attachment
(Fonagy, pg. 687, 1997)
Successful parental mentalizing —reflects understanding of
cause of distress and appreciation of the child’s affective
stance
Just as secure attachment is a necessary precondition for mentalizing,
so a secure therapeutic base is required for the ‘exploration’ of
psychotherapy (Not “trust” but a secure base – parentified child….)
…Help them find their mind, via your mind
What is Mentalizing?
Attending to mental states in oneself and others
• Holding mind in mind
• Understanding misunderstanding
• Seeing oneself from the outside and others from the
inside
Mentalizing is a form of imaginative mental activity,
namely, perceiving and interpreting human
behavior as conjoined with intentional mental
states (e.g., needs, desires, feelings, beliefs, goals,
purposes, and reasons)
• Involves appreciating intentionality as different from
behaviour (e.g. the half eaten chocolate bar)
Impaired mentalizing in
maltreated children
•
•
•
•
Less inclined to engage in symbolic play
Less conversation about internal emotional states
Difficulty understanding emotional expressions
Less likely to respond empathically to peers’
distress
• Show more emotionally-dysregulated behavior
“Small t trauma”
Risk Factors for PTSD
Pre Trauma:
Trauma:
Post trauma:
Brewin 2000, Shalev 2002
Gender
Younger age at trauma
SEC
Education
Intellect
Race
*Psychiatric History
*Childhood abuse
Other previous trauma
Other adverse childhood events
*Family Psychiatric History
Trauma Severity
Lack of social support
Ongoing life stressors
<0.2
>0.2
0.3
AROUSAL DYSREGULATION
FOLLOWING TRAUMA/NEGLECT
Ogden and Minton 2000
HYPERAROUSAL
A
R
O
U
OPTIMAL
AROUSAL
ZONE
S
A
L
NUMBING/FROZEN/
DISSOCIATED
OPTIMAL AROUSAL
Ogden and Minton 2000
HIGH ACTIVATION
A
R
O
AROUSAL
CAPACITY
BOUNDARIES
U
S
A
L
LOW ACTIVATION
Differences between the behavioral curves of normal and highrisk infant-mother dyads (Field, 1985)
Gaze Avert
Cry
Stimulation
Laugh
Smile
Stimulation
Gaze Avert
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional activating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
PTSD AND CO-MORBIDITY (COMPLEX PTSD)
DISORDER OF EXTREME STRESS NOS
PTSD “comorbidity”
78% with one other Axis I conditions
44% with 3+ other Axis I conditions
Substance abuse
Depression
General anxiety
Phobia - simple
- social
Panic disorder
Somatization
Psychotic - dissociation
Personality disorders
(Antisocial/borderline)
60-80%
65%
31%
50%
20%
30-50%
DSM-IV ASSOCIATED FEATURES AND DISORDERS
IN PTSD X 14














Guilt feelings
Phobic avoidance
Impaired affect modulation
Self destructive and impulsive behavior
Dissociative symptoms
Somatic complaints
Feelings of ineffectiveness, shame, despair, or hopelessness
Feeling permanently damaged
Loss of previously sustaining beliefs
Hostility
Social withdrawal
Feeling constantly threatened
Impaired relationships with others
A change from the individual’s previous personality
characteristics
Disorders of Extreme Stress Not Otherwise Specified (DESNOS) Proposed Criteria
A: ALTERATIONS IN REGULATION OF AFFECT AND IMPULSES
• Chronic affect dysregulation
• Difficulty modulating anger
• Self-destruction and suicidal behaviour
• Difficulty modulating sexual involvement
• Impulsive and risk-taking behaviour
B: ALTERATIONS IN ATTENTION OR CONSCIOUSNESS
• Amnesia
• Dissociation
C: SOMATIZATION
• GI; chronic pain; cardiopulmonary; sexual
Disorders of Extreme Stress Not Otherwise Specified (DESNOS) Proposed Criteria
D: ALTERATIONS IN SELF-PERCEPTION
• Chronic guilt and responsibility; shame; feelings of self-blame and
ineffectiveness; of being permanently damaged; feeling no one can
understand; a tendency to minimize
E: ALTERATIONS IN PERCEPTION OF PERPETRATOR
• Adopting distorted beliefs and idealizing the perpetrator
F: ALTERATIONS IN RELATIONS WITH OTHERS
• An inability to trust others
• A tendency to be re-victimized; a tendency to victimize others
G: ALTERATIONS IN SYSTEMS OF MEANING
• Despair and hopelessness
• Loss of previously sustaining belief
Dissociation
Nightmares
Alcohol/Substance
Abuse
Flashbacks
Schematic Illustration of
Emerging Symptoms of Post
Traumatic Stress Disorder
(Post et al, 1998)
Anger
Explosive
Irritability
Hyper-arousal
Avoidance
Numbing
Priming
Event
Traumatic
Event
Startle
Depression
Truncation
of
Future
Stressors
(*GAD = General Anxiety Disorder)
Panic
Social Phobia
Isolation
Spontaneous Flashbacks
Cue Precipitated Flashbacks
GAD
Self-mutilation
Somatization
Re-exposure
Re-traumatization
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional activating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
Suicide and Psychological Trauma
Symptoms….
 Mood disorders…vs affect dysregulation, biphasic
pattern of PTSD spectrum disorders, grief?
 Self harm…vs trying to calm down
 “Impulsivity and Aggression”?...vs fear panic and escape
 Personality Disorder…vs chronic self punishment and
poor interpersonal skills
 Substance Abuse…are you prescribing?
 Family history of sexual abuse…6x increase of risk for
suicide
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional motivating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma”
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
Psychological sequelae of 9/11
– Galea et al NEJM March 2002
Prevalence of PTSD
Prevalence of Depression
Either/or
Both
7.5%
9.7%
13.4%
3.7%
vs
vs
3.6%
4.9%
Significant Predictors:
Of PTSD
Of Depression
Hispanic Ethnicity
2 or more stressors 1 yr
Panic Attack
Residence south of Canal St.
Loss of possessions
Hispanic Ethnicity
2 or more stressors 1 yr
Panic Attack
Level of social support
Death of friend/relative
Loss of job
Grief vs Trauma
Grief and grief work are adaptive and fairly
predictable. Cocoanut Grove fire in Boston 1944 Lindemann
Normal grief (?) has much in common with
depression though not equivalent.
Sad, disturbed sleep, agitation, decreased ability to
carry out day-to-day tasks. Resolve without treatment in 2-4 months (?) as the
bereaved person gradually weans from remembered experiences with the
loved one. Reengagement with people and activities. (?)
Increase in medical visits?
Differentiate from depression: which may include suicidal ideas,
preoccupation with worthlessness and psychomotor retardation.
Abnormal grief: delayed or distorted grief
reactions
Delayed: grief is postponed and experienced long after
the loss, e.g. when achieves age of unmourned loved one
– may not be recognized as such, precipitated by more
recent less difficult loss.
Distorted: immediately or years later, no sadness or
dysphonic mood, but MUS present (same as the deceased?)
which have precipitated multiple medical visits. Lots of
variants…over activity, social withdrawal, anger, numb,
or ‘too much’. ?PTSD-like symptoms
Treatment for depression centered on grief.
1. Facilitate the delayed bereavement process
2. Help patient reestablish interests and relationships that
substitute for what has been lost.
Elicit feelings and non judgmental exploration
- think about the loss- discuss the sequence of events prior,
during and after the death- explore associated feelings
Reassurance
- shame, fear, rage, guilt, survivor guilt, fear of
identification, sadness
Reconstruction of the relationship
- maybe fixated on the death and avoid the complexities
of their relationship
Development of awareness
Behavioral change
Likelihood of Abnormal Grief if:
•
•
•
•
•
•
Multiple losses
Inadequate grief in the bereavement period
Avoidance behavior about the death
Symptoms around significant dates
Fear of the illness that caused the death
History of preserving the environment as it was when the loved
one died
• Absence of family or other social supports during the bereavement
period
NB: Arousal from emotions not from the body –
differential trauma from loss
Map for talk
Every “trauma” patient’s symptoms are a function of t:T
Big T traumatic experience: what’s special or different about it?
• emotional motivating systems – fear
• dissociation
• fast pathways, procedural memory and choice
What is t?
“Chronic Trauma” t+T
Suicide?
Recognize the presence and absence of Loss and Grief
Goal of Treatment – to mentalize the trauma and its difficulties
• phase 1. ~ STABILIZE and symptom reduction
• phase 2: ~ Treatment of traumatic memories
• phase 3: ~ (Re) integration and rehabilitation
The problems of traumatic experience
1.
2.
3.
An unmentalized child is unprepared to understand
him/herself and others = a poor mentalizer… (t)
If an event trauma - big T trauma – happens, there is little
resilience and few resources to cope.
The combination in childhood


4.
provokes extreme, repeated stress
undermines the development of the capacity to regulate distress
Result = PTSD to Chronic Complex PTSD
Appreciation that automatic behaviours were originally
adaptive, feel reliable, and are hard to modify or surrender.
Behaviour occurs in lieu of mature mentalizing.
Trauma is the failure to process a serious and
severe experience – goals of treatment:
“the ability to create symbolic representations of terrifying experiences
promotes the taming of terror and desomatization of traumatic
memories.” (Van der Kolk 1994)
• “Making sense”
• Promote mentalizing not discovering a secret, or elucidating a
symptom
• to be able to think about what happened – make sense of it with the
help of another/s - figure out what it means and what if anything
needs to be done – reestablish a “continuous me” or
autobiographical competence.
…if this is not possible, things may get worse… psychological
distress changes and problems accrue
Role of mentalizing in
trauma
AFRAID,
terrified,
overwhelmed,
helpless, out of
control
+
abandoned,
neglected,
unloved,
without needed
comforting and
making sense
+
unmentalized
ALONE,
T
R
A
U
M
A
Phase Approach to Trauma Disorders
(Herman, van der Kolk, van der Hart)
Phase 1: Stabilization
Phase 2: Attention to trauma memories –
exposure techniques?
Phase 3: Re-integration Re-habilitation
Phase I STABILIZE: bio-psycho-social-cultural (think
body!)
Take a thorough history – this can take a while (longer if you need an
interpreter)…don’t just ask about the difficulties – get to know what
she was like before the trouble began – what she liked, who she
enjoyed being with, what she enjoyed doing, what make her laugh,
what her ambitions were what her worries were…
Ensure you check for current safety – physical, sexual and emotional
…housing, money, debt, literacy, job-school, alcohol/drugs, access to
services………
Psychological stability – sleep min. 5 consecutive hrs, max 10 hrs lying
down, eating, ability to relax, what makes her feel better? avoidance?
anxiety? depression? anger? (shame?) When and how is she afraid?
Check again on co-morbidity, social and occupational function (get the
details), addictions and affect regulation strategies
Medications…
Phase I STABILIZE cont…
Work on all the issues that need to be sorted
out…often this is a long task and once stable
sometimes there is no need for phase II memory
work – can she work, play, love?
For new Canadians often the best “trauma
treatment” is encouragement to learn English
Phase I Memory Work
Desensitization
Phase III – Reintegration Re-habilitation
Help the patient maintain a good connection with you - a secure
base, the feeling of safety • This phase is about taking up life again having been able to know
and think about her past: MOURNING HER LOSSES
• What about her health? – gyne exam – dentist?
• How are friendships, spousal relationship different? Closer? More
laughter?
• How is child care different? What is work like?
• How does she feel about her new life?
• What has she learned?
• What is she planning for next year?
• How will Christmas/Ramadan be different?
• What will she tell another new Canadian? Her grandchildren?
• How will it be to leave therapy?
Join us – and connect!
The International Society for the Study of
Trauma and Dissociation
www.isst-d.org