Post Traumatic Stress Disorder Jenn Andrus Psychotherapy Interventions II Appalachian State University Overview History/Background Prevalence Diagnosis Course/Comorbitidy/Associated Features Assessment Treatment – – – – Choosing Treatment Special Populations Overview of Various Approaches CBT Exposure Vicarious PTSD: The importance of Self-Care Some History/Background Fairly “new” disorder In 1980, DSM-III delineated distinct criteria for the diagnosis of PTSD – “The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone”. The diagnosis of Acute Stress Disroder (ASD) was added to DSM-IV in 1995 (APA, 2004) Some History/Background Cont’d Empirical research on the efficacy of treatments for ASD and PTSD is not as extensive as for other DSM Disorders Consider issues with longitudinal studies and prevalence data – Before – Now – Later (Solomon, Z., Horesh, D. 2007 ) Theoretical Models Classical Conditioning Operant Conditioning: Avoidance Learning: doesn't explain intrusion Social Cognitive Theory: information, belief, adjustment Emotional Processing Theory* – By? Guess who!?!? – The “fear structure” – Everybody has it Is yours bigger than mine? – “advanced cognitive model” (Barlow, 2000) Diagnosis Today No longer “outside the range” Wide range of “causes” – – – – – – Combat Violent crime Accidents Abuse Disaster Terror Much more common then was thought then.. Prevalence The NCS report concluded that – “PTSD is a highly prevalent lifetime disorder that often persists for years. The qualifying events for PTSD are also common, with many respondents reporting the occurrence of quite a few such events during their lifetimes.” National Comorbidity Survey – Estimated lifetime prevalence=7.8% Up to 12% (Foa et al, 2000) – Women=10.4% – Men= 5 % – 60.7% of men and 51.2 % of women reported at least one traumatic event. – 10%+ men and 6 % + of women reported FOUR or more types of trauma during their lifetimes. The lifetime prevalence of ASD is unclear Prevalence for children unclear (APA, 2004; Kessler et al., 1995) Prevalence Cont’d The prevalence of both disorders is considerably higher among: – – – – patients who seek general medical care persons exposed to sexual assault mass casualties such as those occurring in wars or natural disasters presence of underlying vulnerabilities such as adverse childhood experiences or comorbid diagnoses Risk Factors – Trauma type and comorbidity Women; Anxiety and depression, Men irritability, impulsiveness, substance abuse – ASD and/or symptom severity – Gender differences – African Americans and Hispanic war vets Prevalence Cont’d The most frequently experienced traumas – – – – witnessing someone being badly injured or killed being involved in a fire, flood or natural disaster being involved in a life-threatening accident combat exposure Traumatic events most often associated with PTSD – Men rape, combat exposure, childhood neglect and childhood physical abuse – Women rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse Rape victims likely constitute the largest number of PTSD sufferers (Rothbaum et al., 2005) Prevalence in Veterans Lifetime prevalence of PTSD among American Vietnam theater veterans – 30.9% men – 26.9% women. – 22.5% men and 21.2% of women have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans, have experienced “clinically serious stress reaction symptoms.” Gulf War vets: 10.1% for PTS among those who had experienced combat Unclear if prevalence of PTSD among those returning from Operation Iraqi Freedom or Operation Enduring Freedom will increase or decrease Freidman, 2004 So Who Gets PTSD? “When we were children, we used to think that when we were grown up we would no longer be vulnerable. But to grow up is to accept vulnerability.. to be alive is to be vulnerable”. Madeleine L’Engle. 50% to 90% of the population may be exposed to traumatic events during their lifetime – – most exposed individuals do not develop ASD or PTSD. Only about 25% (Foa et al., 2000). Exposure alone does not account for the relationship between distress and a traumatic event. Vulnerability “the force with which trauma impacts on the distress of the individual” Consider professions that “expose” to trauma” : Law, fire, EMT, Health professions – “the police socialization process molds him/her into a myth of indestructibility. The effect of trauma on this myth is devastating” Consider risk factors/prevalence rates – Those with high levels of symptoms early on, including those with ASD, are at risk of subsequent PTSD – Some patients with ASD do not develop PTSD – Proportion of patients develop PTSD without first having met the criteria for ASD (Violanti, & Paton, 2006) Diagnosis In 1980, DSM-III delineated distinct criteria for the diagnosis of PTSD. The diagnosis of ASD was added to DSM-IV in 1995 to distinguish individuals with PTSD like symptoms that lasted less than 1 month from persons who experienced milder or more transient difficulties following a stressor. DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder (DSM-IV-TR code 308.3) – Essentially PTSD diagnostic criteria G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder A. Exposed to a traumatic event in which both of the following were present: – – B. Persistent reexperience in one (or more) of the following ways: – – – – – experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior Recollections: images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Dreams Note: In children, there may be frightening dreams without recognizable content Acting or feelings of “reoccurance” (sense of reliving the experience, illusions, hallucinations, dissociative flashback episodes, including when intoxicated). Note: In young children, trauma-specific reenactment may occur. Psychological distress at exposure to internal or external cues Physiological reactivity on exposure to internal or external cues C. Avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: – – – – – – – efforts to avoid thoughts, feelings, or conversations associated efforts to avoid activities, places, or people that arouse recollections inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) DSM-PTSD CON’T D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: – – – – – difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating Hypervigilance exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: – Acute: if duration of symptoms is less than 3 months – Chronic: if duration of symptoms is 3 months or more Specify if: – With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. Some Help? “DREAMS” (Lange, 2000): – Detachment – Reexperiencing the event – Event had emotional effects – Avoidance – Month in duration (symptoms for >1 month) – Sympathetic hyperactivity or Hypervigilance “The Triad” Three primary symptom clusters – Re-experience – Avoidance – Arousal Associated Features Associated Features – Guilt – Interpersonal Problems Interpersonal Constellation – Those exposed to a trauma with an interpersonal element (i.e abuse), often evidence additional symptoms. Impaired affect modulation Self-destructive and impulsive behavior Dissociative Symptoms Somatic Complaints Feelings of: ineffectiveness, shame, despair, hoplessness, "permanently damaged", constant "threat" Loss of beliefs Hostility Social Withdrawal Social impairment Personality Change APA, 2000 Comorbidity Associated with increased rates – affective disorders (MDD, Bipolar Dx) – anxiety disorders (panic, agoraphobia, OCD, Social, Specific, GAD) – substance abuse They may precede, follow or emerge concurrently with PTSD NCS indicates that at least one additional psychiatric disorder is present in 88.3% of men and 79.0% of women who have a history of PTSD. 59 % of men and 44 % of women who have PTSD meet the criteria for three or more psychiatric diagnoses. Women who have PTSD are 4.1x as likely to develop a major depression Women 4.5x as likely to develop mania as women who do not have PTSD. Comorbidity Cont’d Men who have PTSD are 6.9x as likely to develop depression Men are 10.4x as likely to develop mania as men 50%+ men with PTSD also have a comorbid alcohol problem Significant portion of men and women who have PTSD have a comorbid illicit-substance use problem. Phobias tend to be more prevalent than GAD or panic disorder – the risk of almost all anxiety disorders is high Rate of attempted suicide in patients who have PTSD is estimated at 20% Assessment Critical in developing appropriate treatment plan First step in establishing rapport Consider issues such as – Culture – Type of Trauma Need? I.e. forensic, research How to approach? – Video: Dr. Eve Carlson, NCPTSD, Therapeutic Assessment – Notes please Assessment Cont’d MCMI-III, MMPI, Rorschach The Children's Impact of Traumatic Event Scale – Revised The Impact of Event Scale The Impact of Event Scale - Revised The PTSD Checklist - Civilian Version The PTSD Checklist - Military Version The Clinician Administered PTSD Scale for DSM-IV The Mississippi Scale for Civilian PTSD The Posttraumatic Stress Diagnostic Scale The Trauma Symptom Inventory The Trauma Symptom Checklist for Children Victims' Web: Assessment Devices Treatment APA video (2005) – – – – Interview Laura Brown, PhD “Feminist” approach Good casual overview, created for training purposes During the video, please take a few notes – Any questions, concerns, ideas? Choosing a Treatment Trauma treatment research field is still young, and further difficult to conduct in some cases Comparisons of different treatments for PTSD are scarce – lack of empirical evidence in the literature does not necessarily signify a lack of treatment efficacy Choosing a treatment cont’d – – – – – – – – – – Type and impact of trauma Unique client life challenges Side effects and potential negative effects Cost Length of treatment Cultural appropriateness Therapist's resources and skills Client's resources and stressors Comorbidity of other psychiatric symptoms Legal, administrative, and forensic concerns Choosing a Treatment cont’d All treatments approaches essentially have the same goal – Decondition anxiety – Re-establish feeling of integrity and/or control Some great resources to refer to! – Expert Guidelines “The Consensus” – ITSS – Anything from Foa! Treatments for PTSD CBT is most effective! (Foa, Freidman, & Keane, 2000) – We will focus on it more later Again consider all factors – CBT still stronger it appears Variants depending on type of trauma and/or client – No one said this was going to be easy Special Populations Remember to consider – Type of trauma – Setting – Client Children and Adolescents Have generally same symptoms as adults Additional symptoms and difficulties – Separation anxiety – Regression (enuresis, “clingy”, temper) Increased risk for comorbidity Adolescents at risk for substance abuse, depression, promiscuity Treatment similar to adults Lauterbachm, & Reiland, 2007 Children Cont’d CBT most supported – will look at one aspect later Medication has weak support Consider “creative” approaches – more to come Consider: age, intelligence, family & social support, and coping skills Childhood Sexual Assault Survivors Prevalence is 15-33 % – Up to 44% in females seeking treatment Not all survivors can tolerate exposure based CBT – – Many special considerations More to come High rates of concurrent Substance Abuse Gender and Sexuality Issues Interpersonal Difficulties Therapist Gender Revicitmization and Multiple Assaults (Richard & Lauterbach, 2007) Multiple Trauma Survivors Most research on single trauma survivors May need more time Later will look at Narrative Exposure Therapy for this population Cross Cultural Treatment Minority Americans Foreign refugee Asylum seekers Consider – – – – Language Culture Integration of physical and mental Access Likely multiple trauma survivors Wilson et al. Disaster Situations Natural, Terror Emotional effects are direct responses to the trauma of disaster. Consider other, longer-term responses – Interpersonal – Societal – Economic effects the disaster Short term psychosocial interventions – reducing distress – improving adaptive functioning in the face of the practical and emotional demands created by the disaster – preventing longer-term disability Ehrenreich (2001). Mental Health Workers Without Boarders. Coping with Disaster (Foa et al 2000) Critical Incident Stress Debriefing Critical Incident Stress Debriefing – aimed at forestalling the emergence of disabling symptoms or minimizing their enduring effect. – Should not be used as a "one-off" intervention or w/o coping skills training – Inappropriate in situations in which severe stress and danger are ongoing or those not at risk Immediate, group based, CBT approach Veterans Likely more to surface and to come Increase or decrease unclear VA/DOD Guidelines (Freidman, 2004; Solomon, Z., Horesh, D., 2007) Dual Diagnosis Consider safety Consider primary diagnosis Limited research Some manualized treatments – Mostly substance abuse Trauma Recovery and Empowerment Model (TREM) Seeking Safety Trauma Affect Regulation: Guide for Education and Therapy (TARGET) SPMI Diagnostic Issues – Likely under diagnosed? Is TAU appropriate? – Consider illness management and treatment Research often only with women Not directed at PTSD Directed at broad diagnostic groups More research needed (Wilson et al. 2001) Inpatients No satisfactory studies on inpatient treatment for PTSD and trauma-related conditions. Inpatient therapy is appropriate for – crisis intervention – management of complex diagnostic cases, delivery of emotionally intense therapeutic procedures – relapse prevention. (Foa et al., 2000) Various Treatments Psychodynamic Therapy Focus on more fluid intra- and interpersonal processes, not symptom reduction The unconscious and psychological meaning Course of Treatment – – – – 4-5 sessions a week 45-50 mins 2-7 years Brief = 1-2 meeting a week for 12 sessions A certain type of client? Psychodynamic Therapy Cont’d Difficult to conduct research – Mostly case reports Only one randomized clinical trial of efficacy – 10 sessions of Brief Psychodynamic Psychotherapy – Effectively reduction of PTSD intrusion and avoidance symptoms by approximately 40%, and improvement was sustained for 3 months. Has clinician support, especially for complex trauma – Left out of Consensus? More research is needed to demonstrate the techniques effectiveness with PTSD. – But that harder then it seems? IPT Developed for the treatment of Depression Consider utility with “interpersonal trauma” – Interpersonal constellation – Find new ways to understand and behave in relationships IPT group treatment for women assault survivors (Krupnick, 2001) Social Rehabilitative Therapies (PSR) Teaching social, coping, and life function skills Yet to be formally tested with PTSD clients. – Usually have comorbid SPMI Generalizability? – reasonable to expect that they will also work with PTSD clients? Improvement in self-care, family functioning, independent living, social skills, and maintenance of employment Marital and Family Therapy No research studies done on the effectiveness of marital/family therapy in treating PTSD Consider a trauma's unique effects on interpersonal relatedness Thus, clinical wisdom indicates that spouses and families ought to be included in the treatment of those with PTSD – Use as adjunct – Time-limited, problem focused Obviously, marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated Foa, Keaen, & Freidman Creative Therapies No controlled evidence on creative therapies Art, drama, music, body-oriented therapies May be fit to address specific somatic manifestations of trauma (i.e., sensory defensiveness, somatic memories, etc.). Use with children or adults who have trouble responding to questions or describing feelings in verbal form Caution is recommended – Be well trained in this modality. Video: Standing Tall Hypnosis Research indicates very little improvement in trauma symptoms May be helpful as an adjunctive rather than primary treatment, especially – dissociation – nightmares Was left out of Clinical Consensus Pharmacotherapy Hyperarousal Comorbidity SSRI’s* MAOI’s TCA’s Consider for seriously “disruptive symptoms” (Foa et al. 2000) Group Therapy Few tests of group treatments relating to PTSD symptoms Three studies of CBT group treatments – Cognitive Processing Therapy, Assertion Training, Stress Inoculation Therapy – Women traumatized by childhood or adult sexual abuse – All PTSD symptom clusters were reduced 30-60% – Improvement was sustained for six months. CBT group treatment for combat veterans showed a 20% reduction in PTSD symptom severity Group Therapy Cont’d Study of psychodynamic group treatment found an 18% reduction in PTSD symptoms among women with PTSD due to childhood sexual abuse. One controlled trial of supportive group treatment for female sexual assault survivors showed a 19-30% reduction in intrusion and avoidance symptoms, which was maintained for six months. Consider group membership, dynamics, “type” CBT Cognitive-Behavioral Therapy (CBT) More published well-controlled studies on CBT than on any other PTSD treatment (Cahill et al. 2006) CBT Cont’d CBT treatments usually involve some combination, psychoeducation and therapeutic relationship Other CBT treatment methods may be added to address related problems – anger (anger management training, assertiveness training) – social isolation (social skills training, communication skills training) Have proven very effective in producing significant reductions in PTSD symptoms (generally 60-80%) especially rape survivors Magnitude and permanence of treatment effects appears greater with CBT than with any other treatment – Compelling evidence it works! CB Interventions Always begin with psychoeducation – What is PTSD – What is goal/rationale of treatment Most TX’s are combos of a sort (CB+Ex+Relaxation) Combining further OK But research shows it isn’t necessarily more effective Some CB Interventions Stress Inoculation Training Cognitive Therapy Cognitive Processing Therapy Systematic Desensitization Exposure Stress-inoculation training Meichenbaum (1974) Anxiety management Female Skills for managing and reducing anxiety – – – – assault survivors Muscle relaxation Diaphragmatic breathing Covert modeling Role playing Anxiety management = decreases in avoidance and anxiety Cognitive Therapy Beck (1976) Identify their trauma-related negative beliefs (e.g., guilt or distrust of others) and change them to reduce distress Pay attention to appraisals of safety and danger. CPT See Barlow – For rape only – 12 session, structured CT + EX – CT=challenge blame and other cognitions – EX=write narrative and review Therapist helps get “unstuck” (Barlow, 2000; Foa et al., 2000) Systematic desensitization Wolpe (1958) – Exposure and relaxation – Mostly only imaginal exposure – Create hierarchy/SUDS – Become proficient and relaxation – Exposure for hierarchy Eye Movement Desensitization and Reprocessing (EMDR) Francine Shapiro (1995) Think of the trauma (images/memory) – Imagninal exposure Move eyes back and fourth or alternate attention back and forth using taps or sounds More effective than psychodynamic, relaxation, supportive, or placebo wait list therapies Better results in combo CBT particularly at three-month follow-up and on (sustainability) EMDR Cont’d The eye movement component adds no additional treatment effect?!? Consider number of memories, complexity, training Not in consensus EMDR Video Foa et al. 2000 Exposure Consistently proven effective in both children and adults – Is not accepted in clinical practice?!? Fewer than 20% use – even after ITSS guidelines Use in combo with psychoeducation, cognitive restructuring, coping skills Lauterbachm D., & Reiland, S. 2007 Exposure Therapy Exposure results in habituation so trauma can be remember without intense anxiety- ability to think without reexperiencing Framing therapy – Opportunity to process/digest the trauma, organize memories, make sense of the experience, appropriately compartmentalize. – Clear rationale: unrealistic/excessive fears Introduce SUDS and create hierarchy “Expose” to anxiety provoking cues until anxiety decrease Subjective Units of Disturbance (SUDS) A scale of 0 to 10 for measuring the subjective intensity of disturbance or distress currently experienced by an individual. Individual self assesses where they are on the scale. Used as a benchmark to evaluate the progress of treatment. 10 = Feels unbearably bad, beside yourself, out of control as in a nervous breakdown, overwhelmed, at the end of your rope. You may feel so upset that you don't want to talk because you can't imagine how anyone could possibly understand your agitation. 9 = Feeling desperate. What most people call a 10 is actually a 9. Feeling extremely freaked out to the point that it almost feels unbearable and you are getting scared of what you might do. Feeling very, very bad, losing control of your emotions. 8 = Freaking out. The beginning of alienation. 7 = Starting to freak out, on the edge of some definitely bad feelings. You can maintain control with difficulty. 6 = Feeling bad to the point that you begin to think something ought to be done about the way you feel. 5 = Moderately upset, uncomfortable. Unpleasant feelings are still manageable with some effort. 4 = Somewhat upset to the point that you cannot easily ignore an unpleasant thought. You can handle it OK but don't feel good. 3 = Mildly upset. Worried, bothered to the point that you notice it. 2 = A little bit upset, but not noticeable unless you took care to pay attention to your feelings and then realize, "yes" there is something bothering me. 1 = No acute distress and feeling basically good. If you took special effort you might feel something unpleasant but not much. 0 = Peace, serenity, total relief. No more bad feelings of any kind about any particular issue. Exposure Techniques A lot of variation in implementation and duration –Imaginal: think about it –In vivo: feared persons or situations that are realistically safe –In virtuo: i.e virtual reality, images –Narrative: tell your “story” Imaginal Exposure Describe and visualize, as vividly as possible, the trauma in the present tense. Focus on the entire trauma, including events immediately before and after. Keep eyes closed and proved detail. – Level of involvement, adjust as needed I.e. past tense, eyes open Homework: Listen to tape of session once a day Virtual Exposure Virtual Reality Good findings War Vets WTC/911 A Protocol: Prolonged Exposure Prolonged Exposure Protocol as Described by Foa, Dancu and Humbree – Most comprehensively studied exposure treatment 9 bi-weekly 90 minute sessions Four components – education about the nature of trauma and trauma reactions – training in controlled breathing – Imaginal exposure to the memory of the traumatic event Other approaches can and have been used – Homework In vivo exposure to trauma reminders Listen to tapes (Barlow, 2000; Foa, Davidson, et al., 1999) Narrative Exposure Therapy for Multiply Traumatized clients Not uncommon for people to define themselves in trauma: I.e. war torn regions, CSA, police, firefighters, EMT’s ongoing assaultees Similar to Protocol – – – – 4 sessions, trauma focused 60-120 minutes or until distress is diminished Detailed oral recall Psychoeducation Full Autobiography: Not jut trauma Probe for sensory, emotional and cognitive elements Point out ambiguity or inconsistency Narrative Therapy Cont’d Goal is to develop less fragmented narrative Therapist transcribes Reviewed with client – Encouraged to make corrections and add detail Use of translator? Sending it out? i.e. human rights Empirical Support: One year post treatment 80% vs 29% Neuner et al 2004; Richard & Lauterbach Exposure and CSA Special Considerations – Hyper arousal Those who exhibit high arousal, or are reactive are not good candidates for exposure – Numbing/Dissociation Those who are prone to dissociate and/or are depressed are likely unable to experience sufficient arousal for exposure – Intrusive Thoughts – Affect Regulation and Resistance – Incomplete or Suspect Narrative Lauterbachm, & Reiland, 2007 Exposure and Children Coping skills training – muscle and breathing relaxation, positive imagery training, “safe-place” Explain SUDS Explain rationale Same “scripting” – close eyes? Ask for periodic SUDS Drawing and play may facilitate Assessment of imagery skill – Rate 1-10 how clear the image is Difficult imaginers? – Bring and or use stuff that is representative of the trauma i.e. tapes, clothes, sounds. Children Cont’d Imaginal Exposure Protocol – – – – – – relax positive imagery recall/recount collect SUDS, continue until decrease close with relaxation Consider fatigue and developmental level Consider adjunct Family therapy (psychoeducation) Lauterbachm, & Reiland, 2007 Vicarious Trauma Negative effects of working with those with trauma “Disruption of the therapists schemas about the self and world” Recognize and acknowledge Avoid isolation HALT!