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2. Trauma-Focused (TF) CBT
"... PTSD requires the occurance of a specific type of event from which a person does not recover , (Barlow)"
3. EMDR
4. Case Study
1. Post Traumatic Stress Disorder
*PTSD may be especially severe or long-lasting when the stressor is interpersonal or intentional (ie. torture, sexual violence)
"Post traumatic stress disorder is the development of characteristic symptoms following exposure to one or more traumatic events " - DSM 5
309.81 (F43.10)
Psalm 31:9,10,14-16
PTSD 309.81 (F43.10)
Diagnostic Features
PTSD 309.81 (F43.10)
Diagnostic Features:
Diagnostic Features:
PTSD 309.81 (F43.10)
"The trauma doesn't come back as a memory but as a reaction" Bessel Vander Kolk
1. "A deeply distressing or disturbing experience." -Webster's Dictionary
2. "Exposure to actual or threatened death, serious injury or sexual
violation" - DSM 5
3. "Physical injuries of sudden onset and severity which require immediate
medical attention" -University of Florida
4. “PTSD is a whole-body tragedy, an integral human event of
enormous proportions with massive repercussions.”
- Susan Pease Banitt LCSW
DSM-I: 1952, "Gross Stress Reaction"
DSM-II: 1968, previous diagnosis eliminated; "Situational Reaction"
DSM-III: 1980 PTSD officially listed as Anxiety Disorder
DSM-IV: 1994 added numbing and avoidance to criterion for PTSD
DSM-5: 2013 PTSD is listed as a Trauma- and Stressor-Related Disorder
What is TRAUMA?
PTSD 309.81 (F43.10)
Diagnostic Features
1917 - The Statistical Manual for the Use of Institutions for the Insane
1840 - The begining...
Dr. Chaim Shatan
PTSD 309.81 (F43.10)
Diagnostic Features
Historical Journey of PTSD
in the
1.) Irritable or aggressive
behavior
2.) Self-destructive or reckless
behavior
3.) Hypervigilance
4.) Exaggerated startle response
5.) Problems in concentration
6.) Sleep disturbance
Specify whether:
With dissociative features:
Specify if:
With delayed expression
the traumatic event; the criteria may be partially met during this time
PTSD 309.81 (F43.10)
Diagnostic Features
Temperamental
Environmental
Developmental regression - including language
Auditory pseudo-hallucination
Emotional disregulation
Difficulty maintaining stable interpersonal relationships
PTSD 309.81 (F43.10)
1. Depersonalization: feeling as if "this is not happening to me" or one were in a dream
2. Derealization: feeling like "things are not real"
(occurring during trauma)
Environmental
Dunmore (2001) found that the "perceived life threat" and "injury threat" during the trauma were significantly correlated with PTSD severity
Criteria B – no change
Criteria C - combines adult Criteria C & D
At least 1/6 symptoms - including avoidance AND negative alterations in cognition and mood
*Preschool does not include: amnesia; foreshortened, future; persistent blame of self or others
Criteria E – 5/6 Symptoms - alterations in arousal and
reactivity
*Preschool does not include: self- destructive or
reckless behavior
PTSD 309.81 (F43.10)
Especially during childhood
Economic deprivation (poverty)
Family dysfunction
Parental separation/death
Fatalistic/Self-blaming coping strategies
Onset: any age
Symptoms begin with 3months of traumatic event
Clinical Expression may vary across stage of development
Children
Adolescents
Common Comorbid Disorders:
PTSD 309.81 (F43.10) Diagnostic Features
PTSD 309.81 (F43.10)
Epidemiology
Recovery rates vary:
33% of people exposed to trauma develop PTSD
• Complete recovery within 3 months in about 1/2 of adults
• Others remain symptomatic for more than 12 months - years
Recovery is significantly quicker in people exposed to unintentional trauma
Factors known to hinder recovery:
Older Adults
in relation to younger adults, those whose PTSD symptoms continue into older adulthood, have reduced:
in relation to younger adults, those who experience trauma as older adults (leading to PTSD) have increased:
PTSD is associated with:
*Older Americans make up 13% of the population, they account for 20% of the people who commit suicide. In fact, older Americans have the highest suicide rate of any age group.
Social support is a protective factor that moderates outcome after trauma
Lifetime risk of PTSD - 8.7%
12month prevalence - 3.5%
Higher Rates among:
• Veterans, High Risk Occupations: Police, Fire Fighters,
Emergency Medical Personnel
1/3 to more than 1/2 of those exposed to trauma, are survivors of:
• rape
• military combat
• captivity
• ethnic/political internment and genocide
Prevalence varies by age/development
Higher rates reported in USA of Latinos, African American, and American Indians than Non-Latino whites; and Asian Americans have a lower rate than non-Latino whites
PTSD 309.81 (F43.10)
- ie. racism, genocide
- Inability to perform funeral rites
- Mass killing
- Unpunished perpetrators
- Avoidence, numbing, distressing dreams,
somatic symptoms
* dizzyness, shortness of breath, heat
sensation
- may need to be assessed according to
cultural template
- ie: Cambodians (khyal attacks); Latin
Americans, (ataqu de nervios)
Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide, and women with both disorders were more likely to have attempted suicide than men with both disorders.
Approach (int/ext) fear cues
Block Avoidance
Emotion subsides
3. SUDS - set anchor points of things the client anticipates to not being able to get passed with exposure
Trauma Focused CBT (TF-CBT)
3. The new pattern:
History: PTSD treatment derived originally from classical and operant conditioning (pairing of stimuli
and response)
Clients: Women are almost three times more likely to suffer with PTSD than men
Settings: Mainly outpatient
People involved: in TF-CBT (C&A) conjoint sessions with parents
Treatment Protocol: Exposure therapy and cognitive approaches are the first line treatment approaches
Assessment: CAPS (30 item) most widely used, may be used also by paraprofessionals
Medication: paroxetine, fluvoxamine, sertraline,
prozac, zoloft
CBT (trauma focused):
- Cognitive Processing
- Exposure Therapy
Acceptance & Commitment Therapy
1. Psychoeducation & Treatment rational:
Explain clients that PTSD is a set of expected and normal responses to abnormal circumstances such as intrusive memories and hyper arousal
2. Explain the avoidance pattern:
Fear Cue Anxiety increase
anxiety increase Avoidance
2. Hierarchy of Fear & Avoidance
G'day - howz it goin'?
1. Repeatedly and gradually (really important to avoid re-traumatization!!) approach avoided situations or memories & triggers
TAKE A DEEP BREATH
PTSD 309.81 (F43.10)
5. Processing natural emotions
4. Use of worksheets* & Socratic questioning*
3. Identifies and challenges maladaptive beliefs
2. Identify 'Stuck Points'
TF-CBT Triangle of Life
1. Focuses on the particular meaning of the traumatic & impact of event
Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
Acceptance: Allowing thoughts to come and go without struggling with them.
Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness.
Observing the self: Viewing the self (identity) as separate from the content of their experience
Values: Discovering what is most important to one's true self.[9]
Committed action: Setting goals according to values and carrying them out responsibly
Focused on the meaning individuals make in response
to the traumatic event and how people cope as they try to
regain a sense of mastery or control over their lives
(Resick & Schnicke, 1993).
for treating sexually abused children
Core Principles (6)
focused on the meaning individuals make in response to the traumatic event and how people cope as they try to regain a sense of mastery or control over their lives (Resick & Schnicke, 1993).
3. However, in most studies trauma is not differentiated (e.g. disaster, accident, CSA), so it is difficult to discern what therapy may work better for what type of trauma
4. Some clients do not have improved functioning
despite CBT
Data on treating complex PTSD is limited and inconsistent
Non trauma focused treatment showed no reduction in
PTSD symtoms
A comparison study between trauma focused CBT
and SSRI (paroxetine) showed more (cost) effectiveness long-term
1. A recent meta analysis of PTSD treatment dropout
(Imel et al, 2013) showed that in particular trauma focused CBT had significantly higher drop out rates compared to non-trauma focused therapies (36/18)
2. Complex PTSD still shows poor outcomes of first line treatment
Shows overall effectiveness in adults for CBT
both CPT & Exposure therapy, with the latter being
the most effective component
Research II..but..s
appropriate information processing
movements; Experimented with friends
(70+ ppl)
> Aim: To resolve trauma symptoms by
desensitizing traumatic memories
> Case Study (1991)
refined and published
assimilating or integrating them with the
existing memory network
experience are not adequately processed
and are dysfunctionally stored in its own neural network > Contains thoughts, images, emotions, and sensations, that when triggered influence perceptions, attitudes, and behaviour in the present
resolution of dysfunctionally stored memories
20-50 second interrupted exposures, rather than continuous 20-100 min exposures
Shapiro believes information processing is primarily facilitated by:
The process of assimilation is different than
the theory of extinction
- Early childhood memories
- Recent events that trigger
current disturbances
- Memory of traumatic event
- Identify the image
- Identify negative cognition
- Identify desired positive cognition (VOC scale)
- Emotions & level of disturbance (SUD scale)
- Physical sensations
In a Nutshell:
"EMDR utilizes dual attention tasks to help the patient process the traumatic event and involves him or her focusing on negative trauma-related memories, emotions, and thoughts while engaging in a task involving some form of bilateral stimulation (eye movements, taps, tones) until distress has reduced and positive cognitions have increased" (Ponniah & Hollon, 2009)
1) Client history and treatment planning
2) Preparation phase
3) Assessment
> Identify components of target; Identify baseline
4) Desensitization
> Working with targets
5) Installation
> Strengthening positive cognitions
6) Body scan
7) Closure
> Reestablishing equilibrium; Debriefing
8) Reevaluation
> Checking maintenance of effects
1) Facilitation of resolution of memories (elicitation of insight, cognitive reorganization, adaptive effects, physiological responses)
2) Desensitize stimuli that trigger present distress as a result of second-order conditioning
3) Incorporate adaptive attitudes, skills, and behaviours for enhanced functioning within larger social systems
Phase 1 (1989-1998): Demonstrating EMDR's effectiveness in treating PTSD
Phase 2: Demonstrating EMDR's effectiveness against other trauma-focused treatments for PTSD
Phase 3: Focused on understanding underlying mechanisms of EMDR effective treatment
EMDR considered EBT for Adult PTSD by:
Ponniah & Hollon (2009) - Review of 57 RCTs on Treatment for Adults PTSD (and ASD)
> There are many components besides EMs
> Is actually an 8-phase treatment
Summary:
- Some studies found EMDR superior to trauma-focused CBT on some measures of PTSD symptoms
- Others reported PSTD symptom reduction as similar between trauma-focused CBT and EMDR
- Others report that EMDR produced smaller shift than trauma-focused
Leah is a 70 year-old Caucasian Canadian female client who has been recently married (1.5 years). She was diagnosed with PTSD 6 months after a brutal attempted murder attack that she barely survived whilst she was in her holiday accommodation 2 years ago. Leah presents with flashbacks and reoccurring nightmares where she is being chased either by people or by a bear and can’t escape. She is very disturbed by her lack of memory and has been withdrawing from people who know her, in fear that she has to talk about what has happened. Leah believes she has brought this attack upon herself as she filed a case with the court to obtain back funds she lent a friend, who in turn hired someone to murder her. As the police (local at the holiday destination) were extremely reluctant to investigate or even check up on her, she now believes ‘if even the police can’t be trusted who can?.' Leah frequently experiences disorientation and is easily startled when her husband approaches her or speaks to her. The client recently reported of dream like visions such as large dangerous animals appearing on the road swallowing her up. Leah's husband reports that she frequently has bursts of anger. Her symptoms are causing her significant distress impairing her social activities and relationships, and as a result she gave up her volunteer work as part of an animal rescue service. She abstains from both alcohol and drugs. No suicide ideation reported. Her support system has declined significantly, but she has a supportive husband. Leah came to counselling 1.5 years after the attack and is still presenting all symptoms above.
No use of drugs or alcohol (not attributable to substance or medical condition)
The client recently reported of dream like visions such as large dangerous animals appearing on the road swallowing her up. (Derealization)
Her husband reports his wife frequently bursts of anger and irritability (Alterations in arousal and reactivity)
Her symptoms are causing her significant distress impairing her social activities and relationships (Clinical distress and impairment)
She gave up her volunteer work as part of an animal rescue service (vocational impairment)
She now believes ‘if even the police can’t be trusted’ who can (nobody) (Negative Cognitions)
Client beliefs she has brought this attack upon herself
Lack of memory, has been withdrawing from people who know her (Avoidance)
Flashbacks, reoccurring nightmares (Intrusive symptoms )
A brutal attempted murder attack she barely survived (Trauma Incident)
Phase 1 > Taking Client History & Planning Treatment
DIAGNOSTIC CRITERIA FOR PTSD
Phase 2 > Preparation
Phase 3 > Assessment
Phase 4 > Desensitization
Phase 5 > Installation
Phase 6 > Body Scan
Phase 7 > Closure
Phase 8 > Evaluation
* Continue working through targets until resolved