Trauma and Evolving Clinical Models. Science Update. Zachary Steel. St John of God Chair of Trauma and Mental Health

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1 Trauma and Evolving Clinical Models Science Update Zachary Steel St John of God Chair of Trauma and Mental Health School of Psychiatry, University New South Wales St John of God Health Care, Richmond Hospital

2 Historical Overview Impact of extreme trauma was described in World War I Veterans and in survivors of the Nazi Holocast. concentration camp or KZ syndrome (Eitinger,1959). survivor syndrome (Nierderland, 1968). persisting anger (De Wind 1972) Posttraumatic character disorder (Horowitz et al. 1986) Complex PTSD (eg. Marmar, 1991; Herman,1992); Posttraumatic stress disorder with personality change (Brunt, 1994)

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4 Political Terror Scale Level 5 : Terror has expanded to the whole population. The leaders of these societies place no limits on the means or thoroughness with which they pursue personal or ideological goals. Level 4 : Civil and political rights violations have expanded to large numbers of the population. Murders, disappearances, and torture are a common part of life. In spite of its generality, on this level terror affects those who interest themselves in politics or ideas. Level 3 : There is extensive political imprisonment, or a recent history of such imprisonment. Execution or other political murders and brutality may be common. Unlimited detention, with or without a trial, for political views is accepted. Level 2 : There is a limited amount of imprisonment for nonviolent political activity. However, few persons are affected, torture and beatings are exceptional. Political murder is rare. Level 1 : Countries under a secure rule of law, people are not imprisoned for their view, and torture is rare or exceptional. Political murders are extremely rare.

5 Main Findings of TFPE Rates of reported PTSD and depression showed large variability (0%-99% and 3%- 85.5%, respectively) 145 surveys reported PTSD with an unadjusted average of 30.6% (95% CI, 26.3%-35.2%) (n=64 332) 117 surveys reported depression with anunadjusted average of 30.8% (95% CI, 26.3%-35.6%)

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8 Diagnostic Models DSM-IV draft criteria - DESNOS - DSM IV EPCACE - ICD-10 Enduring Personality Change after Catastrophic Exposure Complex PTSD ICD-11 draft criteria

9 Diagnostic guidelines for EPCACE (a) a hostile or mistrustful attitude towards the world; (b) social withdrawal; (c) feelings of emptiness or hopelessness; (d) a chronic feeling of being on edge, as if constantly threatened; (e) estrangement. Does not include from prolonged stress in childhood

10 DSM-5 Reactive Attachment Disorder Distinguished Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor- Related Disorder (Bereavement Related Disorder)

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12 PTSD Complex PTSD ICD-11 Prolonged Grief Disorder Adjustment Disorder Reactive attachment Disorder Disinhibited Social Engagement Disorder Acute Stress Reaction Unspecified Trauma- and Stressor- Related Disorder

13 Classic Model of Complex Trauma arising in childhood Internalising Borderline Personality Disorder Dissociative Identify Disorder Dissociative Amnesia Depersonalisation/ Derealization Disorder Externalising Narcissistic Personality Disorder Antisocial Personality Disorder

14 ICD 11 - Complex PTSD Three core features of PTSD Problems in emotional regulation Heightened in emotional reactivity Dissociative states Behavioural Disturbances Explosive anger Self destructive Problems in Self Concept Persistent negative beliefs about one self as diminished defeated worthless Difficulties in sustaining relationships

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21 Evidence Based Treatments for Trauma Related Disorders Prolonged Exposure Disorder Cognitive Therapy for PTSD (Updating Memories and Meanings of Trauma) Cognitive Processing Therapy EMDR Narrative Exposure Therapy (NET) Brief eclectic psychotherapy for PTSD (BEPP) STAIR Narrative Therapy Complicated Grief Treatment for PGD

22 Five cognitive themes addressed in CPT for PTSD safety trust power/control esteem intimacy

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28 Models of care is refugee and post-conflict mental health

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34 Adaptive Systems threatened by Security/Safety Attachment Justice Identity-role Existential-meaning mass HRVs

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36 1. Promote Safety 2. Promote Calming 3. Promote sense of self and collective efficacy. 4. Promote connectedness. 5. Promote hope

37 ADAPT Five Essential Elements CPT 1. Security/Safety 2. Attachment 3. Identity-role 4. Justice Promote Safety Promote Calming Promote connectedness. Promote sense of self and collective efficacy. Safety Trust intimacy Power / control 5. Existentialmeaning Promote hope Esteem

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40 Most refuges have little access to mental health professionals Western MH Services tend to be underutilised and are culturally alien Clinic based services are of limited value in meeting the constellation of displacement-related stressors

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