Recognising and Treating Psychological Trauma. Dr Alastair Bailey Dr Andrew Eagle -

Transcription

1 Recognising and Treating Psychological Trauma Dr Alastair Bailey Dr Andrew Eagle - andrew.eagle@nhs.net

2 Normal Human Distress Risk of pathologising normal human behaviour It is normal to feel Shock Emotional numbing Fear Despair Grief Sadness Anger Confusion Mistrust

3

4 Risk Factors I (Brewin et al., 2000) Effect size of all risk factors is modest Factors operating during and after the time of the trauma have stronger effect (small to moderate effect sizes) than pre-trauma factors: Trauma severity (greater effect in military) Lack of social support (variable effect) More subsequent life stress (consistent effect)

5 Risk Factors II (Brewin et al., 2000) Small effect sizes identified for a range of demographic and prior history variables: Female gender (variable) Lower socio-economic status (variable) Less education (variable) Lower IQ (variable) Psychiatric history (consistent across studies) Abuse history (consistent across studies) Childhood adversity (highly variable) Family psychiatric history(consistent across studies)

6 Risk Factors Impact of Previous Trauma Studies of rape victims (Frank and Anderson, 1987; Nishith, Mechanic, and Resick, 2000; Roth, Wayland, and Woolsey, 1990) have demonstrated a relationship between prior victimization, posttraumatic pathology, and problematic recovery.

7 Cognitive Risk Factors Negative cognitions about self, world and self-blame (Foa et al., 1999) Negative appraisals of symptoms, negative responses from others, and permanent change (Dunmore et al., 1999, 2001) Alienation, perceived permanent change, and Mental defeat (Dunmore et al., 1999, 2001; Ehlers, Maercker and Boos., 2000) Mental defeat - the perceived loss of all autonomy, a state of giving up in one s own mind all efforts to retain one s identity as a human being with a will of one s own

8 Acute Stress Reaction A transient disorder of significant severity which develops in response to exceptional physical and/or mental stress Mixed and changing picture with no one type of symptom predominating for long Shock, numbing, disorientation, depression, anger, despair, agitation, over-activity, withdrawal etc Resolves rapidly when person is removed from the stressful environment Symptoms diminish after hours and are usually minimal after 3 days

9 Post Traumatic Stress Disorder A delayed and/or protracted response to a stressful event of an exceptionally threatening or catastrophic nature (would cause pervasive distress in almost anyone) Symptoms persists for at least four weeks Onset normally with in six months of event But can get delayed and chronic sequelae which should be classified under F62.0 in ICD 10 Enduring personality change after catastrophic experience Idea of Shattered Assumptions

10 Three Clusters of PTSD Symptoms ICD 11 Re-experiencing of the Trauma in the present Spontaneous intrusive memories of the traumatic event Recurrent dreams related to the event Flashbacks Heightened reactions to related stimuli Other intense or prolonged psychological distress

11 Three Clusters of PTSD Symptoms ICD 11 Avoidance Symptoms including active avoidance of - Distressing memories Thoughts or images Feelings External reminder of the event Use of drugs and alcohol to numb distress and blunt emotion

12 Three Clusters of PTSD Symptoms ICD 11 Alteration in Arousal and Reactivity Aggressive, reckless or self-destructive behaviour Sleep disturbance Hypervigilance Startle response Autonomic hyperarousal Bursts of panic and fear

13 Three Clusters of PTSD Symptoms DSM 5 Negative alterations in cognitions and mood Persistent and distorted sense of blame of self or others Estrangement and alienation from others Mistrust and withdrawal Markedly diminished interest in activities Depressive symptoms Shame Inability to remember key aspect s of the event

14 Complex PTSD (proposed diagnosis for ICD 11) Core PTSD symptoms plus persistent and pervasive impairments in affective, self and relational functioning, including difficulties in emotion regulation, beliefs about oneself as defeated, powerless or worthless, and difficulties sustaining relationship Exposure to a stressor/s typically of an extreme nature from which escape is difficult or impossible e.g., childhood abuse, torture, domestic violence, prolonged war A development trauma disorder as a consequence of repeated experiences

15 Other factors in manifestation of PTSD Children Trouble sleeping and nightmares Separation anxiety and clingy behaviour Bed-wetting and thumb sucking Stomach aches and headaches Poor concentration Aggression and disobedience Re-enactment in play Cultural Factors Physical symptoms e.g., fatigues, headaches, dizziness

16 Adjustment Disorder A state of subjective distress and emotional disturbance, usually interfering with social and occupational functioning, arising in a period of adaptation to a significant life change or event Range of manifestations and symptoms Role of resilience and vulnerability factors Onset normally with in one month of the event Duration normally less than six months

17 Angry rumination vs PTSD Some people may experiencing angry rumination about the fire that is being mis-diagnosed as PTSD? Ways to distinguish between PTSD and rumination: Are there actual snippets of trauma memory which are popping into their heads i.e. bits of the 'video' made by their mind during the trauma? If not, more likely to be rumination Are these snippets more real and more vivid than normal memories? If not, more likely to be rumination Are they choosing to think about these memories (rumination) or are they popping into the person's head when they really don't want them to and aren't expecting them to (PTSD)

18 Grenfell Tower as a trigger that activates preexisting difficulties? Is there a difference between a trigger and a cause? How should we treat clients where Grenfell was more of an incidental factor in them presenting at services? Vicarious trauma Complex PTSD

19 Three Stage Model of Treatment Phase one: Stabilisation and Psychoeducation improving symptom management, self-soothing and addressing current life stressors to achieve safety and stability in the present Phase two: Trauma Processing Trauma-focused work to process traumatic memories Phase three: Reintegration, reconnection and recovery Re-establishing social and cultural bonds and enabling the client to develop greater personal and interpersonal functioning

20 Models to explain PTSD Ehler and Clark s cognitive model Negative appraisals of the trauma and its sequelae Current and continuous sense of threat Disturbance of autobiographical memory with strong perceptual memories disconnected from context and time-line Brewin s dual representation theory of PTSD Two types of memory storage sensation-based (hot) and contextual (cold) Under extreme stress, contextual memory is weakened and sensation-based memory dominates Underactive hippocampus and over-active amygdala Foa s fear network Trauma forms an associative fear network in long-term memory which is activated by trauma-related cues Focus on integration of the fear network and memory structures

21 Models to explain PTSD Attachment Theory and Social Support At time of threat or distress the attachment system is activated Notion of internal working models e.g., stable, anxious/ambivalent, avoidant, disorganised Ability to safely regulate emotion depends on attachment styles Social support mediates the effects of trauma Fight and Flight versus Tend and Befriend

22 NICE Debriefing Guidance Early interventions A number of sufferers with PTSD may recover with no or limited interventions. However, without effective treatment, many people may develop chronic problems over many years. The severity of the initial traumatic response is a reasonable indicator of the need for early intervention, and treatment should not be withheld in such circumstances. Watchful waiting Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual sufferers, should be considered by healthcare professionals. A follow-up contact should be arranged within 1 month.

23 NICE Debriefing Guidance Immediate psychological interventions for all As described in this guideline, practical support delivered in an empathetic manner is important in promoting recovery for PTSD, but it is unlikely that a single session of a psychological intervention will be helpful. For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident should not be routine practice when delivering services.

24 Debriefing Guidance Limited evidence for value of critical incident debriefing close to the time of the event May be different for teams? Do not interfere with natural coping responses Don t press people to talk about traumatic events if they don t want to Better evidence for individual rather than group interventions for PTSD Identifying at-risk groups for closer follow-up Screen and treat

25 What have we done? Weeks 1-4 Screening all Grenfell Fire referrals Trauma Screening Qre Watchful waiting and Psychological First Aid Weeks 4+ Continued screening PTSD assessments Treatment starting Please continue to refer via SPA

26 Trauma Screening Questionnaire Please consider the following reactions that sometimes occur after a traumatic event. This questionnaire is concerned with your personal reactions as a result of the traumatic event. Please indicate whether or not you have experienced any of the following AT LEAST TWICE IN THE PAST WEEK: (please circle those that apply to you) Upsetting thoughts or memories about the event that have come into your mind against your will Yes No Upsetting dreams about the event Yes No Acting or feeling as though the event were happening again Yes No Feeling upset by reminders of the event Yes No Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event Yes No Difficulty falling or staying asleep Yes No Irritability or outbursts of anger Yes No Difficulty concentrating Yes No Heightened awareness of potential dangers to yourself and others Yes No Being jumpy or being startled at something unexpected Yes No

27 Learning from Phase 1 Iterative process rapid learning essential Basic needs first Flexibility important challenge silos People difficult to contact GP engagement has been crucial Staff have responded well, but there is variance Vicarious trauma beginning to appear

28 Screen and Treat Screen and treat Approach well established following major trauma e.g. London Bombings - Phased approach 1. CNWL to be given list of patient cohorts affected through the postcodes provided by public health colleagues. 2. CNWL to sort list and divide those with and without LTCs 3. CNWL to inform you of patients on the list with LTCs with a request that you offer screening to this cohort and a briefing note - Screening template on SystmOne 4. If you are not able to screen, you let CNWL so that patients can be added to the CNWL list for screening

29 Screen and Treat 5. CNWL screening of list in a phased approach Tier 1 tower and bereaved Tier 2 surrounding area directly affected Tier 3 everyone else. 6. CNWL offer treatment via - Grenfell Fire Trauma team PTSD and other disorders due to the Fire - Routine Primary Care Mental Health care (PCLNs, Talking Therapy) for those not affected by the fire but where a need is identified. 7. Recall process