Integrating EMDR for tailoring trauma therapy to the needs of patients with complex PTSD

Transcription

1 Integrating EMDR for tailoring trauma therapy to the needs of patients with complex PTSD Martin Sack, MD Klinik für Psychosomatische Medizin und Psychotherapie Klinikum rechts der Isar, Munich, Germany

2 Topics Complex PTSD a useful clinical concept Treatment needs and treatment planning for cptsd EMDR and Gentle Trauma Therapy principles EMDR in cptsd practice & manual Modifications for dissociative clients

3 Complex PTSD (DESNOS) Judith Herman (1992) 1. Alterations in affect regulation and impulsivity 2. Alterations in self-perception 3. Dissociative symptoms 4. Disturbances in relationships 5. Somatization 6. Alterations in systems of meaning Disorders of Extreme Stress not Otherwised Specified

4 Lancet 2013

5 Proposal for ICD 11 Posttraumatic Stress Disorder Intrusions = 6 Questions Avoidance Nightmares Flashbacks Thoughts or Emotions Places, People, Objects Hyperarousal Startle Reactions Hypervigilance

6 Proposal for ICD 11: Complex Posttraumatic Stress Disorder PTSD plus Affect dysregulation Negative self concept Interpersonal Disturbances

7 Proposal for ICD 11: ICD 10: Common Critieria of Personality Disorder PTSD plus Affect dysregulation Instable (negative) self concept Interpersonal Disturbances

8 Specific Comorbidity of BPD Self injuring Behavior 30 75% Suicide Atempts 70 90% Prevalence PTSD: 50 80% Prevalence Trauma History: 60 90%

9 Complex PTSD in Patients with Borderline Personality Disorder (N= 136) 80 % 20 % Sack et al., Nervenarzt (84) 2013, S

10 Clinical differentiation of BPD from cptsd no cptsd 70% BPD 30% Anger Outbursts yes Chi² = 42.4 no cptsd 97% BPD 3% cptsd 90% BPD 10% Instable Relationships Chi² = 16.1 cptsd 25% BPD 75% Instable Relationships Chi² = 9.2 yes kptbs 5% BPD 95%

11 Two varieties of complex PTSD Resick (2007) Externalizing Symptoms compl. PTSDType Borderline Intrusions Neg. Cognitions Emotions/ Arousal Internalizing Syptoms compl. PTSD Type DESNOS Basal reactions Adjustment / Coping

12 : Early life stress is the major cause of any psychiatric disorder

13 Anda & Felitti 2011

14 Alterations in the dental structure indicate early life stress

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16 Genes and environment: the brain of James Fallon Positron-Emission-Tomographie (PET): Grossly reduced cortical activity. Pattern such as in antisocial personality disorder Family history: Several siblings in the fathers line were violent deliquents or murderers Genetic risk: Monooxygenase A Gen Polymorphism (Risk for agression and violence) Gewalttätigkeit) Protective factors:

17 Need for two separate diagnostic approaches Categorial diagnostic System of classification (ICD-10) Descriptive, free from aetiology Documentation Financial accounting Scientific categorization Therapy related diagnostic Related to aetiologic hypothesis Individualised, Non-standardized Often implicitly practiced Useful for treatment planning

18 Stressor (trauma) based therapy If possible, therapy should adress the primary stressors (e.g. by using EMDR) When necessary, care first for secundary problems (symptoms) e.g. when they are dangerous or very distressing

19 State dependent unlearning Preconditions to modify traumatic memory and stress related interpersonal schemata Realisation this happend to me Reconstruction Elaboration of a coherent and functional narrative Empowerment Gaining experiences of acting competence Mastery Aquiring a perspective of surviving and healing potentials

20 A pragmatic concept of therapy: How to gain life quality as fast as possible Fostering social skills and relation capacities Fostering self awareness and self care Reduction of trauma related symptoms

21 Aspects of suffering as a compass for therapy Self-blame Feeling guilty Despair Anger Disgust Grief Shame Helplessness

22 cptsd General principles of treatment Take symptomatic treatment needs into account Help fostering self relatedness and self compassion Clarify individual treatment needs by adressing the individual suffering Include trauma confrontative therapy (EMDR) as early as possible

23 The stress-trauma continuum a model Traumatic experiences Trauma Fragmentation of memory (peritraumatic dissociation) Generalized and chronified traumatic anxiety Neglect Experiences of lack and deprivation Unmet developmental needs Negative experiences in close relationships Interpersonal learning experiences under high-stress Stress

24 Typical consequences of negative relational experiences during childhood Alterations in self-experiencing Unsecurity about ones own experiences Experiences of powerlesness and helplesness Unsecure or avoidant binding behavior Fear of beeing completely alone (dependent behavior) Fear of close contact (avoidant behavior) Problems in close relationships Conflict-avoiding behavior Aggressive behavior or violation of boundaries of others Lack of regulative flexibility in relationships

25 Typical steps in the treatment of disturbances of the capacity to relate Establishing of a sustainable working relationship Fostering self-awareness and experiencing of emotions Fostering self-acceptance and self-confidence Helping to recognize ones own emotional needs Learning to tune in into emotional states and needs of others Learning to formulate needs and to advocate hem Learning to recognize boundaries and to defend them Learning to argue out conflicts

26 Resource oriented treatment of trauma related disorders Activating resources means activating potentials of change

27 Day-care clinic for resource activation Activation of personal resources by fostering: Self-acceptance and problem understanding Skills and competences for self-regulation Ability to establish contact and social competence Creativity and motivation for behavior change Individualized psychotherapy: Negotiation of individual treatment goals

28 Amplifying circle of resource oriented therapy Activation of resources Positive self-awareness Positive emotions Positive feed back loop Experiences of competence Increased well-being Increased openness to new ideas More engagement in therapy

29 Recomendations for gentle trauma therapy Start trauma work by focussing daily symptoms Appply techniques for Distancing Activation of situational needed resources Changing traumatic narratives Care for the individual suffering Actively help gaining experiences of mastery

30 Dosing the stress by the amount of memory actualization Activation of situational specific resources e.g. wedging technique' Oscillating between resource activation and activation of trauma memory e.g. CIPOS (Constant Installation of Positive Orientation and Stimulation) Distancing techniques e.g. Screen technique, imaginary trauma work Accelerated memory processing e.g. EMDR Amount of actualization

31 Behandlungselemente schonender Traumatherapie Ein Modell Primary aim: Stress reduction and resource activation Primary aim: modification of trauma memory Therapeutic alliance (Activation of the binding system) Therapeutic setting (Feeling safe) Dosing stress during confrontation (Distancing techniques, resource activation) Protection and caring for traumatized parts of the self (Ego-state work) Adressing the individual suffering (Sensing and validating e.g. pain, grief anger) Exploration of the trauma memory (Completing of fragmentized parts of memory) Adding of positive memory to the traumatic narrative (e.g. having survived, having well acted) Modification of dysfunctional cognitions (e.g. shame, guilt, self-blame) Creating a functional narrative on the traumatic event (Fostering a sense of mastery)

32 Gentle Trauma Therapy a treatment manual 1. Identify trauma related stress apparent in daily life symptoms 2. Get informed consent for confrontave trauma work 3. Focussing and actualization of the trauma memory 4. Exploring and gathering of information (EMDR Phase 4) 5. Facilitating experiences of mastery by activating resources, active modification of the traumatic narrative or by ego-state work 6. If needed: help the patient to care for traumatized parts of the self 7. Evaluation whether the distress is reduced and/or whether further actualization of traumatic memory (see 3) is needed 8. Reorientation to the present situation, debriefing

33 How to regain a reflexive meta-level Making the agreement to maintain a reflexive position: 'I need you being an active partner in therapy. Therfore, I will ask you from time to time, what you think from the present posittion abouth your perceptions which arise during working on the past traumatic experiences.' When needed: change to the role of an observer: What do you think now about what happened in the past?' Reflexive evaluation of emotional reactions: 'What du you think today as an adult about the past situation? Would it have been possible for the child to defend oneself?'

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35 Dissociation is the key for understanding trauma related symptoms Unified model of disturbances Common underlying neurobiology Constitution of specific treatment strategies

36 Evidence for a dissociative subtype of PTSD Lanius et al. AmJPsychiat 2010

37 Dissociation a disorder of disturbed capacities of relationship Self relatedness (self awareness, self compassion) Lack of presence relatedness (lack of awareness and mentalization) Disturbances in interpersonal relationships (social avoidance, not percieving boundaries of others)

38 Ego State Therapy for cptsd Classical Hypnotherapy Therapist Patient Trauma Therapy Therapist Patient

39 Domains of psychotherapeutic work Competences and skills (cognitive) Psychoeducation Behavior modification Development of Ego-functions (e.g. mentalizing) Corrective experiences (emotional) Traumatherapy Modification of implicit (fragmentized) memories Satisfying individual developmental needs Fostering experiences of mastery Growth and maturing (personal) Individuation and personality development Development and activation of personal (creative) resources Value orienting and finding of meaning Resource activation

40 Literatur zum Thema: Sack M, Sachsse U, Schellong J: Komplexe Traumafolgestörungen Diagnostik und Behandlung von Folgen schwerer Gewalt und Vernachlässigung Schattauer Verlag, 2013 Sack, M: Schonende Traumatherapie Schattauer Verlag,