n Raped or Sexually abused n Violent crime n Airplane or Car Crash n War n Terrorist Attack n Hurricane n Tornado n Fire n Illness

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1 EMDR Immediate Treatments for Manmade and Natural Disasters Gary Quinn, M.D. The Jerusalem EMDR Institute Man Made to Natural Disasters n Raped or Sexually abused n Violent crime n Airplane or Car Crash n War n Terrorist Attack n Hurricane n Tornado n Fire n Illness 3 Damage & Death Toll n Angola from year civil war 3 of 10.5 million displaced or directly affected n Bangladesh Flood /3 of country underwater 30 million people affected over 9 weeks n Venezuela 1999 mud slides 30,000 80,000 affected n Earthquake Turkey , ,000 homeless n Tsunami ,408 dead n China earthquake ,016 dead, 368,545 (injured)18,830 (missing) n Haiti ,000 dead, 300,000 injured and 1,000,000 homeless 4 Yael # 6 bus n Got off bus just before exploded n Actively hallucinating the explosion n In silent terror 5 Acute Stress Disorder (ASR) Definition n Transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress and which usually subsides within hours or days. n The stressor may be an overwhelming traumatic experience involving serious threat to the security or physical integrity of the individual or of a loved person(s) 6 ASR Definition n The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within 2-3 days (often within hours). Partial or complete amnesia for the episode may be present. n There must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate. 7 1

2 Not treating ASR n Most people recover n Incidence PTSD after Traumatic Event n Men 8-13% n Woman 20-30% Importance of treating severe ASR n 80 % of those whose symptoms are initially severe enough to meet criteria for ASD will have PTSD 6 months later n % will have PTSD 2 years following the event ( Bryant & Harvey, 2000 ) National Institute for Clinical Excellence (N.I.C.E.)UK Clinical Guidelines (2005) 8 John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page Some Treatment Helps ASD Prevents PTSD n CBT studies show helpful in ASD n Prevents later PTSD n Drugs do not help (one study of hydrocortisone does) Early Intervention May Prevent the Development of Posttraumatic Stress Disorder n 3 sessions modified prolonged exposure intervention n hours after trauma n 1-3 months post treatment n Reduced PTSR 10 Rothbaum, B.O.,et albiol PSYCHIATRY 2012;72: Society of Biological Psychiatry 11 Psychological First Aid (PFA) 8 Core Actions n 1. Contact and Engagement n 2. Safety and Comfort n 3. Stabilization (if needed) n 4. Information Gathering: current needs & Concerns n 5. Practical assistance n 6. Connection with Social Supports n 7. Information on Coping n 8. Linkage with Collaborative Services Psychological First Aid (PFA) 8 Core Actions n 1. Contact and Engagement n 2. Safety and Comfort n 3. Stabilization (if needed) n 4. Information Gathering: current needs & Concerns n 5. Practical assistance n 6. Connection with Social Supports n 7. Information on Coping n 8. Linkage with Collaborative Services

3 n Bilateral stimulation Yael #6 ERP n You are safe in the ER n That explosion is in the past n You are here n Repeat often n Take a deep breath, Let it all go, What are you noticing? (took time before she could answer) Yael #6 after ERP n Talked about the event (narrative) n Debriefed regarding expected normal reactions to trauma n Gave referral if before follow up visit needed to consult n Came in 1 week later with no ASD Acute Stress Reaction Similar Traumatized Before Treatment After EMDR treatment compared to Neutral condition Taking Pictures of Duty-Induced PTSD & HEALING Article: High Resolution Brain SPECT Imaging and Eye Movement Desensitization and Reprocessing in Police Officers With PTSD Karen Lansing, M.F.T, B.C.E.T.S. Daniel G. Amen, M.D. Chris Hanks, Ph.D Lisa Rudy, B.A. Published in the Jrnl of Neuropsychiatry Clinical Neuroscience17:4, Fall

4 Debriefing with first responder n 2 weeks after war ended (not within 72 hours) n Heterogeneous group: Police, Firemen, Ambulance and Zaka (removal of dead) workers n Different events n Each person reported a huge amount of trauma ERP with Dov n Zaka (removal of dead) worker n After hearing most of the group walked out n Said was going to bathroom n Followed him and he was in dissociated state n After ½ hour of walking got him to sit down n ERP protocol n 10 minutes responded and returned to group Treatment on Consecutive Days n Teams of therapists for short term field work n Complete therapy in days not weeks or months n War front n Disaster response n Remote areas with few mental health workers n Highly disturbed clients of all kinds Ellen ERP Initial Phone Call n Successful professional n Had severe trauma that not discuss on phone n Asked for explanation of EMDR n Had been told had Complex PTSD and need long treatment n In discussing elements of EMDR Ellen started to abreact n ERP with self tapping n Calmed and came for treatment Gary Quinn, M.D., The Jerusalem EMDR Ellen ERP while process recent trauma n Processed relational loss n Processed childhood abuse by step-father n Processing work related disturbing life experience n Sucked into black hole total terror n ERP of present safety n Returned to room and present n Continued disturbing life experience Pilot Case Study ERP n Treatment in last war grad bombs hitting Ashdod n Sirens hear impact- 15 minutes later victims pour in n Treatment as usual: explain their reactions- normalize n ERP n Both groups n=6 n Impact of event scale 1 week 2 years

5 Results Pilot Case study n Treatment as usual: 75% PTSD symptoms (bombs still falling) n ERP : 25% PTSD symptoms n Woman had symptoms had come before this session and was already on medication n She came several times to the center n Emergency room ERP Usage n During initial hospitalization n Immediate intervention in communal distress centers n Critical incident scenes such as car accidents, earthquakes, natural or manmade disasters, death of a loved one, and in ambulances ERP Usage Patient Indication n Abreaction during the initial history taking, prior to the Preparation Phase of EMDR n During EMDR, and at other times when patients appear to be deeply fearful, it can be used as an interweave, to return them to a sense of present-time safety. n Highly Agitated n Silent Terror ERP Assessment ERP Assessment n The assumed initial negative cognition (NC): I am in danger, or My family or friends are in danger n The assumed initial positive cognition (PC): I am/they are safe now from that event. The term from that event is added to give truth to the PC, allowing for ongoing danger (e.g., war, terrorism, natural disaster) n Emotion is assumed to be high fear or terror. n Subjective Units of Disturbance (SUD) is assumed to be at or close to 10 where 0 is no disturbance and 10 is the worst disturbance imaginable n Body Sensation: The therapist observes the body sensations such as muscle tension, catatonia, shaking uncontrollably, breathing rapidly, and so forth

6 Goal of ERP n Recognition of being in the present n Recovery of the ability to communicate verbally n Demonstration of body language suggesting a calmer state n Ability to respond to the SUDS scale (SUDS = 3-4/10) Addressing Lack of Control/ Choices (if needed) n And yes, in the future there are many different things that can happen but what we have found is that letting yourself be in the present here right now can be helpful to figure out how to deal with those later situations even if it is 5 minutes from now. n Can you let yourself realize that at this moment you are here and safe now with me? Because you are safe, right now Addressing Lack of Control/ Choices (if needed) n What happened is over. n And later we can try to figure out a way to make sure you remain as safe as is possible, but now just notice that right now you are here and you are safe. n All these other things can be dealt with much more easily when you can let yourself just be here safe right now 34 Addressing Responsibility (if needed) n At times like this, it is common to try to find someone responsible for this terrible incident. n You might blame yourself or blame others. n But right now, whatever the reason that this happened, even though it is a horrible thing that happened, what has happened has occurred in the past and you are here right now. n Being able to just let yourself know that you are here now and that this event is over is an important step for what needs to be done next. 35 Addressing Responsibility (if needed) n So please allow my tapping/hand movement to help you realize that you are here now -for whatever reason it happened- and you can be here this moment. n Recognizing you are here now can help you deal with the other things you will need to do later. n If this issue remains it can be addressed at a later time. Narrative of Event (optional) n Please tell me what happened from just prior to the start of the event until now. Feel free to tell me just what you are comfortable relating

7 Closure Closure n It is common to have a reaction to what has happened to you. You might have flashbacks of what happened, difficulty sleeping, and a number of emotions such as distress, fear, or anger. n You may notice that you are much more jumpy and startle more easily by loud sounds or anything that reminds you of what happened. n If you find these symptoms lasting longer than 2 to 3 days and not subsiding, this is not unusual, but we can help you to handle these reactions so that you will be calmer. n Here are some numbers to call (give contact information), if you would like more assistance. n Do you have any questions? ERP Role Play n See Role play Handout 40 7

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