Traumatic Stress and PTSD An Update

Transcription

1 Traumatic Stress and PTSD An Update Dr Walter Busuttil Consultant Psychiatrist and Medical Director Combat Stress

2 Updates on Classification Co-morbidity vs Complex PTSD Early Intervention Post Disaster Carers Moral Injury

3 PTS: CORE CLUSTER SYMPTOMS: Re-Experiencing Phenomena Hyperarousal Phenomena / Numbing Avoidance Phenomena Cognitive Change

4 A Dynamic Model for symptom cluster Interaction in Acute Stress Disorder and Post Traumatic Stress Disorder Modified by Busuttil (1995) from Horowitz Information Processing Model (1976) Stressor Arousal / Numbing Re-experiencing Avoidance

5 Aetiological Models of PTSD Information Processing Model Prime model on which others are based on. Psychosocial Model Support before, during and after exposure Behavioural Model Triggers & stimulus generalisation Cognitive Model Cognitive distortions & hot spots (Ehlers & Clark) Cognitive Appraisal Model Meaning of stressor & its effects on the future, -man-made vs acts of God. (Janoff Bulmann) Dual Representation Theory Situationally accessible memory versus verbally accessible memory (Brewin) Biological Models Unproven & various FMRI studies Attachment Theory Models (De Zulueta)

6 Relationship between: ASD and PTSD DSM & ICD ASD ----->Acute PTSD---->Chronic PTSD fluid state >fixed state Mont hs time in months

7 Concepts for Discussion Classifications Simple and Complex PTSD Complicated presentations Co-morbidity Single versus multiple vs ongoing traumatic exposure Neuro-Developmental stage/age Personality development

8 DSM-IV Complex PTSD Working Party Study Developmental Stage Multiple traumatisation below the age of 26 years predicted development of Complex PTSD Exposure to Multiple traumatisation after the age of 26 years did not predict Complex PTSD

9 Complex PTSD DSM-IV Field Trials Adult survivors of CSA (van der Kolk et al, 1994) Alterations in 7 dimensions: Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation. Attention & concentration: dissociation, amnesia, depersonalization Self-Perception: helplessness, guilt, shame. Perception of perpetrator: idealization of the perpetrator or feelings of vengeance. Relationships with others: isolation, mistrust, victim role, victimization of others Somatisation: GIT; CVS; Chronic pain, conversion etc. Systems of meaning: despair, hopelessness, major changes to previously well held beliefs

10 Complex PTSD: A diagnostic frameworkdisturbance on three dimensions (Bloom, 1997) Symptoms Characterological / personality changes Repetition of Harm

11 Complex PTSD Disturbance on Three Dimensions (after Bloom 1999) Symptoms of PTSD Somatic Propensity to Repetition of Harm To the self - faulty boundaries Affective : By others - battery, abuse Dissociation Of others - become abusers Psychotic Presentations Deliberate self harm Characterological Changes of: Control: Traumatic Bonding Lens of Fear Relationships: Lens of extremity- attachment Identity Changes: Self structures Internalized images of stress Malignant sense of self Fragmentation of the self versus withdrawal

12 DSM-V Developmental Trauma Disorder in children & adolescents Exposure to (Multiple)Trauma Triggered dysregulation in response to trauma cues Persistently altered attributions and expectations Functional Impairment.

13 Diagnostic Criteria for PTSD: DSM-IV Criterion A1 - Extreme Traumatic Exposure Criterion A2 - Fear Horror and helplessness Criterion B - Re-experiencing symptoms. Criterion C - Avoidance and numbing symptoms. Criterion D - Symptoms of increased arousal. Criterion E - Duration of at least one month. Criterion F - Significant distress or impairment of functioning.

14 DSM-V Changes to Inclusion criterion A The DSM-IV Criterion A2 deleted. Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure Witnessing the trauma Learning that a relative or close friend was exposed to a trauma Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

15 PTSD DSM-V Significant changes compared to DSM IV Instead of three major symptom clusters for PTSD, the DSM-5 now lists four clusters: Criterion B Re-experiencing the event Intrusive thoughts; Nightmares; Flashbacks; Emotional distress after exposure to traumatic reminders; Physical reactivity after exposure to traumatic reminders Criterion C Avoidance Trauma-related thoughts or feelings; Trauma-related reminders Criterion D Negative thoughts and mood or feelings Inability to recall key features of the trauma; Overly negative thoughts and assumptions about oneself or the world; Exaggerated blame of self or others for causing the trauma; Negative affect; decreased interest in activities; Feeling isolated; Difficulty experiencing positive affect Criterion E Heightened arousal Irritability or aggression; Risky or destructive behaviour; Hypervigilance; Heightened startle reaction; Difficulty concentrating; Difficulty sleeping

16 Criterion F (required): Symptoms last for more than 1 month. Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational). Criterion H (required): Symptoms are not due to medication, substance use, or other illness.

17 DSM-V includes two new subtypes PTSD Preschool Subtype PTSD in children younger than 6 years. Post-traumatic stress disorder is also now developmentally sensitive, meaning that diagnostic thresholds have been lowered for children and adolescents. PTSD Dissociative Subtype PTSD is seen with prominent dissociative symptoms including: experiences of feeling detached from one s own mind or body, or experiences in which the world seems unreal, dreamlike or distorted (Depersonalisation Derelaisation).

18 DSM V: Acute Stress Disorder ASD updated consistently with PTSD criteria. The DSM-IV Criterion A2 deleted.

19 Adjustment Disorders Adjustment disorders: reconceptualised in the DSM-V as a stress-response syndrome. Same criteria and definitions as DSM IV

20 Reactive Attachment Disorder & Disinhibited Social Engagement Disorder Two distinct disorders in DSM-V, based upon the DSM-IV subtypes. So we now have reactive attachment disorder which is separate from disinhibited social engagement disorder. Both of these disorders are the result of social neglect or other situations that limit a young child s opportunity to form selective attachments. Although sharing this aetiological pathway, the two disorders differ in important ways. (APA 2013) The two disorders differ in many ways, including correlates, course, and response to intervention. 1. Reactive Attachment Disorder The APA suggests that reactive attachment disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. In reactive attachment disorder, there is a dampened positive affect the child expresses joy or happiness in a very subdued or restrained manner. 2. Disinhibited Social Engagement Disorder The APA further suggests that disinhibited social engagement disorder more closely resembles ADHD: It may occur in children who do not necessarily lack attachments and may have established or even secure attachments.

21 Other specified trauma and stressor related disorder (Partial PTSD) Symptoms characteristic of a trauma and stressor related disorder that cause significant distress, functional occupational etc impairment but do not meet full criteria or any of the disorders in the trauma stressor disorder diagnostic class.

22 Unspecified trauma and stressor related disorder Where there is insufficient information about the trauma exposure but trauma symptoms are present with clinically significant distress and impairment (eg in A&E workers where no specific trauma is evident).

23 ICD-10 Acute Stress Reaction Looser Criteria Than DSM-IV PTSD Looser criteria, Criterion A equivalent Three core symptom clusters ICD-11 due in 2018?!

24 KZ Syndrome Konzentrations Lager Syndrome: Concentration Camp Syndrome (Herman & Thygersen, 1953) Characterized by 12 severe chronic psychiatric and non-specific somatic symptoms comprising: 1. fatigue 2. impaired memory 3. dysphoria 4. emotional instability 5. sleep impairment 6. feelings of insufficiency 7. loss of initiative 8. nervousness 9. restlessness & irritability 10. vertigo 11. vegetative lability

25 Enduring Personality Change after Catastrophic Stress (ICD-10, F ) Prolonged exposure to life threat/s PTSD may precede the disorder features seen after exposure to threat: a hostile mistrustful attitude towards the world social withdrawal feelings of emptiness or hopelessness chronic feelings of being on edge or threatened estrangement

26 PTSD Classification ICD-10 (1992) Acute Stress Reaction PTSD Re-experiencing Avoidance Hyperarousal Multiple trauma exposure Enduring Personality Change Following Catastrophic Stress (F62.0) DSM-IV (1994) Acute Stress Disorder Acute PTSD Chronic PTSD Delayed PTSD Re-experiencing Avoidance Hyperarousal Multiple Trauma Exposure Disorders of Extreme Stress: not classified but defined. (DESNOS) DSM-V (2013) (Reactive Attachment Disorder) (Disinhibited Social Engagement Disorder) Acute Stress Disorder PTSD No distinction between acute and chronic: duration only Delayed PTSD Re-experiencing Avoidance Negative alterations in cognitions and mood Hyperarousal Multiple Trauma exposure not mentioned Dissociative or Nondissociative sub-types Adjustment Disorders Other specified Trauma and stressor related disorders Unspecified Trauma and stressor related disorders

27 ICD-11 Simpler? Not an anxiety disorder stress disorder section Multiple Traumatisation properly defined; CPTSD well defined CPTSD=DSO=AD+NSC+DR* (Karatzias et al 2017)? Distinguished from Borderline PD and other PDs Traumatic grief/ traumatic bereavement *(DSO=Disturbance of self organisation;ad=affect dysregulation; NSC=Negative self image; DR= Disturbance of relationships)

28 Co-morbidity vs CPTSD

29 PTSD and Co-morbidity relationship with Complex PTSD Implications for service planning Mental health profile of new referrals to Combat Stress Health outcome % (N=425) (Murphy 2014) PTSD 79% Depression 88% Anxiety 79% Anger problems 46% Alcohol problems 44% Drug misuse 13% Functional impairment Childhood adversity (e.g. CSA, neglect etc) Significant 25% Severe 64% 52% Significant Physical illness 71%

30 Early Interventions for Disasters Disaster planning First response physical Secondary response - psychological First responders Emergency Workers Military Identify Disaster Community Disaster Management Psychological response Early psychological interventions Longer term treatment options

31 Brewin et al (2000) Meta analysis of Risk Factors for PTSD Can we control for some of these? They examined Female gender Younger age Low s-e status Lack of education Low intelligence Race (minority status) Psychiatric history Childhood abuse Previous trauma Adverse childhood Family psych history & main effects were from 1. Trauma severity dose response effect 2. Lack of social support (0.40) 3. Subsequent life stress (0.32)

32 Military Psychiatry Prevention and Mitigation of ASD and PTSD Measures taken before, during and after combat. Pre deployment Screening Pre deployment briefings Realistic Professional Training Stress Inoculation Training (SIT) Induction Training Deployed Prophylactic Medications Leadership, Cohesion and Buddy/Buddy Care Trauma Risk Management (TRiM) PIE-B (Proximity, Immediacy, Expectancy, Brevity) Harmony Guidelines Post Deployment Psychological Decompression Support by the public Little evidence any of these prevent mental health difficulties.

33 Predictable Phasic Psychological Response of Civilians to Disaster and War (Ursano 1989; Greenberg et al, 2015) Immediate disbelief, numbness, fear, confusion for most a normal response to an abnormal situation 1 week several months - Assistance from outside agencies and communities adaptation to austere environment hyperarousal, intrusive thoughts, somatic symptoms fatigue, dizziness, headaches, nausea, anger, irritability, apathy, social withdrawal. Longer term increased feelings of disappointment if hopes for aid/restoration not met weakened community bonds personal needs take precedence. Reconstruction phase years rebuilding lives, work, home etc.

34 Acute Phase: Incident Management General Principles Post Disaster Safe Zone for all. Assess those with signs of mental health problems Community outreach/education/community groups Education about trauma reactions information giving Treat those who need it. In: Safe zone: Coordinated responses from rescuers & good social and support, including delivering creature comforts food, sleep, amenities etc may prevent mental health breakdown Supportive environment for all Psycho-educational & self-help interventions Identify those who need acute mental health interventions and treat Later: mental health services likely to be required.

35 Presenting symptoms None Loss and grief Behavioural Alcohol ASD PTS & PTSD Dissociation, shock, numbing Depression Anxiety, phobias Reactivated psychiatric illness

36 Psychological First Aid Five elements of PFA (drawn from research on risk and resilience, field experience and expert agreement). 1. safety 2. calm 3. connectedness 4. self-efficacy and group efficacy 5. hope. Reassurance, keep families together, information, crisis intervention and support; empower.

37 Aims of PFA 1. Humane caring and compassionate. 2. Addresses emotional and practical needs and concerns above all else. 3. Builds people s own capacity to recover; by supporting people and helping them to identify their immediate needs and their strengths and abilities to meet these needs. 4. One of the most important research findings is that a person s belief in their ability to cope can predict their outcome. 5. Typically people who do better after trauma are those who are optimistic, positive and feel confident that life and self are predictable, or who display other hopeful beliefs.

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40 World Round Table Project Sydney 2015 InterPar Intervention post Psychological First Aid Not specialised and not treatment for mental illness Aims to improve adjustment post disaster and improve wellbeing and reduce risks of longer term mental illness Aims to help re-engagement in helpful behaviours Emotional processing encouraged To be delivered by trained non-specialist staff (mentors) supervised by clinicians Currently being designed and evaluated

41 World Round Table Project Sydney 2015 Main areas of work Healthy Living and wellbeing Managing strong emotions Coming to terms with disaster and emotions Getting back to life Worry and rumination

42 Secondary Victims Ripple effect emotional contamination carer fatigue

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44 Partners Mental health profile Mental Health Profile of Veterans Partners (n=100) Percentage meeting criteria Depression 39% Anxiety 37% PTSD 17% Alcohol Disorder 45% Significant/severe Functional Impairment 62% (Scale measures five areas: work, home management, social leisure, private leisure and family & relationships). Comparison with female population within the Adult Psychiatric Morbidity Survey England Common mental health disorders Percentage meeting criteria 20% PTSD 3% Hazardous drinking 16%

45 Barriers to accessing help Percentage Previously Sought Help for Mental Health Yes 47% No 53% Too embarassed to seek help Too scared to seek help Others would not understand Concerned about what others would think Did not meet clinical criterea for anxiety Met clinical criterea for anxiety 0% 10% 20% 30% 40% 50% 60%

46 Moral Injury The perceived philosophical meaning related to the impact of trauma exposure was seen by Janoff-Boulman (1985) as an aetiological factor for PTSD. This was described as a shattering of well held positive values and assumptions about the world, oneself and others. Incorporated within the diagnostic criteria for PTSD in the Diagnostic Statistical Manual (DSM) since DSM-III-revised (1987) and further developed and formally included in the most recent Fifth Edition (DSM-V; 2013) are concepts such as guilt relating to acts of commission and omission as well as negative cognitive change following trauma exposure. The relatively new concept of Moral Injury (Litz et al, 2009) expands on Janoff-Boulmann s concepts and guilt symptoms and was reported by military medical staff and chaplains operating close to combat.

47 Moral Injury Ethical, moral and religious challenges caused by violations to deeply held beliefs. Military operations and training emphasize mission aims, with suppression of individual needs and beliefs. Usually arises from cumulative events. collateral damage; bystander to ongoing atrocities, powerless when their own leaders and colleagues flaunt the rules of engagement. Perceived organisational or personal betrayal - ethical dilemmas resulting in chronic feelings of guilt, anger and frustration. Can take time to sink in and state that a healthy mind that can empathise is a requirement for its development. Moral Injury does not lead to, or amount to, diagnosable mental illness, although in some moral injury may form part of a mental illnesses presentation including PTSD. Intervention: generate an understanding of moral codes of conduct and emotions that are linked to this; the effect of shame on social behaviour, and self-forgiveness. Access to spiritual help working in conjunction with therapy interventions is advised. A modified exposure treatment approach is also included.