Trauma and Addiction New Age Treatment versus Traditional Treatment

Transcription

1 Trauma and Addiction New Age Treatment versus Traditional Treatment Marc J. Romano, Psy.D., RN, PMHNP, BC, CAP, LHRM Delphi Behavioral Health Group delphihealthgroup.com

2 Presentation Objectives Review the various treatment approaches to PTSD Discuss the prevalence of PTSD within society and among individuals with addiction To address or not to address - PTSD in early recovery

3 PTSD - History PTSD Symptoms first identified during WWI Combat Fatigue Battle Fatigue Shell Shock Soldier s Heart Gross Stress Reaction PTSD Symptoms identified in WWII Gross Stress Reaction PTSD Symptoms found among Vietnam War Veterans Post - Vietnam Syndrome

4 PTSD - Diagnosis PTSD Diagnosis - First Appeared in DSM III (APA, 1980) The introduction of PTSD into the DSM III helped to view this disorder as outside of the individual (i.e. traumatic event) and not due to the individual (i.e. weakness) The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000) One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common

5 PTSD - Diagnosis DSM-5 (2013), Includes many revisions to the PTSD diagnostic criteria Includes anhedonic/dysphoric presentations No longer categorized as an Anxiety Disorder. PTSD is now classified in a new category, Trauma- and Stressor-Related Disorders

6 PTSD - DSM 5 Criteria Criterion A: stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence Criterion B: intrusion symptoms The traumatic event is persistently re-experienced Criterion C: avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event Criterion D: negative alterations in cognitions and mood Negative alterations in cognitions and mood that began or worsened after the traumatic event

7 PTSD - DSM 5 Criteria Criterion E: alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month Criterion G: functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational) Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness

8 PTSD - DSM 5 Criteria Specify if: With dissociative symptoms In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream) Derealization: experience of unreality, distance, or distortion (e.g., "things are not real") Specify if: With delayed expression Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately

9 Complex Trauma Not in DSM 5 Identified in 1992 Prolonged trauma involving harm or abandonment by a caregiver or other interpersonal relationship with an uneven power dynamic Examples of such traumatic situations include: Concentration camps Prisoner of War camps Prostitution brothels Long-term domestic violence Long-term child physical abuse Long-term child sexual abuse Organized child exploitation rings

10 PTSD Alternative Views Trauma related symptoms Normal human survival instincts Adaptive mental processes Normal response becomes pathological if left unacknowledged and untreated Trauma more broadly defined A sudden and forceful event that overwhelms a person s ability to respond to it and does not always involve physical harm

11 Lifetime Prevalence Rates for PTSD 8% for US Adults Overall 9.7 % for women 3.6 % for men 3% to 58% for high risk populations (e.g. combat veterans, survivors of natural disaster)

12 Traumatic Experiences Lifetime Experience for at least one traumatic event (National Comorbidity Study, 1995) 51.2 % of women 60.7 % of men

13 Traumatic Experiences (National Comorbidity Study, 1995) Most Common Witnessing someone being badly injured or killed Men 35.6% Women 14.5% Second Most Common Fire, flood or other natural disaster Men 18.9% Women 15.2% Third Most Common Life threatening accident/assault such as automobile accident, gunshot, fall Men 25% Women 13.8%

14 Trauma Events (National Comorbidity Study, 1995) Men Women One Traumatic Event 26.5% 26.3% Two Traumatic Events 14.5% 13.5% Three Traumatic Events 9.5% 5% Four Traumatic Events 10.2% 6.4%

15 Cultural Differences (National Epidemiologic Survey on Alcohol and Related Conditions, 2011) Exposure to traumatic events by race, ethnicity or cultural group: Whites 83.7% African-Americans 76.4% Latinos 68.2% Asian-Americans, Native Hawaiians, or Pacific Islanders 66.4%

16 Cultural Differences (National Epidemiologic Survey on Alcohol and Related Conditions, 2011) White Americans more likely to report an unexpected death of someone they know African-Americans more likely to report being victim of assaultive violence Asian Americans, Native Hawaiians and Pacific Islanders more likely to have been exposed to a war zone as civilians

17 World Health Organization Survey (WHO) Trauma Experience by Category per WHO: 30.5% reported death of a loved one 21.8% reported witnessing violence to others 18.8% reported experiencing interpersonal violence

18 HMO in California Conducted a Trauma Survey of 7, 641 Customers Men Women Physical Abuse 29.9% 1st 27% 2nd Sexual Abuse 16% 2nd 24.7% 3rd Emotional Abuse 7.6% 13.1% Parental Substance Abuse 14.8% 3rd 29.5% 1st Parental Mental Illness 14.8% 3rd 23% Violence toward Mother 11.5% 13.7%

19 Trauma Characteristics Men more likely than women to experience a traumatic event during their lifetime, but women more likely to experience intimate partner violence and sexual assault Women more likely to seek treatment for PTSD compared to men People with lower SES increased risks for all types of trauma Higher PTSD among LGBT compare to heterosexuals People who have physical or cognitive disabilities have higher PTSD Homeless have higher PTSD and more likely to have experienced physical and sexual abuse in childhood

20 PTSD Risk Factors Female Low SES Racial Minority Status Less Education Prior Behavioral Health Disorders History of Childhood Abuse History of Prior Trauma Lack of Social Support History of Behavioral Health Disorders in Family Other Adverse Child Events

21 Limitations to Data Data is RETROSPECIVE which tends to UNDERESTIMATE compared to PROSPECTIVE LONGITUDINAL studies

22 Treatment for PTSD Trauma Informed Care (TIC) (SAMHSA, 2017) 1. Realizing the prevalence of trauma 2. Recognizing how trauma affects all individuals involved with the program, organization or system 3. Responding by putting this knowledge into practice TIC emphasizes physical, psychological and emotional safety for both providers and survivors that creates opportunities for survivors to rebuild a sense of control and empowerment

23 Prevention and Early Identification Psychological First Aid to minimize or prevent the development of PTSD Pharmacological interventions most effective for preventing PTSD

24 Effective PTSD Prevention 1. Promote a sense of safety 2. Promote calmness Decrease anxiety and heightened emotional response 3. Promote a sense of personal and collective efficacy Belief in one s own ability to recover from trauma (self-efficacy) or ability of one s community to recovery (collective-efficacy) 4. Promote connectedness Greater social support reduces likelihood of developing PTSD 5. Instilling hope Greater sense of hope associated with better outcomes

25 Assessment Avoid having the client describe in detail the traumatic event due to the risk of retraumatizing the client until the therapeutic alliance has developed Therapeutic alliance is one of the best predictors of treatment success Use supportive empathetic style Keep questions brief and general at first to desensitize the client to the topic being discussed Identify Co-Occurring Disorders Identify Strengths and Supports Identify Cultural Needs Determine Disability and Functional Impairment Determine Level of Care

26 Treatment Various treatment approaches to address PTSD CBT Exposure therapy Stress Inoculation Training EMDR Mindfulness Medication Group Therapy Emotion Focused Therapy for Trauma Hypnosis Manual Driven Treatments

27 Cognitive Behavioral Therapy Exposure Therapy Stress Inoculation Training

28 Exposure Therapy (ET) Patients asked to vividly recount traumatic event repeatedly until the emotional response decreases Gradually confront fear evoking trauma reminders Prolonged exposure includes education Breathing retraining Relaxation therapy Homework Exposure helps patients to face traumatic memories and situations without the accompanying anxiety and emotional dysregulation CBT focuses on reducing anxiety and avoidance related to the trauma memories

29 Stress Inoculation Training (SIT) Donald Meichenbaum, Ph.D. early 1980 s Just as vaccines inoculates us against diseases, SIT inoculates use against PTSD triggers and cues that cause distress Individuals under stress have difficulty coping with their symptoms of PTSD and SIT teaches patients to react differently to stressful situations and PTSD Symptoms Basic goal of SIT is to boost self-confidence that the patient can respond fast and effectively when trauma related cues occur SIT does not necessarily require you to talk about your trauma just learn skills to minimize distress associated with trauma

30 SIT Phase One Phase One Conceptualization Phase Patient interviewed Psychological testing Education on nature and impact of stress Patient educated on self-monitoring and how thoughts can exacerbate anxiety

31 SIT Phase Two Phase Two Skill Acquisition and rehearsal phase Teaching patients coping skills and relaxation techniques Cognitive restructuring Problem solving skills Interpersonal communication skills Acceptance Attention diversion methods

32 SIT Phase Three Phase Three Application and follow through practicing and applying skills Role playing Modeling Visualization Repetition Graded in vivo exposure Helping others with similar struggles

33 Eye Movement Desensitization and Reprocessing (EMDR) Francine Shapiro, PhD, 1990 s One of the most researched methods used to treat trauma Research demonstrates that after 3 90 minute sessions 84% to 90% of patients no longer have symptoms of PTSD Underlying premise is that EMDR facilitates the accessing and processing of traumatic memories to bring about an adaptive resolution Thinking about a memory while focusing on other stimuli (eye movement, hand taps, sounds) facilitates re-processing

34 EMDR - Three pronged approach Past focus on past disturbing memories and related events Past events that have laid the groundwork for dysfunction are processed Present current situations that cause distress Current circumstances that elicit distress are targeted and internal and external triggers are desensitized Future use skills learned for future actions Imaginal templates of future events are incorporated to assist client in acquiring the skills needed for adaptive functioning

35 Mindfulness A way of thinking and focusing that can help you become more aware of your present experiences, as simple as noticing a taste of mint on your tongue Involves paying attention to the feelings and sensations of experiences Limited research on mindfulness and PTSD but research has shown it to be beneficial with anxiety problems

36 Mindfulness and PTSD Two Key Elements in Mindfulness Paying attention to and being aware of the present moment Accepting and being willing to experience your thoughts and feelings without judging them Mindfulness may help patients cope with difficult emotions when they arise Focusing on the moment may help cope with emotions that arise after a traumatic experience Can be used along with Exposure Therapy and Cognitive Processing Therapy to manage negative feelings when they arise

37 Present Centered Therapy Non-trauma focused treatment for PTSD Primary mechanisms of change from a present centered perspective include: Altering present maladaptive relation patterns/behaviors Providing psycho-education regarding the impact of trauma on the client s life Teaching the use of problem solving strategies that focus on current issues The treatment omits the use of exposure and cognitive restructuring techniques

38 Cognitive Processing Therapy Type of Cognitive Behavioral Therapy 12 Session Psychotherapy Goal is to learn to evaluate and change upsetting thoughts since the trauma Changing thoughts can change emotions For example, blaming oneself for the trauma leads to depression Write about your trauma and share details with therapist or others in a group format

39 Medication Medications have proven effective in the context of talk therapy Medications used to treat PTSD include SSRI s, SNRI s, Neuroleptics Prazosin has been shown to be effective in treating PTSD in Military Veterans Alpha blocker High arousal levels disrupts normal REM Sleep and contributes to nightmares Prazosin lowers the arousal level thereby lowing risk of nightmares associated with PTSD and the return of normal dreaming

40 Group Therapy Talking about trauma experiences with others who have had similar experiences Sharing stories may help a patient feel more comfortable Group therapy helps build relationships with others who understand what you have been through Patients learn to deal with shame, guilt, anger, rage, and fear Sharing with a group can help build self-confidence and trust

41 Emotion Focused Therapy for Trauma Specific for PTSD from child abuse Grounded in experiential therapy Premise is that disrupted emotional processes are at the core of therapy Therapy focuses on unresolved feelings and unmet needs in relation to the abuse typically directed at attachment figures Primary Intervention Resolve attachment injuries through imaginal confrontation in which client imagines the perpetrators in an empty chair and express their thoughts and feelings about the abuse cathartic experience

42 Hypnosis Hypnosis provides controlled access to memories that may otherwise be kept out of reach of consciousness Hypnosis involves positive restructuring of those memories Hypnosis can help a patient face a traumatic experience by embedding it in a new context

43 Manual Based Treatments Addiction and Trauma Recovery Integration Model (ATRIUM) 12 week curriculum for survivors of sexual and physical abuse with cooccurring substance use disorders Helping Women Recover Integrated curriculum addressing trauma and addiction Seeking Safety Present focused therapy designed to promote safety and recovery for individuals with PTSD and substance use

44 Manual Based Treatments Trauma Recovery and Empowerment Model (TREM) sessions to help members learn strategies for self-comfort and accurate self-monitoring; help members establish safe physical and emotional boundaries; focus directly on the trauma experience; finally focus on skills building Triad Women s Trauma Model Goal is to reduce psychiatric and trauma related symptoms with histories of violence, abuse, and substancse use Early research shows promise for these modes but more research is needed to determine which model works best in which setting

45 Most Effective Treatment - CBT Cognitive Behavioral Therapy Most effective type of counseling for PTSD VA uses Cognitive Processing Therapy and Exposure Therapy Meta-analysis looking at various therapies shows that CBT and EMDR are more effective than other treatments that do not focus on the trauma memories or their meaning Brief CBT shortly after a traumatic experience reduces risk of PTSD

46 Treatment Effectiveness Exposure Therapy versus Present Centered Therapy Women who received exposure therapy had greater reduction in PTSD symptoms compared to women who received present centered therapy Drop out rate is higher in exposure therapy 2/3 s in both groups had a good response but those with exposure therapy were 1.8 times more likely to no longer meet criteria for PTSD and 2.4 times more likely to have full remission

47 Research CBT and Exposure Therapy had lower prevalence rates compared to control group receiving a placebo and group receiving medication VA and DOD reviewed research on treatment for PTSD and found CBT had the most benefit Most meta-analyses found that the most effective trauma related behavioral health treatments are CBT which includes Exposure Therapy and EMDR

48 Research Limitations to Research Study attrition Inadequate methods for addressing missing data Investigator bias Difficulty generalizing results from one population to another (rape victims versus veterans) Inadequate follow up Lack of high quality randomized controlled studies

49 Most Effective Exposure Therapy EMDR Research

50 Research National Institute of Medicine found insufficient evidence supporting the use of EMDR, cognitive restructuring, coping skills therapy, and group therapy for PTSD and only endorsed the use of Exposure Therapy United Kingdom s National Institute for Clinical Excellence endorsed trauma focused CBT and in some cases EMDR Study reviewed research comparing EMDR and Exposure Therapy and found some showing EMDR better while others show that Exposure Therapy is better

51 Research Meta-analyses of Exposure Therapy included 13 studies and found it more effective than non-treatment control conditions and as effective as other treatments including, EMDR and CBT Clients in meta-analyses had 86% better post-treatment outcomes compared to control groups Most research and meta-analyses found psychodynamic therapies to be relatively ineffectual in the treatment of PTSD Medications tend to be effective at reducing PTSD symptoms and severity

52 PTSD and Substance Use Disorders Research shows a relationship between substance use and mental disorders dating back to 1970 s Co-Occurring Disorders include the use of alcohol and/or drugs of abuse and one or more mental disorders Diagnosis of co-occurring disorders occurs when at least one disorder of each type (SUD and Mental Disorder) can be established independent of the other and not just symptoms due to each other

53 PTSD and Substance Use Disorders Each feature of PTSD can lead to substance use Hyperarousal can lead to attempts to reduce anxiety and tension through selfmedicating Use of stimulants can be used to maintain high arousal Psychoactive substances may be used to reduce distress associated with intrusive reexperiencing and to provide temporary forms of avoidance of traumatic memories and associated distress Emotional numbing and social detachment in PTSD may lead to the use of substances to feel pleasure and connection to other people

54 PTSD and Substance Use Disorders Lifestyle - leads to involvement with peers that increase the risk of exposure to traumatic stressor (e.g. violence, crime, accidents) Misdiagnosed trauma related symptoms can interfere with treatment, engaging in treatment, early dropout, and relapse rates Focus of trauma work should be on stabilization, safety, and understanding the links between trauma and substance use

55 PTSD and Substance Use Disorders When PTSD is worse, people use more drugs and/or alcohol When substance use is worse, severity of PTSD does not change Physical and sexual abuse in childhood are associated with higher rates of substance use disorders Individuals with PTSD and substance use disorders are more likely to Have severe PTSD Have a greater chance of PTSD symptoms returning after remission of substance use Have a greater chance of relapse

56 PTSD and Substance Use Disorders High Risk Hypothesis People who use drugs and alcohol are around people, places, and things that increase risk of exposure to events that lead to PTSD

57 PTSD and Early Recovery Research Research shows a poorer outcome for individuals in Substance Abuse Treatment who do not address trauma Research shows that integrated models that address substance use and trauma show promise in decreasing relapse rates Individuals completing treatment for substance use and for PTSD sustained significantly positive change six months later in substance use and employment areas 17 women in treatment for PTSD and substance use using Seeking Safety showed a reduction in both PTSD symptoms and substance use

58 PTSD and Early Recovery Substance abuse treatment programs Create trauma informed environments Provide services that are sensitive and responsive to trauma survivors Integrate an understanding of trauma and substance use Help clients understand the connection between trauma and substance use

59 PTSD and Early Recovery Use your judgment and clinical assessment skills Go slow and at the client s pace Continually assess the client s discomfort Employ experienced clinicians Refer out if needed

60 Final Comments Internal Resilience Self-esteem Trust Resourcefulness Self-Efficacy Internal Locus of Control Self-Sufficiency Sense of Humor Sense of Mastery Optimism External Resilience Sense of Safety Religious Affiliation Strong Role Models Emotional Sustenance Trauma Support Groups AA/NA

61 Final Comments Do not focus on the client telling the traumatic story but focus on helping the client to feel safe while understanding the link between trauma and substance use Teaching skills for the here and now while helping the client prepare for future events More research is needed looking at evidenced based substance use treatment and treatment for PTSD

62 The End!