The assessment and treatment of PTSD from an attachment perspective

Transcription

1 The assessment and treatment of PTSD from an attachment perspective Dr Felicity de Zulueta Emeritus Consultant Psychiatrist at Psychotherapy in South London and Maudsley NHS Foundation Trust Honorary Senior Lecturer at Kings College London

2 The aims of this presentation Looking at the implications of DSM-5 in relation to the Assessment and diagnosis of PTSD and the likely PTSD diagnoses in ICD11 Understanding PTSD and its more complex manifestation from an attachment perspective, focusing specifically on attunement failure Using attachment research to make sense of PTSD symptoms, particularly complex PTSD

3 From DSM IV to DSM-5 This is what Dr Insel, director of the American National Institute of Mental Health wrote, in relation to the Diagnostic & Statistical Manual of Mental Disorders : The weakness is its lack of validity. Unlike our definitions of ischemic heart disease or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.

4 Why PTSD? The word trauma comes from the Greek and means wound or injury. Whilst physical trauma has always been recognised, psychological trauma was only briefly acknowledged in the last wars ( shell shock ).The loss of the Vietnam War led to the formulation of PTSD. The medicalisation of trauma has been strongly criticised by professionals using a Psychosocial approach. The two can integrated using an attachment approach (Miller, K.E, Rasmussen, A 2010, Zulueta, 2007)

5 What are the major changes in the diagnosis of PTSD according to DSM-5? PTSD (and Acute Stress Disorder) are now included in a new chapter on Trauma and stressor related disorders and is no longer seen as an anxiety disorder. There are now 4 clusters of symptoms (not 3) to which some new symptoms have been added and a) Dissociative subtype has been added which could sometimes be used to classify patients suffering Complex PTSD or Developmental Trauma, both of which were rejected by the board. b) Separate diagnostic criteria for children aged 6 years or younger.

6 The diagnostic criteria in DSM-5 or PTSD: Criteria A Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways: Directly experiencing the traumatic event; Witnessing the traumatic event in person; Learning that it occurred to a close family member or a close friend (the actual or threatened death being either violent or accidental, or a suicide, or a serious accident) Experiencing first hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, TV, or movies unless work related i.e. porn police).

7 Other events qualifying for Criterion A include but are not limited to: Exposure to war as combatant or civilian Threatened or physical assault (i.e. childhood physical abuse, mugging) Child sexual abuse, sexual trafficking. Being taken hostage or kidnapped Terrorist attack Torture Incarceration as a prisoner of war Natural disasters Severe RTAs

8 Criteria B (TE = traumatic event) Presence of 1 or more of the following intrusion symptoms beginning after the TE Recurrent, distressing memories of the TE or repeatedly expressing it in play in children Recurrent nightmares related to the TE but not in children. Dissociative reactions or flashbacks in which the individual feels or acts as if the TE was recurring +/- an awareness of present surroundings. Re-enacted in play in children. Intense prolonged distress at exposure to internal or external cues resembling the TE Marked physiological reactions to internal or external cues that symbolise or resemble the TE

9 Criteria C Persistent avoidance of stimuli associated with the TE & beginning after the TE as evidenced by 1 of the following: Avoidance or attempts to avoid distressing memories, thoughts or feelings associated to the TE. Avoidance or attempts to avoid external reminders (people, places, conversations, objects, activities, situations) that arouse distressing memories, thoughts or feelings about or related to the TE

10 Criteria D 2 or more negative alterations in cognitions & mood associated with TE beginning or worsening after TE: Inability to remember important aspects of the TE due to dissociative amnesia, (not HI, alcohol, drugs). Persistent exaggerated -ve beliefs about oneself, others or the world i.e. No one can be trusted Persistent distorted cognitions about the causes and consequences of the TE leading to self blame. Persistent ve emotional state (fear, anger, shame). Markedly diminished interest in significant activities. Feeling detached or estranged from others. Persistent inability to experience +ve emotions i.e. love, joy

11 Criteria E 2 or more marked alterations in arousal & reactivity associated with the TE, beginning or worsening after the TE: Irritable or angry behaviour Reckless or self destructive behaviour Hypervigilance. Exaggerated startle response Problems with concentration. Sleep disturbances

12 Other 3 criteria in DSM-5 for PTSD F. Duration of disturbance is more than one month. G. The disturbance causes clinically significant distress or impairment in social, occupational or other areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

13 Duration of symptoms for diagnosis of PTSD and Implications The disturbance causes clinically significant distress or impairment in the individual s social interactions, capacity to work or other areas of functioning. The disturbance must continue for more than a month to warrant this diagnosis and there is no distinction between acute and chronic phases of PTSD. PTSD can occur at any age & usually occurs within the first 3 months after the TE but can take years to develop full criteria referred to as Delayed expression Cultural variability is acknowledged and a chapter on cultural formulations give you a questionnaire to use.

14 The hero Billy Pilgrim in Slaughterhouse 5 by Kurt Vonnegut

15 Dissociative subtype of PTSD This is applicable to individuals who meet the criteria for PTSD and experience additional depersonalisation or out of body experience in which individuals observe their own body from above & can create the perception that this is not happening to me. derealisation symptoms in which things don t appear real that can create the perception that this is not happening to me.

16 Research rationale for the dissociative subtype DSM-5 Studies showed about 15-30% of cases suffered from depersonalisation & derealisation and showed: Repeated traumatisation and early adverse experiences prior to onset of PTSD. Increased psychiatric co-morbidity i.e. specific phobia and borderline & avoidant personality disorders among women but not men. Increased functional impairment Increased suicidality i.e. social ideation, plans and attempts

17 Therapeutic rationale for the dissociative subtype of DSM -5 Individuals who exhibited the symptoms of depersonalisation and derealisation tended to respond better to treatments that included cognitive restructuring and skills training in affective and interpersonal regulation in addition to exposure based therapies ( Lanius et al, 2010, 2012) (Cloitre et al. 2012), For such individuals exposure therapy on its own can lead to further dissociation and inhibition of the affective response.

18 Associated features supporting the diagnosis of PTSD Developmental regression in children i.e. loss of language, wetting of bed Paranoid ideation Following prolonged severe and repeated severe traumatic events (i.e. child abuse, torture) the individual may experience difficulties regulating emotions & maintaining stable inter-personal relationships (?BPD) Problematic bereavement with PTSD after a violent death.

19 So why reject the diagnosis of Complex PTSD or Developmental trauma? (Herman, 1992, van der Kolk, 2005) Impaired affect modulation Dissociative symptoms Self destructive/ impulsive behaviour often reenacting the trauma; i.e. Vietnam veteran Social withdrawal and distrust of others Impaired relationships with others Somatic complaints: fibromyalgia, irritable bowel disorder, digestive pbs, allergies, chronic fatigue and pelvic pain and other gynaecological symptoms in CSA survivors

20 Objectives for ICD-11 PTSD Identify core features from knowledge of what symptoms are unique to and predictive of PTSD and dispense with criteria A. Make these core features of the disorder more explicit, so as to (a) simplify diagnosis, (b) reduce qualifying combinations of symptoms, (c) reduce co-morbidity, (d) provide a meaningful contrast with DSM-5 by addressing some of its shortcomings, (e) facilitate scientific research Introduce impairment criterion to address possible over-leniency relative to DSM-IV and DSM-5

21 Complex PTSD in ICD 11 formerly: Enduring personality change after catastrophic experiences Symptom pattern core symptoms of PTSD (re-experiencing in the present, avoidance, hyperarousal) persistent and pervasive impairments in affective functioning: Affect dysregulation, heightened emotional reactivity, violent outbursts, tendency towards dissociative states when under stress self functioning: Persistent beliefs about oneself as diminished, defeated or worthless; pervasive feelings of shame, guilt relational functioning: Difficulties in sustaining relationships or feeling close to others.

22 Problems with the diagnosis The diagnosis remains a collection of symptoms occasionally present without fulfilling criteria A such as a non severe car accident therefore diagnosed with an Adjustment disorder. Some people are more vulnerable to develop PTSD than others i.e. people with psychological problems or whose mother suffered from PTSD (epigenetic factors) And the most important risk factor is the lack of social support (NICE 2005) at the time and after the traumatic experience (examples). How can these aspects be explained?

23 Research links between PTSD and cortisol levels. Yehuda (1997) found that only victims of a RTA whose response led to a lower than normal release of cortisol, developed PTSD. She said that PTSD may reflect a biologic sensitisation disorder rather than a post traumatic stress disorder Wang attributes this sensitisation to changes in the attachment system i.e. suppression of cortisol levels observed by many in insecurely attached children (Wang, 1997) 23

24 The effects of PTSD are transmitted down the generations Low urinary cortisol levels in adult holocaust survivors with PTSD and in their adult offspring (Yehuda, 1997, 2002). Israeli soldiers whose parents were Holocaust survivors had higher rates of PTSD than their counterparts. Children of mothers who suffered from PTSD following 9/11 have lower levels of cortisol via Epigenetic transmission. Low cortisol levels predispose to PTSD 24

25 Epigenetics and PTSD Epigenetic modifications, such as DNA methylation, can occur in response to environmental influences to alter the functional expression of genes in an enduring and potentially, inter-generationally transmissible manner via the mother(yehuda & Bierer, 2009) In the case of PTSD, an environmental exposure alters the function of the gene, which then biases an individual s response to a subsequent traumatic event (Meaney & Szyf, 2005) 25

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27 Transmission of vulnerability to PTSD in the cycle of violence Already Attachment research shows a 75% correspondence between a mother s attachment and that of her infant (Van Ijzendoorn et al. 1997). These findings and the epigenetic studies show there is transmission of the potential for PTSD (and trauma related violence) in PTSD afflicted families and communities. This underlies the importance of preventive therapeutic interventions in traumatised families and communities. 27

28 What else does Attachment Research contribute to our understanding of PTSD Our need for Social Support when in a state of fear and need brings us back to the important link between PTSD and our attachment response. Attachment research provides the Psycho-biological framework to understand both the origin and the symptoms of PTSD and in particular complex PTSD and Developmental trauma disorder or its Dissociative subtype in DSM-5. Therefore an understanding of attachment disorders is important in order to understand and treat patients suffering from these conditions. 28

29 Separation and reunion Infants separated from their caregiver protest, despair and detach (Bowlby, 1988) and resulting damage occurs dependent on the age of the infant and the duration of the separation as shown by Harlow s monkeys. Children and adults are genetically predisposed to want access to an attachment figure when frightened! When reunited with those we love, we usually have warm feelings through the experience of attunement largely produced by endogenous opiates: We are all Opiate addicts (Panksepp, 1985). 29

30 PTSD as an attachment disorder involving the right hemisphere PET Scans of PTSD> Shut down of Broca s speech area and Right hemisphere involvement (Rauch et al. 1996) Can be a cause of Selective mutism in children or in adults losing their speech when talking about their traumas. Examples; Anna O etc

31 Primary intersubjectivity