A Cognitive Approach to the Understanding and Treatment of Posttraumatic Stress Disorder POSTTRAUMATIC STRESS DISORDER (PTSD) Reexperiencing Avoidance Anke Ehlers Institute of Psychiatry, London, UK DGVT, Frankfurt, 1 st October, 2 Numbing/ Amnesia Hyperarousal Proportion of people not recovered by months post trauma (Kessler et al., Archives of General Psychiatry, 199) Starting points for developing cognitive model of PTSD 1.9.8.7.6..4.3.2.1 6 12 18 24 3 36 42 48 4 6 Why do some people not recover? (onset versus maintenance of symptoms) Why anxiety symptoms? General Cognitive Model of Anxiety Applied to PTSD Negative Appraisal of Trauma and/or its Sequelae Added meanings Fact that trauma happened Current Threat Arousal Symptoms Strong Emotions Own behavior/ emotions/ sensations during event Initial symptoms Reaction of others Strategies Intended to Control Threat/Symptoms 1
Negative Interpretations of Initial PTSD Symptoms Prospective Studies RTA adults (Ehlers, Mayou & Bryant, 1998).4*** RTA children (Ehlers, Mayou & Bryant, 22).3** Assault 1 (Dunmore, Clark & Ehlers, 21).42*** Assault 2 (Halligan, Michael, Clark & Ehlers, 22).62*** RTA adults (Ehring, Ehlers & Glucksman, 2).*** Negative Interpretations of Symptoms Predict PTSD severity over and above Objective stressor severity Subjective stressor severity Initial PTSD symptoms Other known predictors of PTSD Maintaining Behaviours/ Cognitive Strategies: Correlations with Subsequent PTSD severity Safety Behaviours Assault (Dunmore, Clark & Ehlers, 21).4*** RTA (Ehring, Ehlers & Glucksman, 2).6*** Rumination RTA outpatients (Ehlers, Mayou & Bryant, 1998).48*** RTA inpatients (Murray, Ehlers & Mayou, 22).69*** RTA outpatients (Murray et al., 22).3*** RTA children (Ehlers, Mayou & Bryant, 22).*** Maintaining Behaviours/ Cognitive Strategies cont. Thought Suppression RTA adults (Ehlers, Mayou & Bryant, 1998).3*** RTA children (Ehlers, Mayou & Bryant, 22).3** Persistent Dissociation RTA inpatients (Murray, Ehlers & Mayou, 22).64*** RTA outpatients (Murray et al., 22).*** RTA children (Ehlers, Mayou & Bryant, 22).42*** Assault (Halligan, Michael, Clark & Ehlers, 22).3*** Persistent PTSD (Ehlers & Clark, Behaviour Research and Therapy, 2) Nature of Trauma Memory Matching Triggers Negative Appraisal of Trauma and/or its Sequelae Ordinary Autobiographical Memories Awareness of remembering Emotions less strong Reexperiencing Limited awareness of remembering, Nowness Original emotions (physiology, behavior) Current Threat Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms Details have context Rarely spontaneous If spontaneous, close/ specific match of triggers Details without context, not updated Easily triggered involuntarily Wide range of triggers, sensory similarity, partial match 2
Recall of Trauma in PTSD Parts of memory disjointed/ lack of updating Confusion about order of events Important details may be missing Memory processes leading to reexperiencing: Ehlers & Clark (2) model 1. Autobiographical memory for trauma is not sufficiently elaborated (insuffient links between different parts of memory, and poorly integrated with other information) -> Poor inhibition of unintentional memories and retrieval without context 2. Two basic learning mechanims lead to easy triggering of memories (including those without awareness of remembering) by matching stimuli: Strong perceptual priming and strong associative learning Picture 1 Traumatic Neutral Peripheral Stimuli Glass, Light Teapot, Yellow pages Picture 2 Central Stimuli Picture 3 Cord Woman strangled Telephone Woman looks happy % Enhanced Priming 2 2 1 PRIMING FOR PERIPHERAL OBJECTS AND INTRUSIONS DURING FOLLOW-UP (Ehlers et al., Memory, in press) None Prediction of PTSD Symptoms after Accidents Ehring, Ehlers & Glucksman, submitted PREDICTORS ESTABLISHED IN PREVIOUS RESEARCH PREDICTORS DERIVED FROM COGNITIVE MODEL Trauma memory elaborate Treatment Goals Ehlers & Clark (2) Triggers discriminate Appraisals of trauma and/or sequelae identify and modify Current threat intrusions arousal Strong emotions reduce 7 Known Predictors Unexplained Unexplained 7 Cognitive Factors Dysfunctional behaviours/ cognitive strategies give up 3
Cognitive Therapy for PTSD (Ehlers & Clark, 2) Close interweave between work on appraisals and trauma memory work Imaginal reliving/ narrative writing: 3./12 sessions, no habituation rationale CT: Strong emphasis on testing predictions (Behavioral experiments) Therapeutic Techniques Derived from Ehlers & Clark (2) Memory Model (1) Updating Trauma Memories Identify worst moments and its meanings Reconstruct sequence of events Identify information that updates impressions/ predictions during worst moments, either from trauma account or insights from cognitive therapy Incorporate updating information into memory (narrative, reliving, imagery) Therapeutic Techniques Derived from Ehlers & Clark (2) Memory Model (2) Stimulus discrimination Identify triggers of intrusive memories Then vs. now discrimination (observe differences, observe context) Bring on intrusive memory and practice discrimination PDS 3 3 2 2 1 Baseline CHRONIC PTSD RCT Ehlers et al., BRAT, 2 3 months 6 months 9 months 12 months CBT WAIT PDS 3 3 2 2 1 EARLY INTERVENTION STUDY Ehlers, Clark et al., Arch. Gen. Psychiatry, 23 Initial Allocation 3 w eeks 3 months 6 months 9 months Wait Self-Help CT Can the results of RCTs be achieved in more routine NHS settings? Omagh Bomb Example (Gillespie et al, 22) No local expertise in PTSD treatment Ehlers/Clark team provides specialist training Psychiatrist, social worker, nurses All patients accepted. No exclusions. Outcome audited (9 cases) Equivalent improvement to RCTs 4
CT for PTSD: Effect sizes for change before versus after treatment d 3 2. 2 1. 1. CBT SSRIs Pilot Van Etten & Taylor, 1998, Meta-analysis Chronic Early Omagh Intensive CT for PTSD studies