Treatments for PTSD: A brief overview Dr Jasmine Pang DPsych(Clin) Snr Clinical Psychologist Psychotraumatology Service Department of Psychological Medicine Changi General Hospital, Singapore
Outline Brief overview of trauma What is trauma? Trauma Reactions Understanding trauma memory Treating trauma Therapeutic Approaches CBT and EMDR in a nutshell A Model of Trauma Treatment 2
What is a traumatic event? Life threatening? Causes intense fear? Horror? Helplessness? Witnessed? Experienced? Sudden, unplanned? Disruptive? Undermines basic beliefs My world is safe I wouldn t be hurt Bad things don t happen to good people 3
Trauma Traumatic events overwhelm the usual methods of coping that give people a sense of control, connection and meaning. Judith Herman (1992) Trauma and Recovery 4
Post Traumatic Symptoms 5 Intrusive recollection Recurrent, intrusive distressing recollections of the event Nightmares Flashbacks Intense psychological distress and/or physiological reactivity in response to cues Avoidance/numbing Cognitive and/or behavioural avoidance Inability to recall important aspects of trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of forshortened future Hyper arousal Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hyper vigilance Exaggerated startle response Functional Impairment
Trauma & Memory
7 Memory
Memory Normal Memories Formed of words and stories Fluid and updatable Linked to other memories Placed in historical context There and then Coherent Recalled on purpose Traumatic Memories Formed of vivid sensory information Static and frozen Isolated and stand alone Here and now Disorganized, fragmented, incoherent Triggered automatically 8
Memory Normal Event Memory Traumatic Event 9
Maintenance Cycle of Avoidance Memory not processed Memory or thought suppressed or avoided Intrusions e.g. memories, images, dreams, thoughts Original fear, horror, helplessness 10 David Trickey
Memory Normal Event Memory Traumatic Event 11
Treating Trauma
Evidence Based Guidelines Crochrane Review International Society for Traumatic Stress Studies (ISTSS) Practice Guidelines NICE Practice Guidelines NHMRC Guidelines Australian Centre for Posttraumatic Stress Practice Guidelines 13
Psychological Treatment of PTSD 14 Empirically validated therapies for trauma 1 : Cognitive Behavioral Therapy (CBT) Exposure Therapy Cognitive Processing Therapy Cognitive Therapy Stress Inoculation Training (Female sexual assault survivors) TF-CBT (Children and Adolescents) Eye Movement Desensitization Reprocessing (EMDR) Hypnosis (in combination with other 1. ISTSS Practice Guidelines techniques)
Psychological Treatment of PTSD Other promising approaches Creative Arts Therapies Art Therapy Music Therapy Dance/movement Therapy Bibliotherapy Family & Marital therapy Narrative Therapy Psychosocial Rehabilitation (in combination) 15 Brief Psychodynamic Therapy (for acute focal problems) Etc
CBT View of Trauma PTSD = Anxiety disorder Cognitive, behavioural and physiological features Based on Behavioural and Cognitive Theories Fear is learned (Conditioning) Benign stimuli labelled incorrectly as dangerous Avoidance failure to learn corrective information Exposure Negative emotional reactions Guilt, anger and shame Assumptions and beliefs challenged Fail to organise traumatic experience successfully (make sense of it) 16 Cognitive Restructuring
EMDR View of Trauma PTSD = Incomplete information processing Networks containing related thoughts, images, emotions, and sensations Stored in an accessible and useful form Learning new associations are forged with material already stored in memory 17
EMDR View of Trauma Traumatic experience Memory stored dysfunctionally No appropriate associative connections With many elements still unprocessed Information processing is thought to occur when the targeted memory is linked with other more adaptive information Learning the experience is stored with appropriate emotions Used to appropriately guide the person in the future 18
A Model of Trauma Treatment A Phased Approach
A Model of Trauma Treatment Phase model of treatment of trauma Safety/Stabilization Trauma Processing (Re)integration/Meaning-making ~ Judith Herman 20
Safety / Stabilization Phase The general who wins the battle makes many calculations in his temple before the battle is fought. The general who loses makes but few calculations beforehand. ~ Sun Tzu
Safety/Stabilization Phase Reduce/manage dangerous behaviours /relationships, self harm, substance abuse Safety in therapeutic relationship Psychoeducation & skill building (e.g. breathing control, relaxation skills, positive self-statements) Enhance affect regulation & internal safety Symptom management (e.g. grounding, managing flashbacks, containment) 22
Trauma Processing Phase "The only thing we have to fear is fear it'self ~ FD Rosevelt Courage is not the lack of fear but the ability to face it." ~ Lt. John B. Putnam Jr.
Trauma Processing Phase Paced approach to addressing traumatic memories Integration of trauma into normal memory 24
(Re)integration / Meaning making phase Making light of the dark - Coral Anika Theill He who knows the why of his existence can bear almost any how - Nietzsche
(Re)integration / Meaning making phase Personality (re)integration & rehabilitation Reconnection, reconsolidation, restructuring Support patient in living a functional life Increase awareness of current safety Spiritual issues Enhance capacity for physical, sexual, emotional, interpersonal autonomy & intimacy Reclaiming their life! 26
7 Criteria for the resolution of trauma Mary Harvey 27 The physiological symptoms of PTSD have been brought within manageable limits The person is able to bear the feelings associated with traumatic memories The person has authority over the memories; can choose both to remember the trauma or to put the memory aside The memory of the traumatic event is a coherent narrative, linked with feeling The person s damaged self esteem has been restored The person s relationships have been reestablished The person has reconstructed a coherent system of meaning and belief that encompasses the story of the trauma
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