Cognitive Behavioural Therapy for PTSD. Dr Renuka Arjundas (Consultant Psychiatrist in CBT)

Transcription

1 Cognitive Behavioural Therapy for PTSD Dr Renuka Arjundas (Consultant Psychiatrist in CBT)

2 The puzzle of PTSD Cognitive Theories of PTSD PTSD is classified as an anxiety disorder BUT IS IT? Anxiety - Appraisals relating to impending threat PTSD - The problem is with a memory about an event that has happened

3 How do we solve the puzzle? Persistent PTSD occurs if individuals process the traumatic event and or its sequelae in a way that produces a sense of serious current threat Flashbacks/nightmares due to inadequate information and emotional processing (Ehlers & Clark 2000)

4 Cognitive Theories of PTSD Event Disbelief, shock Bewilderment Avoidance, intrusion, emotion Reintegration In PTSD this does not happen

5 Why do some people develop PTSD Inadequate emotional processing Depends on 3 factors (Foa, 1998) The person s pre-trauma beliefs about self/ world and records of specific events Memory records of the traumatic event Memory records of post trauma experiences

6 Model of Emotional Processing of Trauma (Foa, 1998) Pre-Trauma Records Traumatic Event SCHEMAS Post-Trauma Events Trauma Records Self Schema World Schema Post-Trauma Records RECOVERY PATHOLOGY

7 Assessment Symptoms of PTSD (Flashbacks, nightmares, sleep disturbance etc) What is the event? Outline of it Is there more than one? Pre-morbid presentation personality, quality of life, coping strategies. Co-Morbidity Depression, Substance misuse Current coping skills Family Relationships/Support Networks

8 Assessment (continued) Medication Previous Treatment Risk Assessment Sexual Problems Basic Psycho-education Scales Impact of Event Scale Trauma interview (Foa,1998)

9 Suitability Resources Do I have the skills to do the work? Does it need referral to a specialist? Stability Vs Trauma Focused Work - Is it the right time?

10 2 Scenarios Suitability Exercise Scenario 1 40 yr old male with multiple traumas developed PTSD Worked offshore for long periods hence could not attend appointments regularly Alcohol abuse Marital problems

11 Suitability Exercise (continued) Scenario 2 28 yr old female; Road Traffic Accident PTSD Avoidance of driving In supportive relationship

12 Factors that could be De-stabilising Co-Morbid Conditions Alcohol/Drugs Can impede information processing/uptake of information Moderate/Severe Depression Ongoing trauma/threat Current stressors - environmental, financial Self harm, suicide History of dissociation Abusive relationships

13 Initial Steps Treat Co-morbid conditions Improve environmental factors Reduce stressors Reduce risk factors via risk management techniques Psycho-education Sleep Hygiene Mindfulness or affect regulation techniques (relaxation) Self soothing exercises

14 Trauma Focused Work (Processing) Foa et al 1981 (Exposure Model) Initially devised for rape victims Manualised 8 sessions of prolonged exposure

15 Foa et al (1981) Use of exposure via imaginal flooding Activation of fear memories (measurement of SUDS) Integration of new information gathered via discussion with patient (this may not have been considered previously) This information challenges fear structure and new memories are formed (Measurement of SUDS)

16 In Vivo Exposure Construct hierarchy of avoided situations Collaboratively develop homework assignments based on hierarchy Client begins with situations that have moderate anxiety levels Record SUDS

17 Imagery Rescripting Exposure (Imaginal) Developing Mastery Imagery Reprocessing

18 Which Interventions are Helpful (Sally Standart, 2000) Exposure Interventions Fear is the predominant symptom Avoidance is the most significant coping strategy Exposure with Cognitive/Imagery Interventions When other non fear reactions are prominent (e.g. anger, shame, guilt) When exposure alone does not reduce symptoms

19 Case Example : Type 1Trauma 35 yr old male involved in accident at work Crushed by a machine Not supported by Seniors at work Flashbacks/nightmares Fear predominant emotion Avoidance of reminders of accident

20 Case Example: Type 1 Trauma (continued) Preparation/psycho education In vivo exposure (situations on hierarchy basis) Imaginal exposure with cognitive restructuring

21 Case Example : Type 2 Trauma Patient History 22 yr old lady Diagnosis of PTSD in relation to Childhood Sexual and Emotional Abuse Sexually abused by two different perpetrators at different points in childhood Perpetrator One Uncle (18yrs) when patient was 8yrs Perpetrator Two Neighbour (16yrs) when patient was 10yrs

22 Case Example : Type 2 Trauma Other information (continued) Claire experiencing flashbacks, nightmares on a regular basis Emotions Anger, guilt, shame, low mood, fear and anxiety Suicidal Ideation intermittently Crisis Team involved Beliefs I am weak, I am worthless

23 Imagery Rescripting Imagery focused treatment designed to alleviate: PTSD symptoms Abuse related beliefs and schemas (powerlessness, badness, unlovable)

24 Imagery Rescripting Procedure combines Imaginal Exposure Visually recalling and re-experiencing the images, thoughts and affect of the event Imaginal Rescripting Changing the abuse imagery to produce a more favourable outcome

25 Imagery Rescripting The aims being to Replace victimisation imagery with mastery image Enabling the victim to experience themselves responding to the abuse as an empowered individual (psychodrama)

26 Imagery Rescripting Outcome The recurrent victimisation imagery is modified Abuse-related cognitions are identified, explored and challenged Use of imagery allows the core beliefs/ schemas to be addressed directly through the eyes of a traumatised child

27 Treatment Programme Eight Sessions minutes each Patients appropriate if they meet criteria for PTSD and experiencing flashbacks, images or nightmares Patients fully informed prior of affective distress that may occur temporarily

28 Example of Exposure Session (Session Taped) Sexual abuse by uncle Child s perspective Imaginal Exposure (scene of abuse - detail) Establish Beliefs Rate and re-rate level of distress (SUDS) regularly during session Adult Perspective

29 Example of Exposure Session Meeting the needs (rescue and nurture) of the abused child Challenging the abuser about their behaviour Establishing if (child) beliefs are correct, or if there is any contradictory evidence Re-rate level of belief Managing emotional changes in session Homework Listening to tapes everyday or as much as possible during week

30 Summary Treatment Outcome This process was repeated for each of the exposure sessions Claire noted a significant reduction in SUDS as the exposure work progressed The reliving process was not as terrifying Initially driving away the abuser was very difficult but as the exposure work progressed Claire found this easier LEADING TO Reduced frequency of flashbacks Reduced frequency of nightmares Greater control over flashbacks when they do occur Greater control over intrusive memories

31 Why/How Did This Happen? Client/Therapist perspectives Revisiting childhood experiences in a safe, controlled way Exploration and differentiation of child and adult perspectives Significant shift in perception about responsibility Significant shift in emotions both in terms of different emotions emerging and level of distress associated with emotions Challenging patients long held viewpoint on abuse using CBT techniques Changes in general themes of thinking, core beliefs and dysfunctional assumptions

32 Example of Challenging a Core Belief Evidence For I was abused by these men I let it happen It was my fault I enjoyed the attention Evidence Against I was only a child I fought these men off How could an 8yr old know it was wrong? I didn t enjoy what they did I just wanted to be loved They betrayed my trust Other people are more responsible for what happened than me

33 Why Does Treatment Not Work? Smucker Inadequate assessment Inadequate preparation/psycho education Mismatch between interventions and trauma characteristics Clinician s skill levels Client s non compliance

34 Further Reading Ehlers, A & Clark, D.M. A Cognitive Model of PTSD (2000) Behaviour Research & Therapy Foa, E.B & Rothbaum, B.O (1998) Treating the Trauma of Rape Cognitive Behavioural Therapy for PTSD Herbert, C & Grand, D (2003) Understanding your reactions to trauma: a guide for survivors of trauma and their families Oxon: Blue Stallion Publications Williams, M, & Poijula, S (2002) The PTSD Work book: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms