Lecture 2: Trauma and PTSD II

Question 1

cognitive model of Ehlers and Clark

Answer 1

• most recent big PTSD model
• synthesis of earlier models
• clear implications for treatment
• model of chronic (persistent) PTSD -> gaat niet alleen over de eerste dagen na een trauma, maar over wanneer natural recovery niet plaatsvindt en mensen hier echt veel langer last van hebben

Question 2

kijken naar model in schrift: wat zijn de onderdelen

Answer 2

• characteristics of trauma/sequelae/prior experiences/beliefs/coping
• cognitive processing during trauma
• nature of trauma memory
• negative appraisal of trauma and or its sequelae
• matching triggers
• current threat: intrusions, arousal symptoms, strong emotions
• strategies intended to control threat/symptoms

Question 3

welk gevoel speelt de hoofdrol bij trauma

Answer 3

trauma is fear, and fear is something that usually happens in the near future, not in the past. trauma is in the past. this is because ptsd patients have the sense of current threat, of which the intrusions, strong emotions and these arousal symptoms are a direct consequence

Question 4

what 2 factors explain the sense of current threat

Answer 4

• negative trauma-related thoughts and cognitions, appraisals, of the trauma and sequelae
• the way the traumatic event is encoded and stored in the memory of patients

Question 5

in which ways can we categorize the negative trauma-related cognitions

Answer 5

• trauma (fact that it happened, behaviour and emotions during trauma) vs consequence (irritability, anger outbursts, other peoples responses)
• external (nowhere is safe) vs internal (i deserve that bad things happen to me)

Question 6

negative appraisals are a self-maintaining cycle, and predict the development of ptsd

Answer 6

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Question 7

negative trauma-related cognitions and the subsequent feelings

Answer 7

• danger - fear
• violation of rules/norms/values - anger
• responsibility - guilt
• violation internal norms - shame

Question 8

the memory of the trauma is usually …. in ptsd patients. in addition, ptsd patients feel a lot of …

Answer 8

data driven (compared to more conceptual processing)
mental defeat

Question 9

nature of trauma memory characteristics

Answer 9

• sensory/visual
• here and now quality
• difficult to correct
• affect without recollection
• easily triggered

Question 10

difficult to correct voorbeeld

Answer 10

iemand die een familielid is kwijtgeraakt, maar nog steeds verwacht dat ze thuiskomen voor het eten

Question 11

affect without recollection

Answer 11

being aroused, fearful or on edge without knowing why

-> during a traumatic event there are a lot of stimuli, therefore many of these will be associated with the trauma. therefore many stimuli could cause these negative emotions, without people realising this is the cause

Question 12

how trauma-related info can get encoded/stored into memory

Answer 12

• incomplete/imperfect integration with autobiographical memory (isolated, easy to be triggered because you have never experienced this)
• strong stimuli-stimuli and stimuli-response associations (good for survival -> protects you from future danger)
• strong sensory priming for stimuli

Question 13

welke twee factoren zijn het meest belangrijk in het ontstaan van current threat

Answer 13

• nature of trauma memory
• negative appraisal of trauma/sequelae

(+ strategies intended to control threat/symptoms)

Question 14

dysfunctional strategies voorbeelden

Answer 14

• try hard not to think about the trauma, keep mind occupied, control feelings, drugs
• numb emotions, avoid anything that could cause feelings
• ruminate about how event could have been prevented
• ruminate on how to get even with assailant

Question 15

dus welke onderdelen kun je targeten met therapie

Answer 15

• nature of trauma memory
• negative appraisal of trauma/sequelae
• strategies intended to control threat/symptoms

Question 16

twee redenen voor latere onset ptsd

Answer 16

1. later event gives original event new/more threatening meaning
2. trauma reminders only become available after some time

Question 17

anniversary reactions

Answer 17

1. increased external and internal reminders
2. negative appraisals about the progression (i should already be over this)

Question 18

frozen in time

Answer 18

1. negative appraisals
2. disconnect from reality through continuous reexperiencing
3. abandoning/avoiding activities

Question 19

sense of impending doom (anticipatory anxiety)

Answer 19

due to nature of trauma memory

Question 20

talking or thinking about trauma does not help

Answer 20

1. ruminating
2. emotional avoidance

Question 21

3 soorten interventies voor ptsd

Answer 21

1. secondary prevention (debriefing)
2. pharmacological
3. psychological

Question 22

debriefing

Answer 22

• Refers to early intervention
• Trauma is a clear risk factor
• Wanting to help is normal/human
• 7 phases: introduction, facts, thoughts, feelings, symptoms, education, closure
• Possible aims: prevention, support, education
• But not more effective, even worsens the symptoms

Question 23

possible explanations for this effect

Answer 23

• Disturbs natural processing/oscillation of reexperiencing vs. avoidance
• Discourages using social support
• Sensitization instead of habituation/no corrective information

Question 24

should we quit debriefing?

Answer 24

• Be clear about aims
• Research of predictors
• Guideline is nu dat we het niet moeten uitvoeren

Question 25

Studies of selective prevention show inconsistent findings; single session interventions that are strongly focused on emotions, like debriefing, are ineffective and sometimes even harmful. Do not use psychological interventions (such as debriefing) to prevent psychotrauma- and stressorrelated disorders in people exposed to shocking events.

Answer 25

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Question 26

pharmacological treatment

Answer 26

kan werken maar niet verwerken, symptom reduction may lead to more or less avoidance. also side effects and relapse.

Question 27

wat zegt de guideline over pharmacotherapy

Answer 27

Finally, it can be decided to start pharmacotherapy in addition to psychological treatment (preferred) or as a mono therapy.

Question 28

4 treatments that are recommended by the Nice guideline

Answer 28

• cognitive processing therapy
• cognitive therapy for ptsd
• narrative exposure therapy
• prolonged exposure therapy

Question 29

wanneer EMDR

Answer 29

tussen 1-3 maanden na een non-combat related trauma als de persoon hier een voorkeur voor heeft, en na 3 maanden sowieso aanbieden.

Question 30

dutch guidelines

Answer 30

first choice:
- imaginal/prolonged exposure
- cognitive therapy/cognitive processing therapy
- emdr
- trauma focused cognitive behaviour therapy

second:
- brief eclectic psychotherapy for ptsd
- narrative exposure therapy
- writing therapy
- imaginal rescripting

Question 31

prolonged exposure

Answer 31

Exposure in vivo/imaginal exposure:
* Patiënt exposes oneself to traumatic memories through internal (imaginal) or external (in vivo) cues, until they no longer evoke problematic fear
* Imaginal exposure: first person present tense, ‘as if it is happening again’
* Therapist guided in session, audiotapes (imaginal) or homework (in vivo) between sessions

Question 32

prolonged exposure: learning theory

Answer 32

• Neutral stimuli become associated with anxiety response (classical conditioning)
• Avoidance of these stimuli becomes reinforced by reduced fear (operant conditioning)
• Avoidance hinders extinction, fear and avoidance remain
• Exposure promotes extinction, fear and avoidance reduce

Question 33

prolonged exposure cognitive theory

Answer 33

• Changes in explicit/verbal cognitions about trauma (and about exposure)
• Changes in memory representation (elaboration, integration in autobiographic memory)

Question 34

trauma focused CBT=

Answer 34

Prolonged exposure (imaginal & in vivo) + cognitive restructuring (identifying and modifying irrational dysfunctional cognitions)

Question 35

writing therapy=

Answer 35

Imaginal exposure, cognitive restructuring, coping, social sharing/support

1. describe the event in details
2. write advice to friend who experienced what you did
3. write a letter to a trusted person, sharing your feelings.

Question 36

efficacy writing therapy

Answer 36

lijkt beter te werken dan WLC en even goed als CBT

Question 37

working memory theory of EMDR

Answer 37

Long term memory (stable) -> Working memory (labile, limited capacity) -> Competing task (reduces vividness and emotionality traumatic memory) -> Modified memory reconsolidation into long term memory

Question 38

cPTSD does not require complex treatment, the same as ptsd suffices

Answer 38

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