Lecture 2: Trauma and PTSD II Flashcards
cognitive model of Ehlers and Clark
- 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
kijken naar model in schrift: wat zijn de onderdelen
- 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
welk gevoel speelt de hoofdrol bij trauma
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
what 2 factors explain the sense of current threat
- 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
in which ways can we categorize the negative trauma-related cognitions
- 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)
negative appraisals are a self-maintaining cycle, and predict the development of ptsd
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negative trauma-related cognitions and the subsequent feelings
- danger - fear
- violation of rules/norms/values - anger
- responsibility - guilt
- violation internal norms - shame
the memory of the trauma is usually …. in ptsd patients. in addition, ptsd patients feel a lot of …
data driven (compared to more conceptual processing)
mental defeat
nature of trauma memory characteristics
- sensory/visual
- here and now quality
- difficult to correct
- affect without recollection
- easily triggered
difficult to correct voorbeeld
iemand die een familielid is kwijtgeraakt, maar nog steeds verwacht dat ze thuiskomen voor het eten
affect without recollection
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
how trauma-related info can get encoded/stored into memory
- 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
welke twee factoren zijn het meest belangrijk in het ontstaan van current threat
- nature of trauma memory
- negative appraisal of trauma/sequelae
(+ strategies intended to control threat/symptoms)
dysfunctional strategies voorbeelden
- 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
dus welke onderdelen kun je targeten met therapie
- nature of trauma memory
- negative appraisal of trauma/sequelae
- strategies intended to control threat/symptoms
twee redenen voor latere onset ptsd
- later event gives original event new/more threatening meaning
- trauma reminders only become available after some time
anniversary reactions
- increased external and internal reminders
- negative appraisals about the progression (i should already be over this)
frozen in time
- negative appraisals
- disconnect from reality through continuous reexperiencing
- abandoning/avoiding activities
sense of impending doom (anticipatory anxiety)
due to nature of trauma memory
talking or thinking about trauma does not help
- ruminating
- emotional avoidance
3 soorten interventies voor ptsd
- secondary prevention (debriefing)
- pharmacological
- psychological
debriefing
- 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
possible explanations for this effect
- Disturbs natural processing/oscillation of reexperiencing vs. avoidance
- Discourages using social support
- Sensitization instead of habituation/no corrective information
should we quit debriefing?
- Be clear about aims
- Research of predictors
- Guideline is nu dat we het niet moeten uitvoeren
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.
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pharmacological treatment
kan werken maar niet verwerken, symptom reduction may lead to more or less avoidance. also side effects and relapse.
wat zegt de guideline over pharmacotherapy
Finally, it can be decided to start pharmacotherapy in addition to psychological treatment (preferred) or as a mono therapy.
4 treatments that are recommended by the Nice guideline
- cognitive processing therapy
- cognitive therapy for ptsd
- narrative exposure therapy
- prolonged exposure therapy
wanneer EMDR
tussen 1-3 maanden na een non-combat related trauma als de persoon hier een voorkeur voor heeft, en na 3 maanden sowieso aanbieden.
dutch guidelines
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
prolonged exposure
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
prolonged exposure: learning theory
- 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
prolonged exposure cognitive theory
- Changes in explicit/verbal cognitions about trauma (and about exposure)
- Changes in memory representation (elaboration, integration in autobiographic memory)
trauma focused CBT=
Prolonged exposure (imaginal & in vivo) + cognitive restructuring (identifying and modifying irrational dysfunctional cognitions)
writing therapy=
Imaginal exposure, cognitive restructuring, coping, social sharing/support
- describe the event in details
- write advice to friend who experienced what you did
- write a letter to a trusted person, sharing your feelings.
efficacy writing therapy
lijkt beter te werken dan WLC en even goed als CBT
working memory theory of EMDR
Long term memory (stable) -> Working memory (labile, limited capacity) -> Competing task (reduces vividness and emotionality traumatic memory) -> Modified memory reconsolidation into long term memory
cPTSD does not require complex treatment, the same as ptsd suffices
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