PTSD Flashcards
What is the NICE definition of PTSD?
It can develop after a single traumatic event, like a serious accident. Can also be caused by repeated or prolonger experiences (abuse, living in war)
Can happen to anyone, any age
What does PTSD involve?
Reliving the event through vivid memories or nightmares, feeling angry or on edge, having negative thoughts and feelings, problems thinking clearly and difficulty sleeping
Symptoms in the first few weeks after a trauma and most have symptoms do not go on to develop PTSD - but for some, PTSD becomes an on going problem that makes everyday life every hard
Symptoms usually occur quite soon after the event, but for some it can start later on
What is the history of PTSD?
Psychological distress in response to traumatic events was recognise by the ancient greeks
More recently traumatic stress disorders were recognised in the first world war as shell-shock - but people were dismissed and not given the help they needed
What is the DSM-5 criteria for PTSD?
Criteria A - exposure to the trauma (event causing actual or threatening death, injury) from experiencing trauma themselves, witnessing it, threatened death of family/friend, extreme exposure to aversive details of events (police)
Criteria B - intrusion symptoms (recurrent memories/dreams, flashbacks, re/living which causes distress)
Criteria C - avoidance symptoms (memories, thoughts feelings, reminders of trauma so avoiding objects)
Criteria D - negative alterations in cognition and mood (poor memory, self concept, detachment, loss of pos emotions)
Criteria E - alterations in arousal and reactivity (hypervigiliance, poor concentration, irritability, sleep disturbances, startle response)
Criteria F - duration: persistence of symptoms for more than one month
Criteria G - functional significance (symptom related distress or impairment, work etc)
Criteria H - attribution (not due to medication, substances etc)
What is hypervigilance?
Scanning for threats all the time
Turned on flight or fight response - ready to detect threat
What are symptoms of PTSD?
Intrusive thoughts/ memories
Sleep problems (nightmares and/ or insomnia)
‘Body memories’ (physiological arousal/pain)
Dissociative episodes (flashbacks: reliving not just recalling)
Numb and detached
Hypervigilant (e.g. exaggerated startle response; checking behaviours; scanning environment)
Mood changes: depressed, irritable, short-tempered
Behavioural problems such as delinquency & offending behaviours (part. young people)
Cognitive changes: guilt & shame & self-blame
Presenting problem could be something else (e.g. depression; anxiety; phobia, offending)
Suicidality (risk of self-harm & suicide)
What are flashbacks?
Vivid experience in which you relive some aspects of a traumatic event or feel as though it is happening right now - sometimes like watching a video of what happened, but flashbacks don’t always involve seeing images
What would you experience in a flashback?
Seeing full or partial images of what happened
Noticing sounds, smells or tastes connected to the trauma
Feeling physical sensations, such as pain or pressure
Experiencing emotions that you felt during the trauma (emotional flashbacks)
There can be intrusive images without a flashback!
What is complex PTSD?
Occurs when exposure to trauma has been prolonged (violence, neglect, abuse)
People with complex PTSD find it hard to manage emotions and may be more likely to dissociate when under stress - they find relationships hard and feel guilt
Similar to BDP
How many people experience a traumatic event?
Many people - 70.4% - will experience at least one traumatic event in their life - the majority will recover natural, only a small percentage will develop PTSD
How many people develop PTSD?
Only about 10% of people actually develop the case
A study of 9282 adults showed lifetime prevalence of PTSD ranges from 6.1 - 9.2% in the US and Canada
Study of 1968 adults in London put trauma rate of 78.2%. Prevalence of PTSD was 5.5%
Who is there an increased risk of developing PTSD for?
Females Lower SES Pre-existing MH problems Ethnic minorities Inadequate social support Severity of exposure Trauma is interpersonal (rape, torture, terroism) rather than natural or technological (something which involves technology: train crash, plain crash)
What is the cognitive model of PTSD?
Ehlers and Clark
Believes there is a puzzle: anxiety is about future threat. PTSD is to do with memory, but PTSD is classed as an anxiety disorder?
The solution:
individuals are remembering the trauma in a way that poses current threat,, in the hear and now (PTSD brings them into the hear and now)
What is the role of the amygdala and PTSD?
The amygdala is part of a threat system - there to alert us to danger and keep us safe from it - usually inhibits responses but sometimes doesn’t work
When there is a threat, the amygdala triggers the adrenaline response getting our body ready to fight or flight
But the amygdala cannot discriminate very well between real and perceived danger - it triggers the same response even when the danger is perceived - so over actively search for danger
What is the role of the hippocampus in PTSD?
It helps store and remember information - processes memories and then stores them
With non traumatic memories, it puts a timestamp on the memory, before filing it away so that it is stored in an organisation way
During a traumatic event, when the amygdala is very active, the hippocampus doesn’t work very well and it unable to put a time stamp on the memory - this is why traumatic memories are often reexperienced rather than remembered. there is no time stamp so the brain feels as though the trauma is happening again in the here and now
What happens to the brain during PTSD?
The amygdala cannot discriminate between Real and perceived danger, so it triggers a response. Because the amygdala is very active during a traumatic event, the hippocampus doesn’t work very well and it unable to put a timestamp on the memory - causing them to be reexperienced
Cortisol shuts down the hippocampus - so experience can be processed or stored
What are the key features of trauma memories?
They come to mind uninvited - not wanted or expected
When memories come to mind, they are vivid and can be accompanied by smell and other sensory qualities and can feel very distressing
Because they are very vivid, it can feel like the traumatic event is happening again
A key approach of trauma focused CBT is to work with the memory of the trauma
Why do you have to provide a rational when working with trauma memories?
Have to provide a clear rationale for why you are doing the work you are doing - people are fearful so need to ensure they understand
If you say you are spending the whole session talking about the trauma, people will panic and avoid future sessions
What is the wardrobe analogy?
Imagine a well-organised wardrobe – everything is put away carefully with other items, there is a place for everything, and everything stays put. Our memories for events are similar – each memory is stored alongside other memories. When we recall it, we bring it to mind, and when we’ve finished, we can put the memory back
If someone throws a duvet at you full of stinging nettles and asks you to put it away, it would hurt to touch and you might shove it away quickly and try and close the door, but as it is not put away properly, the doors won’t close – would fall out
Traumatic memories are like the duvet – painful to handle and we try and avoid them, shoving them away. This means they aren’t stored in the same way as other memories, so they fall in our minds when we don’t want them too – avoiding them won’t work
We need to take the duvet out, which might sting, and we might need someone to help us, we need to fold it up, make room by moving other things
In the same way, traumatic memories need to be processed, something this is best done with help – we might need to adjust our view of the world a bit, but thinking the memory through enables the memory to be processed and stored with other memories
What does the cognitive model of PTSD emphasise?
PTSD maintenance and proposes that people with persistent PTSD process the trauma in a way that leads to serious and current threat
What does the feeling of current threat arise due too?
- People make negative appraisals of the trauma and consequences - processed using sensory means rather than stored as memory
- The disturbance of autobiographical memory prevents elaboration and contextualisation of memories - can’t fit them in
- Change in neg appraisals and trauma memory are prevented by behavioural and cognitive strategies. e.g. inefficient, short term coping strategies are used avoidance, thought suppression) and this worsens PTSD symptoms
- Treatment aim: process the trauma so it is seen as a time limited past event, which does not have global implications for the future
What is the aim of CBT?
Process the trauma so it is seen as a time limited past event, which does not have global implications for the future
What are the NICE guidelines (2018)?
Debriefing after trauma events should not be offered
Symptoms less than 4 weeks - watchful waiting and review
Offer an individual trauma-focussed CBT intervention to adults with PTSD to those who have presented symptoms more than 1 month after an event
What are the types of interventions?
Cognitive processing therapy
Cognitive therapy for PTSD
Narrative exposure therapy
Prolonged exposure therapy
When should EMDR be considered?
For adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if the person has a preference for EMDR
What is the key aim in a formulation diagram?
Help clients to reclaim life and live in accordance with their goals - rather than living life based on fears generated by past events
What is a formulation diagram for PTSD? Wild and Elhers
Memory - feeling of threat (physiological response) - unhelpful thought: short term - unhelpful behaviours (safety behaviours, e.g. avoidance) unhelpful thoughts: long term (long term beliefs such as I shouldn’t do things) - failure to update memory of traumatic event
Clinical example of formulation diagram
Memory - daughter and grandson dead in car
Feeling of threat - hot and sweaty when driving
Unhelpful thoughts - I cannot keep my family safe
Unhelpful behaviours - avoidance/thought suppression
Unhelpful thoughts - I am responsible for harm/I am a irresponsible person
What is the therapy structure for CBT?
Session 1: Set goals, psychoeducation, formulation and rationale for re-living work (bringing in wardrobe analogy etc)
Session 2: Re-living work, identify hotspots, cognitive restructuring
Session 3 & 4: Reliving and updating the memory
Session 5 – 12: Re-living, site visit (where it happened), stimulus discrimination, addressing anger, guilt, shame
Session 12: Therapy blueprint as relapse prevention
How can people update their trauma memories?
Therapists help sufferers confront trauma memories and specific situations, people or objects
usually either:
imaginal - get person to re live the event through describing the event in the present tense in full detail with eyes closed, identifies hot spots, in cognitive appraisals
wouldn’t just do it once - do it continuously
in vivo - behavioural experiments with now safe stimuli, revisiting the trauma site of situations (driving car, going in a lift)
What are hot spots?
Moments of high distress than create nowness of memory - part of memory which gives trauma the importance and why it is so bad
What are examples of questions used to identify hotspots?
What image represents the worst moment?
Rate intensity of current emotion?
Appraisal: what does the image mean to you?
Update: what do you now know about the situation?
What are the maintaining factors which need to be addressed?
Rumination - teach strategies to take attention away from stimulus
Avoidance and safety behaviours
Numbing (substances)
Misinterpretation of symptoms
Pre-trauma beliefs look at validity of beliefs
Sense of permanent change
Thought suppression
What is stimulus discrimination?
Update from what happened in the trauma and what they know now
Describe the event THEN, sounds and smells
then describe whats different NOW, e.g. if you go in a car, it will be ok, not trapped
notice the intrusive memory:
stop
take a breath
observe - feelings, images
pull/back: discriminate, what is different now?
practise what works: choose to do what will help most
Does trauma work impact the therapist?
Trigger fear/panic in therapist - cause worry and concern as exposed to biased views, lots of information about risk
Could trigger memories for them if something similar has happened to them
Compassion fatigue - not enough resources yourself to provide the correct amount of support
How was eye movement densitisation and reprocessing therapy discovered?
Francine Shapiro - 1989/1995
Walking in the park, when she realised that eye movements appeared to decrease the negative emotion associated with her own upsetting memories - moving eyes from left to right desensitises difficult thoughts and feelings
What is EMDR?
Assumed eye movements were desensitising and found that others had the same response to eye movements
EMDR dded other cognitive treatment elements since eye movements alone are insufficient to develop a standard procedure
Distinct features of EMDR involves making side-to-side eye movements (bilateral eye movement), usually followed by the movement of the therapists finger, whilst recalling the traumatic incident
What does EMDR consist of?
Structured therapeutic intervention, usually 5-12 sessions, follows 8 phases:
1) History and Treatment Planning
2) Preparation (e.g. relaxation; ‘safe place’)
3) Assessment (visualise image from event with associated negative cognition, then generate positive cognition)
4) Desensitisation phase (bilateral eye movements initiated for 15-20s whilst focussing on disturbing memories. Continues until distress decreases)
5) Installation (focus on event alongside the positive cognition in phase 3, bilateral eye stimulation continues).
6) Body Scan (identify any uncomfortable physical sensations identified, diminished using eye movements; continues until physical & psychological distress removed)
7) Closure (relaxation and debrief)
8) Re-evaluation (what’s been done and what’s still to be covered)
What has research into the mechanisms of EMDR shown?
Van Den Hout
Researchers didn’t think that there was any scientific evidence behind this
But they find it is an effective treatment for alleviating trauma symptoms under well controlled conditions
Experiments disproved the idea that eye movements are necessary and that bilateral stimulation is needed (moving eyes up and down produces same effect as horizontal eye movement and so do tasks that require no eye movement at all)– but it is important that whatever task you use taxes working memory
What did Deise and Mendes et al find?
Conducted a review of the efficacy of CBT in comparison with other studies used
found that CBT had better remission rates than other therapies, however, it was comparable to exposure therapy and cognitive therapy in terms of efficacy - no differences between CBT and exposure therapy
Shows that specific therapies, such as CBT, exposure therapy and cognitive therapies are equally effective and more effective than supportive techniques in the treatment of CBT
