PTSD

Question 1

What is the NICE definition of PTSD?

Answer 1

Can develop after a single traumatic event, like a serious accident. Can also be caused by repeated or prolonged experiences like abuse, or living or working in a war zone. PTSD can happen to anyone, at any age. PTSD usually involves reliving the event through vivid memories or nightmares, feeling angry or ‘on edge’, having negative thoughts and feelings, problems thinking clearly and difficulty sleeping. These symptoms in the first few weeks after a trauma are common and most people who have early symptoms do not go on to develop PTSD. For those who develop PTSD, these symptoms do not drop off. But for an important few, PTSD becomes an ongoing problem that makes everyday life very difficult, both for them and for their family, friends or colleagues.

Question 2

What is the history of PTSD?

Answer 2

Psychological distress in response to traumatic events was recognised by the ancient Greeks. More recently traumatic stress disorders were recognized in the First World War as ‘shell-shock’. This is where there was first documented literature.

Question 3

How is PTSD categorised in the DSM 5?

Answer 3

It is quite a complex process to see whether someone meets the criteria for PTSD. There are 7 criteria.

Question 4

What is Criterion A (DSM 5)?

Answer 4

Exposure to the trauma – an event that must include actual or threatened death, serious injury or sexual violation (threat to self or threat to life) resulting from one or more of the following scenarios:

• Directly experiencing the traumatic event.
• Witnessing the traumatic event in person.
• Experiencing the actual or threatened death of a close family member or friend that is either violent or accidental.
• Directly experiencing repeated or extreme exposure to aversive details of the event (e.g. those experienced by police officers or first responders).

Question 5

What is Criterion B (DSM 5)?

Answer 5

Intrusion symptoms - recurrent memories and/or dreams (flashbacks and nightmares), re-living/re-experiencing which causes distress.

Question 6

What is Criterion C (DSM 5)?

Answer 6

Avoidance symptoms - avoidance maintains psychological difficulties. Memories, thoughts, feelings. External reminders of the trauma, e.g. in an environment that was not linked to the event.

Question 7

What is Criterion D (DSM 5)?

Answer 7

Negative alterations in cognition and mood - poor memory, self-concept, detachment, loss of positive emotions, lose sense of who they are in the world - dissociated from a place/themselves.

Question 8

What is Criterion E (DSM 5)?

Answer 8

Alterations in arousal and reactivity - hyper vigilance (e.g. not allowing a knife in the house), poor concentration, irritability, sleep disturbances, exaggerated startle response (turned on physiological arousal for threat, its heightened).

Question 9

What is Criterion F (DSM 5)?

Answer 9

Duration - persistence of symptoms (criteria B, C, D and E) for more than one month, as these symptoms are common for anyone that experiences a trauma for a few weeks.

Question 10

What is Criterion G (DSM 5)?

Answer 10

Functional significance - what impact is this having on their lives/is it negatively impacting their lives? Significant symptom-related distress or functional impairment (e.g. in social and occupational domains).

Question 11

What is Criterion H (DSM 5)?

Answer 11

Attribution - disturbance is not due to medication, illicit substances or other conditions.

Question 12

What is clinical presentation of PTSD?

Answer 12

Things you may see when working with someone with PTSD:
Intrusive thoughts/memories, sleep problems (nightmares/insomnia), ‘body memories’ (physiological arousal/pain, distress of disorder can manifest into bodily pain), dissociative episodes (flashbacks, reliving, not just recalling), numb and detached, hyper-vigilant, mood changes (depressed, irritable, short-tempered), behavioural problems e.g. delinquency and offending behaviours, cognitive changes e.g. guilt and shame (even if trauma was no fault of their own), suicidality (risk of self-harm and suicide).

Question 13

What are flashbacks?

Answer 13

Quite unique to trauma work. A flashback is a vivid experience in which you relive some aspects of a traumatic event or feel as if it is happening right now. This can sometimes be like watching a video of what happened, but flashbacks do not necessarily involve seeing images, or reliving events from start to finish. You might experience any of the following:
¥ 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!

Question 14

What is complex PTSD?

Answer 14

May occur when exposure to trauma has been prolonged, e.g. violence, neglect, abuse. May have additional needs when thinking about help, may have greater difficulty with emotional regulation. May have developed coping mechanisms that prolong the symptoms. People with complex PTSD can find it hard to manage emotions and may be more likely to dissociate when under stress. People with complex PTSD often find relationships difficult and feel guilt/shame. Overlap in presentation with BPD.

Question 15

What is the epidemiology of PTSD?

Answer 15

Many people (70.4%) will experience at least 1 traumatic event in their lifetime. The majority of people who experience a traumatic event never recover naturally. Only a small percentage of people who have experienced a traumatic event will develop PTSD (Kessler et al. 2017). Study of 9282 adults showed lifetime prevalence of PTSD ranges from 6.1 - 9.2 percent in the US and Canada (Kessler et al. 2005). Study of 1698 adults in South East London put lifetime trauma rate of 78.2%. Prevalence (of current symptoms) of PTSD was 5.5% (Frissa et al. 2013).

Question 16

What factors mean you have an increased risk of developing PTSD?

Answer 16

You have an increased risk of developing PTSD if:
¥	Female 
¥	Lower SES 
¥	Pre-existing mental health problems 
¥	Ethnic minorities
¥	Inadequate social support
¥	Severity of exposure 
¥	The trauma is interpersonal (e.g. rape; torture; terrorism) rather than natural or technological disasters (e.g. train or plane crash, out of your hands what happens).

Question 17

What is a cognitive model of PTSD?

Answer 17

Ehlers and Clark, 2000. Anxiety is about future threat. PTSD is to do with memory. But … PTSD is classed as an anxiety disorder. Proposed individuals are remembering the trauma in a way that poses current threat in the here and now. Feel threatened at this moment in time.

Question 18

What happens in the brain in PTSD?

Answer 18

The amygdala is part of our ‘threat system’. It is there to alert us to danger and keep us safe from it. When there is a threat, the amygdala triggers the adrenaline response getting our body ready to ’fight or flight’. Unfortunately, the amygdala can’t discriminate very well between ‘real’ and ‘perceived’ danger. It triggers the same response even when the danger is ‘perceived’ (e.g. when we are thinking about a traumatic memory). The hippocampus helps store and remember information. It processes memories and files them away in our memory storage (‘the filing cabinet’). With non-traumatic memories, it puts a ’timestamp’ on the memory, before filing it away, so that it is stored in an organised way. During a traumatic event, when the amygdala is very active, the hippocampus doesn’t work very well and is usually unable to put a ‘timestamp’ on the memory. This is why traumatic memories are often re-experienced, rather than remembered. As there is no timestamp, the brain feels as though the trauma is happening again in the ‘here and now’, because it hasn’t been categorised properly.

Question 19

What are key features of trauma memories?

Answer 19

1. They come to mind uninvited – intrusive, not prepared for them
2. When memories comes to mind they are vivid and can be accompanied by smell and other sensory qualities and can feel very distressing.
3. Because they are very vivid, it can feel like the traumatic event is happening again.
4. A key approach of trauma focused CBT is to work with the memory of the trauma.

Question 20

What is the rationale for working with trauma memories?

Answer 20

Not enough to say to trust in the process, have to provide a rationale for the work you are going to do. Wardrobe analogy – don’t think about traumatic memories in the same way as other memories, so they ‘fall out of the wardrobe’ when we don’t want them to, intruding on everyday life. Therefore, traumatic memories need to be processed, sometimes this is best with the help of someone else. We might need to adjust our view of the world, but thinking the memory through enables it to be processed and stored with other memories so it stays put.

Question 21

What does Ehlers and Clark (2000) say a current threat arises due to? (cognitive model of PTSD)?

Answer 21

Ehlers and Clark (2000) emphasises PTSD maintenance and proposes that people with persistent PTSD process the trauma in a way that leads to serious and current threat. The feeling of current threat arises due to:

1. Negative appraisals of the trauma and its consequences which means the trauma is processed using sensory means rather than conceptually within autobiographical memory.
2. This disturbance of autobiographical memory prevents elaboration and contextualisation of memories – like the wardrobe analogy
3. Change in negative appraisals and trauma memory are PREVENTED by behavioural and cognitive strategies e.g. Inefficient, short-term coping strategies are employed (e.g. avoidance, thought suppression) and this worsens PTSD symptoms.
4. Key treatment aim: Process the trauma so it is seen as a time limited past event, which does not have global implications for the future.

Question 22

What are NICE guidelines?

Answer 22

¥ Debriefing after trauma events should not be offered
¥ Symptoms less than 4 weeks – watchful waiting (keeping an eye on people) and review
¥ Offer an individual trauma-focused CBT intervention to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1month after a traumatic event. These interventions include:
- cognitive processing therapy
- cognitive therapy for PTSD
- narrative exposure therapy
- prolonged exposure therapy
¥ Consider EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3months after a non-combat-related traumaif the person has a preference for EMDR.[2018]
¥ Offer EMDRto adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma.[2018]

Question 23

What is CBT for PTSD?

Answer 23

Wild and Ehlers, 2013 - key aim is to help clients to reclaim their life and live in accordance with their goals. Rather than live life based on fears generated by past events. Focuses on the link between memory, feeling of threat, unhelpful thoughts (short-term), unhelpful behaviours (also known as safety behaviours), unhelpful thoughts (long-term), and failure to update.

Question 24

What is the therapy structure for CBT for PTSD?

Answer 24

¥ Session 1: set goals, psychoeducation, formulation and rationale for re-living work (specific to CBT, e.g. bringing in wardrobe analogy)
¥ Session 2: re-living work, identify hotspots (most difficult/traumatic part of the memory), cognitive restructuring
¥ Session 3 & 4: reliving and updating (the memory)
¥ Session 5-12: re-living, site visit, stimulus discrimination, addressing anger, guilt, shame
¥ Session 12: therapy blueprint as relapse prevention

Question 25

What are updating trauma memories?

Answer 25

¥ Therapists help sufferers confront trauma memories and specific situations, people or objects which provoke symptoms.
¥ Usually either:
Ð Imaginal: “Re-living” the event through describing the event in the present tense in full detail with eyes closed. Identifies ‘hot spots’ (moments of high distress that create ‘nowness’ of memory) in cognitive appraisals. Also written accounts. Help recode in an environment that is free from stress and where they can encode properly. Encourage to record reliving of event.
Ð OR In vivo: e.g. behavioural experiments with now safe stimuli (e.g. smells/ sounds); revisiting the trauma site or situations (e.g. driving car; going in a lift in a safe space). See situation as it is, not how they remember it.

Question 26

What are examples of questions used to identify ‘hotspots’?

Answer 26

¥ Q: what image represents the worst moment?
¥ Current emotion, rate intensity 0-100
¥ Appraisal: What does the image mean to you or what did it mean in that moment?
¥ Update: What do you know now about that moment or situation?

Question 27

How are maintaining factors addressed?

Answer 27

¥ Rumination – spend a lot of time going over past events, so teach people to move attention away from rumination when it starts.
¥ Avoidance and safety behaviours – try to stop avoiding things.
¥ Numbing (substances).
¥ Misinterpretation of symptoms – having physical symptoms (negative interpretations) and flashbacks. Interpret this as losing control, help people to understand this isn’t the case.
¥ Pre-trauma beliefs.
¥ Sense of permanent change – assess the validity of the belief that their life has permanently changed.
¥ Thought suppression - teach people not to do this, although it may feel like an adapting response.

Question 28

What is stimulus discrimination?

Answer 28

Compare what happened in the trauma and what we know about the situation now, e.g. describe environment at the time of trauma and what happened, and then asked to highlight the differences to what they experience today.

Question 29

What is Eye Movement Desensitisation and Reprocessing Therapy (EMDR)?

Answer 29

Created by Francine Shapiro (1989/1995). A walk in the park… Shapiro was walking in the park when she realized that eye movements appeared to decrease the negative emotion associated with her own upsetting memories. Moving eyes from left to right desensitised emotions. Assumed eye movements were desensitising: found that others had the same response to eye movements. EMDR added other cognitive treatment elements since: Eye movements alone insufficient to develop a standard procedure. Distinct feature of EMDR involves making side-to-side eye movements (bilateral eye movement), usually by following the movement of the therapist’s finger, whilst recalling the traumatic incident. Overloads working memory, weakens the strength of the event.

Question 30

What does EMDR look like?

Answer 30

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 (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 (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).

Question 31

What does van den Host and Engelhard say about EMDR?

Answer 31

EMDR works, but eye movements aren’t necessary. Just need additional cognitive load (not specific to eye movements).

Question 32

When did Mendes, Mello and Ventura find about the treatment of PTSD? (Reading)

Answer 32

Compared CBT with other treatments for CBT (e.g. EMDR, Exposure therapy, and cognitive therapy). Found CBT had better remission rates than EMDR or supportive therapies. CBT was comparable to Exposure therapy and cognitive therapy in terms of efficacy and compliance. Suggests that specific therapies such as CBT, exposure therapy, and cognitive therapy are equally effective, and more effective than supportive techniques in the treatment of PTSD.