Week 3 - treating trauma, treatment slelection and dealing with comorbidity Flashcards
What is EDMR, prolonged exposure and cognitive therapy?
EMDR
Combination of traditional talk therapy with following rapidly moving object (e.g. fingers) with eyes for several seconds at the time while patient is talking about upsetting image. Repeated several times. Will cause upsetting image to be less disturbing. REM (rapid eye movements) helps us cope → gets disrupted with trauma
Benefits EMDR
- A decrease in emotional distress related to memory
- Long-lasting behavioral changes
- Successfully treating symptoms of post-traumatic stress disorder that can be linked to drug and alcohol addiction
Cognitive processing therapy
Stuck points (dysfunctional thoughts, e.g. ‘I don’t deserve to be happy) after trauma keeps people stuck in PTSD. Break negative thinking. Thoughts affect how we feel and act. Negative thoughts about trauma have changed the individual with PTSD. Challenge stuck points/negative thoughts. Learn other ways to think about the trauma that are less upsetting. Small changes in thinking can have big impact on how they feel.
Prolonged exposure
Avoiding places/people/thoughts. ‘I can’t’ rules → ‘I can’. Helps client do safe things they’ve been avoiding. Practice exposure: approach things they’ve steered clear of since event. Challenge ‘I can’t’ rules to prove they can. Exposure gets easier with time. Do hard things at own pace. Talk through details of traumatic event → helps with emotions (e.g. anger, sadness). Listen to recording of it. Learn to talk about trauma without being overwhelmed.
EMDR is more than exposure. The client talks about the traumatic event (same as exposure) while following a moving object with their eyes (unique to EMDR). This will cause the memory to be less disturbing.
Prolonged exposure is about approaching memories/feelings/situations while cognitive processing therapy is about changing negative thoughts obtained after/about the traumatic event.
What are the differences in treatment of the three mentioned treatments (also the psychological components underlying it)?
Both PE and EMDR therapy require considerable effort and a certain amount of courage from the patients, but the disclosure of traumatic events is much more detailed in PE.
· PE involves a considerable amount of homework whereas EMDR does not.
· One of the more distinctive elements of EMDR is the use of a dual attention (DA) task.
· EMDR is reported to require fewer periods of intense exposure compared to alternative exposure-based therapies for PTSD.
· In EMDR there is no need for the client to describe the trauma as the procedure involves the client holding it in mind rather than verbalizing their experience.
· CPT emphasizes the role of maladaptive thinking patterns in maintaining PTSD symptoms more than PE.
· The primary components of Prolonged Exposure include imaginal exposure to the trauma memory followed by processing of the trauma memory as well as in vivo exposure to feared but safe situations. The theorized mechanisms underlying PE are based on emotional processing theory and broader extinction models of fear reduction.
o Specifically, dysfunctional meaning associations underlying he trauma-related fear are altered or disconfirmed via information obtained during the exposure exercises.
o PE is thought to work through fear extinction mechanisms, allowing the patient to emotionally engage and process the traumatic memories in the absence of feared outcomes.
· Cognitive-based therapies:
o Cognitive Processing Therapy (CPT): relies more heavily on interventions that directly target maladaptive thinking patterns. It emphasizes the role that maladaptive or inaccurate interpretation of a situation plays in maintaining disorders such as PTSD, and intervenes directly with the thoughts rather than the resulting behaviors.
Þ The last several sessions focus on specific areas of one’s life that are likely affected by maladaptive trauma-related thought patterns, including the areas of safety, trust, power/control, esteem and intimacy.
· EM may not permanently change memory vividness, but may rather facilitate imaginal exposure, and thereby foster desensitization.
· EM change memory vividness and emotionality, which may explain part of the EMDR treatment effect.
· Eye Movement Desensitization and Reprocessing (EMDR): has received empirical support for the treatment of PTSD. The model used to explain PTSD in EMDR is similar to cognitive-behavioral therapies in that PTSD is viewed as a result of insufficient processing of the traumatic memory.
o EMDR hypothesizes that the trauma memory, if not fully processed, is stored in its initial state, preserving any misperceptions or distorted thinking patterns that occurred at the time of the trauma.
o Developers of EMDR hypothesize that bilateral eye movements reduce distress attached to the trauma memory, thereby reducing avoidance, and allowing for increased attention to more adaptive thinking patterns that are then attached to the traumatic memory.
Þ Other researchers have hypothesized, however, that the exposure-based components of EMDR are all that is required, and a review of dismantling studies has demonstrated that the EMDR protocol works just as well without the bilateral stimulation component.
· There are a number of accounts of how EMs may ameliorate negative reactions.
o The orienting response (OR) hypothesis: the therapist’s hand movements trigger an orienting response, a specific behavioral response that is an evolutionary development enabling humans to effectively assess the environment for opportunities or threats.
Þ ORs occur when attention has to be reoriented to a different stimulus.
Þ The Or involves two types of eye movements:
¨ 1. Eye movement is induced by an external stimulus (alerting response).
¨ 2. Induced by an active search of the environment (investigatory response).
Þ Research suggests that more intense ORs occur when a response to a stimulus is required. The Or induces a REM sleep-like neurobiological state. The continuous reorienting of attention required by bilateral tasks of EMDR activates the brain systems that shift the brain into a memory processing mode similar to that found in REM sleep.
¨ This neurobiological state permits the consolidation of traumatic episode memories into semantic cortical networks, a process that has not yet occurred in the case of PTSD.
o Increased interhemispheric interaction account: research suggests that retrieval of episodic memories is enhanced by increased interhemispheric interaction.
Þ Bilateral saccadic EMs enhance interhemispheric interaction, which in turn facilitates retrieval of episodic memories.
Þ A growing body of literature suggests that EMs increase interaction between the left and right hemispheres. The authors proposed that since previous research has shown an interhemispheric basis for episodic memories, episodic memory should be improved if there is more communication between the two hemispheres.
¨ Thus bilateral EMs may produce changes in the accuracy of episodic memories, learning to an increased ability to recall non-traumatic memories and hence organize memories into network that include adaptive information.
Þ EMDR may decrease levels of distress associated with the memory as previous research has demonstrated that increased hemispheric interaction is associated with decreased stress.
Þ The EM component of EMDR could facilitate the recollection and integration of episodic memories through the mechanism of interhemispheric interaction.
Þ Hemispheric encoding-retrieval asymmetry (HERA) model of episodic memory: purports that the left and right cerebral hemispheres are specialized for the encoding and retrieval of episodic memories respectively.
o Working memory account: working memory consists of a central executive that is responsible for higher order cognitive functions such as planning; a phonological loop that stores verbal and auditory information for later use; and the visuospatial sketchpad (VSSP), which stores visuospatial information for later use.
Þ The working memory account of the role of EMs in EMDR hypothesizes that images of unpleasant memories are held in the VSSP. These images become less vivid as EMs use up processing resources concurrently; working memory becomes less efficient when doing two tasks at once.
What treatment with PTSD with dissociation or PTSD with psychotic disorder?
PTSD with psychotic disorder:
PE and EMDR were significantly associated with less severe paranoid thoughts post-treatment and at 6-month follow-up
- more patients remitting from schizophrenia, at post-treatment (PE and EMDR) and over time (PE)
- PE was significantly associated with a greater reduction of depression at post-treatment and at 6-month follow-up
- Auditory verbal hallucinations and social functioning remained unchanged
- patients with chronic psychotic disorders PE and EMDR not only reduced PTSD symptoms, but also paranoid thoughts
→ PTSD was found to be associated with an increased likelihood of endorsing one or more psychotic symptoms, so reducing PTSD might reduce paranoia
- in PE and EMDR more patients accomplished the status of their psychotic disorder in remission
- Participants in the PE and EMDR conditions showed a greater reduction of PTSD symptoms than those in the WL (waiting list) condition
- Participants in the PE condition or the EMDR condition were significantly more likely to achieve loss of diagnosis during treatment than those in the WL condition
- Participants in the PE condition, but not those in the EMDR condition, were more likely to gain full remission than those in the WL condition
- Treatment effects were maintained at the 6-month follow-up in PE and EMDR
PTSD with dissociation:
Cognitive-Based Therapies
- PE is categorized as a cognitive-behavioral therapy, and its exposure-based protocol does produce changes in negative thinking patterns associated with PTSD
→ BUT the intervention strategies themselves are primarily behavioral rather than cognitive
- Cognitive Processing Therapy (CPT) directly target maladaptive thinking patterns
- CPT, alongside other cognitive-based therapies for PTSD, emphasizes the role that maladaptive or inaccurate interpretation of a situation plays in maintaining disorders such as PTSD, and intervenes directly with the thoughts rather than the resulting behaviors
CPT
- initial sessions of CPT include psycho-education about PTSD symptomatology and the role of avoidance in maintaining PTSD
- Early in therapy, the patient writes a statement of impact that the traumatic event had on their life, about how the trauma affected the patient’s beliefs about self, others, and the world
→ This is read aloud and discussed with the therapist
→ The therapist question any potential maladaptive thinking patterns, thereby helping the patient discover over-generalized or unhelpful automatic thoughts
- therapist works with the patient to develop strategies for generating more useful or accurate thinking patterns
- In the standard CPT protocol, the patient additionally writes one to two detailed accounts of the trauma and reads this account aloud in session
- The last several sessions focus on specific areas of one’s life that are likely affected by maladaptive trauma-related thought patterns, including the areas of safety, trust, power/control, esteem, and intimacy
- At the end of treatment, the patient re-writes the impact statement, which is used to evaluate treatment gains
- those with higher levels of dissociation (especially depersonalization) responded best to the full protocol (with written trauma account)
- those with lower dissociation responded more rapidly to CPT without the trauma account
What do psychotic episodes look like in PTSD?
Intrusions (flashbacks, unwanted upsetting memories) or psychosis
Doscociation: Depersonalisation: Experience being outside observer of or detached from oneself/ Derealisation: experience of unreality, distance, or distortions (things aren’t real)
50 to 98 % of patients with a psychotic disorder have had a traumatic experience in their life Goodman et al,1997; Morgan and Fisher, 2007; Mueser et al., 1998; Read, Os, Morrison, & Ross, 2005; Shevlin, Houston, Dorahy, & Adamson, 2008
Psychosis and PTSD can occur together
Psychotic episodes can lead to traumatic experiences
Traumas contribute directly to psychosis
