Week 6 Lecture - Trauma

Question 1

what is trauma

Answer 1

• The experience of being exposed to events that can be distressing
  
  • Our bodies way of responding to distressing events
  • One of the biggest and most wide ranging health concerns
  • Trauma care is associated with significant cultural change in mental health care
  • Trauma takes its name from what causes it unlike other mental health disorders e.g. sexual abuse trauma

Question 2

trauma types/timings

Answer 2

○ Single incident trauma (PTSD based off a single exposure when spoken about)
○ Multiple incident (as a child only, adult only, as both a child and adult)
○ Chronic exposure (life long multiple settings)

Question 3

psychological trauma types

Answer 3

○ PTSD
○ Complex PTSD
○ Disorders of extreme stress - DSM version of complex PTSD
○ Developmental trauma disorder - pervasive impact of people exposed to trauma
○ Complex trauma - different to complex PTSD
○ Moral injury - deep psychological wound
○ Secondary or vicarious trauma - comes about from learning about other peoples trauma

Question 4

ACEs and inclusion - who is excluded in research?

Answer 4

• Marginalised and disenfranchised populations are significantly more likely to experience ACES and other forms of adversity
  ○ Ethnic minorities
  ○ Intellectual disabilities and developmental disorders
  ○ Minority sexualities
  ○ Gender minorities
  ○ Older people
  ○ Deaf people

Question 5

gender and trauma

Answer 5

○ Females report higher exposure and PTSD rates
○ Male trauma is less recognised, underreported, rated as less severe (by males and females), treated less seriously
○ Males and females endorse symptoms differently but therapies are built on females symptoms
○ Trials for stabilisation therapies, especially DBT are with females
○ Outside of veteran samples males are largely absent from literature
○ Ethnic minority males are particularly absent and less likely to be offered psychotherapy
○ Men and women are different clusters on PTSD questionnaires and the questions are much more cognitive which relates to female experience rather than males

Question 6

Adverse experiences in childhood (ACEs):

Answer 6

negative events in childhood that can have an enduring impact
○ Originally formulated as 10 different types of events, now recognised there are many more
○ Lack of consistency on what life events are classed as ACEs
○ ACEs are about childhood only

Question 7

Life stressor events (repeat victimisation)

Answer 7

negative events than can disrupt an individuals activities that can cause disruption can require readjustment.
○ Can include illness, experiencing or witnessing violence

Question 8

resilience

Answer 8

ability to mentally or emotionally cope with adverse events and return to a pre-stressor status quickly
○ Personal resources that protect us from negative effects of stressors

Question 9

post traumatic growth

Answer 9

positive psychological change as the result of adversity

Question 10

number of ACEs avg

Answer 10

• On average people have had 7
  
  • National average of 1
  • Congo children after the war have 5.5

Question 11

what are the ACEs

Answer 11

• Entering the looked after system (multiple placements and breakdowns, including sudden change)
  
  • Emotional/physical neglect and sever economic deprivation
  • Witnessing or experiencing verbal, emotional, physical or sexual violence
  • Peer, parental and intimate relationships
  • Giving birth
  • Illness and accidents, especially those that cause life changing conditions
  • Parental mental illness, substance use or incarceration
  • Armed conflict, including displacement
  • Bereavement and parental separation
  • Our own actions: self harm, suicide attempts and aggressive behaviour

Question 12

prevalence of ACEs - community samples

Answer 12

• Neurotypical:
  ○ 47% of individuals experienced at least 1 ACE, with the most common being verbal abuse
  ○ 14% experienced 4 or more
  
  • Intellectual disability:
    ○ Up to 90% experience at least 1
    ○ Up to 87% experience some form of familial violence
    ○ 7 times more likely to experience adversity than neurotypical populations
    ○ 50% will experience 4+

Question 13

prevalence of ACEs - clinical samples

Answer 13

• Neurotypical:
  ○ Up to 50% experience 4+
  
  • Intellectual disability:
    ○ 47-87% experience multiple (average 4.2 for males and 7.5 for females)
    ○ 58% experience 4+
    ○ 36% experience 6+

Question 14

prevalence of ACEs - prison samples

Answer 14

• 84% at least 1
  
  • 46% had 4+

Question 15

prevalence of ACEs - international studies

Answer 15

• Congo: 5.2 (post civil conflict)

Question 16

impact of trauma on neurological development

Answer 16

○ Smaller whole brain volume
○ Dysregulated neural function,
reduced neuroplasticity, accelerated and truncated growth in the brain
○ Smaller volume in key areas of the brain associated: with memory, emotional regulation, attachment, social processing, executive functioning skills (planning, organising, sustaining, problem solving, mental flexibility)
○ Should trauma be classified as a brain injury?

Question 17

impact of trauma on psychological wellbeing

Answer 17

○ Increased vulnerability to psychopathology
○ Trauma: Developmental Trauma, PTSD, Complex PTSD
○ Mood Disorders: Anxiety, Depression, bipolar disorder
○ Psychosis
○ Personality disorder: All ‘clusters’
○ Psychopathy
○ ‘Impulse control and risk taking behaviours’

Question 18

impact of trauma on scholastic and employment

Answer 18

○ Greater risk of expulsion from school
○ Poorer attainment
○ Fewer qualifications
○ Increased unemployment
○ Lower income
○ Higher levels of disability benefit
○ Living below the poverty level

Question 19

impact of trauma on physical health

Answer 19

○ Poorer global outcomes
○ Depressed and dysregulated immune systems
○ Greater risk of developing life threatening, chronic and limiting conditions: Obesity, cardiovascular, respiratory, cancer, sleep, skin, metabolic and GI disorders
○ Less likely to engage in screening programmes
○ Less likely to attend appointments
○ Greater used of GP and A&E services
○ More health risk taking behaviours

Question 20

impact of trauma on mortality

Answer 20

○ Experiencing a high number of ACEs in childhood is associated with a significant reduction in life expectancy
○ Greater lifetime risk of suicide

Question 21

impact of trauma on epigenetics

Answer 21

○ ACEs can lead to epigenetic modifications which impacts on the molecular structure of genomes, which influences future health outcomes for future generations

Question 22

impact of trauma on economics

Answer 22

○ The economic impact of trauma care is a major public health concern
○ US California study: 21% higher health care costs
○ Direct cost to the economy in one year $10.4 billion dollars

Question 23

life expectancy and ACEs

Answer 23

• 4-6+ ACEs can reduce life expectancy by up to 20 years

Question 24

developmental trauma disorder (DTD)

Answer 24

• 15 symptoms across 3 symptom clusters mirroring PTSD
  ○ Emotion and somatic dysregulation (can’t work out feelings or explain them)
  ○ Cognition and behavioural dysregulation (numb or hypervigilant, non-suicidal self-harm to cope)
  ○ Self and relationship dysregulation
  
  • Can be diagnosed despite not being in DSM or ICD yet (Mental health act)

Question 25

common comorbidities

Answer 25

• 70% of people with PTSD have comorbidities
  
  • Depression and anxiety common
  • Substance misuse, autism and ED increasingly common
  • Personality disorder 50% overlap
  • Comorbidities include:
    ○ Acquired brain injury
    ○ Depression and anxiety disorders
    ○ Substance misuse
    ○ Personality disorder
    ○ Psychosis
    ○ Bipolar disorder
    ○ Attachment disorder
    ○ Self harm
    ○ ED
    ○ Complex/traumatic grief

Question 26

neurobiological models

Answer 26

○ Multiple models
○ Stress the role of neurological factors
○ Memory
○ Abnormal fear learning models (conditioning)
○ Information processing
○ Diminished executive functioning skills
○ Diminished emotional regulation
○ Implications:
* Stress the ‘whole’ body response of trauma
* Predict difficulties that may develop in psychological therapies and offer an account of why people may drop out of therapy (lack of cognitive resources needed to navigate therapy)
* Suggest that talking therapy may not be an efficacious approach and other work maybe needed prior to talking therapy
* Have relevance to our understanding of resilience and protective factors
* Some clinically based researchers suggest that childhood trauma should be repositioned as an acquired brain injury.
* However neurological factors alone, can’t explain all aspects of PTSD, as they don’t take into account contextual and social factors

Question 27

behavioural models

Answer 27

○ Keane and Barlow
○ Conditioning – older, but often explain how fear / distress are maintained in a way that service users can understand
○ Early models stressed the role of operant and classical conditioning to account for symptoms
○ Fear arises from the learnt association of a neutral (condition) stimuli with an aversive TRAUMA stimuli (unconditioned stimuli)
○ Avoidance behaviours develop as a result of instrumental conditioning, namely the reduction of distress through avoidance / escape of a stimuli (negative reinforcement)
○ Fear doesn’t become extinguished because exposure is incomplete (not sufficient to habituate to).

Question 28

• Emotional processing theory (EPT) Edna Foa et al

Answer 28

○ EPT is a trans diagnostic theory focused on information processing
○ Offers an account of both the causes and maintaining factors underlying PTSD
○ Focus on the role of ‘pathological’ fear (Fear networks) and its generalised effects
(to stimuli and responses)
○ Based on the premise that as an emotional disorder PTS / PTSD reflect pathological
emotion structures in memory and that treatment therefore modifies that pathological representations in memory.
1. Trauma related fear network is activated by stimuli
2. Triggers information from the network to enter our consciousness (intrusive
symptoms)
3. Attempts to avoid symptoms (threat information) lead to avoidance behaviours
Treatment therefore should focus on integrating information from fear networks
into memory systems
4. Therefore to assimilate information you need to trigger it.

Question 29

cognitive theory of PTSD
Ethers and Clark

Answer 29

○ Builds on basic assumptions of cognitive theory
○ Includes the basic tenants of Foa’s EPS model and basic ideas of Associative
network theories
○ PTSD is the manifestation of the reciprocal relationship between:
○ Gives prominence to the role of conscious articulated verbal thoughts
○ Cognitions have a causative mechanism in triggering anxiety
○ (cognitive) appraisals of threat that give rise to the perception of continued threat,
even though the trigger event is in the past
○ Triggers for threat can either be internal or external events
○ The nature of the memory and its integration with other episodic memories also
influence current perception of threat
○ Trauma memories are fragmented with incomplete narratives, which impacts on
processing and differentiating between past and present.
○ Empirical basis:
○ Strong empirical support, especially for single episode trauma’s
○ BUT, including CT to exposure therapy doesn’t lead to better outcomes

Question 30

dual representation theory
Brewin et al

Answer 30

○ Focuses on intrusive images in PTSD
○ Focuses on using findings from cognitive neuroscience to drive the theory
○ 2 main components
○ C-Reps: Contextual representations: Verbal narratives
§ Secondary emotions: Generated through appraisals of information
§ In trauma responses / presentations C-Reps are weakened
○ S-Reps: Sensation based representations, they can’t be deliberately recalled,
but are involuntary triggered (mechanism for flashbacks),
§ They lack contextualisation
§ in trauma responses S-Reps are strong
○ Still relatively new model, has potentially greater explanatory power
○ Initial results support elements of the model that have been tested.
○ Is likely to better bridge the gap between psychological and neurological models

Question 31

psychological formulation

Answer 31

• Formulation is a key skill for clinical psychologists:
  
  • Can be defined as: “ An ideographic theory” that describes the origins, development and maintenance factors of someone’s difficulties; including how these different parts relate to each other.
  • Currently there is no agreement to use specific PTSD models.

Question 32

advantages of psychological formulation

Answer 32

• Can help determine the problems to prioritise (and safe to address)
  
  • anticipate challenges that may arise in therapy (Develop crisis plans)
  • identify criteria necessary for successful outcome (what would make this worthwhile)
  • can promote collaborative therapy, by sharing the rationale for intervention (reduce drop out)
  • Can be experienced as validating to the person “It makes sense now’
  • Can be a key relationship building activity with service users (Shared narrative)
  • Can help explain the relationship between morbidities

Question 33

disadvantages of psychological formulation

Answer 33

• Can be ‘exposing’ and overwhelming
  
  • Can be overly complex and inaccessible to people without clinical knowledge or limited educational abilities
  • Currently no empirically investigated model or method for psychological approaches to formulation in trauma care
  • Psychological formulations can often reflect the idiosyncrasies and knowledge of the therapist
  • Inequality of knowledge and power in formulations
  • Very time consuming to develop and share

Question 34

role of clinical psychologists

Answer 34

• A history of trauma is relatively common in people who come into contact with psychologists who work in applied settings.
  
  • Working with people exposed to trauma is a significant aspect to the working life of clinical psychologists
  • ‘Trauma informed care’ and ‘trauma work’ are commonly used phrases within services. NO consensus as to what this means are looks like
  • British Psychological Society has outlined standards of care in this area of practice:
  • Standards for competencies for psychologists working in trauma
    ○ Trauma informed
    ○ Trauma Skilled
    ○ Trauma Expert

Question 35

stigma and trauma

Answer 35

• Compared to other mental health needs, stigma has been less investigation in trauma populations
  
  • Most of the literature has explored stigma in veteran populations
  • Some evidence that stigma is less prevalent in PTSD than in other MH needs
  • Self with stigma (internalising social stigma) is associated with in the trauma research
    
    • Hesitancy to seek support, especially in veterans
    • Drop out in therapy
    • Poor outcomes in therapy
    • Exacerbation of PTSD symptoms
    • Exacerbation of co mood disorders
    • Reduced sense of self worth
    • Alienation and social withdrawal

Question 36

vicarious trauma

Answer 36

• Working with people who experience trauma is both rewarding and challenging
  
  • Increased recognition of the impact trauma can have on health professionals
  • The risks of developing VT relate to the individual, the nature of the work and organisational factors++
    ○ Supervision / training / support
    ○ Culture / workload
  • Impact can manifest as
    ○ PTSD
    ○ Burnout
    ○ Altered neurological functioning (MRI scans)
    ○ Sexual Dysfunction and intimacy difficulties
    ○ Interpersonal conflict
    ○ Moral Injury
    ○ Compassion fatigue or ‘spiritual fatigue’
    ○ De sensitisation to traumatic materials
  • Some Health services now offer trauma support services that focus on the needs of staff
  • Models can, however, be reactive rather than proactive
    ○ Reflective practice
    ○ Post incident de brief
    ○ EMDR
    ○ Prolonged exposure therapy