the psychological effects of trauma what to look for and what to do kerry young 1, 2 consultant...

The Psychological Effects of Trauma

What to look for and what to do

Kerry Young 1, 2

Consultant Clinical Psychologist

Annual Student Health Association Conference

Bristol 2014

1. Forced Migration Trauma Service, Central and North West London NHS Foundation Trust2. EPACT – Experimental Psychopathology and Cognitive Therapy Lab Department of Psychiatry, University of Oxford

Kerry Young, CNWL NHS Foundation Trust 2014


Who am I to talk to you about this?Kerry Young

• Trained as Clinical Psychologist in Oxford, qualified 1994

• 1997-2004 Traumatic Stress Clinic, London

• 2001-2010 Clinical Director, Doctoral Training Programme in Clinical Psychology, UCL

• 2005 – 2010 Refugee and Asylum Seeker Service, St Ann’s Hospital, London

• 2012 – 2013 Consultant Clinical Psychologist, The Haven, Paddington

• 2011 – Clinical Lead, Forced Migration Trauma Service, Central and North West London

• 2012 – Clinical Psychologist, EPACT, Dept. Psychiatry, Oxford University

• Teach, train and supervise in CBT (general and specific)

• Particular interest in how to treat PTSD in refugees and asylum seekers

Aims

• To inform you about the common psychological effects of trauma

• To help you identify PTSD in particular• To inform you about the treatment options for PTSD

• To answer any questions you may have


Examples of traumatic events

• Natural disasters (e.g. Tsunami)• Man-made disaster s (e.g. London bombings)• Accidents (e.g. Fall, RTA, train crash, medical)• Physical assault• Robbery• Murder• Sexual assault or rape• War• Ethnic cleansing• Torture


Outcomes After Trauma

• Acute Stress Disorder

• PTSD• Phobias• Somatization• Depression

• OCD• Suicide• Substance Abuse• Psychosis• Neurological

damage• Pain


Focus on PTSD today


How common is it after trauma?


Conditional risk of PTSD across specific traumas (Breslau et al., 1998)

Trauma type % PTSDHeld captive/tortured/kidnapped 53.8

Rape 49.0Badly beaten up 31.9 Sexual assault (other than rape) 23.7

Other serious accident 16.8


Conditional risk of PTSD across specific traumas (Breslau et al., 1998)

Trauma type %PTSDShot/stabbed 14.3Sudden unexpected death of associate 10.4

Child's life-threatening illness 8.0Mugged/threatened with weapon 7.3Witness killing/serious injury 3.8Natural disaster 2.3


So quite likely after an inter-personal trauma


What is PTSD?


Historical Perspectives• 1666, Great Fire of London - Samuel Pepys’ diaries, trauma-related

nightmares, “..much terrified in the nights nowdays with dreams of fire and falling down of houses” (1667)

• Debate for many years about whether symptoms were organic or psychological in origin:

- 19th Century - “railway spine”

- World War I - “shell shock”

- World War II - “concentration camp syndrome”

• War in Vietnam – large numbers of sufferers showing similar psychological reactions to overwhelming stress

• PTSD officially defined DSM-III, 1980


DSM-IV Diagnostic Criteria

• NB now DSM-V….


Post-traumatic Stress Disorder

• Criterion A– Experience/witness actual/threatened death/serious

injury/threat to physical integrity self/others

– intense fear, helplessness or horror

• Symptoms (present for >1 month)– Re-experiencing

– Avoidance / numbing

– Hyper-arousal

• Must cause clinically significant distress/

impairment


Re-experiencing Symptoms

• Intrusive recollections of trauma

• Nightmares of trauma

• Reliving the trauma - flashbacks

• Intense distress at reminders

• Physiological reactivity at reminders

• Need 1 or moreKerry Young, CNWL NHS

Foundation Trust 2014

Avoidance Symptoms

• Avoid thoughts, feelings, conversations

• Avoid activities, places, people associated with trauma

• Psychogenic amnesia• Diminished

interest/participation in significant activities

• Feelings detachment/ estrangement from others

• Restricted range of affect

• Sense of foreshortened future

• Need 3 or more


Increased Arousal

• Difficulty sleeping

• Irritability

• Difficulty concentrating

• Hypervigilance

• Exaggerated startle response



Case Example: Ahmed

• Student, 6 months ago, assaulted on way home at night by group of youths

• Has PTSD

• What symptoms can you notice?

• Huge thanks to Deborah Lee for DVD


Play DVD

Scene 1 - 6:33 to 12:57


Ahmed: PTSD SymptomsRe-experiencing

• Intrusive images of assailant/bottle (feel ‘pathetic’, frightened)

• Nightmares• Flashbacks to image of bottle• Distress at reminders (crowds of young

people, stuff on TV)• Physiological arousal at reminders (sweaty,

tense)


Ahmed: PTSD SymptomsAvoidance

• Avoid thinking about it • Avoid TV, places with young people, going out,

college• Doesn’t enjoy anything• Doesn’t feel connected


Ahmed: PTSD symptomsIncreased Arousal

• Difficulty sleeping

• Irritable with friends

• Difficulty concentrating

• Looking over shoulder all of the time, think will be attacked again

• Jumpy at door banging


DSM-V – changes May 2013• Event

Expanded to include repeated exposure to aversive details trauma & learning event happened to close person

• Intrusive SxAbout the same

• Avoidance Sx Narrowed to avoidance thoughts and things/places

• Negative alterations in cognition and mood New category, some as before, plus change belief about self/world/others, blame self/others, persistent fear/horror/anger/guilt/shame

• Hyperarousal

As before


Keep using DSM-IV until measures normed on DSM-V


What is Acute Stress Disorder ?



• Remember most people will have PTSD symptoms in month after trauma (94% after rape in one study) – it is ‘normal’

• ASD refers to a more dissociative version of PTSD that occurs within 2-30 days of trauma

• Rates 6-33% of those involved in trauma



• All criteria as for PTSD plus

• Dissociative Sx:– Numb, detached, emotionally unresponsive– Reduced awareness of surroundings– De-realization (your environment seems not real)– De-personalization (your thoughts/emotions don’t seem

real/to come from you)– Dissociative Amnesia (can’t remember significant aspects of

trauma in absence of TBI)




• Highly predictive of subsequent PTSD

• Need:- Psychiatric evaluation- Hospitalization if risk- Information- CBT- Medication


Back to PTSD


How to identify it

• If someone recently involved in a trauma

• Complaining of any of the PTSD Sx

• Give them Trauma Screening Questionnaire (Brewin et al., 2002)

• 6 or more positive responses indicate at risk of having PTSD diagnosis


What to do if they look like they might have PTSD

• Refer to appropriate mental health service i.e.

- IAPT

- student counselling service if offer evidence based

PTSD treatments (CBT or EMDR)


What to do if they look like they might have PTSD

• In meantime, leaflets a good idea

• Student counselling service may have PTSD information leaflet

• Or suggest obtain PTSD psycho-educational material online;

- Royal College of Psychiatry

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.aspx

- NICE

http://www.nice.org.uk/nicemedia/live/10966/29782/29782.pdf




http://www.nice.org.uk/nicemedia/live/10966/29782/29782.pdf

What are evidence based PTSD treatments?


NICE Guidelines – early intervention

• Consider watchful waiting when symptoms are mild and have been present for less than 4 weeks after a trauma

• Arrange a follow up contact within 1 month• For individuals who have experienced a

traumatic event, do not routinely offer brief single session interventions (debriefing)


NICE Guidelines – after 1 month

• All PTSD sufferers should be offered a course of tfCBT (trauma-focused cognitive behavioural therapy) or EMDR (Eye Movement Desensitization and Reprocessing) regardless of the time since the trauma


What is tfCBT ?

• Based on the understanding that trauma memories aren’t properly integrated into memory

• Need to get the patient to ‘re-process’ the memory so it can be integrated and will stop popping into their heads when they don’t want it to


Kerry Young, May 2011

Duvet and CupboardImagine that memory is a little bit like a linen cupboard: lovely and organized, with towels on one shelf, sheets andpillow cases on another and, finally, duvet covers andblankets on the last shelf.

When you are involved in a trauma, it is as if someone runsat you with a huge duvet in their arms, screaming “PUTTHAT IN THE CUPBOARD RIGHT NOW!” You take theduvet, stuff it in, jam the door shut and walk away. As youdo so, the cupboard door opens and the duvet flops out.The person screams at you again, their face right up againstyour face, “PUT IT BACK IN, PUT IT BACK IN NOW!” You grab it off the floor,bundle it back in, jam the door shut and walk away. Again the door opens andagain the duvet spills out onto the floor. Growing increasingly agitated, theperson screams, “PUT IT BACK IN, PUT IT BACK IN, PUT IT BACK IN!”

Kerry Young, May 2011

Duvet and Cupboard cont.In the end, you find that the only way to keep the duvet in the cupboard is to standwith your back against the door. But you can’t do that forever and, anyway, you willneed to go into the cupboard eventually to get other things out. When you do, theduvet will tumble out again.

What is tfCBT ?

• Involves talking about the traumatic event in a lot of detail, including all five senses, emotions and thoughts

• Worst moments of the trauma narrative are re-scripted with new/corrective information so that the memory can be nicely packed away

• 10-12 sessions on average for one-off trauma


Does it work?


0

0.5

1

1.5

2

2.5

3

d

CT for PTSD studies

CT for PTSD: Effect sizes for change before versus after treatment

Chronic PTSD – RCT(Ehlers et al, 2005)


Play DVD

• Scene 5 – 5:20 to 10


Medication and PTSD

• NICE say medication a second-line treatment ONLY to be used if tfCBT/EMDR failed/not indicated

• Recommend paroxetine and mirtazepine (NICE Evidence Update 2013 – fluoxetine and venlafaxine might also be useful)

• Worth considering if co-morbid depression

• No robust evidence for mood stabilizers (e.g. carbamazepine) or benzodiazepines (e.g.clonazepam)

• Review Jonathon Bisson (2007) need doses at higher end of therapeutic range and delay decisions about usefulness


What else to watch out for

• Co-morbidity with substance misuse, depression, panic

• Increased rates of suicide

• NB may not want to tell you what happened (especially if sexual assault/rape)


Take home message

• PTSD is quite likely after inter-personal trauma

• PTSD is very treatable (you can expect remission from diagnosis after 10-12 sessions)

• PTSD needs a psychological treatment (tfCBT or EMDR)


Questions?


Contact details

• [email protected]


the psychological effects of trauma what to look for and what to do kerry young 1, 2 consultant...

Documents

cnwl nhs foundation

trauma type

ptsd shotstabbed14

migration trauma service

conditional risk of

clinical psychology

clinical director

clinical lead