trauma& - university of otagopsychiatrytraining.healthsci.otago.ac.nz/wp-content/... ·...
TRANSCRIPT
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Trauma
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Trauma before PTSD
• PTSD included in DSM 3 (1980) • Prior to that, trauma recognised as producing emoAonal numbness, followed by a period of anxiety, poor sleep, nightmares, painful recollecAons and avoidance, which gradually fades, with return to baseline mental health.
• Occurrence and course influenced by temperament, predisposiAon.
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Trauma
“mental shock” Something overwhelming. Sudden fright. An event that shaMers peoples assumpAons.
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1800’s
• American Civil War. Soldiers heart. • AQer Franco Prussian war of 1871, wards for treatment of hysterical men were opened
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Spinal concussion
• 19th century. Disturbances in nervous system may be produced by the physical impact of e.g. Railway accidents
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Charles Dickens
• 1865 train crash. • A year later “I have sudden vague rushes of terror even when riding in a Hanson cab, which are perfectly unreasonable but quite insurmountable”
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Herbert Page 1885
“it could be an advantage to the vicAm to have actually experienced physical injury … the bodily injury saAsfies the requirements of the paAent himself in seeking an explanaAon of the symptoms present aQer the accident”
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Railway Spine “a strong and healthy man reduced by apparently inadequate causes to a state in which all control of the emoAons is well nigh gone; who cannot sleep because he has before his mind an ever-‐ present sense of the accident; who starts at the least noise; who lies in bed almost afraid to move; whose heart palpates when ever he is spoken to, and who cannot hear or say a word about his present condiAon and his future prospects without bursAng into tears”
(Herbert Page, 1883)
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Charcot
• Saw vicAms of Railway spine and other accidents as affected by hysteria
• Influenced Freud, considered hysteria due to repressed memories of traumaAc events
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Pierre Janet
DissociaAon • Predisposed personaliAes, if traumaAsed, their ideas and behaviours get separated from consciousness. PaAents present with hysteria, and loss of memory for the incident
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SeducAon Theory
Breuer and Freud 1885 “ hysterical symptoms are residues of profoundly moving experiences, which have been withdrawn from everyday consciousness … their form is determined by details of the traumaAc effects of the experiences … therapeuAc prospects lie in the possibility of gebng rid of their “repression” to allow part of the unconscious psychical material to become conscious and thus to deprive it of pathogenic power”
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World War 1 Shell Shock
• 80 000 BriAsh soldiers. • IniAal uncertainty. Is shell shock psychogenic, or a organic result of close proximity to explosions?
• Undermined the idea that mental Disorder was the result of an unsound personality.
• “forward psychiatry” pioneered, aQer it was noAced that removal of soldiers to the rear didn’t help them return.
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WW 2
• US screened out the poorly adjusted • SAll had 10% psychiatric casualAes in Europe, oQen affecAng the bravest of soldiers.
• WW 2 “PIE”, “Forward Psychiatry”
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DSM 1
“Gross stress reacAon”
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1960’s
• Vietnam. Few psychiatric casualAes in 1965-‐7 (before the anA-‐war movement)
• DSM 2 – 1968, didn’t include trauma syndromes
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The Stress Response Syndrome
Mardi Horowitz, 1976 • Intrusive experiencing • Avoidance • EmoAonal numbing
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1970’s
PoliAcal lobbying for a new diagnosis • Vietnam vets • BaMered women’s groups.
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Birth of PTSD
• USA draQees involved in an unpopular war. • Much poliAcal interest in vicAm veterans. • “Post – Vietnam syndrome” • Growing incenAves (excuse, enAtlement) in 70’s for distressed, maladjusted individuals to aMribute their difficulAes to the Vietnam war.
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AQer PTSD described
• Massive increase in traumatology. • 1988 study of Vietnam veterans, 479 000 had PTSD 15 years aQer the war, nearly a million (31%) had “full blown” PTSD at some stage. Only 300 000 had been aMached to combat units.
• Massive increase in skepAcal accounts of validity of PTSD diagnosis and therapy.
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US Comorbidity study of PTSD
• 7.8% lifeAme prevalence. • Comorbid with alcohol dependence, depression and other anxiety disorders.
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DSM 5
Trauma and Stress Related Disorders • ReacAve aMachment disorder. • Disinhibited social engagement disorder. • Post traumaAc stress disorder. • Acute Stress Disorder. • Adjustment Disorder. • Other and unspecified.
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Acute Stress Disorder
• Symptoms typically begin immediately aQer the trauma.
• Diagnose if symptoms last 3 days to 1 month aQer trauma.
• Guilt, panic, reckless behaviour: v common. • Predicts later PTSD.
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DSM 5 PTSD
• Contains subjecAve and objecAve elements. • 4 symptom clusters. Many paAents do not have all 4 clusters.
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DSM 4 PTSD A
• Directly experiences the traumaAc event. • Or witnesses it. • Or learns of it happening to a close family member or close friend. (but death from natural causes doesn’t count)
• Or repeated and extreme exposure to aversive details (e.g. first responders, police officers). (doesn’t apply to exposure through electronic media, television … Unless this exposure is work related)
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DSM 5 PTSD B
One or more Intrusion symptoms • Recurrent and intrusive distressing recollecAons. • Recurrent distressing dreams. • DissociaAve reacAons. E.g. flashbacks. • Intense or prolonged distress at exposure to cues that symbolize or resemble an aspect of the traumaAc event.
• Marked physiological reacAvity on exposure to cues.
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DSM 5 PTSD C
Persistent Avoidance of sAmuli associated with the trauma. One or both of:
• Avoidance of distressing memories, thought or feelings about or closely related to the traumaAc event.
• Avoidance of external reminders that arouse distressing memories, thought or feelings about the traumaAc event.
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DSM 5 PTSD D
NegaAve alteraAons in cogniAons and mood associated with the traumaAc event. Two or more of:
• Inability to remember an important part of the event.
• Perssitetn and exaggerated negaAve beliefs about self or world.
• Persitent disotorted ogniAons abut the cause or consequences of the event.
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DSM 5 PTSD D conAnued
• Persistent negaAve emoAonal state • Markedly diminished interest or parAcipaAon in significant acAviAes
• Feelings of detachment or estrangement from others
• Persistent inability to experience posiAve emoAons
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DSM 5 PTSD E
Marked alteraAons in arousal and reacAvity. Two or more of: • Irritable behaviour and angry outbursts. • Reckless or self destrucAve behaviour. • Hypervigilance • Exaggerated startle • Problems with concentraAon • Sleep disturbance.
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DSM 5 PTSD
• DuraAon of disturbance is over 1 month. • ~ 50% start with Acute Stress Disorder. • Causes clinically significant distress or impairment
• Different criteria for children
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Traumas
• Gunfire • Explosions • Combat • Assault • Handling dead bodies • Witnessing events • Witnessing events on
television. • Giving birth • Hearing bad news • Learning of spouse’s affair • Being stalked
• Rape • RTA • Accident • Natural disaster • Bereavement • Illness • Injury • Psychiatric admission • Restraint & Seclusion • Hostage • Bullying • Work stress • Witnessing RTA
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Measuring trauma
• ObjecAve severity • SubjecAve severity
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trauma
• Accidental or deliberate: important? Yes. • Anger • Trust • Self blame • compensaAon
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Severity of trauma, means?
• DuraAon • Surprise • Injury • Threat • A quesAon of appraisal
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Risk factors for PTSD In order of importance... • Lack of social support • Post traumaAc life stress • SubjecAve Trauma severity • Other Adverse child experience • Low IQ • Low socioeconomic status • Childhood abuse • Female • Psychiatric Hx • Lack of educaAon
Age and ethnicity appear unimportant ( Brewin et al, 2000, a meta analysis of 77 studies)
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Before the trauma
• Temperament: childhood emoAonal problems, mental disorder.
• Environmental. • Low socioeconomic status, previous trauma, family dysfuncAon.
• Physiological. Female, youth.
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During the trauma
• Severity of trauma. • ProspecAve studies indicate dissociaAve experiences at the Ame of the truama predict later PTSD.
• For soldiers: killing, perpetraAng atrociAes
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AQer the trauma • Subsequent life stress and poor social support predict PTSD ( in prospecAve studies – although many PTSD symptoms may provoke these)
• ProspecAve studies of early social support suggest it is a cause, not just an effect.
• NegaAve reacAons of others. • Acute stress disorder. • Subsequent financial or other trauma related stressors.
• Poor family support. • Avoidance of unwanted thoughts.
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ShaMered illusions
• If shaMered illusions about a kind world is important in genesis of PTSD, we might expect childhood trauma to protect: but it does not.
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Course • AQer a severe trauma, most meet cross secAonal PTSD criteria.
• Most resolve over ~ 3 months. • Those with enduring distress aQer ~ 6 months need intervenAon.
• Some have delayed onset, months or years later. • Can be recurrent: when a person has powerful reminders or major life changes.
• High levels of anger, and negaAve interpretaAon of symptoms predict slower recovery
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Comorbidity
• Seen in >50% • Depression, drug abuse, anxiety, dissociaAve disorders, psychosomaAc disorders, personality disorder.
• Psychosis. • A consequence, or predaAng the PTSD? US NaAonal comorbidity survey suggests depression and addicAon are likely consequences of PTSD. Anxiety may be more independent.
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CriAcizing PTSD
• DiagnosAc criteria are broad and imprecise. • Discourages broad clinical assessment and formulaAon that takes account of biography, temperament, social circumstances, and values independent informants.
• The normal response to fear, which tends to be prompt and acute, has morphed into something delayed, and chronic.
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McHugh & Treisman 2007 J of Anxiety Dis, 21, 211-‐222
“ Of all the faddish postulates that cluMer the contemporary diagnosAc landscape of psychiatry, none is more pervasive than PTSD. Its themes and alleged psychopathology fill the journals and are discussed incessantly in the clinics. Grief and trauma ‘counselors’ now flock to every disaster and intrude upon the survivors, jusAfying their acAons as prevenAng PTSD”
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• Soldiers in warAme made worse by diagnosis of mental disorder.
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Stolen Valour
BurkeM & Whitley, 1998 • Vietnam vets no more at risk of problems than veterans of other conflicts
• Lots of people make up their combat history
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DissociaAon and PTSD • PTSD “Flashbacks” originally considered dissociaAve. • now more an emoAve term for unpleasant recollecAon. • DissociaAon someAmes defined as any temporary
breakdown in the relaAvely conAnuous, interrelated processes of perceiving the world.
• Mild dissociaAve reacAons are common under stress, • e.g. 96% of soldiers undergoing survival training. • DissociaAve symptoms commonly encountered in
trauma -‐ emoAonal numbing, derealizaAon, depersonalizaAon, and ‘out-‐of-‐body’ experiences -‐ related to the severity of the trauma, fear of death, and feeling helpless.
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Complex PTSD
• Herman 1992 • PTSD oQen has associated features – personality disturnabce, somaAsaAon, mood disturbance, dissociaAve symptoms.
• Argued to result from repeated and severe childhood trauma.
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“Complex PTSD” Marked by • Altered self capaciAes: regulaAon of affect, interpersonal relaAons, concept of self
• Poor self esteem, self blame, expectaAons of rejecAon
• Disturbed mood:anger, irritability, aniety depression.
• Avoidance: dissociaAon, drug missuse. • Somatoform distresss • And more convenAonal PTSD symptoms
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Complex PTSD
Herman J ( 1992) Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. Journal of TraumaAc Stress, 5, 377-‐391.
-‐ Argues that trauma is the origin of borderline personality
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What counts as trauma
• Depends greatly on social context
Many different Kinds of events. • RTA
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A trauma is not a single event • Injury • Painful rehabilitaAon • Police interview • Court appearance • Anger, self blame • Hurxul comments • Loss of work and income • loss of role • Incapacity • Bereavement • Uncertainty about outcome • Disputes about liability
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CompensaAon
• ResoluAon of court case or compensaAon claim is not generally followed by recovery
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Lies?
• 13% of combat veterans referred to the UK defence psychiatric service make facAAous claims of combat exposure or military service.
• US NaAonal Vietnam Veterans Readjustment study. 30% of Veterans have PTSD – twice as may as saw combat.
• Freuh et al (2005) 100 Vietnam veterans seeking Rx for combat trauma: 32 hadn’t seen combat. 5% hadn’t been in Vietnam.
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SkepAcs
• Not an independent enAty different from anxiety or depression.
• Diagnosis lacks specificity. • Individual symptoms are not unique to PTSD.
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Allan Young, 1997
“The disorder is not Ameless, nor does it possess an intrinsic unity. Rather it is glued together by the pracAces, technologies and narraAves with which it is diagnosed, studied, treated and represented and by the various interests, insAtuAons and moral arguments that mobilise these efforts and resources”
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Blame
• Groups/individuals felt to be culpable are seen as less deserving of diagnosis or compensaAon.
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Sympathy for vicAms
• OQen prominent, early on. • But can wear out. • Onlookers can feel helpless. VicAms can be discomforAng: responses include the sympatheAc, and also distancing.
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Mental defeat (Anke Ehlers)
~ helplessness • Perceived loss of autonomy • Giving up efforts to maintain ones own idenAty
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Common experiences
• Experiencing powerlessness • Feeling inferior • Self blame, guilt ( survivor uilt) • Feeling stupid • Lacking a future, feeling permanently damaged • Other do not understand • A sense of betrayal • PosiAve change: Feeling stronger, more appreciaAve of life
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Flashbacks
• Vivid • Full of sensory detail • OQen fragmented • The horror is re-‐experienced • Normal sensaAons are excluded. The person is relaAvely unresponsive to the social situaAon
• Usually follow triggers, which become objects of avoidance.
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Recovered memory
• Some paAents recover memories of abuse in therapy.
• Some therapists seek this, may have joint moAvaAon and theoreAcal commitment to recovered memory.
• “You remember this, but what happened next, what do think happened, why do you think you can’t remember”
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Recovered memory
• Based on idea of repression – we forget what is too horrible to remember. The forgoMen events enter consciousness in disguised forms and cause apparently unrelated problems, which can be treated by rediscovering the forgoMen event
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memory
• Strong emoAons are responsible for beMer or worse memory (studies conflict).
• Flashbulb memory – seems to improve recall. • EmoAons that narrow aMenAon are likely to worsen memory.
• Weapon focusing – recall of other aspects suffer.
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Freud
• Repression: a defence mechanism. • The purpose of analyses was to liQ the repression of unacceptable mental content that was excluded from awareness.
• 1893 Freud and Breuer. Trauma is repressed – bring it to consciousness and so heal hysteria.
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Freud
• 1896. Early sexual trauma causes later psychological disturbance (the seducAon theory).
• Later. Repression is of infanAle drives and wishes, rather than of events
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Freudian repression
• Referred to an unconscious process, not under voluntary control, and to a “turning way” from things that have already had some conscious processing ( AKA suppression”, and “moAvated forgebng”). This may be commonplace, and allow for accurately recovered memory
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Forgebng Trauma?
Q. Surely, if it really was “traumaAc”, people wouldn’t forget it?
A. No one knows. And it might depend on what is meant by traumaAc
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Memory
• Amnesia for traumaAc events noted in ww1 shell shock – in absence of brain injury.
• From what age can people form, for later recovery, memories?
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Repression
• Unfalsifiable. • A record of events is not accurately stored in the brain.
• Memory is sketchy, reconstrucAve, decays over Ame, is corrupted by current bias, incorporates post event informaAon that becomes indisAnguishable from the actual event.
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1990’s Memory wars
• 1980’s increasing recogniAon of prevalence of CSA, and service provision.
• Some paAents recalled previously forgoMen memories.
• Linked to MulAple personality • Much angry rhetoric
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• Some therapists did assume recovered memory were likely to be accurate.
• Some use age regression techniques and hypnosis – in a suggesAble compliant paAents
• Much rhetoric about needing to believe the vicAm
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Elizabeth LoQus • Recovered memories are oQen highly unusual. • Events oQen occur at an age too young for veridical memory.
• Typically no corroboraAon. • Some therapists had a fixed idea about the ubiquitous influence of CSA.
• Techniques such as guided imagery likely to reveal whatever memory was assumed to be there.
• i.e. False memories do occur.
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The courage to heal
Bass and Davis (1988) • “for many survivors, remembering is the first step in healing”
• “if your memories are incomplete, even if your family insists nothing ever happened, you sAll must believe yourself”
• “If you think you were abused and your life shows the symptoms, then you were.”
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False Memory
• How common? Data comes from surveys, and from False memory socieAes.
• Can memories of Sex abuse be forgoMen, and then recovered? Several studies say so. – Perhaps they just needed to be asked.
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Recovered Memory
• Content someAmes bizarre. • Memories are someAmes corroborated. • TherapeuAcally helpful?
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Child sex abuse
• Is necessarily harmful? • If we assume so, we begin examinaAon of an abused person in search of a mental injury already assumed to be present
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Child sex abuse
• A risk factor for later mental disorder
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Notes for assessment • Pre trauma Hx. What is baseline funcAoning. • Immediate pretrauma psychosocial context. • The traumaAc event. Single or mulAple. Degree of danger. Injury. DuraAon.
• The meaning of the trauma. • Post trauma psychosocial context. • Responses of family and social agencies • Evidence of exaggeraAon or zricaAon • comorbidity • secondary gain
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Drug treatment of PTSD
• Some evidence for SSRI and Venlafaxine. • Effect not rapid. Persist for 3 months. • Less good evidence for Phenelzine, Lamotrigine, & Mirtazapine.
• Olanzapine or Risperidone if other approaches fail.
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Psychological Rx
• Trauma focused CBT. • Exposure, (an hour, daily or more, habituaAon. Can be imaginal exposure or real life exposure to avoided sAmuli)
• Anxiety management/stress inoculaAon. • CogniAve therapy. Address fear, shaMered assumpAons and negaAve schemata
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Psychological Rx
• Anxiety management (educaAon on nature of anxiety, muscle relaxaAon, controlled diaphragmaAc breathing, thought stopping, cogniAve restructuring, guided self dialogue, problem solving – breaking difficulAes into their components, role playing)
• Does rediscovering old memories help?
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Debriefing
• Mitchell model/criAcal incident stress debriefing.
• A prevenAon approach, originally for emergency workers.
• Talking about the incident and feelings about it is promoted in group.
• RCT’s demonstrate ineffecAve.
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Psychodynamics
5 defences commonly considered. • Denial • DissociaAon ( argued to account for amnesia and flashbacks)
• Splibng ( lose holisAc view of others, e.g. all men are bad).
• IdenAficaAon with the aggressor. • ProjecAon( unacceptable feelings aMributed to others)
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“Psychogenic Psychosis”
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DSM 4
Brief PsychoAc Disorder • Sudden onset. • The disturbance is less than one month. • The individual recovers fully. • OQen occurs in response to marked stressors. (DSM 3 R category -‐ “brief reacAve psychosis”
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DSM 4 Brief psychoAc episode
• Typically emoAonal turmoil or overwhelming confusion.
• Personality disorder may predispose.
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Jaspers 1913 PrecipitaAon Psychoses – where the psychoAc content is unrelated to the precipitaAng factor.
Contrasted with…
ReacAve psychoses. • The content is understandable reflecAon of the cause.
• The psychosis would not have occurred without it.
• Removal of the stressor resolves the psychosis.
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Psychogenic Psychosis August Wimmer, 1916 “Psychogenic psychoses… generally on a predisposed terrain… are caused by psychic factors… decisive for the Ame of erupAon of the psychosis, its movements (remissions, intermissions, exacerbaAons, terminaAon). Likewise, in form and content the psychosis directly and completely reflects the precipitaAng psychic casual factor… to these criteria we may further add the predominant tendency to recovery”.
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“hysterical” psychosis
• Some brief psychoAc episodes give impression of intent and dissociaAon.
• No consensus on how dissociaAon relates to psychosis.
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CSA and schizophrenia
• Parallels between SZP symptoms and PTSD symptoms?
• An associaAon
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DissociaAon
• AlteraAons in conscious awareness that are defensive changes in otherwise integrated thoughts, feelings, memories, and behaviours.
• Argues to reduce the distress of trauma. • A hypothesis masquerading as a descripAon.