How anxiety and fear allow the Bogeyman

Posttraumatic Stress Disorder:

PTSD: Phenomenon and its Empirically-Supported Treatment

Johan Rosqvist, Psy.D. Pacific University Spring 2011

Ice breaker exercise: What is PTSD?

Break into small groups / pairs What do you believe constitutes trauma?

Why is something traumatic to one person and sometimes not to another? Operationally define trauma and PTSD What kinds of etiology? Personal / professional reactions to working with it? What treatments have you employed with PTSD?

Have you worked with PTSD and/or trauma?

Come back and have larger discussion

PTSD: New and old phenomenon

DSM-III (1980): trauma-related sequelae finally classified together under common PTSD rubric Previously: separated by specific experience (e.g., combat fatigue, rape, MVA) not unified by common, similar symptoms This strong trauma response has been a known quantity for a long time (e.g., Civil War and WWIs shellshock or battle fatigue response) Question & Debate: Is it uniquely human to be predisposed for developing posttraumatic stress disorder?

Dragonfly vs. Police officer example Is a sense of future required to experience fear and trembling and the sickness unto death ? (Kierkegaard, 1954)

PTSD: Definition and terminology

Necessarily secondary to particularly distressing event(s)

Responded w/intense fear, helplessness, or horror

Unique: Etiology is known

DSM-III: Outside realm of normal human experience

What about being unconscious, then informed of what happened?????

3 major symptom clusters

Normative vs. normal Truth be told

Reliving / Reexperiencing Avoidance

Functioning distress/impairment

Arousal / Vigilance

Numbing vs. effortful avoidance

Accurately Diagnosing PTSD

Clinician driven:

Structured Clinical Interview for DSM-IV (SCID-IV) Anxiety Disorders Inventory Schedule IV (ADIS-IV) Clinician Administered Posttraumatic Scale (CAPS)

Patient driven:

Posttraumatic Stress Scale Self Rated (PSS-SR)

Cautions:

No matter which method: Consider 2 gain (malinger)

Litigation in MVA PTSD Benefits in combat PTSD

Beware psychosis Multimethod/source obviously best overall

More PTSD Instruments

Impact of Events Schedule

Intrusion/ re-experiencing Avoidance Different norms for different traumas

Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychological Medicine, 4, 209-218.

Mississippi Scale for Combat Related PTSD

Total score w/ cutoff correctly classifies 90% as PTSD.

McFall, M.E., Smith, D.E., Mackay, P.W., & Tarver, D.J. (1990). Reliability and validity of Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. Psychological Assessment, 2, 114-121.

Trauma-Related Guilt Inventory

Assesses: responsibility, wrongdoing, & lack of justification norms w/ combat & battering relationships

Kubany, E.S., Haynes, S.N., Abueg, F.R., Manke, F.P., Brennan, J.J., & Stahura, C. (1996). Development and validation of the trauma-related guild inventory. Psychological Assessment, 8, 428-444.

Motor vehicle accident information

1996: Death rates for MVA = 16.2 / 100,000 2003:

Low rate behavior which statistically is not increasing with increasing populations

42,643 people died 2,889,000 people injured How many fender benders???? Exposure to heart-wrenching (toxic) life experiences is actually surprisingly common

Higher risk groups / behaviors? What does the MVA PTSD client believe will happen in future?

Larger number, but % remains stable

Normative and normal experiences

Car accidents are a normative experience: %age/year MVA induced PTSD is not a normal result of car accident

abnormal reaction to traumatic event

What differentiates between those who develop PTSD and those who dont?

Two ways of making sense of experience (assimilate/accommodate)

PTSD: Most common etiology

Overall:
1.

2.
3.

appear to be responsible for most cases of PTSD Men: Combat & witnessed violence Women: Sexual & physical assault Non-white ethnicity, personal/family hx of psychopathology, younger age (18-39) Perception of threat better predictor than

Sexual assault (65% male & 46% women; Kessler et al, 1995) Physical assault (32%; Breslau, 1998) Motor vehicle accidents (17%; Breslau, 1998)

1 wk = 94%; 1 mo = 65%; 3 mo = 65%; 17 yrs = 16.5% (Kilpatrick et al, 1987)

actual injury

PTSD Norm (epidemiological) information

60% men, 51% women have experienced traumatic event in their lives 49% of rape victims develop PTSD 4% of natural disaster survivors develop PTSD Lifetime prevalence rates 5-10%, making it amongst the most common anxiety disorder PTSD is often very debilitating, and secondary clinical problems are common

Persists for over 1 year in 50% Likely to be chronic if persists more than 3 months

High social cost: $3 Billion loss (work days lost and reduced productivity)

Overaccomodation

Overaccomodation involves an extreme distortion in schema. Accomodation vs. assimilation e.g., Instead of changing ones schema to include the possibility that some trusted individuals can be dangerous, the victim of acquaintance rape may change their schema to suggest that all men are dangerous and cannot be trusted. May result from dichotomized thought processes and restrict cognitive flexibility with which individuals should interpret and evaluate future information

Warranted conclusions

Traumatic events are common Only a minority of individuals who experience a traumatic event go on to develop PTSD One-third of those with PTSD experience a chronic course of the disorder, regardless of treatment Treatment is associated with a markedly shorter course of the disorder Individuals with PTSD often have other comorbid psychiatric diagnoses

Comorbid diagnoses

Between 60-100% of PTSDs have another Axis I (Litz, Penk, Gerardi, & Keane, 1992)
Anxiety Disorders Mood Disorders Substance Abuse or Dependence (2x as high as normal population) Marital Problems Emotional regulation, self-injurious behavior, dissociation, somatization, hopelessness, feeling damaged, loss of previous beliefs

Some Axis II may be forms of severe PTSD (e.g. BPD)

Those who develop PTSD

less social support

Before trauma (Keane et al, 1998) After trauma (Richards, 2000) Perception that post-trauma social support was less helpful (Tucker, Pfefferbaum, Nixon, & Dickson, 2000) more pre-trauma psychopathology (Keane et al, 1998)

more guilt (Bownes, O'Gorman, & Sayers, 1991; Kubany et

al, 1996)

hx of previous trauma
childhood sexual abuse w/ current sexual trauma (Nishith, Mechanic & Resick, 2000) family violence (Udwin, Boyle, Yule, Bolton, & O'Ryan, 2000)

predisposition to respond to stress w/ chronic autonomic overarousal (Jones & Barlow, 1992)

PTSD Case Illustration: Mia

28-year-old, Egyptian-American heritage, female Cohabitating with long-term boyfriend College graduate Comes from intact family, and has one younger brother No pre-morbid mental health history

Intake: I had the perfect life until all this happened.

June 30, 2003: A day of extreme trauma in Vietnam

Riding motorcycle with best friend in remote part of Vietnam Caught in landslide Fell down 60 cliff into raging river swollen from monsoon rains, almost drowned several times Broken ribs, punctured lung, mangled foot, bruised and bleeding Friend was killed, she lived Remote/primitive hospital where operation without anesthesia was performed on her foot Randomly found by American traveler and brought to Bangkok

Presentation at start of treatment: PTSD

March 27, 2004; 9 months following accident Criterion B: Reexperiencing Cluster (1 sx required)

Nightmares, Flashbacks Reactivity to exposure to cues resembling event Intrusive thoughts and memories Avoided thoughts and feelings Avoided activities, people, and places Inability to recall important aspects of accident Sleeping problems, irritability, difficulties with concentration & decisions Exaggerated startle response

Criterion C: Avoidance Cluster & Numbing (3 sxs required)

Criterion D: Arousal Cluster (2 sxs required)

What constitutes effective PTSD treatment?

Foa/Kozak: Requires exposure to corrective information

Imaginal exposure

Intense events cause fear-conditioning to a wide range of stimuli (e.g., sights, sounds, odors, and bodily responses associated with the trauma) Stimuli act as reminders of event(s), and activates fear structures (i.e., fight-flight mechanisms) Imagine trauma until emotional habituation (break link between event[s] and conditioned arousal) Exp to distressing but harmless stims (teaching stims are not dangerous)

In Vivo exposure

Cognitive Restructuring

Help person make better sense of event

Correctly appraise PTSD sxs

Im not a bad person for being in that accident, I simply was in the wrong situation at the wrong time. Repeated nightmares dont mean Im going crazy; theyre simply an indication my mind is still processing my traumatic experience.

Best predictor of optimal outcome

For patients who do not drop out of treatment, findings suggest that the most consistent

predictor of good outcome is whether or not the patient receives exposure therapy (Taylor, 2003)

Exposure is amongst the most effective treatments for PTSD (e.g., Chambless & Ollendick, 2001) Efficacy of treatment is not improved/nor diminished when exposure is diluted by adding cognitive restructuring (Foa, Dancu, et al., 1999)

Practitioner attitudes towards & utilization of exposure therapy for PTSD

Substantial evidence supports efficacy of exposure therapy for PTSD (Foa, Keane, & Friedman, 2000) Empirically-supported treatments under-utilized for anxiety disorders (Barlow, Levitt, & Bufka, 1999) Exposure under-utilized in clinical practice (Foy et al., 1996) Exposure is grossly under-utlized for PTSD (Becker, Zafert, &
Anderson, 2004)

Therapist factors affect use of exposure for PTSD

50% aware of exposure for PTSD; only 17% use it Lack of training (30% have formal training) Believe patients will drop out & symptoms will worsen Believe exposure will negatively affect relationship Believe exposure is inflexible & ignores idiosyncratic patient issues

EST for Mia: Cookbook or ????

Psycho-ed about PTSD Scheduling & Activation DB & PMR Cognitive Restructuring Exposure

In-imagination In-vivo

Grief work

1-year anniversary

Generalization training & Relapse prevention

PTSD, chronic: How bad was it????

PTCI

Scale 1: Neg cog about self - 2 std dev above clinical mean Scale 2: Neg cog about world at PTSD mean Scale 3: Self-blame (guilt) at PTSD mean
3 std dev above clinical mean (score = 52) SIAS - 2 std dev above; SPS 3 std dev above Baseline = 128 (clinical cut-off = 63)

BDI-II

SIAS/SPS

OQ-45

Treatment: How well did it work???

Mia met criteria for recovered

Started in clinical and finished in normal on all scales Passed clinical cut-offs on all scales Obtained reliable change on all scales
Start: Couldnt keep employment for more than 2 weeks End: Director of after school childrens art program

Everyday functioning

Relationships and hobbies

Adventure sports reengaged Nature passion rediscovered and extensively used

Progress and outcome: Depression, Anxiety, and Anxiety Sensitivity

BDI-II, BAI, ASI
70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Session

Severity

Progress & Outcome: BDI-II, BAI, ASI

BDI-II

Start = 3 std dev above clinical mean End = 1 std dev below normal mean Start = 1 std dev above clinical mean End = 1 std dev below normal mean Start = 1 std dev above clinical mean End = 1 std dev below normal mean

BAI

ASI

Progress and outcome: Social anxiety

SIAS and SPS

70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Session

Severity

Progress & Outcome: SIAS & SPS

SIAS

Start = 2 std dev above clinical mean End = 1 std dev below normal mean
Start = 3 std dev above clinical mean End = 1 std dev below normal mean

SPS

Progress and outcome: Posttraumatic stress

PTCI 1, 2, 3
8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Session

Severity

Progress & Outcome: PTCI 1, 2, and 3

PTCI 1

Start = 2 std dev above clinical mean End = at normal mean Start = at clinical mean End = 1 std dev below normal mean Start = at clinical mean End = at normal mean

PTCI 2

PTCI 3

Progress and outcome: Distress and working alliance

OQ-45, WAI
160 140 120 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Session

Amount

Teaching cases from student perspective

Debunking myths about manual-based treatments

Flexibility and individualized (not cookie cutter) Not cruel and cold Better than a book: Live training and supervision IRL Q & A possible: Immediate feedback Teaching case did not affect working alliance or outcome Students moving from observer to therapist Increased appreciation for empiricism Increased expertise, confidence, and competence

Value of live training

Relationship

Future forward

A word or two about EMDR

Exposure yields greater proportion of patients who no longer meet criteria for PTSD after a formal treatment trial EMDR does not differ from relaxation training on any outcome measure Exposure produces significantly larger reductions in avoidance and re-experiencing sxs Exposure is faster at reducing avoidance Controversy: Emergence of EMDR had an unusual course/poor studies/better than no treatment

Probably efficacious status

A Purple Hat therapy????

You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, I have lived through this horror. I can take the next thing that comes along. You must do the thing you think you cannot do. Do one thing every day that scares you. Eleanor Roosevelt