Trauma and Its Aftermath: Promoting Resilience and Recovery

   Lori A. Zoellner, Ph.D

University of Washington    

Please  do  not  distribute  or  reproduce  without  permission  

Outline of Talk A.  Conceptualizing Risk and Resilience

•  Patterns of Reactions/Symptoms •  Identifying Risk/Protective Factors •  Emerging Trends

B.  Principles related to resilience •  Avoidance •  Memory Processing •  Social Connectedness

C.  Rethinking our Approach •  Community •  Individual

Acknowledgments Funding Sources:

NIMH R01 MH066347 (PI, Zoellner) NIMH R01 MH066348 (PI, Feeny)

Collaborators: Norah Feeny, PhD Peter Roy-Byrne, MD Matig Mavissakalian, MD Richard Reis, MD Michele Bedard-Gilligan, PhD Belinda Graham, DClinPsy Alice Friedman, ANRP Janie Jun, MS Alissa Jerud, MS Libby Marks, MS Natalia Garcia, BS

Part A: Conceptualizing Risk and Resilience

•  Patterns of Reactions/Symptoms •  Identifying Risk/Protective Factors •  Emerging Trends

DSM-IV Criterion A: Event Definition

•  The person has been exposed to a traumatic event in which:

•  1) The person has experienced, witnessed, or been confronted with an event that involves actual or threatened death or injury, or a threat to the physical integrity of oneself or others. (OBJECTIVE)

•  2) The person’s response involved intense fear, helplessness, or horror. (SUBJECTIVE)

 

Posi4ve  &  Nega4ve    Predic4on  of  PTSD  Symptoms    

(Bedard  et  al.,  2008)    

  Female (n = 391)

Mixed (n = 687)

Commun. (n = 65)

Pos. Neg. Pos. Neg. Pos. Neg.

Objective Criteria .20 .76 .15 .81 .74 .44

Subjective Criteria

.22 .93 .18 .95 .73 1.00

Objective & Subjective Criteria

.20 .78 .17 .86 .74 .44

DSM- 5 Criterion A: Event Definition

•  Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: –  Directly experiencing the event –  Witnessing, in person, the event as it occurred to

others –  Learning that the traumatic event occurred to a

close family member or close friend (must have been violent or accidental)

–  Experiencing repeated or extreme exposure to adverse details of the traumatic event (e.g., first responders collecting human remains, police officers repeatedly exposure to details of child abuse). Does not apply to electronic media exposure unless work-related.

 

Type of Event and Risk (Breslau et al., 1999) PT

SD (%

)

53.8 49

31.923.7

16.8 14.3 10.4 7.3 3.80102030405060708090100To

rture

Rape

Beatin

gOthe

r Sex

ual

Acc

ident

Sudde

n Dea

thChil

d's Ill

ness

Witn

ess

Disaste

r

Part A: Conceptualizing Risk and Resilience

•  Patterns of Reactions/Symptoms •  Identifying Risk/Protective Factors •  Emerging Trends

0

10

20

30

40

50

60

70

80

90

100 Rape Victims

Non-Sexual Assault

1 Wk 1 Mo 2 Mo 3 Mo 6 Mo 1 Yr

Monthly Assessment

   Time Since Assault and Risk (Riggs et al., 1995; Rothbaum et al., 1992)

Per

cent

w/ P

TSD

   Common Reactions (w/in 1 mth) (Whitman et al., 2013)

More  than  50%  Report  

   Timing of Symptoms to Develop (Whitman et al., 2013)

• Avoidance/Numbing  Last  to  Develop  

•   Best  Predictor  of  PTSD      

Defining “Resilience” •  Oxford English Definition

–  “Ability of a substance to spring back into shape; elasticity” –  “Capacity to recover quickly from difficulties; toughness”

•  Bonanno Definition (2004, p. 20) –  “Ability of adults in otherwise normal circumstance who are

exposed to an isolated and potentially disruptive event, such as the death of a close relation or a violent or life-threatening situation, to maintain relatively stable healthy levels of psychological or physical functioning.”

•  Problems with Bonanno Definition –  Bonanno’s intimates a degree of equivalence

between bereavement (something almost all experience) and trauma (Litz, 2004)

–  Presence of a normative, temporary reaction makes a person not resilient, but vast majority have reactions

Psychosocial Risk Factors (Brewin et al., 2000)

Effect Size (r)

During/After Trauma Trauma Severity (49) .23 Lack Social Support (11) .40 Life Stress (8) .32 Demographic/History Female (25) .13 Lower SES (18) .14 Lower Intelligence (6) .18 Psychiatric History (22) .11 Childhood Abuse (9) .14 Adverse Childhood (14) .19 Minority Status (22) .05

Psychosocial Risk Factors (Ozer et al., 2003, 2008)

Effect Size (r) During/After Trauma Perceived Life Threat (12) .26 Perceived Support (11) -.28 Peritraumatic Emotions (5) .26 Peritraumatic Dissoc. (16) .35 Demographic/History Family Psych History (9) .17 Prior Trauma (23) .17 Prior Adjustment (23) .17

PTSD Emotional Event Memory  (Zoellner  et  al.,  2001)  

36

38

40

42

44

46

48

Initial 12 Wks

Em

otio

nal I

nten

sity

High PTSD

Low PTSD

Psychosocial Risk Factors in Child PTSD (Trickey et al., 2012)

Effect Size (r) During/After Trauma Perceived Life Threat (6) .36 Trauma Severity (41) .29 Thought Suppress/Distraction (2/2) .70/.47 Low Social Support (4) .33 Poor Family Functioning (7) .46 Media Exposure (3) .11 Demographic/History Parent Psych History (25) .12 Child Prior Psych Problem (14) .15 Younger Age (18) .03 Gender (29) .15

Preventing Long-term PTSD

•  April 29, 1992: LA Riots (53 killed, 2000+ injured)

Strategies for Early Intervention

•  Very brief intervention for all trauma survivors (e.g., 1 session debriefing)

•  4-5 session course of treatment - Selected people at high risk of chronic

symptoms - Over the course of weeks following trauma - Individual therapy

One Session Interventions

•  Within hours/days of event •  All trauma victims •  Emotional processing/ventilation by

encouraging recollection/reworking of the traumatic event

•  Normalization of emotional reaction to the event

Review of One Session (Cochrane Review; Rose, Bisson, Churchill, Wessely, 2009)

•  Review of 15 trials RCT, single session interventions

•  No advantage of the intervention •  If received debriefing, likelihood of PTSD

•  3-6 Mo: Odds ratio 1.17 (ns) •  6-12 Mo: Odds ratio .93 (ns) •  12+ Mo: Odds ratio 2.51 (sig)

•  http://www.cochrane.org/reviews/en/ab000560.html

“Primum Non Nocere” Concerns (Mayou et al., 2000)

0

5

10

15

20

25

30

35

40

Baseline 4 Mo 3 Years

Intervention/HIGH

No Intervention/HIGH

Intervention/LOW

No Intervention/LOW

PTS

D S

ever

ity

One Session Intervention Concerns (Ehlers et al., 2003; Bisson et al. 2009)

•  Why problems with compulsory one session interventions?

– Wrong message: May make negative interpretation of symptoms worse in the long-term

– Too much/too early: Very early processing of the trauma may interfere with natural recovery processes (e.g., memory consolidation, processing event in “small dosages”)

• Compulsory debriefing should cease – With current evidence and sample sizes:

» Unlikely pattern of results will alter substantially » Unlikely that large, clinically meaningful effects will

emerge in new studies

Rethinking Our Approach

•  July 7, 2005: London Bombing (52 killed, 700+ injured)

“Screen and Treat” Mental Health Response (Brewin et al. 2010)

•  Two-year Trauma Response Program •  Systematic outreach to survivors

–  24-hr Hotline with referrals from self and providers –  Advertised Widely –  Names provided by treating hospitals

•  Trauma Screening Questionnaire (TSQ; Brewin et al., 2002) – 10-item screen (6 >= positive)

•  N = 910 contacts; N = 596 completed – Monitored for 3, 6, 9 month intervals – Positive screens either referred to continued

monitoring or full evaulation

TSQ (>= 6) (Brewin et al. 2002)

Please consider the following reactions which sometimes occur after a traumatic event...Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past week.

1. Upsetting thoughts or memories about the event that have come into your mind against your will 2. Upsetting dreams about the event 3. Acting or feeling as though the event were happening again 4. Feeling upset by reminders of the event 5. Bodily reactions( such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event 6. Difficulty falling or staying asleep 7. Irritability or outbursts of anger 8. Difficulty concentrating 9. Heightened awareness of potential dangers to yourself or others 10. Being jumpy or being startled at something unexpected

•  Full standardized evaluation (n = 363) – Structured Clinical Interview for DSM-IV (First,

Spizter, Gibbon, & Williams, 1997) – Decision to continue to monitor or refer to

treatment (n = 278) •  Referred to either trauma-focused CBT or EMDR

(entered n = 217; completed n = 189) –  PTSD Symptoms (ITT): d = 1.87 –  PTSD Symptoms (completer): d = 2.11 –  Depression Symptoms (ITT): d = 1.23 –  Depression Symptoms (completer): d = 1.41

Clinical Care (Brewin et al. 2010)

Part A: Conceptualizing Risk and Resilience

•  Patterns of Reactions/Symptoms •  Identifying Risk/Protective Factors •  Emerging Trends

•  Recurrent, involuntary, and intrusive distressing memories of the trauma

•  Recurrent distressing dreams in which content is related and/or affect of the dream are related to the trauma

•  Dissociative reactions (flashbacks) in which the individual feels or acts as if the event is reoccurring

•  Intense or prolonged psychological distress at exposure to internal or external cues that remind of the trauma

•  Marked physiological reactivity at exposure to internal or external cues that remind of the trauma

DSM-5 PTSD B. Reexperiencing (1 or more)

•  Avoidance of or efforts to avoid distressing memories, thoughts, feelings about or closely associated with the trauma

•  Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the trauma

C. Persistent Avoidance (1 or more)

•  Inability to remember an important aspect of the trauma (typically due to dissociative amnesia and not to head injury, alcohol, or drugs)

•  Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world

•  Persistent, distorted cognitions about the cuase or consequences of the traumatic event that lead the individual to blame himself/herself or others

•  Persistent negative emotion al state (e.g., fear, horror, anger, guilt, or shame)

•  Marked diminished interest or participation in significant activities

•  Feelings of detachment or estrangement from others •  Persistent inability to experience positive emotions (e.g.,

happiness, satisfaction, or loving feelings)

D. Negative Alternations in Mood or Cognitions (2 or more)

•  Irritable behavior and angry outbursts with little or no provocation

•  Reckless or self-destructive behavior •  Hypervigilance •  Exaggerated startle response •  Problems with concentration •  Sleep disturbance (e.g., difficulty falling or staying

asleep or restless sleep)

E. Hyperarousal (2 or more)

F. Duration of more one month acute/chronic G. Clinically significant distress or impairment H. Disturbance not attributable to the physiological effects of a substance or other medical condition Specify Whether: With dissociative symptoms (either):

•  Depersonalization: Feeling detached from, and as if one were an outside observer of, one’s mental processes or body...

•  Derealization: Feelings of unreality of surroundings

DSM-5 PTSD Other Criteria

DSM-5: Acute Stress Disorder •  9 or more symptoms (at least 3 days)

–  Recurrent, involuntary distressing memories –  Recurrent, distressing dreams –  Dissociative reactions (e.g., flashbacks) –  Intense or prolonged distress to cues that remind of event –  Persistent inability to experience positive emotions –  Altered sense of reality to one’s surroundings –  Inability to remember an important aspect of the event –  Efforts to avoid memories, thoughts or feelings –  Efforts to avoid external reminder –  Sleep disturbances –  Irritable behavior –  Hypervigilance –  Problems with concentration –  Exaggerated startle response

•  DSM-5 says 50/50 chance of developing PTSD (p. 284)

     

Research Domain Criteria (RDoCs)

NIMH Director’s Blog: Transforming Diagnosis By Tom Insel April 29, 2013 “In  a  few  weeks,  the  American  Psychiatric  Associa6on  will  release  its  new  edi6on  of  the  Diagnos6c  and  Sta6s6cal  Manual  of  Mental  Disorders  (DSM-­‐5)...the  final  product  involves  mostly  modest  altera6ons...”  “...strength  of  each  of  the  edi6ons  of  DSM  has  been  “reliability”  –  each  edi6on  has  ensured  that  clinicians  use  the  same  terms  in  the  same  ways.  The  weakness  is  its  lack  of  validity.”  

http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Research Domain Criteria (RDoCs)

NIMH Director’s Blog: Transforming Diagnosis By Tom Insel April 29, 2013 “Unlike  our  defini6ons  of  ischemic  heart  disease,  lymphoma,  or  AIDS,  the  DSM  diagnoses  are  based  on  a  consensus  about  clusters  of  clinical  symptoms,  not  any  objec6ve  laboratory  measure...”  “Pa6ents  with  mental  disorders  deserve  beLer.  NIMH  has  launched  the  Research  Domain  Criteria  (RDoC)  project  to  transform  diagnosis  by  incorpora6ng  gene6cs,  imaging,  cogni6ve  science,  and  other  levels  of  informa6on  to  lay  the  founda6on  for  a  new  classifica6on  system.”  

http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Research Domain Criteria (RDoCs)

•  Assumptions Underlying RDoCs –  A diagnostic approach based on the biology as well

as the symptoms must not be constrained by the current DSM categories,

–  Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,

–  Each level of analysis needs to be understood across a dimension of function,

–  Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

Research Domain Criteria (RDoCs)

RDoCs Example Matrix: Example Negative Valence

Transdiagnostic Treatment •  Empirically-supported Principles (ESPs):

–  Principles or techniques that are empirically demonstrated to contribute to clinical change

–  Applied in a flexible manner, based on clinician judgment (Beutler et al., 2000; 2002; 2003)

•  De-emphasizes trademarked therapies and refocuses to scientific mechanisms

•  Transdiagnostic treatment packages –  Match treatment strategies to specific emotional,

cognitive, behavioral, and functional domains –  Examples:

•  Modular Cognitive Behavioral Therapy for Childhood Anxiety Disorders (Guilford Press, 2007) by Bruce Chorpita

•  Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Oxford Press, 2010) by David Barlow et al.    

Part B: Principles Related to Resilience

•  Avoidance •  Memory Processing •  Social Connectedness

Fear Acquisition & Extinction (Bouton et al., 2004)

Brain & PTSD Summary (Mahan  &  Ressler,  2011)    

Fear Learning Model !

Trauma • Heightened Fear

Conditioning • Flatten Fear

Generalization Gradient • Attentional Bias to

Threat • Defense Response:

Avoidance

Genetic Factors • Candidate Genes • Individual Traits (e.g.,

neuroticism)

Environmental Factors

Impaired Extinction Learning

Pre-Trauma Factors: • Lower Socio-Economic Status • Lower Intelligence • Childhood Adversity • Prior Adult or Child Trauma • Prior Worse Adjustment

Peri-Traumatic Factors: • Trauma Severity • Perceived Life Threat • Peri-traumatic Emotions

Post-Trauma Factors: • Ongoing Life Stress • Lack of Social Support • Negative Cognitive Beliefs

(e.g., perception of current danger)

Forms of Avoidance •  Cognitive Avoidance

–  Thought suppression: push thoughts out of mind –  Distraction: keeping mind occupied with other things

•  Experiential Avoidance –  Modification of the form and frequency of unpleasant

internal experiences •  Behavioral Avoidance

–  Deliberate effort to avoid trauma-related activities, situations, places, things, or people

Clinical Recommendations •  Avoidance develops easily, as it is a defense

response to protect us from future danger –  Short-term effective but has long-term

consequences –  Paradoxical nature –  Example: Living in a Cave

•  Careful assessment of avoidance –  Cognitive, emotional, and behavioral –  Subtle or unaware of patterns behavior –  Evaluation of safety

•  “Getting Back to Life” –  Approach feared but safe activities, situations, and

places –  Allow distressing thoughts, images, and feelings to

be present

Part B: Principles Related to Resilience

•  Avoidance •  Memory Processing •  Social Connectedness

Reconstructive Nature of Memory

Hippocampal  Volume    and  Risk  (Bremner  et  al.,  1997)    

 

Hippocampal  Volume  and  Risk  (Gilbertson  et  al.,  2002)  

 

Com

bat T

win •  Combat twin hippocampal

volume and combat twin PTSD severity r = -.64

•  No combat twin hippocampal volume and combat twin PTSD severity r = -.70

Non

-Com

bat T

win

Hippocampal Volume Detrimental to Recovery (Apfel  et  al.,  2011)  

 

smaller than that of participants who recovered from PTSD (meandifference 6.5%, p ! .05) and those who never developed PTSD(mean difference 5.1%, p ! .05). There was no significant differencein mean adjusted hippocampal volume between participants whohad recovered from PTSD and participants who had never devel-oped PTSD (p " .7). When we replicated the analyses including onlyparticipants with trauma exposure, the results did not change in asignificant way.

Discussion

The main finding of this study is that current PTSD symptomswere associated with smaller hippocampal volume, whereas life-time PTSD symptoms were not. Participants with chronic PTSD hadon average a smaller hippocampus than those who recovered fromPTSD or never developed PTSD. The finding remained significantafter accounting for early life trauma, current and lifetime alcoholuse, depression, and treatment with antidepressants. This resultconflicts with our initial hypothesis that hippocampal volume is a

vulnerability marker for PTSD and as such should be associated withboth current and lifetime PTSD. Our results raise the possibility thathippocampal volume is state-dependent and might vary over time,consistent with findings in other pathologies.

This conclusion is supported by the aforementioned studiesshowing that duration and severity of PTSD symptoms werenegatively correlated with hippocampal size (1,20) and that hip-pocampal size increased after long-term paroxetine therapy inPTSD patients (21). A growing literature in other diseases showsthat the hippocampus can change in response to exercise, avariety of pharmacological interventions (42–50), and alcoholabstinence (39). The conclusion is also supported by our previ-ous finding in PTSD patients of reduced volume in the hip-pocampal subfield CA3 and the dentate gyrus (51,52), areas thatare known to undergo neurogenesis in adulthood (10,53,54).This would mean that the hippocampus can be damaged bypathophysiological processes in those with current PTSD andpotentially recover from the associated volume loss, due to cel-lular plasticity including neurogenesis.

The alternative interpretation of our findings modifies the con-clusion of Gilbertson et al. (22) that smaller hippocampal volume isa familial vulnerability factor for PTSD. Gilbertson et al. excludedtwin pairs when the combat-exposed brother had past but nocurrent PTSD; so they excluded recovered PTSD patients and com-pared only chronic PTSD patients with PTSD-resistant trauma-ex-posed veterans (55). Therefore, it is possible that PTSD symptomsdevelop independent of hippocampal volume; yet only patientswith (familial) small hippocampal volume develop a chronic nonre-mitting form of the disorder. This model would suggest that pa-tients with normal-sized hippocampus recover after some time andhas implications for predicting treatment success in interventionstudies. From this perspective a smaller hippocampal volume couldbe considered detrimental to recovery rather than a vulnerabilityfactor for developing PTSD.

It seems reasonable to hypothesize that — considering the roleof the hippocampus in learning, memory, and mood regulation—PTSD patients with normal hippocampal volume have a greaterprospect of recovery than those with decreased volume before

Table 4. Comparison of the Groups

NoTrauma

Trauma,No PTSD

RemittedPTSD

ChronicPTSD

p Valueof ANOVA

Number of Participants 95 (39%) 64 (26%) 41 (17%) 41 (17%)Age 46.4 44.4 43.0 42.1 .094Female Gender 15% 9% 20% 22% nsLifetime Alcohol Usea 25.56 32.82 34.68 37.47 nsCurrent Alcohol Usea 14.15 13.21 11.20 7.87 nsCurrent Marijuana Use 6% 5% 2% 17% .041Early Life Trauma Reported 7% 21% 24% 47% !.001Yrs of Education 15.0 14.7 14.3 14.3 nsUse of Antidepressants 12% 11% 20% 39% !.001ICV (mL) 1582 1606 1583 1569 nsDepression Score (HAM-D) 4.3 5.2 7.2 14.1 !.001Current CAPS Score 0 8.3 19.3 64.4 !.001Lifetime CAPS Score 0 20.7 63.3 84.9 !.001BL Hippocampal Volumea (mL) 5.292 5.343 5.367 5.006 .040BL Hippocampal Volume, ICV-Adjusteda (mL) 5.300 5.300 5.374 5.044 .046

N " 241. The four groups were defined by trauma exposure and PTSD symptom severity. No Trauma: no CriterionA event reported; Trauma, no PTSD: Criterion A event reported, lifetime and current CAPS score ! 40; Remitted PTSD:Criterion A event reported, lifetime CAPS score ! 40, current CAPS score ! 40; Chronic PTSD: Criterion A eventreported, lifetime and current CAPS score ! 40. Data is presented as means and percentages.

ANOVA, analysis of variance; BL, bilateral; other abbreviations as in Table 1.aDrinks/month.

Figure 3. Comparison of mean adjusted hippocampal volume in 241 GulfWar veterans. The error bars show the SD. The numbers at the base of thebars indicate the adjusted hippocampal volume in mm3. ICV, intracranialvolume; PTSD, posttraumatic stress disorder.

B.A. Apfel et al. BIOL PSYCHIATRY 2011;69:541–548 545

www.sobp.org/journal

Role of Retrieval Strength

Clinical Recommendations •  Initial trauma encoding creates a strong storage

strength –  Trauma memories are easily cued

•  Reexperiencing symptoms are a passive form of retrieval –  Potentially increase likelihood of having future

reexperiencing –  Impairs retrieval of other, potentially more adaptive

aspects of the trauma memory •  “Actively Making Meaning”

–  Not suppressing thoughts and memories –  Generation (rather than passive) retrieval is powerful

for altering what is retrieved –  Adaptive manner

Part B: Principles Related to Resilience

•  Avoidance •  Memory Processing •  Social Connectedness

Social Support & Men (King et al., 1998)

  FuncDonal  Support  Strongest  Predictor  

Social Support & Women (King et al., 1998)

 FuncDonal  

Support  Event  Strongest  Predictor  

Social Support •  One Definition (Hobfoll & Stephens, 1990)

–  “Those social interactions or relationships that provide actual assistance or a feeling of attachment to a person or group that is perceived as caring or loving.”

•  Negative Social Support –  Overtly negative –  Indifference or invalidation

•  Positive Social Support –  Quantity versus quality –  Perceived versus received –  Emotional versus instrumental –  Formal versus informal –  Sustained versus acute

 

Clinical Recommendations

•  Validate –  Negative reactions can have a long-lasting impact –  Validate trauma survivors reactions

•  Connect the trauma survivor with family/friends

•  Encourage –  Stick with or reestablish a normal routine –  Willing to listen; encourage to talk when ready

•  Sustain the support –  Acute support declines with time –  Regular and routine contact

 

Part C: Rethinking Our Approach

•  Individual Approaches •  Community Approaches

Maslow’s Hierarchy of Needs

Social Ecological Model for Promoting Resilience &

Recovery •  What is our role and what should we be

doing?

Op4mizing  PTSD  Treatments  (OPT)  Study    R01MH66347  (Zoellner)  R01MH66348  (Feeny)  

PTSD

Choice

No Choice

PE

PE+SER

PE

PE+SER

Randomization 10 Weeks Tx Follow-Up

Responder: 9 Mo FU

Non-Responder:

Alt. Tx 9 Mo FU

OPT:    hXp://www.PTSDOp4ons.org  

Guthrie  Annex  2,  2nd  Floor  Box  351525,  University  of  Washington  SeaXle,  WA  98195    NIMH-­‐sponsored  PTSD  Treatment  Trial:    OPT:    hXp://www.PTSDOp4ons.org    

Study  Coordinator:    (206)  685-­‐3617      

How To Reach Us: