Understanding More About Psychological Trauma Reactions

Working with people with PTSD Whilst Awaiting a Specialist

Therapy

Mike Scanlan

The Problems with Diagnosis

• Strict adherence is unhelpful within a recovery oriented stepped care service

• Lifetime prevalence of about 8%

• We need the person to have had symptoms for over 1 month and often a diagnosis cant be made until 6 months post incident.

The Harry Potter approach

• We often get GP’s referring on people with a cluster of symptoms.

• Hypervigilance• Avoidance• Cued anxiety• Social withdrawal

• What else might cause these symptoms?

What else?

• Early onset dementia (trauma?)

• Adjustment reaction

• Panic

• OCD

• Acute Stress Disorder.

A mnemonic can help • TRAUMA = PTSD

• Traumatic event - the person experienced, witnessed, or was confronted by actual or threatened serious injury, death, or threat to the physical integrity of self or other and, as a response to such trauma, the person experienced intense helplessness, fear, and horror

• Re experiences such traumatic events by intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images.

• Avoidance and emotional numbing emerge, expressed as detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experience

• Unable to function Symptoms are distressing and cause significant impairment in social, occupational, and interpersonal functioning

• Month These symptoms last more than 1 Month • Arousal is increased, usually manifested by startle reaction, poor

concentration, irritable mood, insomnia, and hypervigilance

22 Question -IES

• 24 + PTSD is a clinical concern. Those with scores this high who do not have full PTSD will have partial PTSD or at least some of the symptoms.

• 33 and above represents the best cut off for a probable diagnosis of PTSD.

• 37or more This is high enough to suppress your immune system's functioning (even 10 years after an impact event).

More than just a score

• Intrusion• Hyper arousal• Avoidance• Adds to the MDS• Remember it is subjective – REF?• Care planning tool• Indicator of strengths• Shattered Assumptions, Betrayal, Fear• Indicates a need for CBT / EMDR

So we know they are troubled by psychological trauma – What now?

There’s a lot we can do while waiting for CBT/EMDR • Normalise – Shared understanding (3 or 5)• Assess for risks, strengths and give hope• Be an advocate – (solicitors)• Bibliotherapy (de stigmatisng, hope of recovery, Stories • Sleep w’shop (People with PTSD become afraid of

sleep)• Medication?• Exercise• Watch out for substance misuse• Safe Place• Centering exercise• Cognitive -restructuring

A word about debriefing

• NICE guidance (2005) makes it clear that debriefing should not be routine practice. Wesselly et al (2000) actually states that 'Debriefing may paradoxically induce that distress in those who would otherwise not have developed it'

And Another

• A primary care patient feeling confused, angry and isolated may need to be listened to and to be reassured. They may need to tell their story and ask to be able to do so. Suggest using the 3rd person. This is not debriefing. This is natural empathic caring and is an important function of good stepped care. In these days of protocol driven care it is worth perhaps reflecting on the therapeutic value of just listening (Cox et al 1987) re-framing and normalising.

The Safe Place

• Not restricted to EMDR

• Link with relaxation

• Think of a place where you have felt comfortable and safe

• Are the people your with OK?

• Build it – use olfactory links, visual cues and sounds

• Lets have a go – put in a test

Disassociation

• A common adaptation is spontaneous disassociation when confronted with painful pictures or memories.

• This again limits choice – but is a coping mechanism – Be careful not to omit the behaviour.

• As a stepped care practitioner we can offer the choice of being more centred

Centering

• Think about something you would rather forget – choose wisely

• 5 Things you can See• 4 things you can hear• 3 things you can touch• 2 things you can smell• 1 thing you can taste

Preventative Cognitive Restructuring

• ASD – you are attempting to prevent PTSD from developing. (Foa 1995)

• Partial PTSD – you are helping the patient to limit the damaging impact of self critical cognitions. Needs to be here and now and focussed on the traumatic event and the persons (usually self critical) interpretation of their role in the event.

• Guided Self Help – Needs research

Post Traumatic Growth • PTG research shows changes in 3 areas:• Ones’ philosophy of life. A greater appreciation

of life and small joys.• Enhanced spirituality. The perception of self:

Through existential reevaluation and reconstruction of the challenged or shattered assumptive world

• One’s relationship to others: Perception of others is transformed, intimacy and compassion is deepened.