PTSD in Physicians: A Treatment Approach with Eye Movements

(Accelerated Resolution Therapy)

MS Caduceus Annual RetreatJuly 11-13

Alexis Polles, MD, PLLC

OUTLINE

I: Trauma and its sequelae II: Trauma in physicians III: Treatment options III: Use of special approaches in the

treatment of trauma• Eye Movements

IV: Conclusion

Definition of TraumaThe diagnostic manual used by mental health

providers (DSM-5) defines trauma an event that involves actual or threatened death or serious injury or sexual violation in which the individual:

• directly experiences the event• witnesses the event in person• learns that the event occurred to a close friend or

relative • experiences first-hand repeated or extreme

exposure to aversive details of the traumatic eventDSM-IV requirement that “The person’s response to the event must

involve intense fear, helplessness or horror” has been eliminated in DSM-5.

•

Trauma• May include events that are not beyond

the scope of normal human experience, as long as the event has had a trauma-like impact on the person.

• DSM-5 moved it from an Anxiety Disorder to Trauma- and Stress-or-Related Disorders

• What makes an event traumatic:– The severity of the event– The proximity of the experience– The personal impact of the event– The after-event impact

Potential Victims Of A Traumatic Stressor

1 Primary Victims

Those individuals most directly affected by the event, e.g., the persons whose houses are blown down in a hurricane.

2 Secondary Victims

Those individuals who in some way observe the consequences of the traumatic event on the primary victims, e.g., bystanders, rescuers, and emergency response personnel. (Partners/kids)

3 Tertiary VictimsThose individuals who are indirectly affected by the traumatic event as a result of later exposure to the scene of the trauma or to the primary or secondary victims of the trauma.

Stress Management and Disasters

NoneTransient

or no symptoms

Acute Stress

DisorderPTSD +

TraumaConsequencesImpairment > 30dRe-experience, arousal and avoidant symptoms Co-occurring syndromes

--

+-/+-

++-

++++

+++++++++

Trauma Spectrum

Types of PTS/PTSDSimple PTS/D• The response to one or more traumatic

events that are NOT linked in any way (e.g., one rape, one car accident, one sudden loss).

Complex PTS/D• The response to a combination of specific

traumatic events that ARE linked to each other in some way or occur repeatedly over time

Symptom Clusters(Now four in DSM-5)

• Re-experiencing• Avoidance• Persistent Negative Alterations in

Cognitions and Mood (retains numbing symptoms and includes other symptoms such as persistent negative emotional states and includes inability to remember key aspects of the event)

• Arousal (includes fight and flight) Subtypes include kids < 6 and dissociative

Trauma is an experience that overwhelms our capacity to have a sense of control over ourselves and our immediate environment, to maintain connection with others and to make meaning of our experience.

In Summary:

How does the past become the present?

•Threat + Sensorimotor Experience (Traumatic Cues) + Level of Arousal is imprinted in procedural memory and leads to fear conditioning •There is a walling off of this memory (“dissociative capsule”) that is brought into the present by external representative cues or internal cues

Trauma and the Brain• Thalamus (temporal lobe) receives

sensory signals• Amygdala sorts for immediate

danger- Shuts down ‘thinking brain’- Diverts energy to physical response

• Hippocampus stores episodic long term memory

• Reactivation of this pathway strengthens it

¥ Thoughts that perpetuate arousal: “It is my fault;” “I am being punished;” “the world is not safe.”

And inhibits¥ Thoughts that might attenuate

arousal: “I did the best I could” “These things happen – you can’t control everything” and “the world is usually safe, and fortunately I survived this event… It’s over”…

Leads to

Interference with proper integration of emotional memories

Adapted from Dr. Uri Bergman

14

Trauma Response

Amygdala

Visual Cortex

Trauma Response

Healthcare Professionals and PTSD

• Most studies are with non-physician providers (EMTs), first responders

• Nearly all of those dealing with physicians/nurses are post disaster

• Much written on physician “stress and burnout” that does not specifically look at PTSD spectrum disorders

Physician Specific Literature Review

– There was no association between PTSD symptoms and professional exposure to victims inside the hospital in studies of non-military physicians in terrorist attacks/war zones

– 15.6% had PTSD symptoms– No gender differences– Burnout was significantly more prevalent among

doctors with PTSD– Those with PTSD used more negative coping

strategies and functioning was significantly reduced– Only 15% of those with PTSD and who had identified

themselves as having it actually attended available therapy

– SOOOOO……

What do affected physicians do?

• Drugs/Alcohol• Overwork• Overeat• Some gamble/game

Posttraumatic Stress and Co-Occurring Disorders

• Trauma survivors often attempt to control their internal state of hyper or hypo arousal through the use of substances or behaviors that produce neurotransmitter responses similar to those produced by substances

• While substances may initially restore a sense of control, they actually inhibit the accessing of memories

and integrating the experience in an adaptive manner.