Trauma and stress disorders/PTSD (George Hales)

Approximately how many British Troops were treated for ‘shell shock’ after WW1

80,000

Shell shock was labelled as … rather than admit that war itself if … (Stone, 1985)

‘illness’ rather than admit that war itself is horrific

WW2 brought … from all over the world

psychiatrists

Consensus developed that some standardisation was needed which led to the creation of

the first diagnostic manual

When APA published the first edition of the DSM they included a diagnosis called “Gross Stress Reaction” describe this condition

it occurs in response to an exceptional physical or mental stress, such as a natural catastrophe or battle

• occurs in people who have had no previous diagnosis

• must subside in days to weeks

Between 1968 and 1980 there were no official diagnosis for

stress disorders

In 1980, the DSM 3 included Posttruamatic Stress Disorder, describe it

• it includes 17 symptoms across three clusters:

  • re-experiencing

  • avoidance & emotional numbing

  • hyperarousal

What is the rule to be diagnosed with PTSD in the DSM 5

must have been exposed to a significant traumatic event and for at least 30 days have a recurrent symptom

• symptoms must be associated with impairment in at least one area of life

  • e.g. social, occupational, relational

• symptoms must not be due to other influences

  • e.g. medication, substance use, or other illness

In the DSM 5 criteria for PTSD name the recurrent intrusion symptoms associated with the traumatic event

• distressing memories

• distressing dreams

• flashbacks

• psychological distress or physiological reactions to exposure to cues that resemble the traumatic event(s)

In the DSM 5 criteria for PTSD name the avoidance symptom associated with the traumatic event

• avoidance of distressing memories, thoughts, or feelings about the event

• avoidance of reminders of the event

In the DSM 5 criteria for PTSD name the negative alterations in thought/mood associated with the traumatic event

• inability to remember an important aspect of the traumatic event

• persistent and exaggerated negative beliefs or expectations about self, others or the world

• persistent, distorted thoughts about why the event occurred

• persistent negative emotional state

• markedly diminished interest or participation in significant activities

• feelings of detachment from other people 

• difficult experiencing positive feelings

In the DSM 5 criteria for PTSD name the symptoms associated with arousal and reactivity associated with the traumatic event

• irritability

• reckless behaviour

• hyper-vigilance

• exaggerated startle response

• concentration problems

• sleep problems

Why do some countries have low rates of PTSD

possibly due to stigma about reporting traumatic events

What is one of the strongest protective factors from exposure to traumatic events

marriage

Women significantly more likely than men to experience (Kessler et al., 2017)

intimate partner sexual violence

Men are more likely than women to experience (Kessler et al., 2017)

physical violence and accidents

Traumas involving violence and accidents are more likely to occur in (Kessler et al., 2017)

adolescence and young adulthood

Limitations on studies/diagnosis of trauma

• trauma is hard to quantify

• many studies based on retrospective recall (memory bias)

• evidence that false negatives are more common than false positives

• people more likely to underreport traumas

• differences in response rates per country

  • cultural and societal norms around how acceptable/stigmatised it is to talk openly about trauma

Prevalence of PTSD

• lifetime prevalence rates of 13-20% for women and 6-8% for men (Breslau et al., 1991; Kessler et al., 1995)

• higher 12 month prevalence rates in high income then in low and middle income countries (Karam et al., 2014)

  • high income = Northern Ireland 3.8%, US 2.5%, New Zealand 2.1%

  • low income = Colombia 0.3%, Mexico 0.3%

rates of PTSd are lower than of traumatic events

Trauma responses may differ based on how

resilient we are

• the higher the resilience the:

  • Lower risk of developing PTSD or depression

  • Faster recovery from trauma-related symptoms

  • Better use of coping strategies

  • Greater emotional and physiological regulation

  • Higher likelihood of post-traumatic growth

What are the biological causes of trauma (Pre-trauma)

• heritability

• gene x environment

What are the biological causes of trauma (Pre-trauma) - heritability

• increased risk of developing PTSD if parents had it (Roth et al., 2014)

• but cannot rule out the impact of shared environment

  • e.g. might simply have been born into a traumatic environment

What are the biological causes of trauma (Pre-trauma) - gene x environment

• there is no ‘PTSD’ gene, instead look at gene x environment

• short allele (5-HTTl PR S) associated with PTSD but only in highly traumatic events (Gressier et al., 2013)

Those with PTSD have a smaller (Logue et al., 2018)

hippocampus

What are the environmental causes of trauma (Pre-trauma)

• sociodemographic factors

• prior or current psychiatric disorder

• family history of psychiatric disorder

• social factors

• coping strategies

What are the environmental causes of trauma (Pre-trauma) - sociodemographic factors

• females twice as likely to be diagnosed (Pineles et al., 2017)

• men and women have different emotional, cognitive, and neurobiological risk for PTSD (Pineles et al., 201&)

What are the environmental causes of trauma (Pre-trauma) - prior to current psychiatric disorder

majority of PTSD cases having at least two other disorders, taking into account comparable symptoms (comorbidity) (Perkonigg et al., 2000)

What are the environmental causes of trauma (Pre-trauma) - family

family history of psychiatric disorder

What are the environmental causes of trauma (Pre-trauma) - social factors

unstable family life in early childhood

What are the environmental causes of trauma (Pre-trauma) - coping strategies

• emotion-focused

• avoidant

• negative coping styles

Psychological factors in peri-trauma

• peri-trauma fear

• perceived life threat

• peri-traumatic dissociation consistently found to be a risk factor for development of PTSD 

  • depersonalisation (person feels detached from themselves)

  • derealisation (external world feels unreal or distorted)

  • dissociation amnesia (out of body experience, gaps in memory that are too large to be explained by normal forgetting)

What happens after trauma

• negative coping styles

• maladaptive coping strategies

• lack of social support

• ‘mental defeat’

Complex PTSD (cPTSD) is similar to PTSD but differs in two key ways:

• feelings of worthlessness, shame, or guilt

• problems controlling emotions

• finding it difficult to connect with other people

• relationship problems, having trouble keeping friendships and relationships 

Complex PTSD is caused by…

experiencing recurring or long term traumatic events, such as:

• child abuse or neglect

• domestic violence

• extreme subjugations

  • e.g. torture, trafficking

• war

Describe the study by Hoskins et al., 2015

• reviewed pharmacotherapy for PTSD

• data from 21 studies compared SSRI’s vs. placebo

• SSRIs were found to perform better than placebo, but the effect size was very small

When does medicine get used for PTSD

• medication is typically inferior to affect trauma focused therapies/interventions

• WHO guidelines recommend antidepressants as a second line of treatment of PTSD when psychological interventions don’t work as well

Trauma-focused cognitive behavioural therapy (TF- CBT)

• go to treatment

• targets specific traumas, sensitive to the unique problems resulting from abuse, violence, or grief

• typically 8 to 25 sessions

Trauma-focused cognitive behavioural therapy (TF- CBT) - cognitive behavioural techniques 

used to help modify distorted to unhelpful thinking and negative reactions and behaviour

Trauma-focused cognitive behavioural therapy (TF- CBT) - family therapy techniques 

often implemented

• e.g. with non-abusive parents

What is eye movement desensitisation and reprocessing (EMDR) (Shaprio, 1989)

psychotherapy used mainly to treat trauma and PTSD, but it can also help with anxiety, phobias, and distressing memories

How does eye movement desensitisation and reprocessing (EMDR) work?

A therapist guides you to focus on a traumatic memory while simultaneously engaging in bilateral stimulation, such as:

• Moving your eyes left and right

• Tapping on your hands

• Listening to alternating tones

This left–right stimulation activates both sides of the brain.

How does eye movement desensitisation and reprocessing (EMDR) help?

It’s believed to help the brain:

• Process the memory more normally

• Reduce the emotional intensity

• Separate the trauma from the fear response

• Store the memory in a healthier, non-distressing way

You do not erase the memory — it simply becomes less overwhelming.

Describe the process of eye movement desensitisation and reprocessing (EMDR)

• Usually conducted in 8 parts

•  After the clinician has determined which memory to target first, they ask the client to hold different aspects of that event or thought in mind and to use their eyes to track the therapists hand as it moves back and forth across the client’s field of vision

What is eye movement desensitisation and reprocessing (EMDR) believed to be connected to?

Believed to be connected with the biological mechanisms involved in Rapid eye movement (REM) sleep.

• Internal associations arise and the client begin to process the memory and disturbing images

Describe the study by Bisson, Roberts, Andrew, Cooper, & Lewis, 2013 - Cochrane Systematic Review

• the review support the efficacy of these psychological treatment

  • individual TF-CBT and EMDR were substantially more effective in reducing PTSD symptoms as compared to TAU

  • no difference in efficacy between TF-CBT and EMDR

  • TF-CBT and EMDR were more effective than other psychotherapies

  • effective for children, adolescents, and adults

  • recommended as the treatments of choice