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Special populations

Special populations. Headaches CRPS/Complex trauma GAD UTI/ Vaginismus Complicated bereavement. Headaches. One of most common pain complaints 1 year prevalence rate 12-14% (migraine) Often a symptom of trauma 25% of headache sufferers (migraine clinic) have PTSD

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Special populations

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  1. Special populations • Headaches • CRPS/Complex trauma • GAD • UTI/Vaginismus • Complicated bereavement Mark Grant

  2. Headaches • One of most common pain complaints • 1 year prevalence rate 12-14% (migraine) • Often a symptom of trauma • 25% of headache sufferers (migraine clinic) have PTSD • 50% of combat veterans • Higher likelihood of physical or sexual abuse Mark Grant

  3. Headache case. Mark Grant. MA, MAPs

  4. EMDR ‘targets’ Mark Grant MA

  5. EMDR (present pain) Mark Grant

  6. Caution! When is a headache not a headache? • Sudden onset • Non-responsive to medication • Other symptoms (seizures, changes in vision or hearing) • Aggravated by coughing or sneezing Mark Grant MA

  7. CRP/RSD • Trauma can be a predisposing factor following injury • Median PTSS-10 score similar to trauma survivors (118 patients) • Similar neurological profile to PTSD • CRPS has been reported to be elicited by stress exacerbation in patients with PTSD (Huge et al, 2011) Mark Grant MA

  8. CRPS/complex trauma. Mark Grant. MA, MAPs

  9. EMDR targets Mark Grant MA

  10. EMDR (present pain) Mark Grant

  11. Elements of treatment (complex trauma) • Extended preparation stage • Teaching of grounding techniques • Addressing ‘fear of feelings” • Teaching client how to self-soothe instead of self-injure • Teaching client how to attend to their pain by showing appropriate care and concern • Challenge feelings of unworthiness • Developing resources • Ego-state work Mark Grant. MA, MAPs

  12. Generalized Anxiety Disorder • Prevalence = 2 - 5% of general pop’n • DSM criteria somatic symptoms; restlessness, fatigue, concentration problems, irritability, muscle tension and sleep disturbance. • Often associated with somatic complaints such as low back pain and headaches and insomnia • One study found 50% of IBS sufferers also had GAD • 17% of PTSD sufferers also have GAD Mark Grant MA

  13. GAD case. Mark Grant. MA, MAPs

  14. EMDR targets Mark Grant MA

  15. EMDR (present pain) Mark Grant

  16. UTI/vaginismus • Trauma is a predisposing factor • 1 in 5 women will have a UTI in lifetime • Women sufferers more than twice as likely to report some form of sexual molestation during childhood • UTI can lead to or exacerbate vaginismus Mark Grant MA

  17. UTI/vaginismus case. Mark Grant. MA, MAPs

  18. EMDR targets Mark Grant MA

  19. EMDR (past trauma) Mark Grant

  20. Complicated bereavement • Pain is symptom of trauma • Prevalence = 2% of normal pop’n • 20% of soldiers from Afghanistan, Iraq • Physical symptoms can include shortness of breath, heart palpitations, headaches, lethargy Health issues (increased risk of); • cancer, • cardiac problems, • suicidality , • substance abuse Mark Grant MA

  21. Complicated bereavement Mark Grant. MA, MAPs

  22. EMDR targets Mark Grant MA

  23. EMDR (past trauma + present pain) Mark Grant

  24. Key points: • Although triggered by current stress/trauma, Pain is often a symptom of earlier trauma. • Target sequence addresses both past trauma and present pain, depending on client readiness. • Target may incorporate past and present pain. • Reprocessing often starts with present pain because of safety issues (also easier to address past trauma after present pain is better managed). • Duration of treatment, outcomes and need for additional inputs depends upon complexity of trauma Mark & Ana Grant

  25. Complex trauma and pain • Victims of long-term sexual and physical abuse • Victims of emotional neglect • Victims of childhood abuse and neglect who have also suffered later trauma (eg; serious accident, rape, combat, workplace bullying) + injury, IIIness, disability Mark Grant. MA, MAPs

  26. Elements of treatment • Extended preparation stage • Teaching of grounding techniques • Address ‘fear of feelings” • Teaching client how to self-soothe instead of self-injure • Teaching client how to attend to their pain by showing appropriate care and concern •  Challenge feelings of unworthiness • Developing resources • Ego-state work Mark Grant. MA, MAPs

  27. Grounding techniques Interpersonal: • “Its okay, you are safe now, you are here with me…” Somatic: • “Can you feel your feet touching the floor?” • ”Can you pay attention to your breathing..” • “look at your hands or feet.. you’re a big boy/girl now.” Mark Grant. MA, MAPs

  28. Addressing fear of feelings • Facilitating accepting atmosphere (showing empathy, acceptance) • Psychoeducation about the meaning of feelings, including pain • Normalizing feelings, including feelings of wellness/feeling okay Mark Grant. MA, MAPs

  29. Self-soothing techniques • Psychoeducation (teaching how to self-soothe instead of self-injure); “Pain means you are hurt and need help” “What does an animal do when its wounded” “Humans are the only creature capable of ignoring pain” • Developing self soothing strategies; “What things or places make you feel the most relaxed/safe/secure?” (hints; a trusted friend, a pet, a room or place, music, activity such as craft etc) Mark Grant. MA, MAPs

  30. Self-care skills training • Attending to the pain experience; “Even though I can’t feel your pain, I can see you are hurting and I am going to TRY TO help you” “You’re not alone - I am here” (reparenting) • Addressing feelings of unworthiness; “What have you done that makes you so underserving of even basic medical attention/self-care?” “What have you done to feel that you only deserve to suffer.. forever?” “Everyone is entitled to a pain-free life” Mark Grant. MA, MAPs

  31. Body resource exercise “I want you to mentally scan your whole body… and find a relaxed, calm place… somewhere that feels normal …and just notice how it feels there…maybe soft… warm…loose…maybe a certain size, shape or colour… just noticing how it feels…different to the rest of your body… and maybe you can get an image of how that calm place feels.. and that image can remind you that you can feel better” Mark Grant. MA, MAPs

  32. Pendulation “Now I want you to notice the area of pain [or discomfort] … and notice how that feels… and when you have that clear enough … take your mind back to that relaxed, calm place …and notice how that feels again there… just noticing how it feels…and how different it feels to the pain …and then when you have got that clear, I want you to notice the pain again… and how it feels .. And whether it feels any different to before..” and so on… (Adapted from Peter Levine) Mark Grant. MA, MAPs

  33. Ego state therapy • “..based on the premise that personality is composed of separate parts, rather than being a homogeneous whole.  These parts (which everyone has) are called ego states.  The therapist learns to work directly with the state that can best benefit from change, rather than merely working with an intellectual, talkative state.” Emmerson, Mark Grant. MA, MAPs

  34. Solo mother with chronic pain T: I can almost feel how heavy and defeated you must be feeling CL: I do feel defeated – but I don’t want this to affect my children (staring into space) T: You seem lost CL: That’s how I feel - I dunno where I am at the moment T: I guess you’re just taking things one day at a time – before the pain you sort of had your life figured out but now.. Mark Grant. MA, MAPs

  35. Solo mother with chronic pain CL: (interrupts) No, I had it ALL figured out, I was in control of everything, now I can’t even be bothered cleaning the bathroom. I feel like a complete failure. T: What about the children? CL: Oh well of course I get up and make their breakfast and school lunch etc.. T: I’m hearing that there’s a defeated part, but that there’s also a part that won’t quit, who gets up and makes the children’s breakfast no matter how tired and defeated she feels.. Mark Grant. MA, MAPs

  36. Solo mother with chronic pain Cl: That part is the only part I feel I have control over T: have you ever thought how maybe those parts might compliment each other? Cl: Huh? T: Well the defeated part is telling you to rest, but then the ‘in control’ part tells you to try harder, and motivates the responsible part to keep looking after the children. Cl: I never thought of things that way T: What I’m saying is that you need BOTH parts; Mark Grant. MA, MAPs

  37. Solo mother with chronic pain T: ..and they need to work together, but at the moment they’re kind of pulling in different directions. Cl: Uhuh T: So what if the defeated part could say to the ‘in-control’ part, ‘I’m tired and I need a rest’ and the ‘in-control’ part could actually hear that and use it to pace yourself better? Cl: I dunno… Th: Actually, its already happening, you don’t do as much now so as to conserve energy for the children Mark Grant. MA, MAPs

  38. Solo mother with chronic pain T: The problem is that the ‘in-control’ part labels this as failure instead of seeing it as a form of self-preservation. CL: Yes, that’s true T: So if we could talk to the part that feels defeated first, what do you think it would say to the ‘in-control’ part? CL: I simply can’t do as much as I used to be able to T: And what would the control part say back? CL: I have to adjust my expectations.. Mark Grant. MA, MAPs

  39. CRP/RSD • Trauma can be a predisposing factor following injury • Median PTSS-10 score similar to trauma survivors (118 patients) • Similar neurological profile to PTSD • CRPS has been reported to be elicited by stress exacerbation in patients with PTSD (Huge et al, 2011) Mark Grant MA

  40. CRPS/complex trauma. Mark Grant. MA, MAPs

  41. EMDR targets Mark Grant MA

  42. Elements of treatment (complex trauma) • Extended preparation stage • Teaching of grounding techniques • Addressing ‘fear of feelings” • Teaching client how to self-soothe instead of self-injure • Teaching client how to attend to their pain by showing appropriate care and concern • Challenge feelings of unworthiness • Developing resources • Ego-state work Mark Grant. MA, MAPs

  43. Complex trauma case #2. Mark Grant. MA, MAPs

  44. EMDR ‘targets’ Mark Grant MA

  45. EMDR target (past trauma) Mark Grant

  46. Hysteria “A hysteric is someone who cannot tell a story.. At least a coherent story – a story whose disparate parts hang together. When a hysterics narrative reaches its climax it tends to hang fire … an explanatory scene is missing.” Deborah Elise White, 1989 Mark Grant. MA, MAPs

  47. Summary. • Long preparation phase; don’t start EMDR until affect tolerance evaluated and addressed. • Lots of resourcing (ego states) • Obtain consensus from the ‘parts’ for dissociated or DID clients • Start small (not even a small ‘t’) • “Baby steps” “Baby steps” “Baby steps” • Pacing - EMDR interspersed with… • Lots of re-evaluation, psychoeducation (Acknowledgment: Forgash & Knipe, 2008) Mark Grant. MA, MAPs

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