What’s special about Trauma? Collaborative Mental Health Care Network CME February 19 th 2010 Clare Pain MD

1. What’s special about Trauma? Collaborative Mental Health Care Network CME February 19th 2010 Clare Pain MD

2. Does everyone who is traumatized get PTSD? PREVALENCE OF PTSD IN USA General population60.5% of men and 51.2% of women had one Criterion A event. Life time prevalence of PTSD 5.0% for men and 10.4% for women

3. Longitudinal Course of PTSD Symptoms 6% recovered 53% recovered 58% recovered 15-25% UNRECOVERED Weeks 3 months 9 months YEARS Shalev & Yehuda, Psychological Trauma 1998

4. Relationship of Childhood Abuse and Household Dysfunction (Felitti et al Am J Prev Med 1998)

5. 10 ADULT RISK BEHAVIOURS Smoking Severe obesity Physical inactivity Depressed mood Suicidal attempts Alcoholism Any drug abuse IV drug abuse  50 Sex Partners History of STD DISEASES Ischemic Heart Disease Any Cancer Stroke COPD Diabetes Hepatitis or Jaundice Skeletal fractures Poor self-rated health Relationship of Childhood Abuse and Household Dysfunction (Felitti et al am J Prev Med 1998)

6. Relationship Between Adverse Childhood Events and Mental and Physical Health Graded Relationship Between the Number of Adverse Childhood Events and Mental and Physical Health •  50% had oneAdverse Childhood Event • 25% had  2Adverse Childhood Event • 6% had  4Adverse Childhood Event • 4+ events compared to 0: 4-12 fold - alcoholism, drug abuse, depression and suicide attempts • 4+ events compared to 0: 2-4 fold- smoking, poor self- rated health,  50 sex partners, history STD

7. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional motivating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

8. AROUSAL+++ Poor Sleep Chronic Irritability Bursts Of Anger Poor Concentration Hypervigilence Jumpy Physiologic reactivity Psychological distress Accommodate AVOIDANCE of triggers NUMBING of general responses Support ++ communication rest and food INTRUSIVE RECOLLECTIONS SOMATOFORM DISORDERS SUBSTANCE DISORDERS (Episodic) Model of Acute PTSD Leading to Chronic Complex PTSD SLEEP DISORDER ANXIETY DEPRESSION BIPOLAR DISORDER PANIC AGOROPHOBIA “PSYCHOSIS” TRAUMA PERSONALITY DISORDERS PHOBIA DISSOCIATION MEMORY DISORDER COGNITIVE DISORDERS No Work No Friends No Life SEXUAL DISORDER

9. “Trauma Spectrum Disorders” • Acute Stress Reaction • Acute Stress Disorder • PTSD - acute • Partial PTSD • PTSD – Chronic • PTSD and co-morbidity • Chronic Complex PTSD(dissociation,somatoform disorders, subs abuse, self harm, chronic suicidality, depression - anger– social isolation avoidance – shame – affect sensitivity – alcohol/drugs • Dissociative Disorders (Amnesia, Fugue, Depersonalization,NOS) • Dissociative Identity Disorder

10. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional motivating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

11. Emotional motivational systems • Seeking – curiosity…always on, pleasure turns off seeking curiosity • Attachment • Play • Fear – when activated takes precedence • Sociability • Caretaking • Sexuality/Sensuality

12. Frontal Cortex Limbic Assoc. Midbrain Cortex Brainstem Intimacy VigilanceFearRest Alarm TERROR (Bruce Perry, 1994)

13. Cascade of Fear Defences(Janet, van der Hart, Ogden) “Mobilizing defenses” “Immobilizing defenses” Cry Freeze (a.) increased arousal Flight Fight Freeze (b.) decreased arousal, empty emotional content Detachmentdepersonalization/derealization Submit robotic compliance Recuperate pain, trembling

14. Dissociation High levels of stress reduce the efficiency of memory encoding: – e.g. peritraumatic dissociation – when events may be subjectively slowed down or viewed from an alternative ‘out of body’ perspective. Peritraumatic dissociation is associated with an increase in spontaneous memory intrusions and with disorganization in deliberate trauma recall - PTSD

16. Mentalizing and choice Automatic Behaviour Procedural Memory THREAT Mentalizing Choice

17. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional motivating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

18. Attachment—Strange Situation

19. Attachment and mentalizing The precondition for reliable mentalizing is a secure attachment (Fonagy, pg. 687, 1997) Successful parental mentalizing —reflects understanding of cause of distress and appreciation of the child’s affective stance Just as secure attachment is a necessary precondition for mentalizing, so a secure therapeutic base is required for the ‘exploration’ of psychotherapy (Not “trust” but a secure base – parentified child….) …Help them find their mind, via your mind

20. What is Mentalizing? Attending to mental states in oneself and others Holding mind in mind Understanding misunderstanding Seeing oneself from the outside and others from the inside Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) Involves appreciating intentionality as different from behaviour (e.g. the half eaten chocolate bar)

21. Impaired mentalizing in maltreated children • Less inclined to engage in symbolic play • Less conversation about internal emotional states • Difficulty understanding emotional expressions • Less likely to respond empathically to peers’ distress • Show more emotionally-dysregulated behavior “Small t trauma”

22. Risk Factors for PTSDBrewin 2000, Shalev 2002 Pre Trauma:Gender Younger age at trauma SEC Education Intellect Race *Psychiatric History *Childhood abuse Other previous trauma Other adverse childhood events *Family Psychiatric History Trauma: Trauma Severity Post trauma: Lack of social support Ongoing life stressors <0.2 >0.2 0.4 0.3

23. AROUSAL DYSREGULATION FOLLOWING TRAUMA/NEGLECTOgden and Minton 2000 HYPERAROUSAL A R O U S A L OPTIMAL AROUSAL ZONE NUMBING/FROZEN/ DISSOCIATED

24. OPTIMAL AROUSAL Ogden and Minton 2000 HIGH ACTIVATION A R O U S A L AROUSAL CAPACITY BOUNDARIES LOW ACTIVATION

25. Differences between the behavioral curves of normal and high-risk infant-mother dyads (Field, 1985) Gaze Avert Cry Stimulation AROUSAL (Heartrate) 1 2 3 4 5 1 2 3 4 5 Gaze Avert Laugh Smile Stimulation

26. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional activating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

27. PTSD AND CO-MORBIDITY (COMPLEX PTSD) DISORDER OF EXTREME STRESS NOS PTSD “comorbidity” 78% with one other Axis I conditions 44% with 3+ other Axis I conditions Substance abuse 60-80% Depression 65% General anxiety Phobia - simple 31% - social 50% Panic disorder 20% Somatization Psychotic - dissociation Personality disorders 30-50% (Antisocial/borderline)

28. DSM-IV ASSOCIATED FEATURES AND DISORDERS IN PTSD X 14 • Guilt feelings • Phobic avoidance • Impaired affect modulation • Self destructive and impulsive behavior • Dissociative symptoms • Somatic complaints • Feelings of ineffectiveness, shame, despair, or hopelessness • Feeling permanently damaged • Loss of previously sustaining beliefs • Hostility • Social withdrawal • Feeling constantly threatened • Impaired relationships with others • A change from the individual’s previous personality characteristics

29. Disorders of Extreme Stress Not Otherwise Specified (DESNOS) - Proposed Criteria A: ALTERATIONS IN REGULATION OF AFFECT AND IMPULSES • Chronic affect dysregulation • Difficulty modulating anger • Self-destruction and suicidal behaviour • Difficulty modulating sexual involvement • Impulsive and risk-taking behaviour B: ALTERATIONS IN ATTENTION OR CONSCIOUSNESS • Amnesia • Dissociation C: SOMATIZATION • GI; chronic pain; cardiopulmonary; sexual

30. Disorders of Extreme Stress Not Otherwise Specified (DESNOS) - Proposed Criteria D: ALTERATIONS IN SELF-PERCEPTION • Chronic guilt and responsibility; shame; feelings ofself-blame and ineffectiveness; of beingpermanently damaged; feelingno one can understand;a tendency to minimize E: ALTERATIONS IN PERCEPTION OF PERPETRATOR • Adopting distorted beliefs and idealizing the perpetrator F: ALTERATIONS IN RELATIONS WITH OTHERS • An inability to trust others • A tendency to be re-victimized; a tendency to victimize others G: ALTERATIONS IN SYSTEMS OF MEANING • Despair and hopelessness • Loss of previously sustaining belief

31. Schematic Illustration of Emerging Symptoms of Post Traumatic Stress Disorder (Post et al, 1998) Alcohol/Substance Abuse Nightmares Dissociation Flashbacks Anger Explosive Irritability Hyper-arousalStartle GAD Panic Avoidance Depression Social Phobia Numbing Isolation Self-mutilation Truncation of Future Somatization Priming Traumatic Event Event Spontaneous Flashbacks Re-exposure Re-traumatization Cue Precipitated Flashbacks Stressors (*GAD = General Anxiety Disorder)

32. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional activating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

33. Suicide and Psychological Trauma Symptoms…. • Mood disorders…vs affect dysregulation, biphasic pattern of PTSD spectrum disorders, grief? • Self harm…vs trying to calm down • “Impulsivity and Aggression”?...vs fear panic and escape • Personality Disorder…vs chronic self punishment and poor interpersonal skills • Substance Abuse…are you prescribing? • Family history of sexual abuse…6x increase of risk for suicide

34. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional motivating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

35. Psychological sequelae of 9/11 – Galea et al NEJM March 2002 Prevalence of PTSD 7.5% vs 3.6% Prevalence of Depression 9.7% vs 4.9% Either/or 13.4% Both 3.7% Significant Predictors: Of PTSD Of Depression Hispanic Ethnicity Hispanic Ethnicity 2 or more stressors 1 yr 2 or more stressors 1 yr Panic Attack Panic Attack Residence south of Canal St. Level of social support Loss of possessions Death of friend/relative Loss of job

36. Grief vs Trauma Grief and grief work areadaptive and fairly predictable. Cocoanut Grove fire in Boston 1944 Lindemann Normal grief (?) has much in common with depression though not equivalent. Sad, disturbed sleep, agitation, decreased ability to carry out day-to-day tasks. Resolve without treatment in 2-4 months (?) as the bereaved person gradually weans from remembered experiences with the loved one. Reengagement with people and activities. (?) Increase in medical visits? Differentiate from depression: which may include suicidal ideas, preoccupation with worthlessness and psychomotor retardation.

37. Abnormal grief: delayed or distorted grief reactions Delayed: grief is postponed and experienced long after the loss, e.g. when achieves age of unmourned loved one – may not be recognized as such, precipitated by more recent less difficult loss. Distorted: immediately or years later, no sadness or dysphonic mood, but MUS present (same as the deceased?) which have precipitated multiple medical visits. Lots of variants…over activity, social withdrawal, anger, numb, or ‘too much’. ?PTSD-like symptoms

38. Treatment for depression centered on grief. • Facilitate the delayed bereavement process • Help patient reestablish interests and relationships that substitute for what has been lost. Elicit feelings and non judgmental exploration - think about the loss- discuss the sequence of events prior, during and after the death- explore associated feelings Reassurance - shame, fear, rage, guilt, survivor guilt, fear of identification, sadness Reconstruction of the relationship - maybe fixated on the death and avoid the complexities of their relationship Development of awareness Behavioral change

39. Likelihood of Abnormal Grief if: • Multiple losses • Inadequate grief in the bereavement period • Avoidance behavior about the death • Symptoms around significant dates • Fear of the illness that caused the death • History of preserving the environment as it was when the loved one died • Absence of family or other social supports during the bereavement period NB: Arousal from emotions not from the body – differential trauma from loss

40. Map for talk Every “trauma” patient’s symptoms are a function of t:T Big T traumatic experience: what’s special or different about it? • emotional motivating systems – fear • dissociation • fast pathways, procedural memory and choice What is t? “Chronic Trauma” t+T Suicide? Recognize the presence and absence of Loss and Grief Goal of Treatment – to mentalize the trauma and its difficulties • phase 1. ~ STABILIZE and symptom reduction • phase 2: ~ Treatment of traumatic memories • phase 3: ~ (Re) integration and rehabilitation

41. The problems of traumatic experience An unmentalized child is unprepared to understand him/herself and others = a poor mentalizer… (t) If an event trauma - big T trauma – happens, there is little resilience and few resources to cope. 3. The combination in childhood provokes extreme, repeated stress undermines the development of the capacity to regulate distress Result = PTSD to Chronic Complex PTSD Appreciation that automatic behaviours were originally adaptive, feel reliable, and are hard to modify or surrender. Behaviour occurs in lieu of mature mentalizing.

42. Trauma is the failure to process a serious and severe experience – goals of treatment: “the ability to create symbolic representations of terrifying experiences promotes the taming of terror and desomatization of traumatic memories.” (Van der Kolk 1994) “Making sense” Promote mentalizing not discovering a secret, or elucidating a symptom to be able to think about what happened – make sense of it with the help of another/s - figure out what it means and what if anything needs to be done – reestablish a “continuous me” or autobiographical competence. …if this is not possible, things may get worse… psychological distress changes and problems accrue

43. T R A U M A ALONE,abandoned, neglected, unloved, without needed comforting and making sense + + unmentalized Role of mentalizing in trauma AFRAID,terrified, overwhelmed, helpless, out of control

44. Phase Approach to Trauma Disorders (Herman, van der Kolk, van der Hart) Phase 1: Stabilization Phase 2: Attention to trauma memories – exposure techniques? Phase 3: Re-integration Re-habilitation

45. Phase I STABILIZE: bio-psycho-social-cultural (think body!) Take a thorough history – this can take a while (longer if you need an interpreter)…don’t just ask about the difficulties – get to know what she was like before the trouble began – what she liked, who she enjoyed being with, what she enjoyed doing, what make her laugh, what her ambitions were what her worries were… Ensure you check for current safety – physical, sexual and emotional …housing, money, debt, literacy, job-school, alcohol/drugs, access to services……… Psychological stability – sleep min. 5 consecutive hrs, max 10 hrs lying down, eating, ability to relax, what makes her feel better? avoidance? anxiety? depression? anger? (shame?) When and how is she afraid? Check again on co-morbidity, social and occupational function (get the details), addictions and affect regulation strategies Medications…

46. Phase I STABILIZE cont… Work on all the issues that need to be sorted out…often this is a long task and once stable sometimes there is no need for phase II memory work – can she work, play, love? For new Canadians often the best “trauma treatment” is encouragement to learn English

47. Phase I Memory Work Desensitization

48. Phase III – Reintegration Re-habilitation Help the patient maintain a good connection with you - a secure base, the feeling of safety - • This phase is about taking up life again having been able to know and think about her past: MOURNING HER LOSSES • What about her health? – gyne exam – dentist? • How are friendships, spousal relationship different? Closer? More laughter? • How is child care different? What is work like? • How does she feel about her new life? • What has she learned? • What is she planning for next year? • How will Christmas/Ramadan be different? • What will she tell another new Canadian? Her grandchildren? • How will it be to leave therapy?

49. Join us – and connect! The International Society for the Study of Trauma and Dissociation www.isst-d.org