Treatments for Psychological Trauma:

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Treatments for Psychological Trauma From Acute
PTSD to Chronic Traumatization James L Spira,
Ph.D., MPH, ABPPClinical Professor, Department
of Psychiatry, UCSDClinical Director, Casa
Palmera Residential Treatment Facility
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Overview

• Part 1 Understanding Trauma and Trauma Tx
• Part 2 Clinical Methods Which Can Be Easily
• Used
• Part 3 Applications to Counseling Center
• Settings with Non-specialized Staff

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Outline , Part 1

• Types of Trauma
• Psychophysiology of Trauma
• Predispositions to Develop Trauma
• Traditional Treatments and Efficacy
• Recent Developments in Treatment and Improved
  Efficacy
• Adapting Methods for Therapy with Students

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Types of Trauma

• Recent Single Event
• ASD (dissociative and hypervigilant qualities)
• PTSD Acute (hypervigilant and avoidant qualities)
• PTSD Chronic ( gt 3 mo)
• Complex Acute PTSD
• Other co-existing psychological or physical
  problems
• Complex Chronic PTSD/Trauma
• Ongoing Childhood Abuse, by caregiver
• Adolescent
• by authority figure
• by partner
• Delayed PTSD

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Types of Trauma

• Childhood chronic abuse
• Not necessarily fitting PTSD Criteria
• Involved in personality development
• Understanding of relationship and sexuality
• Bonding Difficulty
• Avoidant or anxious attachment
• Trusting and intimacy
• Borderline Spectrum
• Influences interpretation of and coping with new
  traumatic incidents

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Types of Trauma

• Delayed PTSD
• Delayed Onset (several months)
• Long Delayed (years)
• Early chronic trauma influences later
  susceptibility to PTSD from a traumatic event
• Example of childhood molestation influencing
  susceptibility to later relationship abuse
• Case 19 y/o SWF victimized as 12 y/o by
  fathers business partner father did not take
  appropriate action but later got her
  counseling from a married 52 y/o Church of
  Scientology counselor who then started a sexual
  relationship with her, which quickly turned
  controlling with threats
• Other cases are similar in getting involved in
  abusive relationships, which are seen as normal,
  or from which the victim cant find a way out.

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Psychophysiology of Trauma

• Imaging shows
• Enhanced Reticular Activating System arousal
• Enhanced Periaquiductal Grey arousal
• Limbic Involvement
• Acute trauma related to
• increased limbic/hippocampal processing
• Increased cortisol and glutamate/NMDA receptor
  changes
• Chronic trauma related to decreased limbic
  morphology
• Possibly due to excessive cortisol and glutamate
  involvement

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Psychophysiology

• Hypothalamic-Pituitary-Adrenal Axis
• Situation interpreted as emergency
• Classical Conditioning of paired emotion-episodic
  memory (amygdala-hippocampus)
• Continual Reprocessing of Reaction
• Internal recall kept active, since situation
  could recur
• External generalizability of situation to similar
  elements
• Frontal interpretation (serious life threatening
  problem deal with it)
• ? Limbic Reaction (keep brain and body in
  emergency status)
• ? Frontal Interpretation (Stay alert in case
  emergency returns!)
• ? Limbic Reaction (keep brain and body
  in emergency status)
• ? Etc. (focusing on the problem
  keeps the problem real)

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Prevalence

• According to the National Institutes of Mental
  Health, 5.2 million Americans aged 18-54 have
  PTSD.
• Untold millions have had traumatic experiences
  that affect their lives
• The Veteran's Administration (VA) operates more
  than 140 specialized programs for the treatment
  of PTSD through VA Medical Centers and Clinics.
  In 2001, more than 77,300 veterans were treated
  for PTSD by VA specialists.
• National Institute of Mental Health. Reliving
  Trauma, Post-traumatic Stress Disorder. Available
  at http//www.nimh.nih.gov/publicat/reliving.cfm
• Department of Veterans Affairs. Fact Sheet VA
  programs for veterans with Post-Traumatic Stress
  Disorder (PTSD). Available at http//www.va.gov/p
  ressrel/ptsd402.htm

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Predisposition to PTSD

• Prior psychological difficulties
• Prior traumatic event
• Especially which was not coped with well
• Especially which was chronic
• Especially which involved caregivers
• Prior psychological diagnosis
• (especially Anxiety disorders)
• Personality / Coping Style
• Very reflective and sensitive (hyper-reflective
  anxious PTSD)
• Blunted and non-reflective (angry/repressive type
  PTSD)
• Meaninglessness

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Prevalence and Time Course

• A prospective longitudinal study assessed 967
  consecutive patients who attended an emergency
  clinic shortly after a motor vehicle accident,
  again at 3 months, and at 1 year.
• The prevalence of posttraumatic stress disorder
  (PTSD)
• 23.1 at 3 months
• 16.5 at 1 year.
• Chronic PTSD was related to some objective
  measures of trauma severity
• perceived threat, and dissociation during the
  accident,
• to female gender, to previous emotional problems,
  and to litigation.
• Maintaining psychological factors enhanced the
  accuracy of the prediction
• negative interpretation of intrusions,
  rumination, thought suppression, and anger
  cognitions
• The most important predictors of PTSD symptoms at
  1 year were
• Negative interpretation of intrusions, persistent
  medical problems, and rumination at 3 months,
• Cases of delayed onset related to anger
  cognitions, injury severity, and prior emotional
  problems
• Ehlers, A, Mayou, R, Bryant, B (1998)
  Psychological Predictors of Chronic Posttraumatic
  Stress Disorder After Motor Vehicle Accidents
  Journal of Abnormal Psychology 107(3) 508-519

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Prevalence and Time Course

• Gray, MJ, Bolton, EE Litz, BT (2004).
  Longitudinal Analysis of PTSD Symptom Course
  Delayed-Onset PTSD in Somalia Peacekeepers JCCP
  2004, Vol. 72, No. 5, 909913.
• N1035 sample followed over one year
• Sample Type PTSD Sx Score
  
• Time 1 Time 2
• 902 Resilient (few Sx) 24 25
• 47 Acute onset, no remittance 59 57
• Remitters (acute onset, remitted) 53 35
• 68 Delayed Onset 34 52
• (about 14 of sample developed significant Sx,
  about ½ was delayed onset)

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Typical Treatments

• Medications
• For each type of PTSD
• Cognitive Behavioral Therapies
• For each type of PTSD
• Rational vs automatic responses
• Individual vs group
• Critical Incident Stress Debriefings (CISD)
• Immediately following a disaster to prevent PTSD

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Typical Treatments Medication

• Acute Stress D/O
• Beta Blockade
• Benzodiazepine
• Acute PTSD
• SSRI, TCA
• Chronic PTSD
• SSRI
• Anti-Psychotic
• Benzodiazepine?
• Sleep Support

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Typical Treatments CBT for Complex PTSD

• 121 female rape victims, most of whom had
  extensive histories of trauma, were randomly
  assigned to cognitive-processing therapy,
  prolonged exposure, or a delayed-treatment
  waiting-list condition.
• Both types of treatment were equally effective
  for treating complex PTSD symptoms,
• The sample was then divided into two groups
  depending upon whether they had a history of
  child sexual abuse. Both groups improved
  significantly over the course of treatment with
  regard to PTSD, depression, and the symptoms of
  complex PTSD as measured by the Trauma Symptom
  Inventory. Improvements were maintained for at
  least 9 months.
• These findings indicate that cognitive-behavioral
  and exposure therapies are effective for patients
  with complex trauma histories and symptoms
  patterns.
• Resick PA. Nishith P. Griffin MG. (2003) How
  well does cognitive-behavioral therapy treat
  symptoms of complex PTSD? An examination of child
  sexual abuse survivors within a clinical trial.
  Cns Spectrums. 8(5)340-55.

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Typical Treatments

• Critical Incident Stress Debriefing / Management
  (CISD/CISM)
• Makes Clinical Sense
• Unlikely to do harm
• Likely to be useful as screening assessment
• Likely to be useful to normalize therapy for
  future
• Not good evidence of value in reducing PTSD Dx or
  Sx in studies and meta analysis, and therefore
  not as widely recommended as it once was

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Experiential Therapies Dissociation

• Relaxation
• Physical (Autonomic) Emphasis
• PSNS retraining
• Muscle relaxation
• Slow breathing
• Biofeedback
• Efficacy?
• Alone has limited effects
• More effective in combination with other
  techniques

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Experiential Therapies Dissociation

• Meditation
• Attentional retraining
• Attention is enhanced processing
• Whatever you attend to, you enhance
• (worry, pain, noise, arousal / breath, warmth,
  work)
• Your brain/body support what you attend to
• H-P-A axis
• (ANS activation PAG relay Limbic arousal
  frontal interpretation for SNS or PSNS)
• If you can address a problem, then do so,
  otherwise focus on neutral or positive sensations
  or activity
• Meditation helps reduce background noise and
  enhance foregrounded signal
• ZEN MEDITATION (signal emphasis)
• VIPASSANA MEDITATION (noise reduction)

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Experiential Therapies Controlled Dissociation

• Hypnosis
• Principles
• Controlled dissociation (x4)
• Hypnotizability
• Methods
• Light trance
• CBT relaxation graded exposure
• Bypasses typical conscious resistance (schema)
• Deep trance
• Bypasses conscious resistance/habit schema
• Reassociates new emotions with old memories
• Efficacy?
• Reportedly high for highly hypnotizable pts
• Highly hypnotizable pts may do worse w/o tx,
  better w/tx

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Experiential Therapies Dissociation

• EMDR
• Principles
• Methods
• Efficacy?
• Meta analyses and comparative studies show it may
  be effective in PTSD, but is not more effective
  than other therapies
• May be only exposure therapy with ritual

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Experiential Therapies EMDR

• The authors examined the efficacy, speed, and
  incidence of symptom worsening for 3 treatments
  of posttraumatic stress disorder (PTSD)
  prolonged exposure, relaxation training, or eye
  movement desensitization and reprocessing (EMDR)
  N 60. Treatments did not differ in attrition,
  in the incidence of symptom worsening, or in
  their effects on numbing and hyperarousalsymptoms.
  
• Compared with EMDR and relaxation training,
  exposure therapy (a) produced significantly
  larger reductions in avoidance and reexperiencing
  symptoms, (b) tended to be faster at reducing
  avoidance, and (c) tended to yield a greater
  proportion of participants who no longer met
  criteria for PTSD after treatment. EMDR and
  relaxation did not differ from one another in
  speed or efficacy.
• Taylor, S. Thordarson, D. Maxfield, L. Fedoroff,
  I. Lovell, K. Ogrodniczuk, J. (2003). Comparative
  Efficacy, Speed, and Adverse Effects of Three
  PTSD Treatments Exposure Therapy, EMDR, and
  Relaxation Training Journal of Consulting and
  Clinical Psychology 71(2) 330-338

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Experiential Therapies EMDR

• Meta Analyses Eye movement desensitization and
  reprocessing (EMDR), a controversial treatment
  suggested for posttraumatic stress disorder
  (PTSD) and other conditions, was evaluated in a
  meta-analysis of 34 studies that examined EMDR
  with a variety of populations and measures.
• Process and outcome measures were examined
  separately, and EMDR showed an effect on both
  when compared with no treatment and with
  therapies not using exposure to anxiety-provoking
  stimuli and in pre-post EMDR comparisons.
• However, no significant effect was found when
  EMDR was compared with other exposure techniques.
  
• No incremental effect of eye movements was noted
  when EMDR was compared with the same procedure
  without them.
• R. J. DeRubeis and P. Crits-Christoph (1998)
  noted that EMDR is a potentially effective
  treatment for noncombat PTSD, but studies that
  examined such patient groups did not give clear
  support to this.
• In sum, EMDR appears to be no more effective than
  other exposure techniques, and evidence suggests
  that the eye movements integral to the treatment,
  and to its name, are unnecessary.
• Davidson, P. Parker, K. (2001) Eye Movement
  Desensitization and Reprocessing (EMDR) A
  Meta-Analysis. JCCP 69(2) 305-316.

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Experiential Therapies Exposure

• In the 1980s, Terence Keane and colleagues found
  that exposure therapy was effective in treating
  the PTSD symptoms of Vietnam War veterans.
• In the 90s, research by Edna Foa and her
  colleagues showed that exposure therapy was
  perhaps the most effective Tx for reducing PTSD
  symptoms of rape victims, including persistent
  fear. Improvements were seen immediately after
  exposure therapy, and sustained during a
  three-month follow-up.
• Foa, E. B., Rothbaum, B. O., Riggs, D. S.,
  Murdock, T. B. (1991). The treatment of
  posttraumatic stress disorder in rape victims A
  comparison between cognitive-behavioral
  procedures and counseling. Journal of Consulting
  and Clinical Psychology, 59, 715-723.
• Foa, E. B., Meadows, E. A. (1997). Psychosocial
  treatments for posttraumatic stress disorder A
  critical review. Annual Review of Psychology, 48,
  449-480.
• Keane, T. M. Kaloupek, D. G. (1982). Imaginal
  flooding in the treatment of a posttraumatic
  stress disorder. Journal of Consulting and
  Clinical Psychology, 50, 138-140.
• Keane, T. M., Fairbank, J. A., Caddell, J. M.,
  Zimering, R. T. (1989). Implosive (flooding)
  therapy reduced symptoms of PTSD in Vietnam
  combat veterans. Behavior Therapy, 20, 245-260

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Experiential Therapies Exposure

• Flooding
• Sudden and total immersion into arousing
  environment
• (not recommended for PTSD due to potential for
  retraumatizing)
• Graded Exposure
• Gradually increasing immersion into arousing
  environment, as the patient is able to tolerate.
• Re-associate previously traumatic cognitions with
  comfortable or neurtral affect
• Discussion (CISD)
• Procedure
• Efficacy with different populations
• Imagery
• Using internal visual images for those with
  imagery capacity (-20)
• Virtual Reality

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VR Assisted Graded Exposure

• VR assisted GRADED EXPOSURE with
  biofeedback/attentional retraining
• Combining the best of high tech and low tech

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VR assisted GRADED EXPOSURE
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VR assisted GRADED EXPOSURE

• With Medication that soothes limbic arousal
• Does de-arousing medication
• Allow greater mental and physical relaxation
• Yes
• allow greater exposure
• Yes
• Prevent generalizability post treatment?
• Doesnt seem to instead, it extends long term
  outcome at least in one small, well conducted
  study using DCS
• (Ressler et al (Nov 2004) Cognitive Enhancers
  as Adjuncts to Psychotherapy. Arch Gen
  Psychiatry, 61 1136-1144)

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Meta Analyses

• Van Etten and Taylor analyzed 61 treatment trials
  that included pharmacotherapy and modalities such
  as behavior therapy (particularly exposure
  therapy), eye movement desensitization and
  reprocessing (EMDR), relaxation training,
  hypnotherapy, and dynamic psychotherapy. Overall,
  this meta-analysis found that exposure therapy
  was more efficacious than any other type of
  treatment for PTSD when measured by clinician
  rated measures.
• Specifically, the effect size for all types of
  psychotherapy interventions was 1.17 compared
  with 0.69 for medication. Perhaps more
  significant, the mean dropout rate in medication
  trials was 32 compared with 14 in psychotherapy
  trials.
• A second meta-analysis of psychotherapeutic
  treatments found that treatment benefits for
  target symptoms of PTSD and for general
  psychological symptoms (intrusion, avoidance,
  hyperarousal, anxiety, and depression) were
  significant, with effect sizes ranging from 0.2
  to 0.49
• Van Etten ML, Taylor S. Comparative efficacy of
  treatments for posttraumatic stress disorder A
  meta-analysis. Clinical Psychology and
  Psychotherapy 1998514454.
• Sherman JJ. Effects of psychotherapeutic
  treatments for PTSD. J Trauma Stress
  1998114136

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Consensus Panel on PTSD

• Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ.
  Foa EB. Kessler RC. McFarlane AC. Shalev AY.
• Title Consensus statement on posttraumatic
  stress disorder from the International Consensus
  Group on Depression and Anxiety.
• Source Journal of Clinical Psychiatry. 61 Suppl
  560-6, 2000.
• EVIDENCE The consensus statement is based on the
  6 review articles that are published in this
  supplement and the scientific literature relevant
  to the issues reviewed in these articles.
• CONCLUSION Selective serotonin reuptake
  inhibitors are generally the most appropriate
  choice of first-line medication for PTSD, and
  effective therapy should be continued for 12
  months or longer. The most appropriate
  psychotherapy is exposure therapy, and it should
  be continued for 6 months, with follow-up therapy
  as needed.

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Summary

• SSRI Sleep support along with Experiential
  Therapies which focus on development of cognitive
  and somatic skills are very beneficial in the
  treatment of simple acute PTSD.
• SSRI along with Cognitive and Interpersonal
  Therapies in combination with Experiential
  Therapies may be necessary in the treatment of
  complex chronic PTSD.

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Adapting for Counseling Centers

• Assess
• simple acute vs chronic complex
• existing coping skills vs need for medication
  support (sleep, unable to engage in or benefit
  from therapy)
• willingness to develop personal skills to improve
  vs needing continued external interpersonal
  support and understanding

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Adapting for Counseling Centers

• Provide a cognitive frame
• Psychoeducation for how trauma symptoms occur
• Normalize
• Explain the psychophysiology
• Explain the Sx
• Cognitive Therapy for understanding
• Habit stimuli, cog/emot/physiol/behavioral
  reactions
• Optimal / healthy reactions
• Skills needed to obtain these optimal reactions

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Adapting for Counseling Centers

• Offer interpersonal support if need be
• Group process (but be careful not to develop a
  sick role attitude
• Time limited
• CBT oriented with interpersonal discussion
• Family/couple therapy

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Adapting for Counseling Centers

• If complex/chronic
• Address current crisis
• Consider dynamic approach
• Discuss early childhood traumas
• How these influence current
• Personality and Beliefs about self, others, world
• Interpretations of and reactions to past critical
  and current events
• Discuss optimal / normal interpretations
  reactions

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Adapting for Counseling Centers

• Introduce Experiential Methods
• 1st develop skills of being comfortably in the
  moment
• 2nd take a mildly uncomfortable event and
  practiced with it
• Tolerate sustaining attention to it
• Distance as necessary to sustain attention to it
• Return to being comfortably in the moment
• Go back and forth several times to teach basic
  skill
• (optimally with biofeedback monitoring
  otherwise minimal cues and verbal SUDS)

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Adapting for Counseling Centers

• Experiential Methods
• 3rd Take more relevant but moderately arousing
  event, and repeat step 2 above
• 4th Take most relevant and arousing event, and
  repeat step 2 above
• Continue until no major arousal occurs
• Note Each step could take several sessions
• This can be done in group as well (but
  give
• warnings not to use very arousing
  stimuli at first)

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Adapting for Counseling Centers

• Typical Session
• Review Sx since last session
• Review practice since last session
• Practice meditation (attentional retraining)
• If successful, introduce moderate stressor
• Arousal, distance as necessary
• Return to meditation (alternate every few
  minutes)
• If successful, introduce stronger stressor
• Arousal, distance as necessary
• Return to meditation (alternate, every few
  minutes)
• Debrief and discuss practice times and situations

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Adapting for Counseling Centers

• Practice
• In group
• With partners

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Adapting for Counseling Centers

• Discuss issues related to implementation in
  counseling center context
• Settings/sessions
• Non-specialized staff therapists
• Difficult students