Facilitating Healing in the Traumatically Stressed Victim

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• Facilitating Healing in the Traumatically
  Stressed Victim
• Professor Peter W.H. Lee
• Department of Psychiatry
• The University of Hong Kong

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INTRODUCTION

• Objectives
• Understanding post-traumatic stress syndromes
• Psychopathological processes
• Vulnerable individuals
• Facilitating healing

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Post-traumatic stress syndromes

• DSM-IV-TR
• Posttraumatic stress disorder
• The person has been exposed to a traumatic event
  in which both of the following are present

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Prerequisite Requirements

• (1) experienced, witnessed, or confronted with an
  event or events that involved actual or
  threatened death or serious injury, or a threat
  to the physical integrity of self or others
• (2) the persons response involved intense fear,
  helplessness, or horror

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Characteristic symptoms

• Persistent re-experiencing of the traumatic
  event
• intrusive distressing recollections (images,
  thoughts, or perceptions)
• distressing dreams
• Acting or feeling as if the traumatic event were
  recurring (reliving, flashbacks)

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• Intense psychological distress at exposure (to
  external or internal cues .)
• Physiological reactivity on exposure

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• Persistent avoidance of stimuli associated with
  the trauma and numbing of general responsiveness
• Efforts to avoid thoughts, feelings, or
  conversations associated with the trauma
• Efforts to avoid activities, places or people
  that arouse recollections of the trauma
• Inability to recall
• Markedly diminished interest and/or participation
  .

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• Feeling of detachment or estrangement
• Restricted range of affect (e.g. unable to have
  loving feelings)
• Sense of a foreshortened future (e.g. does not
  expect to have a career, marriage, children, or a
  normal life span)

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• Persistent symptoms of increased arousal
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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• Associating features
• survivors guilt
• impaired affect modulation
• domestic battering, child abuse
• self-destructive and impulsive behaviour
• somatic complaints
• feelings of ineffectiveness, shame, despair,
  hopelessness
• loss of previous beliefs
• social withdrawal
• hostility

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Statistics

• Lifetime prevalence 8 - 23 in USA
• 1/3 to 1/2 in survivors of rape, military combat
  and captivity, political genocide
• Road traffic accidents
• lifetime prevalence of accidents 23
• PTSD rate 12
• 28 seriously distressed persons for 1,000 adults
  in the U.S. (Norris, 1992)

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• Usually develop within first three months, may be
  delayed
• Complete recovery within 3 months in 50 of cases
• Waxing and waning course
• Symptom re-activation
• Severity, duration, and proximity factors are
  most crucial

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Acute stress disorder

• Exposure to traumatic event
• Dissociative symptoms prominent
• Subjective sense of numbing, detachment, or
  absence of emotional responsiveness
• Reduction in awareness of surroundings
• Derealization
• Depersonalization
• Dissociative amnesia
• Plus reexperience of trauma
• Plus avoidance symptoms
• Plus anxiety and/or increased arousal

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Statistics

• Duration 2 days to 1 month
• Predicts 80 of subsequent PTSD after motor crash
  survivors and victims of violent crimes
• 14 to 33 reported in victims (of motor
  accidents, or bystander at a mass shooting)

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The vulnerable population

• Accidents are not random
• Accident proneness
• Inappropriate drinking
• Personality disorder and substance abuse
• Affective disorder
• Sleepiness and sleep disorder
• Risk taking suicidal behaviors
• Difficult social circumstances
• Concurrent continuing or relapsing physical
  disorders
• The chronic or acute person in crisis ?

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• pre-existing psychiatric symptoms and problems
• prior trauma
• psychiatric illness in the family
• concurrent exposure to multiple stressful events
• young/er age

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• Females vs. males
• females more distressed
• verbalize greater fear/distress
• more sensitive
• more likely to request help and/or
• talk about personal issues
• greater risk for developing PTSD after exposure

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• greater problems associated with
• Magnitude of event major injury with distress
• intense intrusive memories
• Previous psychological vulnerability
• Poor psychological adjustment
• Pre-morbid psychopathology
• Severe initial distress
• Continuing medical problems and impairment
• Personal meanings anger and blame

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• Anger towards
• those responsible
• lack of recognition by others of their undeserved
  suffering
• the legal system
• Interferes
• with natural recovery
• harms relationship with family members, friends
  and others
• What is needed
• greater recognition by others of accident
  survivors suffering and misfortunes (especially
  administrative and compensation processes)

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• Importance of focusing on effects on everyday
  QoL
• Need to focus not only on impairment of
  functions,
• but also
• The effect of injury on everyday activities and
  interests important to the person

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Psychological processes
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• Cognitive theories
• A persons beliefs about the world and
  him/herself are disrupted by trauma
• The world becomes frightening and untrustworthy
• Symptoms due to expectations of threat

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• psychologic hypersensitivity
• violation of deeply held beliefs that
• The world is just or fair
• Sense of self (not doing something I should,
  having done something I should not have done)
• Abandonment, betrayal, violation of trust
• Sense of safety violated

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• Behavioral models
• Acquired fear a wide encompassing fear
  structure (Ss, meanings, responses)
• Lack of habituation
• Re-experiencing and arousal symptoms conditioned
  emotional responses (CC) elicited by
  environmental Ss
• Avoidance, problematic behaviours
  (excesses/deficits) operant controlled
• Inappropriate stimulus control response
  appropriate, but situation not appropriate

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• Rx
• Activate the fear structure (exposure)
• Provide new information incompatible with
  pathological elements (psychoeducation and skills
  training)
• fear activation during Rx promotes successful
  outcome

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• Therapeutic mechanisms
• Repeated imaginal reliving promotes habituation
  and reduce anxiety associated with trauma
  thoughts/images
• Corrective expectation (anxiety will not stay for
  ever and does not need to be avoided)
• Confrontation blocks negative reinforcement for
  avoidance (with fear reduction)
• Reliving trauma in supportive setting helps to
  incorporate safety information into the trauma
  memory

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• Focusing on trauma memory for prolonged time
  helps to differentiate the trauma event from
  other nontraumatic events ? trauma as a specific
  occurrence rather than predicting a dangerous
  world or incompetent self
• Reliving helps to change symptoms as sign of
  personal incompetence to sign of mastery and
  control

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• In vivo exposure helps to correct erroneous
  probability estimates of danger and leads to
  further habituation of fearful responses to
  trauma-relevant stimuli

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• Psychodynamic and interpersonal models
• interpersonal and affective disturbances arise
  from trauma
• Loss of hope and trust in others
• Feelings of alienation and difference from others

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• Neurobiological model (Everly and Mitchell,
  2000)
• Neurologic hypersensitivity due to
• Excess of excitatory neurotransmitters, reduced
  inhibitory neurotransmitters, changes in
  dendritic receptor structures
• Lowered depolarization threshold in the
  amygdaloid posterior hypothalamic efferent
  pathways of the limbic system and the anterior
  pituitary
• ?
• Over-reactive cascade of systemic hormonal
  phenomena including impulsivity, irritability,
  and propensity for violence

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Interventions
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Critical incidents debriefing

• Proximity (Rx offered close to scene)
• Immediacy (asap)
• Expectancy (returning to normal functioning)
• Brevity

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• Debriefing
• information gathering
• modulate emotions morale building
• respect individual experiences
• facilitates emotional expression
• develop a narrative of the experience make
  sense of the event

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• Group meetings therapeutic forces, constructive
  support and group interaction to heal
• Crisis intervention temporary support, provides
  a reorganizing influence that assists the
  individual who is feeling overwhelmed, help to
  re-establish rational problem solving

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• Cognitive behavioural therapies desensitization
  as a rationale for minimizing avoidance,
  exploration of cognitive schemas related to
  traumatic memories
• preventive intervention
• Psychoeducation provide a psychological map for
  victims to understand their reactions serve to
  contain distress and facilitate chain of
  self-regulatory processes

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• Catharsis expression of affect associated with
  memory of a traumatic event

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Processes of PD

• Mitchells CISD 7-phase intervention
• Introduction
• Purpose to review reactions, discuss them,
  identify ways of dealing with them and prevent
  future problems
• Debriefer in control and provides credentials
• Rules participants no obligation to talk,
  confidentiality, focus on impressions and
  reactions of participants

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• The fact phase
• Details of what actually happened (not deal with
  thoughts, impressions, and emotions yet)
• Expectations (did they expect what happened?)

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• The thought phase
• Thoughts at the time
• what were your thoughts when you first realized
  you were injured? what did you do?
• Aim construct a picture of what happened, put
  individual reactions in perspective, help
  integrate traumatic experience
• Focus on sensory impressions what did you see,
  hear, touch, smell, taste? to produce realistic
  reconstruction of the trauma

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• The reaction phase
• Focus on emotions
• Release of emotions
• Covers fear, helplessness, frustration,
  self-reproach, anger, guilt, anxiety, depression
• Emotions since the trauma

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• The normalization phase
• Facilitate acceptance of symptoms and emotions
• Stress reactions as being normal
• Sharing of emotions create feeling of
  universality
• Deals with common symptoms
• Move from emotional phase to cognitively
  oriented stage in which trauma related symptoms
  and their meanings are discussed

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• Future planning/coping phase
• ways of managing symptoms when they arise
• mobilize internal support (coping)
• mobilize external support (family and friends)
• open discussions with family and peers
• acknowledge need for additional support for a
  while

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• Disengagement phase
• Clarifies issues
• Questions
• Provides summary
• Cues to watch up and seek help on symptoms
  persist over 4 weeks symptoms increase over
  time ongoing loss of function and
  occupational/family difficulties other
  personality changes
• closure

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• Generally well received
• Provide acute psychological first-aid
• Useful for screening (of high risk individuals),
  education and support
• Forms Rx alliance early
• Address general reluctance of people with PTSD to
  accept Rx
• The earlier the Rx provided, the better the
  outcome

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Cognitive-Behaviour approach

• The interpretation of an event (rather than the
  event itself) is what determines mood states
  (Beck)
• Identify - challenge - replace
• Focus on appraisals of safety
• danger, trust, and views on self

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Stages of recovery

• 1st stage
• Establishment of sense of safety
• Physical well-being
• Regain trust in their bodies
• Safety of surrounding physical and relational
  world

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• 2nd stage
• Remembrance and mourning
• Deal with and accommodate to full or partial
  amnesias, visual images (devoid of feelings),
  affective memories with no historical connections
• Weave traumatic memory into the patients
  general life narrative to develop a more coherent
  sense of self

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• 3rd Stage
• Repair/re-establish relationships with others in
  immediate and wider community
• Status of trauma victim no longer overshadows
  other aspects of personal identity
• Trauma story only one of several stories in the
  survivors life

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Progress signposts

• Authority over memory
• Control
• From besieged by intrusive memories (or no
  access) to able to choose to remember
• Integration of memory with affect
• Memories as interwoven with affect
• Without being overwhelmed by painful feelings
  uncontained in recollected images
• More tolerable negative affects

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• Affect tolerance
• Ability to bear painful feelings
• More comfortable with positive and negative
  feelings
• Symptom mastery
• Anticipate, manage, contain, or prevent cognitive
  and emotional disruptions
• Self-esteem and self-care
• Self as worthy of care
• Behaviors that promote own best interests

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• Self-cohesion
• Experience self as integrated (or fragmented) in
  thoughts, feelings, and actions
• Safe attachment
• Develop feelings of trust, safety, and enduring
  connection in relationships with others
• Meaning-making
• Understanding about self in relation to the
  traumatic experience and to the world in which
  the trauma occurred

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Detoxifying Crisis

• A calm, reassuring approach as antidote for
  anxiety
• Structure as antidote for chaos
• Thinking as antidote for dysfunctional emotions
• Catharsis as antidote for psychological tension
  and frustration
• Information as antidote for loss of control
• Acceptance and social support as antidote for
  alienation
• Action as antidote for helplessness

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• . The story of PTSD is the tale of the
  indomitable and indefatigable human spirit to
  survive and adapt
• (Meichenbaum, 1994).