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The Psychological Effects of Trauma What to look for and what to do

The Psychological Effects of Trauma What to look for and what to do. Kerry Young 1, 2 Consultant Clinical Psychologist Annual Student Health Association Conference Bristol 2014 Forced Migration Trauma Service, Central and North West London NHS Foundation Trust

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The Psychological Effects of Trauma What to look for and what to do

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  1. The Psychological Effects of Trauma What to look for and what to do Kerry Young 1, 2 Consultant Clinical Psychologist Annual Student Health Association Conference Bristol 2014 • Forced Migration Trauma Service, Central and North West London NHS Foundation Trust • EPACT – Experimental Psychopathology and Cognitive Therapy Lab Department of Psychiatry, University of Oxford Kerry Young, CNWL NHS Foundation Trust 2014

  2. Who am I to talk to you about this?Kerry Young • Trained as Clinical Psychologist in Oxford, qualified 1994 • 1997-2004 Traumatic Stress Clinic, London • 2001-2010 Clinical Director, Doctoral Training Programme in Clinical Psychology, UCL • 2005 – 2010 Refugee and Asylum Seeker Service, St Ann’s Hospital, London • 2012 – 2013 Consultant Clinical Psychologist, The Haven, Paddington • 2011 – Clinical Lead, Forced Migration Trauma Service, Central and North West London • 2012 – Clinical Psychologist, EPACT, Dept. Psychiatry, Oxford University • Teach, train and supervise in CBT (general and specific) • Particular interest in how to treat PTSD in refugees and asylum seekers Kerry Young, CNWL NHS Foundation Trust 2014

  3. Kerry Young, CNWL NHS Foundation Trust 2014

  4. Aims • To inform you about the common psychological effects of trauma • To help you identify PTSD in particular • To inform you about the treatment options for PTSD • To answer any questions you may have Kerry Young, CNWL NHS Foundation Trust 2014

  5. Examples of traumatic events • Natural disasters (e.g. Tsunami) • Man-made disaster s (e.g. London bombings) • Accidents (e.g. Fall, RTA, train crash, medical) • Physical assault • Robbery • Murder • Sexual assault or rape • War • Ethnic cleansing • Torture Kerry Young, CNWL NHS Foundation Trust 2014

  6. Acute Stress Disorder PTSD Phobias Somatization Depression OCD Suicide Substance Abuse Psychosis Neurological damage Pain Outcomes After Trauma Kerry Young, CNWL NHS Foundation Trust 2014

  7. Focus on PTSD today Kerry Young, CNWL NHS Foundation Trust 2014

  8. How common is it after trauma? Kerry Young, CNWL NHS Foundation Trust 2014

  9. Conditional risk of PTSD across specific traumas (Breslau et al., 1998) Trauma type % PTSD Held captive/tortured/kidnapped 53.8 Rape 49.0 Badly beaten up 31.9 Sexual assault (other than rape) 23.7 Other serious accident 16.8 Kerry Young, CNWL NHS Foundation Trust 2014

  10. Conditional risk of PTSD across specific traumas (Breslau et al., 1998) Trauma type %PTSD Shot/stabbed 14.3 Sudden unexpected death of associate 10.4 Child's life-threatening illness 8.0 Mugged/threatened with weapon 7.3 Witness killing/serious injury 3.8 Natural disaster 2.3 Kerry Young, CNWL NHS Foundation Trust 2014

  11. So quite likely after an inter-personal trauma Kerry Young, CNWL NHS Foundation Trust 2014

  12. What is PTSD? Kerry Young, CNWL NHS Foundation Trust 2014

  13. Historical Perspectives • 1666, Great Fire of London - Samuel Pepys’ diaries, trauma-related nightmares, “..much terrified in the nights nowdays with dreams of fire and falling down of houses” (1667) • Debate for many years about whether symptoms were organic or psychological in origin: - 19th Century - “railway spine” - World War I - “shell shock” - World War II - “concentration camp syndrome” • War in Vietnam – large numbers of sufferers showing similar psychological reactions to overwhelming stress • PTSD officially defined DSM-III, 1980 Kerry Young, CNWL NHS Foundation Trust 2014

  14. DSM-IV Diagnostic Criteria • NB now DSM-V…. Kerry Young, CNWL NHS Foundation Trust 2014

  15. Post-traumatic Stress Disorder • Criterion A • Experience/witness actual/threatened death/serious injury/threat to physical integrity self/others • intense fear, helplessness or horror • Symptoms(present for >1 month) • Re-experiencing • Avoidance / numbing • Hyper-arousal • Must cause clinically significant distress/ impairment Kerry Young, CNWL NHS Foundation Trust 2014

  16. Re-experiencing Symptoms • Intrusive recollections of trauma • Nightmares of trauma • Reliving the trauma - flashbacks • Intense distress at reminders • Physiological reactivity at reminders • Need 1 or more Kerry Young, CNWL NHS Foundation Trust 2014

  17. Avoid thoughts, feelings, conversations Avoid activities, places, people associated with trauma Psychogenic amnesia Diminished interest/participation in significant activities Feelings detachment/ estrangement from others Restricted range of affect Sense of foreshortened future Need 3 or more Avoidance Symptoms Kerry Young, CNWL NHS Foundation Trust 2014

  18. Increased Arousal • Difficulty sleeping • Irritability • Difficulty concentrating • Hypervigilance • Exaggerated startle response • Need 2 or more Kerry Young, CNWL NHS Foundation Trust 2014

  19. Case Example: Ahmed • Student, 6 months ago, assaulted on way home at night by group of youths • Has PTSD • What symptoms can you notice? • Huge thanks to Deborah Lee for DVD Kerry Young, CNWL NHS Foundation Trust 2014

  20. Play DVD Scene 1 - 6:33 to 12:57 Kerry Young, CNWL NHS Foundation Trust 2014

  21. Ahmed: PTSD SymptomsRe-experiencing • Intrusive images of assailant/bottle (feel ‘pathetic’, frightened) • Nightmares • Flashbacks to image of bottle • Distress at reminders (crowds of young people, stuff on TV) • Physiological arousal at reminders (sweaty, tense) Kerry Young, CNWL NHS Foundation Trust 2014

  22. Avoid thinking about it Avoid TV, places with young people, going out, college Doesn’t enjoy anything Doesn’t feel connected Ahmed: PTSD SymptomsAvoidance Kerry Young, CNWL NHS Foundation Trust 2014

  23. Ahmed: PTSD symptomsIncreased Arousal • Difficulty sleeping • Irritable with friends • Difficulty concentrating • Looking over shoulder all of the time, think will be attacked again • Jumpy at door banging Kerry Young, CNWL NHS Foundation Trust 2014

  24. DSM-V – changes May 2013 • Event Expanded to include repeated exposure to aversive details trauma & learning event happened to close person • Intrusive Sx About the same • Avoidance Sx Narrowed to avoidance thoughts and things/places • Negative alterations in cognition and mood New category, some as before, plus change belief about self/world/others, blame self/others, persistent fear/horror/anger/guilt/shame • Hyperarousal As before Kerry Young, CNWL NHS Foundation Trust 2014

  25. Keep using DSM-IV until measures normed on DSM-V Kerry Young, CNWL NHS Foundation Trust 2014

  26. What is Acute Stress Disorder ? Kerry Young, CNWL NHS Foundation Trust 2014

  27. What is Acute Stress Disorder ? • Remember most people will have PTSD symptoms in month after trauma (94% after rape in one study) – it is ‘normal’ • ASD refers to a more dissociative version of PTSD that occurs within 2-30 days of trauma • Rates 6-33% of those involved in trauma Kerry Young, CNWL NHS Foundation Trust 2014

  28. What is Acute Stress Disorder ? • All criteria as for PTSD plus • Dissociative Sx: • Numb, detached, emotionally unresponsive • Reduced awareness of surroundings • De-realization (your environment seems not real) • De-personalization (your thoughts/emotions don’t seem real/to come from you) • Dissociative Amnesia (can’t remember significant aspects of trauma in absence of TBI) • Need 3 or more Kerry Young, CNWL NHS Foundation Trust 2014

  29. What is Acute Stress Disorder ? • Highly predictive of subsequent PTSD • Need: • Psychiatric evaluation • Hospitalization if risk • Information • CBT • Medication Kerry Young, CNWL NHS Foundation Trust 2014

  30. Back to PTSD Kerry Young, CNWL NHS Foundation Trust 2014

  31. How to identify it • If someone recently involved in a trauma • Complaining of any of the PTSD Sx • Give them Trauma Screening Questionnaire (Brewin et al., 2002) • 6 or more positive responses indicate at risk of having PTSD diagnosis Kerry Young, CNWL NHS Foundation Trust 2014

  32. Kerry Young, CNWL NHS Foundation Trust 2014

  33. What to do if they look like they might have PTSD • Refer to appropriate mental health service i.e. - IAPT - student counselling service if offer evidence based PTSD treatments (CBT or EMDR) Kerry Young, CNWL NHS Foundation Trust 2014

  34. What to do if they look like they might have PTSD • In meantime, leaflets a good idea • Student counselling service may have PTSD information leaflet • Or suggest obtain PTSD psycho-educational material online; - Royal College of Psychiatry http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.aspx - NICE http://www.nice.org.uk/nicemedia/live/10966/29782/29782.pdf Kerry Young, CNWL NHS Foundation Trust 2014

  35. What are evidence based PTSD treatments? Kerry Young, CNWL NHS Foundation Trust 2014

  36. NICE Guidelines – early intervention • Consider watchful waiting when symptoms are mild and have been present for less than 4 weeks after a trauma • Arrange a follow up contact within 1 month • For individuals who have experienced a traumatic event, do not routinely offer brief single session interventions (debriefing) Kerry Young, CNWL NHS Foundation Trust 2014

  37. NICE Guidelines – after 1 month • All PTSD sufferers should be offered a course of tfCBT (trauma-focused cognitive behavioural therapy) or EMDR (Eye Movement Desensitization and Reprocessing) regardless of the time since the trauma Kerry Young, CNWL NHS Foundation Trust 2014

  38. What is tfCBT ? • Based on the understanding that trauma memories aren’t properly integrated into memory • Need to get the patient to ‘re-process’ the memory so it can be integrated and will stop popping into their heads when they don’t want it to Kerry Young, CNWL NHS Foundation Trust 2014

  39. Duvet and Cupboard Imagine that memory is a little bit like a linen cupboard: lovely and organized, with towels on one shelf, sheets and pillow cases on another and, finally, duvet covers and blankets on the last shelf. When you are involved in a trauma, it is as if someone runs at you with a huge duvet in their arms, screaming “PUT THAT IN THE CUPBOARD RIGHT NOW!” You take the duvet, stuff it in, jam the door shut and walk away. As you do so, the cupboard door opens and the duvet flops out. The person screams at you again, their face right up against your face, “PUT IT BACK IN, PUT IT BACK IN NOW!” You grab it off the floor, bundle it back in, jam the door shut and walk away. Again the door opens and again the duvet spills out onto the floor. Growing increasingly agitated, the person screams, “PUT IT BACK IN, PUT IT BACK IN, PUT IT BACK IN!” Kerry Young, May 2011

  40. Duvet and Cupboard cont. In the end, you find that the only way to keep the duvet in the cupboard is to stand with your back against the door. But you can’t do that forever and, anyway, you will need to go into the cupboard eventually to get other things out. When you do, the duvet will tumble out again. Kerry Young, May 2011

  41. What is tfCBT ? • Involves talking about the traumatic event in a lot of detail, including all five senses, emotions and thoughts • Worst moments of the trauma narrative are re-scripted with new/corrective information so that the memory can be nicely packed away • 10-12 sessions on average for one-off trauma Kerry Young, CNWL NHS Foundation Trust 2014

  42. Does it work? Kerry Young, CNWL NHS Foundation Trust 2014

  43. CT for PTSD: Effect sizes for change before versus after treatment CT for PTSD studies

  44. Chronic PTSD – RCT(Ehlers et al, 2005) Kerry Young, CNWL NHS Foundation Trust 2014

  45. Play DVD • Scene 5 – 5:20 to 10 Kerry Young, CNWL NHS Foundation Trust 2014

  46. Medication and PTSD • NICE say medication a second-line treatment ONLY to be used if tfCBT/EMDR failed/not indicated • Recommend paroxetine and mirtazepine (NICE Evidence Update 2013 – fluoxetine and venlafaxine might also be useful) • Worth considering if co-morbid depression • No robust evidence for mood stabilizers (e.g. carbamazepine) or benzodiazepines (e.g.clonazepam) • Review Jonathon Bisson (2007) need doses at higher end of therapeutic range and delay decisions about usefulness Kerry Young, CNWL NHS Foundation Trust 2014

  47. What else to watch out for • Co-morbidity with substance misuse, depression, panic • Increased rates of suicide • NB may not want to tell you what happened (especially if sexual assault/rape) Kerry Young, CNWL NHS Foundation Trust 2014

  48. Take home message • PTSD is quite likely after inter-personal trauma • PTSD is very treatable (you can expect remission from diagnosis after 10-12 sessions) • PTSD needs a psychological treatment (tfCBT or EMDR) Kerry Young, CNWL NHS Foundation Trust 2014

  49. Questions? Kerry Young, CNWL NHS Foundation Trust 2014

  50. Contact details • kerryyoung1@nhs.net Kerry Young, CNWL NHS Foundation Trust 2014

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