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Facilitating Healing in the Traumatically Stressed Victim

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Title: Facilitating Healing in the Traumatically Stressed Victim


1
  • Facilitating Healing in the Traumatically
    Stressed Victim
  • Professor Peter W.H. Lee
  • Department of Psychiatry
  • The University of Hong Kong

2
INTRODUCTION
  • Objectives
  • Understanding post-traumatic stress syndromes
  • Psychopathological processes
  • Vulnerable individuals
  • Facilitating healing

3
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

4
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

5
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)

6
  • Intense psychological distress at exposure (to
    external or internal cues .)
  • Physiological reactivity on exposure

7
  • 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
    .

8
  • 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)

9
  • Persistent symptoms of increased arousal
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response

10
  • 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

11
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)

12
  • 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

13
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

14
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)

15
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 ?

16
  • pre-existing psychiatric symptoms and problems
  • prior trauma
  • psychiatric illness in the family
  • concurrent exposure to multiple stressful events
  • young/er age

17
  • 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

18
  • 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

19
  • 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)

20
  • 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

21
Psychological processes
22
  • 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

23
  • 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

24
  • 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

25
  • Rx
  • Activate the fear structure (exposure)
  • Provide new information incompatible with
    pathological elements (psychoeducation and skills
    training)
  • fear activation during Rx promotes successful
    outcome

26
  • 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

27
  • 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

28
  • In vivo exposure helps to correct erroneous
    probability estimates of danger and leads to
    further habituation of fearful responses to
    trauma-relevant stimuli

29
  • 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

30
  • 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

31
Interventions
32
Critical incidents debriefing
  • Proximity (Rx offered close to scene)
  • Immediacy (asap)
  • Expectancy (returning to normal functioning)
  • Brevity

33
  • Debriefing
  • information gathering
  • modulate emotions morale building
  • respect individual experiences
  • facilitates emotional expression
  • develop a narrative of the experience make
    sense of the event

34
  • 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

35
  • 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

36
  • Catharsis expression of affect associated with
    memory of a traumatic event

37
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

38
  • The fact phase
  • Details of what actually happened (not deal with
    thoughts, impressions, and emotions yet)
  • Expectations (did they expect what happened?)

39
  • 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

40
  • The reaction phase
  • Focus on emotions
  • Release of emotions
  • Covers fear, helplessness, frustration,
    self-reproach, anger, guilt, anxiety, depression
  • Emotions since the trauma

41
  • 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

42
  • 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

43
  • 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

44
  • 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

45
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

46
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

47
  • 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

48
  • 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

49
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

50
  • 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

51
  • 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

52
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

53
  • . The story of PTSD is the tale of the
    indomitable and indefatigable human spirit to
    survive and adapt
  • (Meichenbaum, 1994).
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